Is it recommended to use alcohol and nicotine (nicotine replacement therapy) concurrently?

Concurrent Use of Alcohol and Nicotine Replacement Therapy

Concurrent use of alcohol and nicotine replacement therapy is not recommended due to potential safety concerns, including increased risk of side effects and possible interactions that may affect treatment efficacy.

Safety Concerns with Concurrent Use

The FDA drug label for varenicline (a smoking cessation medication) specifically notes that when nicotine replacement therapy (NRT) was combined with other smoking cessation treatments, there was an increased incidence of adverse effects 1. Specifically:

• When NRT (transdermal nicotine 21 mg/day) was co-administered with varenicline, patients experienced higher rates of nausea, headache, vomiting, dizziness, dyspepsia, and fatigue compared to NRT alone
• 36% of patients using the combination prematurely discontinued treatment due to adverse events (compared to only 6% with NRT alone)

Alcohol-Specific Concerns

The U.S. Preventive Services Task Force (USPSTF) has highlighted potential interactions between alcohol and smoking cessation treatments 2. The FDA has issued a warning about potential interactions between varenicline and alcohol, indicating regulatory concern about combining alcohol with smoking cessation treatments 2.

Additionally, the National Comprehensive Cancer Network (NCCN) guidelines note that smoking can impact the metabolism of various drugs through effects on cytochrome P450 enzymes, which may alter drug clearance time and plasma concentration 2. Since alcohol is also metabolized through similar pathways, concurrent use could potentially complicate treatment efficacy.

Approach to Smoking Cessation in Alcohol Users

For patients who consume alcohol and want to quit smoking:

1. Address alcohol consumption first or simultaneously:

   • For heavy drinkers, the American Heart Association/American Stroke Association recommends eliminating or reducing alcohol consumption 2
   • Light to moderate alcohol consumption (≤2 drinks/day for men, ≤1 drink/day for non-pregnant women) may be considered 2

2. Choose appropriate smoking cessation methods:

   • Combination of pharmacotherapy and behavioral counseling is most effective 2
   • Options include:
     • Nicotine replacement therapy (patch, gum, lozenge)
     • Varenicline
     • Bupropion SR

3. Timing considerations:

   • If a patient chooses to drink while using NRT, they should separate alcohol consumption and NRT use by at least several hours to minimize potential interactions
   • For breastfeeding mothers who smoke, the American Academy of Pediatrics recommends smoking immediately after breastfeeding to minimize nicotine transmission to the infant 2

Special Populations and Considerations

• Patients with cardiovascular disease: Despite concerns, research has found no evidence of increased risk of cardiac events associated with NRT treatment 3

• Pregnant women: Limited data exists on pharmacotherapy for smoking cessation in pregnant women, but behavioral interventions are considered safe 2

• Patients with history of seizures: The FDA has issued a warning about a potential but rare occurrence of seizures with varenicline use 2, which could potentially be exacerbated by alcohol

Bottom Line

While both alcohol and nicotine replacement therapy can be used separately for their intended purposes, concurrent use is not recommended due to potential increased side effects and interactions. Patients should be advised to avoid alcohol consumption while using nicotine replacement therapy, or at minimum, to separate their use by several hours.