The use of both tobacco and alcohol products—known as “co-use”—is common, and there is strong correlation between dependence on tobacco and alcohol. In addition to each causing cancer individually, the co-use of tobacco and alcohol is associated with synergistically higher risk of head and neck and esophageal cancers, and potentially with cancer at other sites. This monograph highlights the importance of addressing co-use of tobacco and alcohol for cancer prevention and health promotion goals. Designed to inform researchers, clinicians, public health practitioners, and the public, this monograph summarizes the most recent evidence and effective practices related to addressing tobacco and alcohol co-use and identifies research gaps related to these topics.
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Suggested Citation
U.S. National Cancer Institute. Tobacco and Alcohol: Understanding Co-Use to Reduce Cancer Incidence and Mortality. National Cancer Institute Tobacco Control Monograph 24. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute; 2026.
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Chapters and key topics covered within each chapter are listed below. Chapters generally include an introduction, a chapter summary, and a reference list.
- Front matter (PDF, 841 KB)
- Foreword
- Table of Abbreviations and Acronyms
- Glossary
- Chapter 1. Introduction and Overview (PDF, 1.65 MB)
- The Need for a Monograph on Tobacco and Alcohol Co-Use
- Effects of Tobacco and Alcohol Co-Use
- About This Monograph
- Monograph Strengths and Limitations
- Major Conclusions
- Chapter 2. Surveillance and Behavioral Epidemiology of Tobacco and Alcohol Use Among Adolescents and Adults in the United States (PDF, 6.57 MB)
- Measurement of Tobacco and Alcohol Co-Use
- Methods
- U.S. Population Patterns of Tobacco and Alcohol Use
- Trends Over Time in Tobacco and Alcohol Consumption
- Co-Use of Tobacco and Alcohol Among Adolescents
- Co-Use of Tobacco and Alcohol Among Adults
- Chapter 3. Surveillance and Behavioral Epidemiology of Tobacco and Alcohol Use Among Population Subgroups in the United States (PDF, 8.89 MB)
- Methods
- Within and Between Group Heterogeneity in Tobacco and Alcohol Use
- Co-Use by Race and/or Ethnicity
- Co-Use by Educational Attainment
- Co-Use by Income
- Co-Use by Geographic Location: Region, Urban/Rural, and Other Location Differences
- Co-Use Among People Who Identify as Part of a Sexual Minority Group
- Co-Use Among Military Service Members and Veterans
- Co-Use Among People with Comorbidities
- Co-Use Among Other Populations: Unhoused or Criminal Justice-Involved Individuals and People with Disabilities
- Chapter 4. Cancer Epidemiology of Tobacco and Alcohol Co-Use (PDF, 946 KB)
- Cancer Epidemiology of Tobacco, Alcohol, and Their Co-Use
- Epidemiology of Synergistic Cancer Risk for Joint Tobacco and Alcohol Exposures
- Measurement and Analysis
- Chapter 5. Physiological, Cellular, Molecular, and Genetic Basis of the Combined Effects of Tobacco and Alcohol Use on Carcinogenesis (PDF, 2.31 MB)
- Exposure to Tobacco-Related Carcinogens
- Exposure to Alcohol Carcinogens
- Alcohol and Increased Absorption of Tobacco-Related Carcinogens
- Role of Alcohol-Mediated Increase in Exposure to Tobacco-Related Carcinogens and Effects of Reduced Alcohol Intake
- The Role of Acetaldehyde
- Further Mechanisms of Tobacco and Alcohol Carcinogenesis
- Inflammation and Oxidative Stress
- Epigenetic Changes
- Tumor Promotion
- Genetic Susceptibility
- Lung Cancer
- Aerodigestive Tract Cancers
- Interactions Between Nicotine and Alcohol
- Potential Interactions of Electronic Cigarettes and Alcohol
- Chapter 6. Shared Physiological and Genetic Factors Contributing to Tobacco and Alcohol Co-Use (PDF, 2.4 MB)
- Nicotine, Ethanol, and Biological Pathways in the Brain
- Shared Genetic Factors That Contribute to Tobacco and Alcohol Behaviors
- The Potential for Personalized Medicine for Prevention and Cessation
- Chapter 7. Treatment Approaches for Tobacco and Alcohol Use (PDF, 1.1 MB)
- Understanding and Leveraging Neurobiological and Neurobehavioral Connections
- Evidence Base for Smoking Cessation Therapies in the Presence of Alcohol Use
- Integrated Therapies for Smoking and Alcohol Use
- Chapter 8. Prevention of Tobacco Use in Relation to Alcohol (PDF, 2.87 MB)
- Scope of the Chapter
- Common Modifiable Risk and Protective Factors for Tobacco and Alcohol Use
- History of Tobacco and Alcohol Prevention Programs for Adolescents and Young Adults
- Individual-Level Interventions
- Group-Level Interventions
- Population-Level Interventions
- Policy Influences on Tobacco and Alcohol Use
- Chapter 9. Economic, Environmental, and Policy Factors Related to Tobacco and Alcohol Use (PDF, 5.78 MB)
- Systems of Influence on Tobacco and Alcohol Use
- Economic Factors
- Environmental Factors: Retail Availability and Marketing Environments
- Policy Factors
- Chapter 10. Future Research Directions (PDF, 435 KB)
- Key Monograph Findings
- Research Opportunities