Why Smoking Keeps Getting Ignored in Addiction Treatment—and What a New Study Reveals

For decades, the assumption seemed straightforward: people who smoke spend money on cigarettes that could go toward food, leading to hunger. It is a tidy narrative that places blame on individual choice. But new research suggests the reality is far more complex—and the implications for how we treat addiction are significant.

A study published this month in the American Journal of Health Promotion challenges the conventional wisdom about the relationship between cigarette smoking and food insecurity. The research, led by Elizabeth Goldsborough, a doctoral candidate at UConn School of Social Work and predoctoral fellow at New York University's NIH-funded Behavioral Sciences Training program, analyzed data from the Future of Families and Child Wellbeing Study—a longitudinal birth cohort following nearly 5,000 children and their parents in large U.S. cities between 1998 and 2000.

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What the Data Actually Shows

Goldsborough and her colleagues set out to answer a question that has long puzzled public health researchers: does smoking cause food insecurity by diverting limited funds, or does the stress of not having enough food drive people to smoke more?

Using cross-lagged panel analysis—a statistical method that tracks variables over time to infer causal direction—the team examined mothers participating in the collaborative study. What they found upends the simple cause-and-effect story.

"What we found was that it's not smoking causing food insecurity—or food insecurity causing smoking," Goldsborough explains. "This widely observed link may instead be explained by underlying poverty, financial stress, and mental health challenges, since both depression and economic hardship affect food access and smoking behavior."

In other words, the correlation between smoking and food insecurity that researchers have documented for years is not a direct transaction where cigarette purchases displace grocery budgets. Rather, both behaviors emerge from deeper structural conditions: inadequate income, financial instability, and mental health struggles. The cigarettes do not cause the empty refrigerator; both are symptoms of the same systemic pressures.

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The Overlooked Addiction

Goldsborough's findings carry particular weight for the field of substance use treatment, where tobacco use has historically occupied an awkward position. Despite being the leading cause of preventable death in the United States, smoking is often treated as a separate issue—or ignored entirely—within addiction care settings.

"So many times, tobacco treatment doesn't get addressed and those with mental health conditions and substance use disorders continue to smoke at much higher rates," Goldsborough notes. "Treating tobacco use alongside other substance use is a more holistic approach to care and can improve both quality of life and longevity of the groups that social workers serve."

The statistics support her concern. While smoking rates have declined dramatically in the general population over the past two decades, they remain stubbornly high among people with substance use disorders. Some studies suggest that as many as 75 to 90 percent of individuals in addiction treatment smoke cigarettes—compared to roughly 11 percent of the general adult population.

Yet many treatment programs still allow smoking on premises, offer cigarettes as rewards for program compliance, or simply defer addressing tobacco until after a patient has achieved stability with other substances. The rationale—that quitting smoking might jeopardize recovery from drugs or alcohol—has persisted despite growing evidence that concurrent treatment is safe and effective.

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Provider Gaps in Connecticut

Goldsborough's dissertation research, conducted in Connecticut, reveals another layer of the problem: even when providers recognize the importance of addressing tobacco, gaps in training and organizational support limit their ability to deliver care.

In a survey of 374 behavioral health providers, more than 87 percent reported offering tobacco treatment at least some of the time. But many also acknowledged deficits in knowledge, attitudes, and confidence—all factors that influence whether they actually provide that care in practice.

"These are things we can change," Goldsborough says. "If we improve training, build provider confidence, and create supportive organizational policies, we can strengthen how tobacco treatment is delivered."

Her recommendations are straightforward but require institutional commitment. Social work education should include competency-based tobacco treatment training. Agencies need clear policies that support evidence-based care. And the field must move away from the notion that tobacco can wait—that it is somehow less urgent than other substances.

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Structural Factors, Not Individual Choices

The broader significance of Goldsborough's research lies in its challenge to individualistic explanations for health disparities. When we see a mother smoking while struggling to feed her children, the easy conclusion is that she is making poor choices with limited resources. The harder but more accurate interpretation is that she is responding to chronic stress, depression, and economic precarity with one of the few coping mechanisms readily available to her.

This reframing matters for policy as much as for clinical practice. If smoking and food insecurity both stem from poverty and mental health challenges, then interventions targeting only the visible behaviors—anti-smoking campaigns, nutrition education—will have limited impact. What is needed are structural changes: living wages, affordable housing, accessible mental health care, and the kind of comprehensive addiction treatment that addresses all substances, including the legal ones.

The Future of Families and Child Wellbeing Study, which provided the data for Goldsborough's analysis, was designed to examine precisely these kinds of interconnections. Originally known as the Fragile Families Study, it has followed nearly 5,000 children born to mostly unmarried parents in large U.S. cities, collecting data on family dynamics, economic conditions, health behaviors, and child development over more than two decades. The study intentionally oversampled births to unmarried couples, providing a window into the lives of families facing higher-than-average economic instability.

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From Research to Practice

Goldsborough's own path to this research was shaped by direct experience. After earning her MSW from Rutgers University, she worked as a medical social worker and later as a clinical research counselor—roles that exposed her to the limitations of one-on-one intervention in the face of systemic barriers.

"In my medical social work roles, I worked with clients one-to-one, but research allows me to make change at a different scale," she says. "It's a way to have an impact beyond the individuals I see directly and to bring a social work perspective to research that affects the populations we serve."

That perspective—one that sees individual behavior in context, that recognizes the interplay of psychological, social, and economic factors—is increasingly central to addiction research. But it has yet to fully penetrate treatment systems, where siloed care remains the norm.

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What's Next

After completing her Ph.D. this August, Goldsborough will continue her work as a postdoctoral fellow at the Yale School of Medicine Division of Prevention and Community Research, supported by a NIDA-funded fellowship. The position will allow her to expand her research on substance use and prevention while building interdisciplinary collaborations.

For New Yorkers seeking addiction treatment, her findings carry a practical message: recovery is not just about stopping the substance that brought you to treatment. It is about addressing the full range of behaviors and conditions that affect health and wellbeing—including tobacco, mental health, and the economic stressors that can derail progress.

The study also serves as a reminder that the most visible symptoms of a problem are not always the most important ones. A mother smoking instead of buying groceries is not making an irrational choice. She is navigating impossible circumstances with limited options. Understanding that—and designing treatment systems that account for it—is the first step toward care that actually works.

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If you or someone you know is struggling with substance use, the New York State Office of Addiction Services and Supports (OASAS) provides a 24/7 HOPEline at 1-877-8-HOPENY (1-877-846-7369) for confidential support and treatment referrals.