The selection hypothesis of smoking prevalence posits that smokers who are not able to quit
successfully are "burdened" by specific characteristics that make it more challenging to
quit1. For example, those less successful in quitting smoking may be more nicotine dependent
or more likely to suffer from substance use, psychiatric, or medical conditions. In line with
this perspective, smoking prevalence has stabilized in the US, presumably because the
remaining population has become increasingly representative of those "at-risk smokers" who
are unable to quit2. Emerging evidence suggests that persons who suffer from opioid misuse,
defined as opioid use without a prescription, at a dose or frequency higher than prescribed,
or for a non-medical purpose (e.g., getting high),3 may constitute such a high-risk group.
Opioid misuse affects greater than 16% adults who use opioids4 and up to 29% of those with
chronic pain.5 The prevalence of tobacco smoking in this group may exceed twice that observed
in the general population, and smokers misusing opioids are almost twice as likely to be
dependent on nicotine6,7. Yet, the role of opioid misuse in periods of early abstinence and
smoking cessation has yet to be explored. The main objective of the present proposal is to
fill existing gaps in knowledge by examining the extent to which opioid misuse is associated
with decreased success during early smoking abstinence and over the course of an attempt to
quit smoking, and to identify mediators and moderators of opioid-smoking relations in this
context. This contribution is clinically-significant from a public health standpoint because
it will directly guide the development of novel psychosocial/behavioral smoking cessation
interventions to help this high-risk population of smokers quit by targeting unique
vulnerability processes that result in poor cessation outcomes.