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Those who are among the heaviest drinkers in England are four times more likely to smoke than the general population, according to a new study led by UCL researchers. The study, published in The Lancet Regional Health - Europe, looked at survey responses from a nationally representative sample of 144,583 people in England, completed over the course of seven years, from 2014 to 2021. They found that 58% of people at risk of becoming alcohol dependent (assessed through a survey designed to detect harmful drinking habits) were current smokers, compared to 15% among the general population. They also found that smoking prevalence and dependency increased in line with alcohol consumption - that is, the more a person drank, the more likely it was that they smoked, and the more cigarettes they were likely to smoke in a day. The researchers said that the government needed to prioritise people at risk of alcohol dependency who smoked in its plans to achieve “smoke-free” status in England by 2030, defined to mean an adult smoking prevalence of 5% or less. Lead author Dr Claire Garnett (UCL Institute of Epidemiology & Health Care) said: “To get close to a ‘smoke-free' England in 2030, the government needs to target groups where smoking is highly prevalent. Our study strongly suggests that those who are among the heaviest drinkers in England, who are risk of becoming dependent on alcohol, should receive targeted smoking cessation support. “Tobacco and alcohol are the two most commonly used substances in England yet we have relatively little evidence about how they are used together. Our study is the first to demonstrate the scale of their co-use.” Senior author Dr Sharon Cox (UCL Institute of Epidemiology & Health Care) said: “When smokers are treated for a drug or alcohol dependency, their smoking habit is often overlooked and they are more likely to miss out on support to quit. But smoking is no less dangerous to people who are using another substance. What's more, there is often a strong behavioural connection - the smoking and drinking often happen in tandem - so it may be more effective to treat the two issues together." For the study, the researchers looked at responses to the Smoking and Alcohol Toolkit Study, a monthly population survey in England. Participants were assessed as being at risk of alcohol dependence or not according to their responses to the Alcohol Use Disorders Identification Test (AUDIT), which includes questions such as how often respondents had failed to do what was normally expected of them because of drinking. Respondents who had the highest score - that is, who were most at risk, and who were England's heaviest drinkers - had the highest smoking prevalence (76% were current smokers, and 81% were past-year smokers). Smokers who were at risk of alcohol dependence also smoked more. The researchers found that nearly a third (30%) of people in this group started smoking within five minutes of waking, compared to 13% of smokers who drank alcohol but were not at risk of dependence, and 17% of non-drinkers. Smokers at risk of alcohol dependence smoked 14 cigarettes a day on average, compared to 11.5 among non-drinkers and 10.9 among drinkers not at risk. In addition to looking at current smoking prevalence, the researchers found that 63% of people at risk of alcohol dependence had smoked in the past year, compared to about 19% of drinkers not at risk and non-drinkers. The study was funded by Cancer Research UK and the National Institute for Health and Care Research.