One in three adults worldwide is a regular smoker, and among these adults, 50% will die from cigarettes . Cigarette smoking is the most important source of preventable morbidity and mortality in the US, with cost exceeding $167 billion annually . Almost 30% of primary care patients use some form of tobacco .
Alcohol use is related to a wide range of harms . Approximately one-third of all US adults are involved in alcohol misuse , including 14 million adults with alcohol abuse or alcoholism and almost twice that number who are involved in at-risk drinking (for women, more than three drinks per day or seven drinks per week and for men, more than four drinks per day or 14 drinks per week). The cost of alcohol misuse in the U.S. is approximately $140 billion annually . Among primary health care patients, 7 to 20 percent engage in alcohol misuse . Alcohol use and tobacco use are often associated, with approximately 50% of alcohol misusers concurrently using tobacco [8, 9]. Concurrent tobacco and alcohol use synergistically increase the risk of head and neck and esophageal cancer [10, 11]. Binge drinking and alcohol abuse also hinder individuals' efforts to stop smoking [12–14].
Primary care intervention for alcohol and tobacco misuse is effective and reduces morbidity and mortality. Brief advice by primary care clinicians increases quit rates for smokers [15, 16]and helps hazardous and harmful drinkers decrease their alcohol consumption . Smoking cessation significantly reduces future cancer risk [18–22]. The U.S. Preventive Services Task Force now recommends screening and office intervention for both tobacco use and problem drinking [23, 24]. Combined tobacco and alcohol intervention has the potential to reduce tobacco- and alcohol-related morbidity and cancer risk. Nonetheless, tobacco and alcohol screening and intervention are not consistently performed in most primary care practices. Despite education and training initiatives in alcohol [25–27] and tobacco [1, 8, 28–30], health care providers screen only 28% of patients for alcohol misuse  and 48% for tobacco abuse [1, 28, 32, 33].
In an effort to increase screening rates, office protocols have been developed to screen patients before they see their clinicians and prompt clinicians to intervene when screens are positive. Using a vital signs stamp that assesses smoking status as part of nursing vital signs has been shown to increase tobacco cessation rates in three of four studies [34–37]. For alcohol screening, a validated single alcohol screening question (SASQ: "When was the last time you had more than X drinks in one day?" where X = 4 for women and 5 for men) has demonstrated acceptable sensitivity and specificity [8, 38, 39], however no previous studies have attempted to include this question in nursing vital signs.
Most studies employing reminder systems which prompt primary care clinicians to intervene have resulted in increased clinician intervention rates for tobacco abuse [40–42] and alcohol misuse [43–45], though some studies have showed mixed results . A study by Milch et al  combined vital signs screening with nurse administration of a brief tobacco assessment instrument which was then used as a clinician prompt, resulting in increased tobacco interventions by clinicians and higher rates of self-reported smoking cessation. Findings from this single study, however, have not yet been replicated. The purposes of this multi-site study were to: (1) determine the feasibility of combined vital signs screening for tobacco and alcohol misuse, (2) assess the impact of vital signs screening alone on alcohol and tobacco screening and intervention rates, and (3) assess the impact of combined vital signs screening plus use of a tobacco prompt for increasing tobacco interventions.