Women & 

Smoking

Cessation

Handbook 

A Resource 

for Providers
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Women &
 

Smoking

Cessation

Handbook
 


 

A Resource 

for Providers
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Foreword 

VA developed Women & Smoking Cessation Handbook to provide clinical 

guidance on evidence-based smoking cessation care targeted to meet the 

needs of female Veterans. Wherever possible, this resource draws upon 

evidence-based and gender-specific literature for information and treatment 

guidance. When adequate literature on gender-specific clinical guidance did 

not exist, general guidance from the U.S. Public Health Service Clinical 

Practice Guideline, Treating tobacco use and dependence: 2008 update, 

was used. 
Acknowledgements
 

The provider-based Women & Smoking Cessation Handbook and the

accompanying My Smoking Cessation Workbook were developed by the San 

Diego Tobacco Cessation Clinical Resource Center (TCCRC) of the Department 

of Veterans Affairs, led by Dr. Timothy Chen. The authors' primary goal was 

to develop materials promoting smoking cessation interventions, based on 

published principles of evidence- and consensus-based clinical practice, 

for use by providers treating female Veterans.

With permission from Dr. Miles McFall and Dr. Andrew Saxon, several

materials used in these publications were modified from smoking cessation 

workbooks they developed for providers of patients with posttraumatic

stress disorder as part of the Smoking Cessation Project of the Northwest

Network Mental Illness Research, Education & Clinical Center of Excellence 

in Substance Abuse Treatment and Education at the VA Puget Sound Health 

Care System. The U.S. Public Health Service Clinical Practice Guideline1 and 

the treatment model described by Richard Brown provided the foundation 

for their work and therefore indirectly ours as well.2

Many thanks to Kim Hamlett-Berry, National Director of Tobacco & Health:

Policy and Programs of Clinical Public Health, for supporting this project and

Leah Stockett, Julianne Himstreet, and Dana Christofferson for editing the

handbook and workbook. Thanks to Natara Garovoy for her comments and

review. Special thanks to the HIV and Smoking Cessation (HASC) Working

Group as this resource was adapted from the HASC provider manual: Ann

Labriola, Maggie Chartier, Linda Allen, Mai Vu, Hannah Cohen-Blair, Jane

Burgess, and Maggie Czarnogorski. As well, the TCCRC Working Group: Tim

Chen, Anne Nisenzon, Dana Christofferson, Pam Belperio, Mark Myers,

Khanh Nguyen, Stacey Nguyen, Julianne Himstreet, and Kim Hamlett-Berry.

1

 Fiore, M. C., Bailey, W. C., Cohen, S. J., Dorfman, S. F., Goldstein, M. G., Gritz, E. R., Heyman, R. B.,

Jaén, C. R., Kottke, T. E., Lando, H. A., Mecklenburg, R. E., Mullen, P. D., Nett, L. N., Robinson, L., 

Stitzer, M. L., Tommasello, A. C., Villejo, L., & Wewers, M. E. (2000). Treating tobacco use and 

dependence. Clinical practice guideline. Rockville, MD: U.S. Department of Health and Human 

Services, Public Health Service.

2 Brown, R. A. (2003). Intensive behavioral treatment. In D. B. Abrams, R. Niaura, R. Brown, 

K. M. Emmons, M. G. Goldstein, & P. M. Monti, The tobacco dependence treatment handbook: A guide

to best practices (pp. 118-177). New York, NY: Guilford Press.
Table of Contents
 

I. Women and Smoking ............................................1
 

Scope of the Problem....................................... 4
 

Benefits Of Smoking Cessation In Female

Veteran Smokers............................................. 5
 

About The Health Care Provider’s Role .................. 7
 

Challenges to Cessation in Female Smokers ............. 8
 

II. Smoking Cessation Interventions............................ 13

Effectiveness of Smoking Cessation Interventions ..... 15

Starting a Smoking Cessation Program for

Female Veterans ............................................ 16

Smoking Cessation Behavioral Interventions............ 16

Identifying Reasons to Quit ............................... 19

III. Real-time Scripts for Brief Smoking
 

Cessation Interventions...................................... 23
 

Approaching Your Patients about
 

Smoking Cessation.......................................... 25
 

Addressing Patient Concerns.............................. 26
 

Sample Scripts for Brief Interventions .................. 28
 

IV. Special Topics for Female Veterans........................ 33
 

Concerns Regarding Weight Gain ......................... 35
 

Smoking Cessation During Pregnancy.................... 37
 

Stress and Mood Management ............................ 39
 

Social Support .............................................. 41
 

V. Medications for Smoking Cessation ......................... 45
 

Nicotine Pharmacology .................................... 48
 

Nicotine Replacement Therapy........................... 49
 

Bupropion.................................................... 54
 

i 
Varenicline .................................................. 55
 

VI. Relapse Prevention and Smoking
 

Cessation Maintenance ...................................... 71
 

Smoking: a Chronic, Relapsing Disorder................. 73
 

Management of Withdrawal Symptoms .................. 74
 

Appendices ........................................................ 79
 

Appendix A. Sample Intensive Smoking Cessation
 

Counseling Programs..................... p. 80
 

Appendix B. Web and Telephone Tobacco
 

Cessation Resources ..................... p. 90
 

ii 
Tables and Charts 

Table 1. The 5 A’s of Brief Smoking
 

Cessation Interventions .............................. 17
 

Table 2. Enhancing Motivation to Quit Tobacco
 

(The 5 R's).............................................. 20
 

Table 3. Fagerström Test for Nicotine Dependence ........ 26
 

Table 4. Sample Responses to Patients’ Concerns About
 

Smoking Cessation .................................... 27
 

Table 5. Sample Scripts for Brief Interventions ............. 28
 

Table 6. Facts About the Risks of Smoking Prior
	

to Conception, During Pregnancy,
 

and Postpartum ....................................... 37
 

Figure 1. Efficacy of Medications for

Smoking Cessation .................................... 48

Table 7. Medications for Smoking Cessation Available

Through the VA National Formulary ................ 58

Table 8. Smoking Withdrawal Symptoms*
 

and Recommendations ............................... 74

Table 9. Example of 8-Session Intervention.................. 85
 

iii 
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1 

I. Women and Smoking
 
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CHAPTER SUMMARY 

Scope of the problem 

 Smoking kills nearly 175,000 women in the United States annually,1 

and has been directly implicated in several life-threatening health 

conditions, including pulmonary disease, cardiovascular disease, 

various cancers, and osteoporosis 

 Women who smoke during pregnancy have been shown to have 

increased birth complications and low birth weight babies2 

 Women who smoke can have fertility difficulties2-3

 Chronic Obstructive Pulmonary Disease (COPD) related deaths have 

increased dramatically in women smokers and the disease risks are 

now considered similar to men3 

 Female Veterans may face increased stressors and barriers to 

quitting, such as greater likelihood of depression, anxiety, and 

other mental health issues2-3 

Benefits of smoking cessation in female Veteran smokers 

 Quitting smoking can reduce and reverse many of the negative 

effects of tobacco use 

 Smoking is the most clinically important modifiable cardiovascular 

risk factor 

 Quitting smoking has been linked to several female-specific health 

benefits, such as decreased risk for cervical and breast cancer, as 

well as improved fertility and healthier pregnancies 

About the health care provider's role 

 Effectiveness starts with the clinical routine: 

• Ask about the patient’s smoking status 

• Advise patients to quit and inquire about readiness 

• Monitor quit attempts and relapses 

 Help patients access comprehensive care to address co-morbidities 

hindering their ability to quit 

 Utilize an integrated model and provide a consistent message
 

about smoking
 

 Greater efficacy with a team approach 

 Stress the importance of using medications coupled with behavioral 

counseling, if possible 

3 
 

 

g 

CHAPTER SUMMARY 

Challenges to cessation in female Veteran smokers 

 Higher rates of comorbidities such as posttraumatic stress disorder 

(PTSD), depression, other psychiatric disorders, and substance and 

alcohol use among smokers 

 Quitting smoking may be harder for women 

SCOPE OF THE PROBLEM 

Women now comprise a substantial portion of the military and hold positions in 

nearly all branches of service. Twenty percent of female Veterans in care at VA 

smoke, as compared to 16.5% in the civilian population, supporting evidence 

that there is an increased vulnerability to smoking initiation and difficulty with 

cessation among female Veterans.4-5

While overall smoking rates among women continue to decrease (perhaps 

due to increased awareness of the dangers of smoking), quitting rates among 

women are consistently lower than those among men, indicating a greater 

need for cessation efforts for female smokers.6 Furthermore, it appears that 

the increase in smoking behavior among military women, as compared to 

civilian women, is even greater than those found between military and civilian 

men.7 Research has shown that smoking has a significant and unique impact 

on the health of women, with additional consequences for those serving in the 

military: 

 Smoking is related to 90% of pulmonary disease among women. 

Chronic obstructive pulmonary disease (COPD) kills more women 

than breast cancer annually, with newly diagnosed cases of COPD 

increasing three times as fast in women as compared to men.3,8

 The 

rate of COPD deaths are increasing in women smokers while rates 

are declining in male smokers.3 The risks associated with COPD 

complications in smokers (e.g. deaths) are considered equal between 

men and women smokers.3 

 Smoking is directly linked to 80% of lung cancer deaths, surpassing 

breast cancer as the leading cause of cancer deaths among women.1 

Evidence also suggests a causal relationship between smoking and 

colorectal cancer and liver cancer.3

 Smoking may also be associated 

with the development and progression of several female-specific 

cancers, such as cervical, ovarian, vulvar, and breast cancers.1,3

4 
5 

g 

 Even light smoking has been shown to triple the risk of
 

coronary disease and stroke among women, particularly when
 

there is concurrent use with oral contraceptives (considered
 

a contraindication).9
 

 Studies have shown a link between smoking and premenopausal
 

signs of osteoporosis among women, most likely due to estrogen
 

deficiencies among female smokers.10 

 Smoking has been identified as an independent risk factor for 

low fertility, gestational complications, birth complications, and 

perinatal morbidity and mortality.11-12 

 Studies have shown a possible association between smoking and 

increased rates of depression, anxiety, and substance abuse among 

military women, particularly those in active-duty.2 Additionally, 

psychiatric comorbidity has been shown to be more prevalent in 

women with COPD.8 

 Psychological comorbidities may complicate quitting efforts, as
 

women may smoke as a method to cope with emotional distress;
 

thus, these issues should be carefully assessed and treated with
 

concurrent therapy, if necessary.
 

BENEFITS OF SMOKING CESSATION IN FEMALE VETERAN SMOKERS 

Smoking cessation can reduce and reverse many of the negative effects of 

tobacco use. 

 Smoking cessation reduces respiratory symptoms, including 

coughing, wheezing, and shortness of breath. Overall lung 

functioning improves within several months of smoking cessation, 

and risk of death from COPD decreases with continued abstinence.13 

 Cigarette smoking continues to be the most important modifiable 

cardiovascular risk factor for both women and men. The risk 

of cardiovascular events in women is substantially reduced 

after 2-4 years of abstinence.14 Additionally, smoking cessation 

substantially reduces the risk of peripheral arterial disease, which 

has been shown to be especially prevalent in female smokers, 

independent of other known risk factors.15 

 Quitting smoking has been shown to decrease the risk of developing 

various cancers, including lung and oral cancers as well as 

female-specific cancers, such as breast, cervical, vulvar, and ovarian 

cancers. For those with a cancer diagnosis, smoking cessation has 
6 

g 

 

been shown to increase responsiveness to cancer treatments as well 

as reduce the risk of developing a second cancer.16 

 Women who quit smoking reduce the risk of infertility, and pregnant 

women who quit early in their pregnancies reduce the risk of 

gestational complications and premature birth, low-birth weight 

infants, and infant death.17 

 Studies have shown that female Veterans who quit smoking report 

significantly less depressive symptoms than current smokers.7 

Smoking Cessation Among Women 

Studies have shown that women may face additional challenges in smoking 

cessation than men, evidenced by lower quit rates and increased difficulty in 

maintaining long-term abstinence.18 These challenges include: 

 Women appear to have a higher rate of nicotine metabolism, leading 

to increased usage8 

 Women may be more sensitive than men to different behavioral 

maintaining factors of smoking, such as social influences of one’s 

smoking community and fears of weight gain following cessation8 

 Self-reported studies have shown a consistent pattern of lower 

confidence and motivation and increased stress during cessation 

attempts among women19-20

 Women’s menstrual cycles may impact success during a quit 

attempt, as studies have shown that quitting during the follicular 

phase (lower estrogen) may be related to higher chances of relapse21 

 Military women in particular may have comorbidity of tobacco
 

use and psychiatric conditions, suggesting smoking may serve as a
 

coping mechanism7
 

Indeed, women may especially benefit from patient-centered smoking cessation 

therapies aimed at addressing these unique challenges. 

Effective Smoking Cessation Strategies 

While there is currently limited research addressing evidence-based treatment 

for smoking cessation specific to female Veterans, studies have shown that 

patient success in quitting and staying tobacco-free can be dramatically 

increased by the selection of appropriate interventions17-18 such as: 

 The use of smoking cessation counseling plus medication 
7 

g 

 The use of combination nicotine replacement therapy, if possible 

 The consistent identification, documentation, and treatment 

of smokers 

 The use of proactive smoking cessation quitlines to
 

provide counseling
 

 Patient-centered methods to address unique maintaining factors for 

women, as listed on the previous page 

 Better patient and staff education (increased gender-specific 

patient education) 

 Increased training for providers in evidence-based care 

ABOUT THE HEALTH CARE PROVIDER’S ROLE 

What We Can Do for Female Veteran Patients Who Smoke 

VA primary care clinicians and health care staff can play a key role in helping 

their female patients quit smoking in the following ways: 

 Recommend quitting, assess readiness to quit, and monitor quit
 

attempts and smoking relapses
 

 Provide education that specifically targets gender-specific motives 

for quitting, such as preventing deaths related to COPD, to improve 

reproductive health and to lower risks for cancer (e.g., lung, 

colorectal, and breast cancer) and osteoporosis 

 Prescribe smoking cessation medications 

 Make referrals to specialists (e.g., mental health, substance abuse) 

and otherwise help patients access comprehensive care, so they 

receive help in resolving co-morbidities that may affect their ability 

to quit smoking 

 Provide information on the availability of Quit VET, the 

Veteran-specific telephone smoking cessation quitline, 

1-855-QUIT-VET (http://vaww.publichealth.va.gov/smoking/quitline.

asp) and VA’s supportive text messaging program, SmokefreeVET 

(http://smokefree.gov/VET/) 

 Provide treatment in group therapy formats when possible to foster 

a supportive non-smoking environment 
8 

g 

 

Additionally, as female Veterans tend to have a higher incidence of comorbidities such as PTSD, depression, and other psychiatric conditions when 

compared to civilian women, using an integrated care model to address smoking 

cessation within mental health care may result in greater quitting success.22 

CHALLENGES TO CESSATION IN FEMALE SMOKERS 

There is a higher incidence of co-morbidities such as depression, anxiety, and 

substance abuse among military women whom smoke2 yet some providers are 

hesitant to attempt smoking cessation in patients with serious co-morbidities. 

Several studies suggest that smoking cessation is possible in populations with 

serious co-morbidities, including women smokers. 

 For Veterans with PTSD who smoke, an integrated model of smoking 

cessation with PTSD providers and staff providing consistent care 

was found to be effective and superior to standard-of-care smoking 

cessation programs given separately from the PTSD clinic.22 Studies 

in populations with psychiatric disorders and depression suggest 

at least moderate efficacy of smoking cessation and little or no 

evidence of exacerbation of these disorders.22-24

 Approximately half of alcohol dependent individuals are daily
 

smokers and a number of studies have evaluated concurrent
 

treatment of nicotine dependence and alcohol use disorders.25-26
 

Overall, evidence indicates that smoking cessation interventions 

for individuals with alcohol use disorders are effective and have no 

detrimental effects on abstinence from alcohol.27 Study results are 

mixed regarding optimal timing of smoking cessation interventions 

for individuals with alcohol use disorders.28-29

Smoking status should be addressed for all individuals with 

alcohol use disorders and the following recommendations have 

been proposed:30 

•	 Smoking cessation interventions should be offered to all alcohol 

use disorder patients who smoke 

•	 A menu of options about how and when to stop should be offered 

•	 Timing of smoking cessation interventions (concurrent versus 

delayed) should be based on patient preference 
9 

g 

 Some women smokers have misconceptions about the impact of 

light smoking. The Surgeon General Report on how tobacco causes 

disease documents in great detail how both direct smoking and 

secondhand smoke causes damage not only to the lungs and heart, 

but to every part of the body.3,31 Researchers found that inhaling 

cigarette smoke from one cigarette causes immediate changes to 

the lining of blood vessels and that light smoking may be almost as 

detrimental as heavy smoking. 
10 

g 

References: 

1.	 Centers for Disease Control and Prevention. (2008). Smoking-attributable 

mortality, years of potential life lost, and productivity losses—United States, 

2000–2004. Morbidity and Mortality Weekly Report, 57(45), 1226–1228. 

2.	 Bean-Mayberry, B., Huang, C., Batuman, F., Goldzweig, C., Washington, D. L.,

Yano, E. M., & Miake-Lye, I. M. (2010). Systematic Review of Women Veterans

Health Research 2004–2008. VA Evidence-based Synthesis Program Reports. 

Washington, DC: Department of Veterans Affairs. 

3.	 National Center for Chronic Disease Prevention and Health Promotion (US) 

Office on Smoking and Health. (2014). The Health Consequences of Smoking—50

Years of Progress: A Report of the Surgeon General. Atlanta (GA): Centers for 

Disease Control and Prevention (US). Retrieved from http://www.ncbi.nlm.nih.

gov/books/NBK179276/

4.	 U.S. Department of Veterans Affairs (2012, March). 2011 Survey of Veteran

Enrollees’ Health and Reliance Upon VA. Accessed at http://vaww.vha.vaco.

portal.va.gov/sites/ADUSH/ADUSH%20Web%20Files/SoE2011_Report.pdf

5.	 Agaku, I., King, B., Dube, S.R. (2012). Current cigarette smoking among adults –

United States, 2011. Morbidity and Mortality Weekly Report, 61(44), 889-894. 

6.	 Bohadana, A., Nilsson, F., Rasmussen, T., & Martinet, Y. (2003). Gender 

differences in quit rates following smoking cessation with combination nicotine

therapy: Influence of baseline smoking behavior. Nicotine & Tobacco Research, 

5, 111-116. 

7.	 Whitlock, E. P., Ferry, L. H., Burchette, R. J., & Abbey, D. (1995). Smoking 

characteristics of female veterans. Addictive Behaviors, 20(4), 409-426. 

8.	 Rahmanian, S. D., Diaz, P. T., & Wewers, M. E. (2011). Tobacco use and 

cessation among women: Research and treatment-related Issues. Journal of 

Women’s Health, 20(3), 349-357. 

9.	 Bjartveit, K., & Tverdal, A. (2005). Health consequences of smoking 1-4 

cigarettes per day. Tobacco Control, 14(5), 315-320. 

10.	 Mazess, R. B., & Barden, H. S. (1991). Bone density in premenopausal women: 

Effects of age, dietary intake, physical activity, smoking, and birth-control 

pills. American Journal of Clinical Nutrition, 53(1), 132-142. 

11.	 Augood C., Duckitt K., & Templeton A. A. (1998). Smoking and female 

infertility: A systematic review and meta-analysis. Human Reproduction, 13(6), 

1532-1539. 

12.	 Castles, A., Adams, E. K., Melvin, C. L., Kelsch, C., & Boulton, M. L. 

(1999). Effects of smoking during pregnancy. Five meta-analyses. American 

Journal of Preventive Medicine, 16(3), 208-215. 

13.	 U.S. Department of Health and Human Services. (1990). The health benefits 

of smoking cessation. Rockville, MD: U.S. Department of Health and Human 

Services, Public Health Service, Centers for Disease Control, Center for Chronic

Disease Prevention and Health Promotion, Office on Smoking and Health. 
11 

g 

14.	 Kawachi, I., Colditz, G. A, Stampfer, M. J., Willett, W. C., Manson, J. E., 

Rosner, B., Speizer, F. E., & Hennekens, C. H. (1993). Smoking cessation 

and decreased risks of stroke in women. Journal of the American Medical

Association, 269, 232-236. 

15.	 Conen, D., Everett, B. M., Kurth, T., Creager, M. A., Buring, J. E., Ridker, P. M., 

& Pradhan, A. (2011). Smoking, smoking cessation, and risk for symptomatic 

peripheral artery disease in women: A cohort study. Annals of Internal 

Medicine, 154(11), 719-726. 

16.	 Parsons A., Daley A., Begh R., & Aveyard P. (2010). Influence of smoking 

cessation after diagnosis of early stage lung cancer on prognosis: Systematic 

review of observational studies with meta-analysis. British Medical Journal, 

340. doi: 10.1136/bmj.b5569 

17.	 Murin, S., Rafii, R., & Bilello, K., (2011). Smoking and smoking cessation in 

pregnancy. Clinics in Chest Medicine, 32(1), 75-91. 

18.	 Katzburg, J. R., Yano, E. M., Washington, D. L., Farmer, M. M., Yee, E. T., Fu, 

S., Trowell-Harris, I., & Sherman, S. E. (2009). Combining women’s preferences 

and expert advice to design a tailored smoking cessation program. Substance 

Use & Misuse, 44, 2114-2127. 

19.	 Etter, J. F., Prokhorov, A. V., & Perneger, T. V. (2002). Gender differences in 

the psychological determinants of cigarette smoking. Addiction, 97, 733-743. 

20.	 Wetter, D. W., Kenford, S. L., Smith, S. S., Fiore, M. C., Jorenby, D. E., & 

Baker, T. B. (1999). Gender differences among smoking cessation. Journal of 

Consulting and Clinical Psychology, 67, 555-562. 

21.	 Allen, A. M., Allen, S. S., Lunos, S., & Pomerleau, C. S. (2010). Severity of 

withdrawal symptomatology in follicular versus luteal quitters: The combined 

effects of menstrual phase and withdrawal on smoking cessation outcome. 

Addictive Behaviors, 35, 549-552. 

22.	 McFall, M., Saxon, A. J., Malte, C. A., Chow, B., Bailey, S., Baker, D. G., 

Beckham, J. C., Boardman, K. D., Carmody, T. P., Joseph, A. M., Smith, M. W.,

Shih, M. C., Lu, Y., Holodniy, M., Lavori, P. W., & CSP 519 Study Team. (2010). 

Integrating tobacco cessation into mental health care for posttraumatic stress

disorder: A randomized controlled trial. Journal of the American Medical 

Association, 304(22), 2485-2493. doi: 10.1001/jama.2010.1769 

23.	 McFall, M., Saxon, A. J., Thompson, C. E., Yoshimoto, D., Malte, C., StraitsTröster, K., Kanter, E., Zhou, X. H., Dougherty, C. M., & Steele, B. (2005). 

Improving the rates of quitting smoking for veterans with posttraumatic stress 

disorder. The American Journal of Psychiatry, 162(7), 1311-1319. Retrieved from

http://ajp.psychiatryonLine.org/articLe.aspx?voLume=162&page=1311

24.	 Ischaki, E., & Gratziou, C. (2009). Smoking and depression: Is smoking 

cessation effective? Therapeutic Advances in Respiratory Disease, 3(1), 31-38. 

doi: 10.1177/1753465809102662 

25.	 Hall, S. M. (2007). Nicotine interventions with comorbid populations. American 

Journal of Preventive Medicine, 33(6 Suppl), S406-S413. doi: 10.1016/j. 

amepre.2007.09.004 
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26.	 Falk, D. E., Yi, H. Y., & Hiller-Sturmhöfel, S. (2006). An epidemiologic analysis

of co-occurring alcohol and tobacco use and disorders: Findings from the 

National Epidemiologic Survey on Alcohol and Related Conditions. Alcohol 

Research & Health, 29(3), 162-171. Retrieved from http://pubs.niaaa.nih.gov/

publications/arh293/162-171.htm

27.	 Hughes, J. R., & Callas, P. W. (2003). Past alcohol problems do not predict 

worse smoking cessation outcomes. Drug and Alcohol Dependence, 71(3), 

269-273. 

28.	 Prochaska, J. J., Delucchi, K., & Hall, S. M. (2004). A meta-analysis of smoking

cessation interventions with individuals in substance abuse treatment or 

recovery. Journal of Consulting and Clinical Psychology, 72(6), 1144-1156. doi: 

10.1037/0022-006X.72.6.1144 

29.	 Joseph, A. M., Willenbring, M. L., Nugent, S. M., & Nelson, D. B. (2004). 

A randomized trial of concurrent versus delayed smoking intervention for 

patients in alcohol dependence treatment. Journal of Studies on Alcohol and 

Drugs, 65(6), 681-691. 

30.	 Baca, T. C., & Yahne, C. E. (2009). Smoking cessation during substance abuse 

treatment: What you need to know. Journal of Substance Abuse Treatment, 

36(2), 205-219. doi: 10.1016/j.jsat.2008.06.003 

31.	 U.S. Department of Health and Human Services, Public Health Service, Office 

of the Surgeon General. (2010). How tobacco causes disease: The biology and 

behavioral basis for smoking-attributable disease: A report of the Surgeon 

General. Retrieved from http://www.surgeongeneral.gov/library/reports/

tobaccosmoke/index.html
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II. Smoking Cessation

Interventions 
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CHAPTER SUMMARY 

Effectiveness of smoking cessation interventions 

 Effective interventions can be brief (3-5 minutes) or intensive 

(lasting for >10 minutes) 

 Brief 3-minute interventions advising patients to quit can enhance 

abstinence rates 

 Even without a smoking cessation program, brief counseling
 

and medications provided as part of ongoing health care can
 

be effective
 

Starting a smoking cessation program for Veterans 

 Identify women's health care providers and key staff with an
 

interest in smoking cessation
 

 Start small and manageable by selecting brief interventions 

appropriate for the setting
 

 Build the program by incorporating more intensive interventions 

when appropriate 

 Monitor and track your patients’ progress 

 Order VA's quit strategies booklet specific to women, information at 

http://vaww.publichealth.va.gov/smoking/publications.asp#women 

(VA intranet) 

EFFECTIVENESS OF SMOKING CESSATION INTERVENTIONS 

Smoking cessation interventions can be extremely effective and providers 

who perform even brief interventions of advice to quit can significantly 

increase abstinence rates. Care providers should present a clear, concise, 

and consistent “quit” message to all their patients who smoke. It is important 

to remember that brief counseling and medications provided as part of an 

ongoing therapeutic relationship can be as or more effective than a referral to 

an outside clinic smoking cessation program or the prescribing of medication 

alone. 

Any type of provider can be effective at increasing quit rates. Strong evidence 

suggests that the more intense the cessation intervention, the greater the 

rate of abstinence. Intervention intensity can be increased by extending the 

length and number of individual treatment sessions.1 Cessation counseling 

lasting between 4 and 30 minutes can double a patient’s chance of abstinence 

15 
16 

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whereas counseling lasting more than 30 minutes can triple a patient’s chance 

of success.1 Conducting 2-3 counseling sessions increases abstinence rates by 

1.5 fold while conducting 4-8 sessions doubles the chance of success.1 

Self-help, proactive group counseling and telephone counseling have all 

been shown to significantly increase abstinence rates compared to stopping 

“cold turkey.”1 

STARTING A SMOKING CESSATION PROGRAM FOR 

FEMALE VETERANS 

Implementing a sustainable and effective smoking cessation program can feel 

daunting, but several key strategies can be helpful when implementing such a 

program in your clinic. 

As you start to build a program in your clinic, identify providers and staff 

who are interested in smoking cessation as these “local champions” can help 

build momentum for the program and get other providers involved. As more 

providers become interested, you can start to implement more intensive 

cessation interventions. Monitoring and tracking patients’ progress over time 

can provide helpful feedback to staff so they can see the impact of their work. 

Finally, each VA facility has a smoking cessation lead clinician who can be a 

valuable resource to your clinic. Please email publichealth@va.gov to obtain 

the name of this clinician at your VA facility. 

SMOKING CESSATION BEHAVIORAL INTERVENTIONS 

Described in this chapter are interventions you can use when talking with your 

patients about their interest in smoking cessation. These brief and intensive 

interventions have been used in health care settings and range from 3-10 minute 

conversations, to intensive counseling that can last an hour. Also addressed 

are challenges and opportunities for implementing these well-established 

interventions with your patients and making smoking cessation a routine part 

of the clinical care you provide. 

Brief Interventions (3-10 minutes) 

The most important factor in smoking cessation is engaging patients. Providing 

patients with information about the impact of smoking in the context of 

women's health, assessing their level of motivation to quit, and helping them 

move to the next step in cessation (i.e., provision of resources, referrals to 

smoking cessation programs) are critical components of brief interventions. 
17 

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Outlined below the five elements of a brief smoking cessation intervention. 

TABLE 1. THE 5 A’S OF BRIEF SMOKING CESSATION INTERVENTIONS1-3

ASK about tobacco use*

Ask patients about tobacco use at every clinic visit 

 If a patient has never used, you do not need to ask again 

 If a patient quit years ago, congratulate and check in periodically 

*Clinical reminders and performance measures within VHA can assist with 

this intervention 

ADVISE patient to quit 

Provide clear, strong, and personalized suggestions 

 Clear: I think it is important that you quit smoking. I can help. 

 Strong: Quitting smoking is one of the most important things you 

can do to protect your health. 

 Personalized: Associate smoking with something that is important 

to the patient, such as exposure of children/family to tobacco 

smoke, the expense of cigarettes, pulmonary and cardiovascular 

comorbidities, risk of COPD and lung cancer deaths, increased risk 

of osteoporosis, pregnancy complications, infertility, and impact of 

smoking on appearance and smell. 

•	 Children often pick up smoking from modeling their parents. 

•	 Do you realize that you can save more than $2,000 a year on 

cigarette expenses if you quit? What else might you be able 

to spend that money on? 

ASSESS readiness to quit 

Assess readiness to quit within 30 days 

 Are you willing to give quitting a try in the next 30 days? 

•	 If patient is ready, assist patient with the quit attempt, 

arrange follow-up 

•	 If not ready, consider using motivational interviewing to 

increase patient's readiness to quit 

(see Table 2. Enhancing Motivation to Quit Tobacco (p. 

20)). 
18 

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ASSIST patients with their quit attempt

Prepare patients for quitting using STAR 

 Set a quit date. Ideally, the target quit date should be within
 

four weeks. The quit date should be a date the patient feels
 

comfortable with and gives them enough time to prepare.
 

 Tell family, friends, and coworkers about quitting, and request 

understanding and support. 

 Anticipate challenges to the upcoming quit attempt, particularly 

during the critical first few weeks. These include addressing 

nicotine withdrawal symptoms. 

 Remove tobacco products from the environment. Before quitting, 

avoid smoking in places where a lot of time is spent (e.g., work, 

home, car). Make your home smoke free. 

Offer pharmacotherapy and discuss the role of medication in treatment 

Provide practical counseling (problem-solving/skills training) 

 Offer intensive treatment options (e.g., tobacco cessation classes, 

telephone clinic) within your VA facility. 

Provide a supportive clinical environment while encouraging the patient in 

her quit attempt 

Provide supplementary materials and other resources available through 

the VA and the community 

 VA smoking cessation quitline: 1-855-QUIT VET (1-855-784-8838). 

Counselors are available Monday-Friday 

 SmokefreeVET text program: text the word VET to 47848 or visit 

http://smokefree.gov/VET 

 Stay Quit Coach, a smartphone app to help Veterans quit smoking 

and stay quit 

 Visit www.publichealth.va.gov/smoking for an up-to-date list of all 

resources available through VA 

ARRANGE follow-up

Arrange follow-up contact by phone or in clinic (enroll in a VHA-based 

smoking cessation clinic, if the patient wishes) 

 Timing 
19 

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•	 First follow-up contact should be around the target quit date 

or within the first week 

•	 Second follow-up should be within the first month of the 

target quit date 

 Actions to take during follow-up 

•	 Assess medication use and any adverse reactions 

•	 Remind patient of reasons for quitting and other resources 

available to them (see www.publichealth.va.gov/smoking for a 

complete list of resources) 

•	 Congratulate patient on abstinence 

 Treat as a chronic disease by addressing at each clinic visit 

For providers with less time or comfort, the 5 A’s can be modified to AAR:

Ask Advise Refer, where the patient is referred to existing smoking

cessation services.

Intensive Intervention (>10 minutes)1 

The components of an intensive smoking cessation intervention consist of: 

 Determining whether smokers are willing to make a quit attempt
 

with intensive counseling
 

 Conducting patient assessments that may be helpful including 

lung function, stress level, and the Fagerström Test for 

Nicotine Dependence (See Table 3. Fagerström Test for
 

Nicotine Dependence on p. 26)
 

 When possible, conducting sessions longer than 10 minutes and 

including ≥ 4 sessions 

 Combining behavioral counseling and medication (essential to
 

successful smoking cessation treatment)
 

 Including problem solving/skills training and intra-treatment social 

support as part of the intervention 

For sample programs and examples of intensive smoking cessation counseling, 

please see Appendix A. 
20 

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IDENTIFYING REASONS TO QUIT 

It is important to help patients identify reasons for quitting. The following 

intervention, based on motivational interviewing, can help motivate patients 

to quit who are not quite ready and can also be used during a patient's quit 

attempt. 

TABLE 2. ENHANCING MOTIVATION TO QUIT TOBACCO (THE 5 R'S)3-6

RELEVANCE Explain why cessation is personally relevant

 Health concerns and patient’s disease status or risk 

 Family situation, such as quitting for children 

 Cost 

RISKS Ask patients to explain their perceived potential risks of smoking; 

discuss these risks with them (female smokers have a particularly high risk 

of developing COPD, women who smoke while using oral contraception 

have increased risks of myocardial ischemia and stroke, smoking

signifiantly interferes with fertility and the healthy growth of a fetus). 

Explain that: 

 20 minutes after quitting, heart rate and blood pressure drop 

 2 weeks to 3 months after quitting, circulation and lung function 

improve by 30% 

 1 year after quitting, risk of coronary heart disease (CHD) is
 

reduced by 50%
 

 5 years after quitting, stroke risk is similar to that of someone that 

never smoked 

REWARDS Ask patients to explain what they might gain from cessation.

The clinician should highlight the rewards that are most relevant to the

patient. 

 Food will taste better 

 Improved sense of smell 

 Saving money 

 Setting a good example for children 

 Performing better in physical activities 
21 

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 Improved appearance (reduce wrinkling, whiter teeth) 

 Decreased risk of osteoporosis, heart disease, lung disease, cancers 

ROADBLOCKS Ask patients to identify barriers to quitting and offer 

options to address those barriers (see Chapter 4. Special Topics 

for Female Veterans for more ideas on how to challenge barriers). 

Some common barriers include: 

 Withdrawal symptoms 

 Fear of failure 

 Weight gain 

 Lack of support 

 Depression 

 Enjoyment of tobacco 

 Being around other tobacco users 

 Stress 

REPETITION Discuss these issues with patients at each visit 
22 

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References: 

1.	 Fiore, M. C., Jaén, C. R., Baker, T. B., Bailey, W. C., Benowitz, N. L., 

Curry, S. J., Dorfman, S. F., Froelicher, E. S., Goldstein, M. G., Healton, C. G.,

Henderson, P. Nez, Heyman, R. B., Koh, H. K., Kottke, T. E., Lando, H. A., 

Mecklenburg, R. E., Mermelstein, R. J., Mullen, P. D., Orleans, C. Tracy, 

Robinson, L., Stitzer, M. L., Tommasello, A. C., Villejo, L., & Wewers, M. E. 

(2008, May). Treating tobacco use and dependence: 2008 update. Clinical 

practice guideline. Rockville, MD: U.S. Department of Health and Human 

Services, Public Health Service. Retrieved from http://www.healthquality.

va.gov/tuc/phs_2008_full.pdf

2.	 Schroeder, S. A. (2005). What to do with a patient who smokes. Journal

of the American Medication Association, 294(4), 482-487. doi: 10.1001/ 

jama.294.4.482 

3.	 Gordon, J. S., Andrews, J. A., Crews, K. M., Payne, T. J., & Severson, H. H. 

(2007). The 5A’s vs 3A’s plus proactive quitline referral in private practice 

dental offices: Preliminary results. Tobacco Control, 16(4), 285-288. Retrieved 

from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2598528/?tool=pubmed 

4.	 Miller, W. R. & Rollnick, S. P. (2002). Motivational Interviewing, Second 

Edition: Preparing People for Change. New York: The Guildford Press. 

5.	 Carpenter, M. J., Hughes, J. R., Solomon, L. J., & Callas, P. W. (2004). Both 

smoking reduction with nicotine replacement therapy and motivational advice

increase future cessation among smokers unmotivated to quit. Journal 

of Consulting and Clinical Psychology, 72(3), 371-381. doi: 10.1037/0022­

006X.72.3.371 

6. Rollnick, S. P., Mason, P., & Butler, C. (1999). Health behavior change: A guide 

for practioners. Edinburgh, England: Churchill Livingstone. 
23 

III. Real-time

Scripts for Brief

Smoking Cessation

Interventions
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CHAPTER SUMMARY 

Approaching your patients about smoking cessation 

 Smoking can be a chronic, relapsing condition 

 Consider tracking smoking as a vital sign 

 Administer the Fagerström Test for Nicotine Dependence 

Address patient concerns 

 Provide factual information to address each concern 

Sample scripts for brief interventions 

 Assess smoking status 

 Advise patients about quitting 

 Assess readiness to quit 

 Encourage confidence in quitting 

APPROACHING YOUR PATIENTS ABOUT SMOKING CESSATION 

Though women's health providers are in an excellent position to provide smoking 

cessation interventions with their patients who smoke, it can be difficult and 

sometimes uncomfortable to approach the topic. We recommend treating 

smoking as a vital sign so that a patient’s smoking status is readily apparent 

upon their entrance into the exam room. This is an easy way to encourage you 

and your patient to integrate conversations about cigarette smoking into your 

clinic visit. 

Smoking can be a chronic, relapsing condition that at times requires varying 

levels of intervention. We encourage you to go as far as you can with each 

patient at each visit as you help lay the groundwork for smoking cessation. In 

order to assess your patient’s level of nicotine dependence, we suggest using 

Table 3. Fagerström Test for Nicotine Dependence (p. 26). The level of your 

patient’s nicotine dependence has important indications for the regimen that 

should be suggested for treatment. 

25 
26 

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TABLE 3. FAGERSTRÖM TEST FOR NICOTINE DEPENDENCE1-2

1. How soon after you wake up do you smoke your first cigarette? 

Within 5 minutes (3 pts.); 6–30 minutes (2 pts.); 31–60 minutes (1 pt.); 

After 60 minutes (0 pts.) 

2. Do you find it difficult to refrain from smoking in the places where it 

is forbidden (e.g., church, library, cinema)? 

Yes (1 pt.); No (0 pts.) 

3. Which cigarette would you hate most to give up? 

The first one in the morning (1 pt.); Any other (0 pts.) 

4. How many cigarettes a day do you smoke? 

10 or less (0 pts.); 11–20 (1 pt.); 21–30 (2 pts.); 31 or more (3 pts.) 

5. Do you smoke more frequently during the first hours after waking 

than during the rest of the day? 

Yes (1 pt.); No (0 pts.) 

6. Do you smoke if you are so ill that you are in bed most of the day? 

Yes (1 pt.); No (0 pts.) 

NICOTINE DEPENDENCE SCORE (Points): 

(0-2 pts.) Very low dependence 

(3-4 pts.) Low dependence 

(5 pts.) Medium dependence

(6-7 pts.) High dependence
 

(8-10 pts.) Very high dependence
 

Note. Adapted with permission from “The Fagerström Test for Nicotine 

Dependence: a revision of the Fagerström Tolerance Questionnaire,” by T. F. 

Heatherton, L. T. Kozlowski, R. C. Frecker & K. O. Fagerström, 1991, British 

Journal of Addiction, 86(9), 1119-1127. Copyrighted. 

ADDRESSING PATIENT CONCERNS 

In the following tables, you will find helpful methods for discussing cigarettes 

and smoking cessation with your patients. For more detailed guidance on 

intensive interventions, please refer to Appendix A. 
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TABLE 4. SAMPLE RESPONSES TO PATIENTS’ CONCERNS ABOUT 

SMOKING CESSATION3-5

Patient Provider 

I don’t want counseling, I only 

want medication. 

 Counseling + medication 

works better than 

medication alone. 

 Counseling will provide 

you with practical skills to 

support the behavior changes 

necessary to quit. 

I want to try acupuncture, 

hypnosis, or laser therapy. 

 Reinforce evidence 

supporting the effectiveness 

of counseling + medication. 

 Suggest that the patient 

augment any substandard 

therapy with counseling 

+ medication. 

I am concerned that I will gain 

weight once I quit smoking. 

 Start to increase physical 

activity as soon as possible. 

 Consider taking a walk 

instead of a cigarette break. 

I don’t understand how nicotine 

replacement therapies (NRTs) 

could be harmless if nicotine is 

also one of the harmful drugs 

in cigarettes. 

 Medicinal nicotine by itself is 

relatively safe. 

 What is harmful in 

cigarettes are the 7,000 

other chemicals, including 

69 carcinogens. 

 Medicinal nicotine in 

dosages approved for 

NRT medications are 

proven to greatly reduce 

withdrawal symptoms during 

smoking cessation. 

My life is too stressful to 

quit smoking.

 Smoking is one way 

that many people deal

with stress. 

27 
pff g 

Patient Provider

 Counseling will help 

you develop new and 

healthier ways to cope with 

your stress. 

I have been smoking for 30 years 

and I have no health problems. 

Plus, my grandmother smoked all 

her life and she lived to be 100. 

 Some people who smoke 

do not develop health 

consequences, however 

about 50% of people 

who smoke will die 

from cigarette-related 

consequences. 

 The average smoker 

lives 10 years less than a 

non-smoker. 

SAMPLE SCRIPTS FOR BRIEF INTERVENTIONS 

TABLE 5. SAMPLE SCRIPTS FOR BRIEF INTERVENTIONS3-5

Approach your patients about smoking 

Assess smoking status 

 How many cigarettes do you smoke a day? 

 Do others in your household or work environment smoke? 

 Have you thought about quitting? 

Advise patient about quitting smoking 

Be clear 

 I think it is important that you quit smoking. I can help. 

Make strong statements 

 Quitting smoking is one of the most important things you can do for 

your health. 

 Smoking is much more likely to harm you than any of your other 

chronic diseases (examples can include diabetes). 

28 
29 

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Personalize your feedback 

 You can save more than $2,000 a year on cigarette expenses if 

you quit. 

 Your risk of lung disease, cardiovascular disease, and other 

problems are much higher. 

 You are at increased risk of developing lung cancer and other 

health problems when you smoke. 

 You can reduce the risk of infertility (or low birth weight) if you 

quit smoking. 

 You complain of shortness of breath; giving up cigarettes will 

improve your breathing and stamina. 

Assess patient’s readiness to quit 

 Are you willing to give quitting a try in the next 30 days? 

 Lets get specific, how much do you want to cut back by the next 

time I see you? 

Assess and build motivation 

 How confident do you feel (on a scale of 1-10) that you can do that? 

What would move that number further up the scale for you? 

 What would have to happen for it to become much more important 

for you to change? 

 I believe you can do this. It's a tough thing to give up. Let's think 

about what some of the main barriers are that might get in the way 

of you being able to do this. 

Support self-efficacy 

 So, getting support from your non-smoking friends was a helpful 

strategy last time you quit. 

 Would you like some resources about smoking cessation that you 

can read on your own time while you decide? 

 Can you think about another time that you dealt with a challenge 

that you were successful in coping with? What skills did you learn 

from that time that you could use to help you quit smoking? 

Encouraging confidence in quitting smoking 

 On a 10-point scale, how confident are you in your ability to stop 

smoking for good? 
30 

pff g 

 What would make you more confident in your ability to
	

stop smoking?
	

 What did you learn from your past quit attempts? 

 How might your past relapses be able to help you with this 

new attempt? 

 Is there anything you found helpful in previous attempts to 

stop smoking? 

Emphasize personal choice and responsibility 

 It is up to you to decide when you're ready and how to quit. I'm 

here to help whenever you're ready. 

 It sounds like you're not ready to think about quitting. It's one of 

the things we consider to be a vital sign so I'll be asking about it 

when you come in. Just let me know when you feel ready to make 

a change. 

 You're interested in quitting, that's an important step. Here's what 

we have available to help you (e.g., services, medications). What 

would you be interested in trying first? 

 If you would like, I can tell you some strategies that will help you 

address those concerns. 

Expressing empathy 

 Lots of people worry about how they'll be able to manage 

without cigarettes. 

 Sounds like you're not ready to quit today, I know this is a tough 

decision. I'm here to help you whenever you decide you're ready to 

quit or start to cut down. 
31 

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References: 

1.	 John, U., Meyer, C., Schumann, A., Hapke, U., Rumpf, H. J., Adam, C., 

Alte, D., & Lüdemann, J. (2004). A short form of the Fagerström Test for

Nicotine Dependence and the Heaviness of Smoking Index in two adult 

population samples. Addictive Behaviors, 29(6), 1207-1212. doi: 10.1016/j.

addbeh.2004.03.019 

2.	 Kozlowski, L. T., Porter, C. Q., Orleans, C. T., Pope, M. A., & Heatherton, T. 

(1994). Predicting smoking cessation with self-reported measures of nicotine

dependence: FTQ, FTND, and HIS. Drug and Alcohol Dependence 34(3), 

211-216. doi: 10.1016/0376-8716(94)90158-9 

3.	 Fiore, M. C., Jaén, C. R., Baker, T. B., Bailey, W. C., Benowitz, N. L., 

Curry, S. J., Dorfman, S. F., Froelicher, E. S., Goldstein, M. G., Healton, C. G.,

Henderson, P. Nez, Heyman, R. B., Koh, H. K., Kottke, T. E., Lando, H. A., 

Mecklenburg, R. E., Mermelstein, R. J., Mullen, P. D., Orleans, C. Tracy, 

Robinson, L., Stitzer, M. L., Tommasello, A. C., Villejo, L., & Wewers, M. E. 

(2008, May). Treating tobacco use and dependence: 2008 update. Clinical 

practice guideline. Rockville, MD: U.S. Department of Health and Human 

Services, Public Health Service. Retrieved from http://www.healthquality.

va.gov/tuc/phs_2008_full.pdf

4.	 Britt, E., Hudson, S. M., & Blampied, N. M. (2004). Motivational interviewing 

in health settings: A review. Patient Education and Counseling, 53(2), 147–155. 

doi: 10.1016/S0738-3991(03)00141-1 

5.	 Miller, W. R., & Rollnick, S. P. (2002). Motivational Interviewing: Second 

Edition: Preparing People for Change. New York: Guildford Publications. 
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33 

IV. Special Topics for

Female Veterans
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CHAPTER SUMMARY 

As discussed in the introduction, female Veterans may face additional 

challenges to quitting smoking than men due to physical and psychosocial 

factors. Thus, in addition to broad-based intervention techniques, it is 

recommended that any smoking cessation programs designed for women 

include topics tailored towards female-specific barriers to quitting such as: 

 Concerns regarding weight gain 

 Smoking cessation during pregnancy 

 Stress and mood management 

 Social support 

CONCERNS REGARDING WEIGHT GAIN 

Fears of weight gain have long been identified as an important factor in 

maintaining smoking behavior amongst women.1 In fact, the tobacco industry 

continues to advertise to women through depicting images of beauty and 

thinness with cigarette use.2 Thus, women in smoking cessation intervention 

groups may express that potential weight gain is a significant barrier to 

quitting, or may be at risk of relapse if weight gain should occur with early 

abstinence. To address this concern, the following intervention strategies are 

recommended: 

1.	 Provide psychoeducation regarding the average weight gain
 

following quitting. Results of a large epidemiological study found
 

that women on average gained only 8-9 pounds after adjusting
 

for possibly confounding factors, such as age, race, education,
 

alcohol use, and comorbid illnesses. Furthermore, less than 15% 

of those who quit smoking experienced major weight gain of more 

than 25 pounds.3

 Informing patients that weight gain is likely to 

be minimal, if present, and that the health benefits of quitting 

smoking far outweigh the risks of minor weight gain, may allay some

concern over weight gain. Smoking cessation significantly reduces 

cardiovascular disease events (e.g., stroke, myocardial infarction) 

and weight gain following smoking cessation does not change the 

cardiovascular benefits of quitting smoking.4 Weight gain for former 

smokers who had been quit for less than four years was less than 

10% and former smokers who had been quit for more than four years

had no significant change in weight compared to smokers.4

35 
36 

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2.	 Use motivational interviewing techniques to help the patient explore

the pros and cons of weight gain versus continued tobacco use on 

health and appearance. For example, you may reflect and validate a

patient’s concern about potential weight gain, and then discuss the 

discoloring and drying effects of smoking on skin, teeth, nails, and 

hair. Remember to provide advice in a nonjudgmental manner and 

use open-ended questions (e.g., What is your view regarding these 

various impacts of smoking?) to help generate a discussion with 

your patient. 

3.	 Cognitive behavioral therapy techniques may also be helpful in 

challenging and restructuring negative thoughts regarding weight 

gain. Help patients explore any cognitive distortions regarding 

weight gain (e.g., that their significant others may not find them 

attractive, that they’ll never be able to lose the weight) and help

them to arrive at more realistic and positive self-statements. 

4.	 Encourage patients to engage in healthful behaviors while quitting 

to avoid excessive weight gain. Studies have shown that engaging in 

a moderate exercise program helps significantly reduce the amount 

of weight gained following quitting to an average of 3-4 pounds.5 

Additionally, consistent exercise has been shown to help women 

manage smoking cravings, withdrawal effects, and mood symptoms 

following cessation.6 Exercise recommendations include moderate 

intensity aerobic exercise (60-80% of maximal heart rate) for 

50 minutes three times per week (Physical Activity Guidelines for 

Americans). Exercise suggestions include brisk walking, jogging, 

swimming, or dancing. 

5.	 In addition to exercise, you may present healthy food alternatives 

to help patients manage cravings, especially crunchy foods (e.g., 

apples, carrot sticks, air-popped popcorn), as they may also relieve

stress or frustration associated with nicotine withdrawal. Patients 

are also recommended to increase their water intake to create a 

sensation of fullness. Significant weight gain can be due to food 

tasting much better after quitting. 

6.	 Stress often contributes to weight gain during the quitting process.

Provide patients various stress management techniques, such 

as joining a social support network, exercise, meditation, and 

stress-balls. Patients may also be referred to therapy for stress 

management if more intensive intervention is needed. 
37 

 

ppf

7.	 Research has shown that offering a concurrent weight management 

program to overweight or obese patients looking to quit smoking 

improves smoking cessation participation and treatment outcome.7 

Thus, proactively informing patients of weight management 

resources within the VA, such as MOVE!®, may help patients 

overcome weight gain concerns as a primary barrier to quitting 

smoking. Look at the qualifications for MOVE!® and refer your 

patient if needed. 

SMOKING CESSATION DURING PREGNANCY 

Women who are pregnant or who are attempting to conceive may be especially 

motivated to quit smoking, given the known risk factors to both the mother 

and fetus/infant. Maternal smoking is associated with 5% of infant deaths, 

10% of preterm births, and 30% of small for gestational age (growth-restricted) 

infants.8 Recent reports cite that 11.4% of women continue to smoke through 

pregnancy, although this rate has dropped from 38% since 1990.9 

Smoking during pregnancy appears to be particularly prevalent among younger 

mothers, thus, smoking cessation intervention strategies are especially 

important for female Veterans under the age of 25. Additionally, lack of 

education regarding the benefits of smoking cessation even after conception 

may prevent women from trying to quit. 

TABLE 6. FACTS ABOUT THE RISKS OF SMOKING PRIOR TO 

CONCEPTION, DURING PREGNANCY, AND POSTPARTUM 

Risks to Mother	 Risks to Fetus/Infant

 Infertility/delayed 

conception

 Miscarriage (heavy 

smoking)
 

 Placental abruption 

 Preterm premature 

rupture of membranes	 

 Placenta previa 

 Reduced milk 

production during 

breastfeeding 

 Low birth weight/small for
	

gestational age
 

 Preterm birth
 

 Fetal death/stillbirth 

 Sudden infant death syndrome

(SIDS) and other causes of 

neonatal death 

(like respiratory illnesses) 

 Increased exposure to nicotine/ 

cotinine if human milk fed 

 Reduced sperm counts as adults 

 Smoking later in life 
38 

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Recommendations to help pregnant women and those hoping to conceive quit 

smoking include: 

1. Present a menu of options to help female Veterans describe their
 

smoking behavior
 

As smoking during pregnancy is highly stigmatized, women may 

be less forthcoming with their smoking behavior when asked 

directly. To make assessment somewhat easier, you may consider 

presenting pregnant patients with a menu of options to describe 

their smoking frequency, ranging from “No smoking prior to or after 

conception” to “Currently smoking at the same level as I was prior 

to conception.”10 

2.	 Educate female Veterans about how smoking harms mothers and
 

babies and how quitting can help
 

Provide education about the benefits of quitting prior to conception 

or as early in pregnancy as possible. Encourage patients to reduce 

smoking as they work toward quitting. The following are points you 

may wish to discuss with your patient: 

•	 Inform women who are hoping to get pregnant that smoking can 

affect the ability to get pregnant. Smoking delays conception 

by as much as two months and some studies suggest that women 

who smoke experience menopause earlier.11 Quitting smoking can 

reverse these negative effects on fertility.12 

•	 For women who are already pregnant, inform them about the 

effects of maternal smoking on a child’s health, growth, and 

development. Children born to mothers who smoke during 

pregnancy have higher risks for low birth weight, sudden infant 

death syndrome (SIDS), and behavioral and cognitive deficits.10 

Children exposed to smoke during pregnancy and in the home as 

infants and children are more likely to smoke themselves and to 

start at a younger age. 

•	 Inform women that quitting during any stage of pregnancy 

reduces the risks of complications for both her and her baby. 

Women who quit during the first trimester have the least 

smoking-related birth complications, but studies have shown that 

quitting smoking at the 30th week of pregnancy decreases the 

effects of smoking on infant birth weight compared to women 

who did not quit.13 

3. Support a non-smoking home—the smoking status of her partner and 

others living in the home matters 

Women living with a partner or other family members who smoke 
39 

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have a higher risk for continued smoking during pregnancy or relapse 

after delivery.13 Always ask your patient if her significant other 

or family members smoke in the home. Inform the patient that 

being around others who smoke increases temptation to smoke and 

that exposure to second hand smoke is a risk to her and her fetus/ 

infant. If the patient’s partner is open to treatment, offer smoking 

cessation services within the VA if spousal support is covered at 

your facility, or provide referrals to programs within the community. 

Continue to follow up with the patient and her partner regarding 

cessation plans throughout pregnancy and postpartum. Women who 

succeed in quitting during pregnancy have a high rate of relapse 

postpartum, especially if others in the home smoke. 

4.	 Offer weekly individual or group counseling sessions for smoking
	

cessation when possible
 

Due to the severe risks of smoking to pregnant women, more 

intensive interventions are highly recommended for this 

population.14-16 When possible, offer weekly individual or group 

counseling sessions that meet for 30 minutes or more using 

behavioral intervention strategies. 

5. Consider offering smoking cessation pharmacotherapy when
 

behavioral intervention alone is not enough
 

Nicotine replacement therapy, bupropion, and varenicline may be 

used during pregnancy/lactation but risk and benefit should be 

discussed with patients. During pregnancy, co-management of 

smoking cessation medications with the maternity care provider is 

recommended. See Chapter 5 subsections Pregnancy Considerations 

with Tobacco Cessation Medication and Lactation Considerations 

with Tobacco Cessation Medications. 

STRESS AND MOOD MANAGEMENT 

Quitting smoking is a stressful process that is both physically and mentally 

draining. Given the lowered rates of smoking cessation and increased rates 

of relapse among women, stress and other psychological symptoms may be an 

especially important factor to consider. Furthermore, women in the military 

have been shown to have higher rates of certain psychological conditions than 

civilian women or men in the military.17 Recommendations to assist women 

with comorbid stress or mood difficulties in quitting smoking include: 

1.	 It is important to be able to recognize observed or reported 

symptoms of common psychiatric conditions among female Veterans, 

namely PTSD and depression. 
40 

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2.	 If it is suspected that a patient suffers from emotional distress, 

you may consider performing a brief assessment of mood using 

standardized measures, such as the Patient Health Questionnaire 

(PHQ-9) or PTSD Check List (PCL), which evaluate depression 

and PTSD symptoms, respectively (measures may be requested 

from mental health providers). If the patient screens positive for 

comorbid psychiatric conditions and is not being seen by a mental 

health provider, you may refer her for additional mental health 

treatment, if she is amenable. An integrated care approach, which

would integrate smoking cessation treatment into PTSD care, would

assist with some of these issues. 

3.	 Help the patient understand the connection between her stress or 

mood symptoms and her smoking behavior by asking her to track her 

smoking frequency and notice associated emotions (e.g., does she 

smoke more when happy, frustrated, scared). By helping the patient 

recognize that smoking is often a learned behavior to cope with 

emotional distress, you can help her break those associations and 

engage in healthier coping skills. 

4.	 If the patient expresses frustration and guilt with relapse or 

difficulty in quitting, inform the patient that relapse and multiple 

quit attempts before successful cessation is common and expected. 

Also, you may inform her that increased quit attempts within the 

past year are associated with successful long-term maintenance. 

5.	 If there is a significant population of female Veterans with comorbid 

psychiatric conditions seeking a smoking cessation intervention, 

you may want to consider conducting a specialized smoking 

cessation group for these patients. Social support and peer-topeer understanding offered through the group, in addition to 

behavioral intervention strategies, may help bolster attendance and 

effectiveness of the therapy. 

6.	 A woman’s hormonal levels may potentially influence mood 

and stress levels, which, in turn, impact her ability to manage 

withdrawal symptoms. In fact, limited research has shown that 

quitting during the luteal (progesterone dominant) stage yields 

better smoking cessation outcomes than quitting during the 

follicular (estrogen dominant) phase. It is thought that estrogen 

mediates nicotine metabolism so in the follicular phase, female 

smokers may be more nicotine dependent.18 This phenomenon 

is likely the result of increased premenstrual symptoms, thereby 
41 

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magnifying craving and anger at a vulnerable time, leading to 

relapse.19 Thus, to increase chances at a successful quit attempt, 

you may recommend that premenopausal patients set their quit date 

about 2-3 weeks into their menstrual cycle (optional). Additionally, 

offer patients several additional coping skills to manage increased 

emotionality due to premenstrual symptoms, such as exercise, 

socialization, or meditation. 

7.	 If a patient expresses difficulty in the intervention due to an
	

inability to cope with other stressors or psychiatric issues, do
 

not hesitate to refer the patient for counseling or more intensive
 

psychiatric care in the appropriate specialty clinic.
 

8.	 Nicotine is a stimulant and does not relieve stress. At times smoking 

may worsen physical stress (i.e., increase blood pressure and heart 

rate) as there is the daily need of more nicotine when smoking. 

Suggest activities that can actually relieve stress (e.g., deep 

breathing, stretching, exercise, yoga). 

SOCIAL SUPPORT 

As previously noted, women have been shown to be more influenced by their 

social network when it comes to smoking initiation as well as cessation. Helping 

the patient obtain and maintain a supportive environment when attempting to 

quit may improve her chance of success. To encourage positive social support, 

the following strategies are recommended: 

1.	 Ask the patient to identify both helpful and discouraging comments 

and/or actions made by friends and family regarding her smoking 

behavior. Patients may have a variety of responses for what 

positive-versus-negative interactions entail when it comes to their 

smoking behavior, so it is important to have an understanding of 

their preferred social support style. 

2.	 Encourage the patient to choose several friends or family members 

who have been supportive in her cessation efforts to be contacts 

for when strong smoking urges arise. You may also encourage the 

patient to identify people for whom she would like to quit (e.g., 

her spouse, children). Suggest the patient carry these individuals’ 

contact information in her pack of cigarettes or wallet to remind her 

of her support network and her motivations to quit. 

3.	 Some patients may find quitlines, text messaging programs, tobacco 
42 

ppf

 

 

 

cessation groups, and online resources helpful in their quit attempt. 

These resources may be particularly useful for patients who have 

fewer supportive friends or family members. Provide patients 

with information about Quit VET, the VA quitline, 1-855-QUIT-VET 

(1-855-784-8838) and SmokefreeVET, a supportive text messaging 

service to help Veterans quit smoking. Patients can sign up to 

use SmokefreeVET by texting the word VET to 47848 or by visiting 

http://smokefree.gov/VET. Information about local tobacco 

cessation groups and online resources such as Smokefree Women 

may also be useful (http://women.smokefree.gov/). 

4.	 Teach the patient assertive communication skills to help her 

maintain her resolve to quit when faced with negative social 

interactions. Encourage the patient to be open and vocal about 

quitting and to tell her friends and family about her quit date. 

Also, encourage the patient to be forthcoming with her triggers to 

friends and family, and to request that others be mindful of these 

high-risk situations. It is also helpful to teach the patient to use “I” 

statements when making these requests. For example, have the 

patient practice saying, “I am trying to quit smoking, and I would 

really find it helpful if ________________________________________.” 

5.	 If the patient’s primary social network consists of smokers, help 

the patient brainstorm different activities she could engage in to 

avoid smoking with them. For example, the patient could read a 

magazine or a book, call friends, take a walk, or chew gum or candy 

in place of going on a “smoke break.” 
43 

ppf

References: 

1.	 World Health Organization (2001). Women and the tobacco epidemic:

Challenges for the 21st century. Retrieved from http://libdoc.who.int/

hq/2001/WHO_NMH_TFI_01.1.pdf

2.	 Lombardi, E. M., Prado, G. F., Santos, U. P., & Fernandes, F. L. (2011). 

Women and Smoking: Risks, impacts, and challenges. Jornal Brasileiro 

de Pneumologia, 37(1), 118-128. 

3.	 Williamson, D. F., Madans, J., Anda, R. F., Kleinman, J. C., Giovino, G. 

A., & Byers, T. (1991). Smoking cessation and severity of weight gain in 

a national cohort. New England Journal of Medicine, 324(11), 739-745. 

4.	 Clair, C., Rigotti, N. A., Porneala, B., Fox, C. S., D’Agostino, R. B., 

Pencina, M. J., & Meigs, J. B . (2013). Association of smoking cessation 

and weight change with cardiovascular disease among adults with and 

without diabetes. Journal of the American Medication Association, 

309(10), 1014-1021. 

5. Tell, K., Goodwin, A., Miesmaa, P., Dupuis, E. A., & Kinnunen, 

T. (2011). Smoking cessation program with exercise improves 

cardiovascular disease biomarkers in sedentary women. Journal of 

Women's Health. 20(7), 1051-1064. 

6.	 Williams, D. M., Dunsiger, S., Whiteley, J. A., Ussher, M. H., Ciccolo, J. 

T., & Jenings, E. (2011). Acute effects of moderate intensity aerobic 

exercise on affective withdrawal symptoms and cravings among 

women smokers. Addictive Behaviors, 36(8), 894-897. 

7.	 Love, S. J., Sheffer, C. E., Bursa, Z., Prewitt, T. E., Krukowski, R. 

A., & West, D. S. (2011). Offer of a weight management program 

to overweight and obese weight-concerned smokers improves 

tobacco dependence treatment outcomes. The American Journal of 

Addictions, 20(1), 1-8. 

8.	 Tong, V. T., Jones, J. R., Dietz, P. M., D’Angelo, D., Bombard, J., 

M., & Centers for Disease Control and Prevention. (2009). Trends 

in smoking before, during, and after pregnancy - Pregnancy Risk 

Assessment Monitoring System (PRAMS), United States, 31 sites, 2000­

2005. Morbidity and Mortality Weekly Report Surveillance Summaries, 

58(4), 1-29. 

9.	 Centers for Disease Control and Prevention. (2008). 

Smoking-attributable mortality, years of potential life lost, and 

productivity losses—United States, 2000–2004. Morbidity and Mortality 

Weekly Report, 57(45), 1226–1228. 

10.	 Murin, S., Rafii, R., & Bilello, K., (2011). Smoking and smoking 

cessation in pregnancy. Clinics in Chest Medicine, 32(1), 75-91. 

11.	 Zenzes, M. (2000). Smoking and reproduction: gene damage to human 

gametes and embryos. Human Reproduction Update, 6, 122-131. 

12.	 Augood C., Duckitt K., & Templeton A. A. (1998). Smoking and 

female infertility: a systematic review and meta-analysis. Human 

Reproduction 13(6), 1532-1539. 
44 

ppf

13.	 Bernstein, I. M., Mongeon, J. A., Badger, G. J., Solomon, L., Heil, S. 

H., & Higgins, S. T. (2005). Maternal smoking and its association with 

birth weight. Obstetrics & Gynecology, 106, 986–991. 

14.	 Penn, G., & Owen, L. (2002). Factors associated with continued 

smoking during pregnancy: Analysis of socio-demographic, pregnancy 

and smoking-related factors. Drug and Alcohol Review, 21(1), 17-25. 

15.	 Fiore, M. C., Bailey, W. C., Cohen, S. J., Dorfman, S. F., Goldstein, 

M. G., Gritz, E. R., Heyman, R. B., Jaén, C. R., Kottke, T. E., Lando, 

H. A., Mecklenburg, R. E., Mullen, P. D., Nett, L. N., Robinson, L., 

Stitzer, M. L., Tommasello, A. C., Villejo, L., & Wewers, M. E. (2000). 

Treating tobacco use and dependence. Clinical practice guideline. 

Rockville, MD: U.S. Department of Health and Human Services, Public 

Health Service. 

16.	 Fiore, M. (2008). United States: Tobacco use and dependence guideline 

panel. Treating tobacco use and dependence: 2008 update. Maryland: 

Department of Health and Human Services. 

17.	 Suffoletta-Maierle, A., Grubaugh, A. L., Magruder, K., Monnier, J., & 

Frueh, B. C. (2003). Trauma-related mental health needs and service 

utilization among female veterans. Journal of Psychiatric Practice, 

9(5), 367-375. 

18.	 Benowitz, N. L., Lessov-Schlaggar, C. N., Swan, G. E., & Jacob, P., 

3rd. (2006). Female sex and oral contraceptive use accelerate nicotine

metabolism. Clinical Pharmacology and Therapeutics, 79(5):480–488. 

19.	 Rahmanian, S. D., Diaz, P. T., & Wewers, M. E. (2011). Tobacco use 

and cessation among women: Research and treatment-related issues. 

Journal of Women’s Health, 20(3), 349-357. 
45 

V. Medications for

Smoking Cessation
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fg 

CHAPTER SUMMARY 

Nicotine pharmacology 

 Use of medications for smoking cessation result in better
 

abstinence rates and durability
 

 Medications for smoking cessation are most successful when 

combined with other interventions (e.g., counseling, monitoring 

and tracking) 

 Use Table 3. Fagerström Test for Nicotine Dependence (p. 26) to 

guide prescribing 

 The goal of titration is to eliminate the need for nicotine 

replacement therapy while maintaining smoking abstinence
 

 Nicotine pharmacology considers the dose response and manages 

withdrawal symptoms, which commonly include irritability, 

impatience, anxiety, difficulty concentrating, restlessness, hunger, 

depression, insomnia, and cravings 

 Selection of the smoking cessation medication should be based on 

the person’s level of addiction to nicotine, product preference, and 

concomitant medical conditions 

 Consider combination therapy in patients with high dependence, 

those who are heavier smokers, or those experiencing cravings or 

withdrawal symptoms while on the patch alone 

Nicotine replacement therapy (NRT) 

 Nicotine transdermal patch 

 Nicotine polacrilex gum 

 Nicotine polacrilex lozenge 

 Nicotine nasal spray*

 Nicotine oral vapor inhaler*

 Consider combination therapy of nicotine patch plus polacrilex gum 

or lozenge for maximum management of withdrawal symptoms 

Non-NRT agents 

 Buproprion 

 Varenicline (second-line agent within VA) 

*Not on VA national formulary 

47 
48 

fg 

NICOTINE PHARMACOLOGY 

First-line agents approved for smoking cessation consist of NRT including

the nicotine patch, gum, lozenge, inhaler and spray; and the non-NRT agent

bupropion. Within VA, varenicline is a second-line agent for smoking cessation.

Combination therapy using the nicotine patch plus either gum, lozenge, nasal

spray, inhaler, or NRT plus bupropion is also recommended as a first-line

treatment option. 

FIGURE 1. EFFICACY OF MEDICATIONS FOR SMOKING CESSATION6,9,12-13

Nicotine Withdrawal3 

Once absorbed, nicotine induces a variety of central nervous system, 

cardiovascular, and metabolic effects.1-3 Within seconds after taking a puff on 

a cigarette, nicotine reaches the brain and stimulates the release of various 

neuro-transmitters including dopamine, which induces nearly immediate 

feelings of pleasure and relieves nicotine-withdrawal symptoms. This rapid 

dose response reinforces the need to repeat the intake of nicotine, thereby 

perpetuating smoking behavior. 
49 

fg 

 

 

When nicotine is discontinued, individuals may develop withdrawal symptoms

such as irritability, impatience, anxiety, difficulty concentrating, restlessness,

hunger, depression, insomnia, and cravings. Most physical withdrawal symptoms

generally manifest within 24–48 hours after quitting and gradually dissipate

over 2-4 weeks; however, strong cravings for cigarettes can persist for months

or even years. 

NICOTINE REPLACEMENT THERAPY (NRT) 

The mechanism of action of these agents, which are ganglionic (nicotinic) 

cholinergic-receptor agonists, is to replace nicotine that would have been 

obtained from smoking.3 These agents improve quit rates by reducing the 

symptoms of nicotine withdrawal and because the onset of action with NRT is 

not as rapid as that of nicotine obtained through a cigarette, patients become 

less accustomed to the nearly immediate reinforcing effects of tobacco.4 

The goal is to use NRT to titrate off a patient’s nicotine addiction over a 

few months. All NRTs are contraindicated in patients with a hypersensitivity 

to nicotine or components and all agents have the potential for nicotine 

overdose. Table 7. Medications for Smoking Cessation Available Through the 

VA National Formulary (p. 58) summarizes the dosing regimens, advantages 

and disadvantages, common adverse effects, and contraindications for three 

forms of NRT, bupropion, and varenicline. 

Nicotine transdermal patch4-6

 Although the patch has the slowest onset of all the nicotine
 

preparations, it offers more consistent levels of nicotine over a
 

sustained period of time resulting in fewer blood level fluctuations.

Plasma nicotine concentrations rise slowly over 1-4 hours and peak 

within 3-12 hours. 

 Steady-state concentration is reached 2-3 days after placement 

of first patch; following removal of the transdermal patch, the 

apparent half-life averages 3-6 hours. Plasma nicotine levels are 

about 50% lower than those achieved with cigarette smoking but still

alleviate symptoms of withdrawal. 

 Can be applied anywhere on the upper body, including arms and
 

back, avoiding hairy areas; rotate the patch site each time a new
 

patch is applied.
 

 Available over the counter in the community without a prescription; 

advise patients not to combine products obtained in the community 

with products dispensed from VA without discussing with 

their providers. 
50 

fg 

 

 

Nicotine polacrilex gum6-9

 Resin complex of nicotine and polacrilin in a sugarfree chewing 

gum base. Gum has a distinct peppery taste and contains sodium 

carbonate/bicarbonate buffers to increase salivary pH thereby 

enhancing absorption of nicotine across the buccal mucosa. 

The amount of nicotine absorbed from each piece is variable 

(approximately 1.1 mg and 2.9 mg from the 2 mg and 4 mg 

formulations, respectively). 

 Nicotine plasma levels peak approximately 30 minutes after 

chewing a piece of gum and slowly decline over 2-3 hours. 

Provides plasma nicotine concentrations approximately 30-64% of 

pre-cessation levels. 

 Allows smokers to take an active coping response to nicotine
 

withdrawal symptoms.
 

 Associated with less weight gain compared to placebo
 

during treatment.
 

 Sticks to dentures, may dislodge fillings and inlays because of 

its density. 

 Patients should be advised not to eat or drink for 15 minutes 

before, during, or after using. Acidic beverages (e.g., coffee, juice) 

inhibit the absorption of nicotine and should be avoided within 

15-20 minutes of use. 

 Available OTC in the community; advise patients not to combine 

products obtained in the community with products dispensed from 

VA without discussing with their providers. 

Nicotine polacrilex lozenge4,6-9

 Resin complex of nicotine and polacrilin in a flavored lozenge 

intended to be sucked and moved from side to side in the mouth 

until fully dissolved. The lozenge contains sodium carbonate/ 

potassium bicarbonate buffers to increase salivary pH thereby 

enhancing absorption of nicotine across the buccal mucosa. 

 Nicotine plasma levels peak in approximately 30 minutes and slowly 

decline over 2-3 hours. Because the lozenge dissolves completely, it 

delivers about 25% more nicotine than does an equivalent dose of 

nicotine gum. 
51 

fg 

 Allows smokers to take an active coping response to nicotine
 

withdrawal symptoms.
 

 Potential to consume too quickly may cause symptoms of high
 

nicotine levels (e.g., nausea, gastrointestinal upset).
 

 Patients should be advised not to eat or drink for 15 minutes 

before, during, or after using. Acidic beverages (e.g., coffee, juice) 

inhibit the absorption of nicotine and should be avoided within 

15-20 minutes of use. 

 Available OTC in the community; advise patients not to combine 

products obtained in the community with products dispensed from 

VA without discussing with their providers. 

Nicotine nasal spray6-10 (not on VA national formulary) 

 Aqueous solution of nicotine available in a metered-spray pump for 

administration to nasal mucosa. Each actuation delivers a 50 mcL 

spray containing 0.5 mg of nicotine. 

 Peak concentrations occur more rapidly than with other NRT 

products; plasma levels peak within 5-15 minutes resembling the 

kinetics of nicotine seen with cigarette use; approximately 53% 

is absorbed. 

 Due to its faster onset, capacity for self-titration, and rapid 

fluctuations of nicotine levels, the nasal spray has the highest 

potential for developing dependence. 

 Local irritant adverse effects including nasal and throat irritation, 

runny nose, sneezing, watery eyes, and cough may occur. These 

effects frequently dissipate after the first week of use. 

 Not recommended for patients with known chronic nasal disorders 

or severe reactive airway disease. 

Nicotine oral inhaler6-9,11 (not on VA national formulary) 

 Consists of a plastic mouthpiece and cartridge that delivers nicotine 

as an inhaled vapor from a porous plug containing nicotine. When 

puffed, nicotine is vaporized and absorbed across the mucosa of the 

mouth and throat (not the lungs). 

 Each foil sealed cartridge contains 10 mg of nicotine and 1 mg of 

menthol. Plastic spikes on the mouthpiece pierce the foil allowing 

the release of 4 mg of nicotine vapor following intensive inhalation 

of which about 2 mg is absorbed. 
52 

fg 

 

 Peak plasma concentrations occur within 15-30 minutes and then
 

slowly decline.
 

 High residual level of nicotine in discarded cartridge can be
 

dangerous to children and pets.
 

 High incidence of mouth and throat irritation. 

 Use cautiously in patients with severe reactive airway disease. 

 Delivery of nicotine from the inhaler declines significantly at
	

temperatures below 40°F.
	

 Patients should be advised not to eat or drink for 15 minutes 

before, during, or after using. Acidic beverages (e.g., coffee, juice) 

inhibit the absorption of nicotine and should be avoided within 

15-20 minutes of use. 

Please note the nicotine oral inhaler is not the same as electronic cigarettes, 

which are not FDA approved for smoking cessation treatment. 

Combination Nicotine Replacement Therapy6,9,12-14 

Monotherapy NRT may be less effective in women smokers compared to men, so 

combination NRT should be considered for most women smokers. Combination 

NRT involves the use of a long-acting formulation (e.g., nicotine patch) along 

with a short-acting formulation (e.g., gum, lozenge, inhaler, or nasal spray). 

A nicotine patch provides a passive sustained form of nicotine delivery and is 

used to prevent the onset of severe withdrawal symptoms. 

Short-acting formulations provide an ad libitum delivery that has a faster onset 

and can be used to control the strong cravings or urges that occur during 

potential relapse situations (e.g., after meals, during times of stress, when 

around other smokers). 

Controlled trials suggest that the nicotine patch in combination with shortacting NRT formulations significantly increases quit rates relative to placebo 

and nicotine patch alone. Combination therapy with the patch and either 

gum or lozenge is superior to monotherapy with the patch in up to one year 

of follow up. Using a combination of patch plus long-term nicotine gum 

(>14 weeks) has been shown to more than triple the likelihood of long-term 

abstinence (OR = 3.6, 95% CI 2.5-5.2). Similarly, studies evaluating the nicotine 

patch in combination with the nicotine lozenge for 12 weeks have resulted in 

abstinence rates of up to 40% at six months. 
53 

fg 

 

 

 

Example Titration Schedule 

 Week 1: Nicotine 21 mg patches and 5 lozenges 

 Week 2: Nicotine 21 mg patches and 4 lozenges 

 Week 3: Nicotine 21 mg patches and 3 lozenges 

 Week 4: Nicotine 21 mg patches and 2 lozenges 

 Week 5: Nicotine 21 mg patches and 1 lozenge 

 Week 6: Nicotine 14 mg patches and 4 lozenges 

 Week 7: Nicotine 14 mg patches and 3 lozenges 

 And so forth... 

**Use behavioral strategies previously listed to assist with titration** 

NRT Safety6,9,15-17

Nicotine can increase one’s heart rate, blood pressure, and myocardial 

contractility, and also act as a coronary vasoconstrictor. In patients with 

stable coronary artery disease, NRT can be initiated at intermediate doses 

with careful monitoring. Large randomized trials have found no significant 

increase in the incidence of cardiovascular events or mortality among patients 

with cardiovascular disease receiving NRT when compared to placebo. A 

large observational study of more than 33,000 patients found that NRT use 

was not associated with an increased risk of myocardial infarction, stroke, 

or death. Serum concentrations of nicotine achieved with the recommended 

dosages of NRT are generally much lower than those attained with smoking 

and most experts agree that the risks associated with NRT use in patients with 

cardiovascular disease are minimal relative to the risks of continued smoking. 

Other conditions for which NRT should be used with caution include 

active temporomandibular joint (TMJ) disease (specifically, NRT gum), 

hyperthyroidism, peptic ulcer disease, and severe renal impairment. Although 

the FDA has developed a uniform warning for all NRTs because of the risks 

of nicotine in pregnancy, they believe that NRT is safer than smoking during 

pregnancy. 

The safety of NRT in the elderly has not been systematically evaluated. 

However, one small pharmacokinetic study concluded that though there were 

statistically significant differences, the disposition of nicotine does not seem 

to be changed to a clinically important extent in the elderly. 
54 

fg 

NRT Use6 

Treatment of nicotine dependence with NRT should adhere to the following 

principles: 

 Dose to effect: The initial dose should be sufficient to provide the 

patient with a nicotine dose similar to that seen prior to stopping 

cigarettes. Providers should always assess the patient’s nicotine 

dependence before prescribing cessation aids. 

(See Table 3. Fagerström Test for Nicotine Dependence on p. 26) 

 Treat withdrawal symptoms: The nicotine replacement dose should 

be sufficient to prevent or minimize craving for tobacco products. 

 Avoid adverse reactions: The nicotine replacement dose should 

be titrated so that signs and symptoms of overmedication (e.g.,
 

headache, nausea, palpitations) do not occur.
 

 Advise patient not to use cigarettes while using NRT: Encourage 

the patient to report to their provider if they have severe cravings, 

which may indicate reevaluation of dosage and type of NRT 

(consider use of combination NRT, such as the patch or gum). 

 Selection of the NRT should be based on the person’s level of 

addiction to tobacco, product preference, and concomitant medical 

conditions: Consider combination therapy in patients with high 

dependence or in those who are heavy smokers. 

BUPROPION6,18-21

Bupropion (Zyban®) is a weak dopamine-norepinephrine reuptake inhibitor

with some nicotine receptor blocking activity.18-19 The mechanism by which 

bupropion enables patients to abstain from smoking is unknown. However, it 

is presumed that bupropion acts by enhancing central nervous noradrenergic 

and dopaminergic release and antagonizes nicotinic acetylcholine receptor

function. The antismoking effect of bupropion does not seem to be related 

to the antidepressant effect, as bupropion is equally effective as a smoking 

cessation therapy in smokers with or without depression.20 There may not be 

gender differences with bupropion and it may be a good agent for female 

smokers.21 

 Steady-state levels of bupropion and metabolites are reached within 

5-8 days, respectively. It is best to start bupropion one week before 

one’s target quit date. 

 In patients with severe hepatic cirrhosis, extreme caution is advised 

since peak bupropion levels are substantially increased. For patients 
55 

fg 

 

with mild-to-moderate hepatic cirrhosis, a reduced frequency or 

dose should be considered. 

 Bupropion should be used with caution in patients with renal 

impairment and a reduced frequency of dosing should be 

considered. Patients should also be closely monitored for possible 

adverse effects that could indicate high drug or metabolite effects. 

 Bupropion has the potential to interact with other drugs that are 

metabolized by or which inhibit/induce the CYP2B6 isoenzyme. It 

can also interact with drugs metabolized by the CYP2D6 isoenzyme. 

 Although the recommended duration of treatment is 7-12 weeks,
 

bupropion is approved for use up to six months to prevent relapse
 

to smoking.22
 

 Bupropion may be associated with less weight gain. 

 Bupropion may be used in combination with NRT (e.g., nicotine
 

lozenge, nicotine gum and nicotine patch).6,23
 

Bupropion Safety25-27

Bupropion is associated with a dose-dependent risk of seizures; maximum 

bupropion SR dose for treating smoking is 300 mg/day. Although higher doses 

of bupropion SR have been used for treating depression, they have not been 

tested for smoking cessation. Also, there is no evidence that higher doses 

improve quit rates. 

Extreme caution is advised in patients with severe hepatic cirrhosis; all patients 

with hepatic impairment should be closely monitored for possible adverse 

effects. Caution is also advised in patients with a history of hypertension, 

myocardial infarction, or unstable heart disease due to risk of hypertension. 

Serious neuropsychiatric symptoms have been reported in patients taking 

bupropion for smoking cessation. These symptoms include, but are not limited 

to, depression, suicidal ideation, and suicide attempt. 

VARENICLINE27-29 

Varenicline tartrate (CHANTIX®/Champix®) is a partial agonist that binds

selectively to the α4β2 subunit of the nicotinic acetylcholine receptor thereby

reducing the symptoms of nicotine withdrawal during abstinence.27-28 Because

of the significantly higher affinity of varenicline for the α4β2 receptor subunit, it
56 

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blocks nicotine from binding to the receptor and attenuates the reinforcement 

and rewarding effects of nicotine (thus this is not used with NRT). 

 Peak concentrations occur within 3-4 hours after oral administration. 

Steady-state conditions are reached within four days. Varenicline 

is well absorbed and levels are unaffected by food or time-of-day 

dosing. However, recommend to patients that they take it after 

eating and drink eight ounces of water in order to minimize nausea. 

 Primarily eliminated via glomerular filtration with active tubular 

secretion. In subjects with decreased renal function, varenicline 

exposure increased from 1.5 to 2.7-fold compared with subjects 

with normal renal function. Varenicline is efficiently removed 

by hemodialysis. 

 Dosage adjustment is necessary for patients with estimated
 

creatinine clearance <30 ml/min.
 

 No clinically significant drug interactions. 

 For patients who have successfully stopped smoking at the end of 

12 weeks, an additional 12-week course of treatment (for a total 

of 24 weeks) may be beneficial in maintaining and increasing the 

likelihood of long-term abstinence and preventing relapse.30 

 To date, the safety and efficacy of varenicline in conjunction with 

NRT or bupropion for smoking cessation has not been studied 

extensively and is not recommended. 

Varenicline for Smoking Cessation in VA 

Within VA, varenicline is a second-line agent for smoking cessation and must be 

prescribed according to Pharmacy Benefit Management (PBM) criteria, which

can be found on the PBM website (https://vaww.cmopnational.va.gov/cmop/

PBM/Clinical%20Guidance/Criteria%20For%20Use/Varenicline%20Criteria%20

for%20Prescribing.doc).31 

Varenicline Safety26,32-34

Varenicline carries a boxed warning about the risk for serious neuropsychiatric 

symptoms, including changes in behavior, hostility, agitation, depressed mood, 

suicidal thoughts and behaviors, and attempted suicide. All patients should 

be monitored closely and advised to stop treatment if any of these symptoms 

appear. 
57 

fg 

Health care providers should perform a careful psychiatric history prior 

to prescribing the drug and avoid use in smokers with a history of suicidal 

ideation or a current unstable psychiatric condition. Consider a temporary or 

permanent dose reduction in patients who cannot tolerate the adverse effects 

of varenicline. 

Varenicline may be associated with a small, increased risk of certain

cardiovascular adverse events in patients who have cardiovascular disease.

Cardiovascular adverse events were infrequent overall, however, certain

cardiovascular adverse events were reported in more patients treated with

varenicline than patients treated with placebo. The FDA is continuing to

evaluate the cardiovascular safety of varenicline. 
fg 

TABLE 7. MEDICATIONS FOR SMOKING CESSATION AVAILABLE THROUGH THE VA NATIONAL FORMULARY

BUPROPION NICOTINE

TRANSDERMAL PATCH

NICOTINE POLACRILEX

GUM 

NICOTINE POLACRILEX

LOZENGE

VARENICLINE

Trade name anddose availability

Bupropion SR

(Zyban®/Wellbutrin®)

150mg tabletBupropion IR 75mg,100mg tablets 

Nicoderm®/Habitrol®7mg, 14mg, 21mg 

Nicorette® Gum

2mg, 4mg 

Commit® Lozenge

2mg, 4mg 

CHANTIX®

0.5mg, 1mg tablets

Pregnancycategory 

C D D D C

Recommended

regimen 

Bupropion SR

150mg daily for 3d,

then 150mg twice daily

(8 hrs apart)

Patients with cirrhosis

need adjusted dose:

150mg every other dayBupropion IR100mg daily for 3d, then100mg three times dailyPatients with cirrhosisneed adjusted dose:75mg daily

Smoking more than

10 cigarettes a day:21mg for 4-6wks,then 14mg for 2wks,then 7mg for 2wks

Smoking 10 or fewer

cigarettes a day: 14mg for 6-8wks,then 7mg for 2wks 

High dependence*:

4mg every 1-2 hrsfor 6wks, then every2-4hrs for 3wks, thenevery 4-8hrs for 3wks

Low dependence:

2mg every 1-2hrs for6wks, then every 2-4hrsfor 3wks, then every

4-8hrs for 3wksNo more than 24 piecesin 24hrs 

High dependence*:

4mg every 1-2hrs for6wks, then every 2-4hrsfor 3wks, then every4-8hrs for 3wks

Low dependence:

2mg every 1-2hrs for6wks, then every 2-4hrsfor 3wks, then every

4-8hrs for 3wksNo more than 20 piecesin 24hrs 

0.5mg daily for 1-3d,

then 0.5mg twicedaily on days 4-7, thenSTOP SMOKING onquit date, then 1mgtwice daily for total of12 weeks duration

CrCl<30ml/min:max dose

0.5mg twice dailyESRD or HD: 0.5mg daily

Start instructions 1-2 weeks before

quit day 

On quit day On quit day On quit day 1-2 weeks before

quit day 

58 
59 

fg 

BUPROPION NICOTINE

TRANSDERMAL PATCH

NICOTINE POLACRILEX

GUM 

NICOTINE POLACRILEX

LOZENGE 

VARENICLINE

Administration

comments

•Continue treatment

for 7-12 wks (if no

progress is made byweek 7, consider

discontinuing therapy)

•If insomnia, take

evening dose in

afternoon

•Dose tapering 

is not required 

upon discontinuation

•Alert patients

to potential for 

drug interactions

•Do not crush or

chew tablets 

•Can be used in

combination

with nicotine patch,

nicotine gum, or nicotine lozenge

•Usually worn for

16-24 hrs

•Apply from shoulders

to waist

•Rotate sites

•Takes 2-3 d for effect

after application of

fi rst patch

•Can be used in

combination with

nicotine gum or 

lozenge at usual

dose. Patch continued

for 8-10 weeks with

lozenge and 8-24

weeks with gum

•Can be used in

combination with

bupropion 

•Chew slowly (about 10

chews) until peppery

taste then “park” between cheek and

gums until taste

disappears. Repeatchew and park process

for 30 minutes on each

piece of gum

•Avoid acidic beverages

(citrus juice, soft

drinks, coffee) within15 minutes of use

•Avoid eating or 

drinking while using

the gum 

•Can be used in

combination with

nicotine patch or 

bupropion; most patients will require6-8 pieces of gum/day as needed whenused in combination.Gum can be continuedfor 26-52 weeks

when initiated as

combination therapy 

•Dissolve slowly

over 20-30 minutes 

shifting in the mouthoccasionally

•Do not chew or

swallow (increased riskof GI side effects)

•Avoid acidic beverages

(citrus juice, soft

drinks), within

15 minutes of use

•Avoid eating or 

drinking while using

the lozenge 

•Can be used in

combination withnicotine patch or 

bupropion; most 

patients will require

6-8 lozenges/day asneeded when used incombination. Lozengescan be continued for12 weeks durationwhen initiated ascombination therapy 

•Take after eating and

with 8 ounces of water

to minimize nausea

•Report depression,

suicidal ideation,

unusual behavior, orworsening psychiatric

illness

•An additional 12 wks

of treatment in

patients who have

successfully stopped

smoking may increase

the likelihood of

long-term abstinence 
fg 

BUPROPION NICOTINE

TRANSDERMAL PATCH 

NICOTINE POLACRILEX

GUM 

NICOTINE POLACRILEX

LOZENGE 

VARENICLINE 

Advantages (+)and disadvantages(-) 

(+) better adherence; ease of use; can becombined with NRT;consistent rate of exposure; helps with

withdrawal symptoms(-) many druginteractions; CNS

side effects; must be

adjusted for hepaticinsuffi ciency; increased

risk of seizures 

(+) best adherence;easy to use; consistent

rate of exposure; unobtrusive; can becombined as neededwith gum, lozenge,or bupropion for

better effi cacy(-) less effective forcravings; diffi cultto control titration;absorption increased atelevated temperatures 

(+) can titrate to adjustfor cravings or suddenurges; oral substitute for cigarettes; can becombined with nicotinepatch or bupropion forbetter effi cacy(-) diffi cult for thosewith poor dentitionor dentures; must use proper chewingtechnique; must abstain

from drinking andeating during gum use;swallowing the nicotinecauses GI side effects 

(+) ease of use;discreet; higherimmediate levels; cantitrate to adjust forcravings; reduces selfreported withdrawal symptoms; can becombined with nicotinepatch or bupropion forbetter effi cacy(-) must abstain fromdrinking/eating duringlozenge use 

(+) better adherence; ease of use; consistentrate of exposure; superior rate ofabstinence compared tobupropion and placebo(-) potential for serious neurologic andpsychiatric side effects(esp. in those withunderlying psychiatricdisease); dose adjustfor renal insuffi ciency(CrCl<30); highincidence of nausea 

Adverse effects •Agitation

•Anxiety•Dizziness•Headache•Insomnia•Constipation•Dry mouth•Nausea 

•Sleep disturbances•Local skin irritation•Bone pain•Headache•Nausea 

•Local mouth irritation•Jaw pain•Hiccups•Dyspepsia•Rhinitis•Nausea•Flatulence 

•Local mouth

irritation and tingling

•Heartburn, indigestion

(if chewed)

•Headache•Nausea, diarrhea•Flatulence 

•Dream disorders•Headache•Insomnia•Agitation•Depressed mood•Suicidal thoughts•Constipation•Flatulence 

60 
61 

fg 

BUPROPION NICOTINE

TRANSDERMAL PATCH

NICOTINE POLACRILEX

GUM 

NICOTINE POLACRILEX

LOZENGE 

VARENICLINE

Adverse effects(cont) 

•Hypersensitivity

reactions

•Seizures (risk 1:1000)

•Nausea and vomitingConsider dosereduction in patientswith nausea, insomnia,headache 

VA nationalformulary 

Open formulary, no

restrictions 

Open formulary, no

restrictions 

Open formulary, norestrictions 

Open formulary, norestrictions 

Yes, must meet criteriafor use.

Criteria available at

https://vaww.cmopnational.va.gov/cmop/PBM/Clinical%20Guidance/Criteria%20For%20Use/Varenicline%20Criteria%20for%20Prescribing.docAvailable to patientswithout active mentalhealth disorders whohave had >1 relapse onNRT or bupropion

Contraindications& relativecontraindications 

Contraindications:•History of seizures•Predisposition to

seizures (severe headtrauma, CNS tumor, 

Relative Contraindications:•Hypersensitivity•Pregnancy category D•Use within 14 days post MI, or serious or worsening angina

RelativeContraindications:

•Serious 

neuropsychiatricdisorders 
fg 

BUPROPION NICOTINE

TRANSDERMAL PATCH 

NICOTINE POLACRILEX

GUM 

NICOTINE POLACRILEX

LOZENGE 

VARENICLINE

Contraindications& relativecontraindications

(cont.) 

hepatic cirrhosis)

•Abrupt withdrawal

from heavy alcohol orsedative use 

•MAO inhibitor

within 14 d

•Bulimia, anorexia

nervosa

•Hypersensitivity•Pregnancy category C

•Patients should be encouraged to avoid smoking while on nicotine

replacement therapy. If the patient has a slip, encourage them to get back

on track and consider using combination therapy if on monotherapy. Ifpatient has a relapse, then suggest patient stop using NRT and restart oncethey are ready to try quitting again.

•TMJ syndrome (gum only) 

(including suicidal andhomicidal ideation)

•History of suicidal,

homicidal, orassaultive behavior inthe past 12 weeks

•Untreated or unstable

mental disorder

•Severe renal

impairment

•Pregnancy category C

Comments •Use with caution in

patients with liver,

kidney failure

•Avoid in patients on

MAO inhibitors

•Monitor for neuropsychiatric signs and

symptoms during use 

•May be used In

combination withnicotine gum/lozengeor bupropion forsignifi cantly better

abstinence ratesand durability

•Using the 21 mg patch

yields roughly 40-50%

the plasma nicotinelevels of smoking 1.5packs per day 

•May be used In

combination withnicotine patch or bupropion forsignifi cantly betterabstinence ratesand durability

•Using 2 mg dose

every 1-2 hours yieldsroughly 40% the

plasma nicotine levelsof smoking 1 pack

per day 

•May be used In

combination withnicotine patch or bupropion forsignifi cantly betterabstinence ratesand durability

•Delivers about 25%

more nicotine thandoes an equivalentdose of nicotine gum

•Should not be used as

fi rst-line therapy

•Ask about psychiatric

history priorto prescribing

•Monitor for signs

and symptoms ofpsychiatric illnessduring use

•Monitor serum

creatinine; if renalfunction decreasesdose reductions maybe necessary 

 High dependence = use of tobacco less than 30 minutes after awakening or greater than or equal to 20 cigarettes (one package) per day. * If these criteria do not

apply the patient is considered to have low dependence. 

62 
63 

fg 

 

 

Pregnancy Considerations with Tobacco Cessation Medications 

During pregnancy, co-management of smoking cessation medications with the 

maternity care provider is highly recommended. 

 NRT (Pregnancy Category D)6,9,17: May be considered during
 

pregnancy for women who are unable to quit smoking with
 

behavioral interventions alone. A 2012 review of published data
 

on pharmacological interventions for smoking cessation during
 

pregnancy found insufficient evidence to determine whether or not 

NRT is effective or safe when used to promote smoking cessation 

during pregnancy or to determine whether NRT has positive 

or negative effects on birth outcomes compared to smoking.35 

This review included six randomized controlled trials of 1,745 

pregnant smokers. 

 Nicotine has well documented adverse effects during pregnancy; 

however, compared with smoking, use of NRT is associated with 

lower maternal blood levels of nicotine. In addition, smoking results 

in fetal exposure to carbon monoxide and hundreds of harmful 

chemicals, some of which are carcinogens. The American College 

of Obstetrics and Gynecology states NRTs can be used during 

pregnancy under close supervision following a provider/patient 

discussion about relative risks and benefits.36 NRTs with intermittent 

dosing (e.g., gum, lozenge, nasal spray) generally achieve lower daily 

exposures to nicotine than 24-hour patches. 

Recommendation: Use NRT only if benefits outweigh risks. If 

patient can’t quit smoking with behavioral interventions, consider

NRT with approval from obstetrician. 

 Bupropion (Pregnancy Category C)6,18-19,37: A relatively weak

norepinephrine and dopamine reuptake inhibitor that is approved 

as an aid to smoking cessation and for the treatment of depression. 

A retrospective managed care database study assessed the risk for 

congenital malformations overall and cardiovascular malformations 

following exposure of 1,213 infants to bupropion during the first 

trimester compared to the risk of malformations following exposure 

of 5,792 other infants to other antidepressants during the first 

trimester or bupropion later in pregnancy. The study found no 

greater risk for congenital malformations overall or cardiovascular 

malformations following first trimester bupropion exposure. There 

are no studies of pregnancy outcomes with bupropion exposure 

among women using the medication as an aid for smoking cessation.
64 

fg 

 

However, slight increase in incidence of fetal malformations and 

skeletal variations were seen in rabbits so risk cannot be ruled out. 

Recommendation: Use bupropion only if benefits outweigh risks. If 

patient can’t quit smoking with behavioral interventions, consider 

bupropion in patients without contraindications with approval 

by obstetrician. It is highly recommended that if patient has 

underlying mood disorders that mental health provider should also 

be involved. 

 Varenicline (Pregnancy Category C)26,32-34: A nicotine receptor partial 

agonist that prevents nicotine from binding to its receptor. It is 

approved for use as an aid to smoking cessation. There are no 

studies on the use of varenicline during human pregnancy. Studies 

in two species of pregnant animals did not show any increased risk 

for birth defects or pregnancy loss, and effects on fetal weights 

did not occur until animal doses reached more than 23 times the 

maximum recommended human dose. 

Recommendation: Use varenicline only if benefits outweigh risks. If 

patient can’t quit smoking with behavioral interventions, consider 

varenicline in patients without contraindications, after failure of 

combination therapy and with approval by obstetrician. It is highly 

recommended that if patient has underlying mood disorders that 

mental health provider should also be involved. Mood assessments 

are required every 28 days for Veterans. 

Lactation Considerations with Tobacco Cessation Medications 

 NRT6,9,17,35,36: Nicotine can pass freely into breast milk and an infant 

has the ability to clear nicotine through first pass metabolism, albeit 

with unclear level of efficiency. Harmful effects to infants are 

unknown and benefits/risks should be assessed for each case. 

Recommendation: Can consider use of NRT only if benefits outweigh

risk (i.e., nursing mother can only quit with NRT). 

 Bupropion6,18-19,37: It is known that bupropion and metabolites are 

excreted in humans. Health effects are inconclusive. The current 

manufacturer recommendation is to discontinue the medication or 

discontinue nursing. 

Recommendation: Bupropion should not be used in conjunction 

with nursing. 
65 

fg 

 

 

 Varenicline26,32-34: It is not known if varenicline is excreted in humans. 

Health effects are inconclusive. However, it is excreted in animals. 

The current manufacturer recommendation is to discontinue the 

medication or discontinue nursing. 

Recommendation: Varenicline should not be used in conjunction 

with nursing. 

Tobacco Smoke and Interactions with Medications18,28,38

Smoking cessation medications (NRT, bupropion, and varenicline) are associated

with minimal drug interactions. However, there are some medications

that have possible interactions with tobacco smoke, specifically with the

polycyclic aromatic hydrocarbons (PAHs) in the smoke. PAHs are potent

hepatic cytochrome P-450 (CYP) 1A2 inducers (1A1 and 2E1 as well). Several

medications (e.g. theophylline, olanzapine, clozapine, benzodiazepines)

and caffeine are metabolized through CYP 1A2. When a patient smokes the

clearance of caffeine and medications are faster, resulting in less drug amount

and less pharmacologic effect in the body (which is why sometimes patient

may be on higher doses of medications). When a patient quits smoking, there is

potential for the drug level to be increased resulting in a higher pharmacological

effect. This may potentially lead to increase adverse drug events.

Recommendation for caffeine: Reduce caffeine intake by 50% as 

increased levels of caffeine upon quitting can lead to more withdrawal 

symptoms, not to mention that caffeine can be a trigger to smoke. 

Recommendation for medication management after quitting: Monitor 

symptoms closely and adjust at first signs of an adverse drug event. 

 Example: A 56 yo woman with history of tobacco use disorder, 

schizophrenia now tobacco free for 2 weeks doing very well and 

mood is also stable. She is noticing some slight tremors and is 

currently on olanzapine 20 mg every day. Given that tremors 

may be due to increased pharmacological effects of olanzapine, 

olanzapine dose was decreased to 15 mg every day. At next 

follow-up, tremors subsided and mood still stable. Patient was 

continued on 15 mg every day. 

 Another important interaction that is serious and a contraindication 

for women 35 and older is the interaction between tobacco 

smoke and hormonal contraceptives. The interaction between 

the two increases risk of cardiovascular events such as stroke and 

myocardial infarction. 
66 

fg 

Recommendation: Do not prescribe hormone replacement in a 

female smoker over the age of 35 (consider not prescribing for 

younger patients as well). 

***Consult your pharmacist about possible interactions*** 
67 

fg 

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16.	 Joseph, A. M., Norman, S. M., Ferry, L. H., Prochazka, A. V., Westman, E. C., 

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content/295/1/321.Long

20.	 Hurt, R. D., Sachs, D. P., Glover, E. D., Offord, K. P., Johnston, J. A., Dale, L. 

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NEJM199710233371703

21.	 Scharf, D., & Shiffman, S. (2004). Are there gender differences in smoking 

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31.	 U.S. Department of Veterans Affairs, VHA Pharmacy Benefits Management 

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71 

VI. Relapse Prevention

and Smoking Cessation

Maintenance
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pg 

CHAPTER SUMMARY 

 Smoking is a chronic, relapsing disorder 

 Multiple quit attempts and interventions may be necessary 

 Relapse is NOT uncommon 

 Continue to address smoking status at every visit and provide 

ongoing support 

 Offer re-treatment with medication and counseling 

 Provide patients with options for the management of
 

withdrawal symptoms
 

SMOKING: A CHRONIC, RELAPSING DISORDER 

Patients who have recently quit smoking are at very high risk for relapse. 

Relapse is more likely to occur early in the process of quitting, but it can 

also occur months or years later. While there have been numerous studies 

attempting to identify strategies or interventions that are effective to prevent 

relapse, these studies have failed to identify specific interventions that are 

effective.1 The most effective strategy to prevent relapse appears to be the 

provision of evidence-based smoking cessation treatment from the start, 

including a combination of smoking cessation medications and behavioral 

counseling, as described in previous chapters. 

For patients who have recently quit smoking, continue to provide support at 

each visit, especially if they express concerns about relapse. Patients should 

receive reinforcement for their decision to quit, be congratulated on their 

success at quitting, and be encouraged to remain abstinent. Ask open-ended 

questions about noticeable benefits they have experienced since quitting. 

It may be helpful to talk with patients about previous quit attempts and 

encourage them to plan for how they will cope with challenges to quitting. 

Encourage patients to identify their sources of support and if needed, refer

them to a counselor or smoking cessation program for additional support.

Additional support available from VA is summarized on the Tobacco &

Health webpage (www.publichealth.va.gov/smoking). Options include the VA

telephone quitline, which can be reached at 1-855-QUIT-VET (1-855-784-8838)

Monday through Friday, and the SmokefreeVET text support program (http://

smokefree.gov/VET). It may also be helpful to consider extending the use of

smoking cessation medications to help reduce withdrawal symptoms.1

73 
pg 

MANAGEMENT OF WITHDRAWAL SYMPTOMS 

For patients who relapse, encourage them to describe the challenges they 

encountered during their quit attempt and to recommit to another quit attempt. 

If needed, also consider referring them to a more intensive smoking cessation 

treatment program. If the previous quit attempt included medication, review 

whether the patient used it in an effective manner and determine whether 

the medication was helpful. Based on this assessment, re-treatment can be 

recommended with either the same medication or with combination NRT.2 

Those who relapse often report problems that have been worsened by smoking 

withdrawal. These may include depression, weight gain, or withdrawal 

symptoms. If a patient reports prolonged cravings or other withdrawal 

symptoms, consider using combination therapy or extending the use of a shortacting medication (such as the gum or lozenge) to be used on an as-needed 

basis when acute withdrawal symptoms and urges to use cigarettes occur.1 

Please refer to the table below for guidance on counseling patients about 

specific withdrawal symptoms commonly associated with quitting smoking. 

TABLE 8. SMOKING WITHDRAWAL SYMPTOMS* AND 

RECOMMENDATIONS 

Withdrawal

Symptoms

Recommendation
 

 Chest tightness

(tension
 

created by 

body’s need 

for nicotine) 

 Stomach pain 

 Constipation 

 Gas (decrease 

of intestinal 

movement) 

 Cough 

 Dry throat 

 Nasal drip 

(body getting 

rid of mucus)
 

 Practice relaxation techniques
 

 Use nicotine replacement therapies 

 Drink fluids 

 Eat fruits and vegetables 

 Drink fluids 

 Avoid stress 

74 
75 

pg 

Withdrawal

Symptoms


 Recommendation

 Cravings/urges 

(nicotine 

withdrawal/ 

habit) 

DEADS Strategy 

(Delay, Escape, Avoid, Distract, Substitute) 

Delay: The most important thing to remember is 

that an urge will go away if you just give it time. 

Waiting out an urge, especially if you begin to do 

something else, is easier than you may expect. 

Believe it or not, the urge will fade after 5-10 

minutes, even if you do not smoke. It also helps 

if you have a positive attitude about the urge 

disappearing. Think "this won't last, the urge will 

go away," or "I would like a cigarette, but I'm not 

going to have one, because I don't need one." 

Escape: Another technique for dealing with an 

urge is to remove yourself from the situation or 

event which led to the urge. If you're in a room 

where others are smoking, and an urge hits, get 

up and take a short walk. You can walk around 

the building, or outside, until you feel ready to 

re-enter the situation without smoking. 

Avoid: Avoiding situations where you’ll be 

tempted to smoke will be particularly important 

in the first days and weeks after you quit. For 

example, if you regularly go to places where 

there’s a lot of smoking, like coffee shops or 

clubs, it’s best to avoid them for a little while to 

allow you to get used to not smoking. 

Distract: Another way to control urges is to get 

busy, get back to what you were doing before 

the urge hit. Also, there may be other things 

you enjoy doing that are incompatible with 

smoking such as working in the yard, reading a 

magazine, walking, taking a shower, or working a 

crossword puzzle. 

Substitute: When you feel that you want a 

cigarette, substitute something else for a 

cigarette. We suggest sugarfree gum, especially 

if you are watching your weight. You could eat 
pg 

Withdrawal
 

Symptoms
 

Recommendation

 Cravings/urges 

(nicotine 

withdrawal/ 

habit) (cont.) 

a piece of fruit or drink a soft drink. You can 

also use something to chew on like a straw 

or a toothpick. The trick is to come up with 

something you like that can be easily substituted 

for a cigarette. 

 Depressed 

mood (normal

process for a 

short period) 

 Increase pleasurable activities

 Get support from family/friends

 Discuss with provider

 Difficulty 

concentrating 

(body needs 

time to adjust 

to not having 

constant 

nicotine 

stimulation) 

 Avoid stress 

 Plan workload accordingly 

 Dizziness 

(body is getting

extra oxygen) 

 Be cautious the first few days

 Fatigue 

(lack of 

stimulation

of nicotine)

 Take naps 

 Do not push yourself 

 NRTs may help 

 Hunger 

(cravings for 

cigarette can

be mistaken 

for hunger)
 

 Drink lots of water 

 Eat low-calorie snacks 

 Insomnia 

(nicotine 

affects
 

brain wave
 

function and 

sleep patterns)

 Limit caffeine (reduce by 50%) 

 Practice relaxation techniques 


 

76 
77 

pg 

Withdrawal

Symptoms 

Recommendation

 Irritability 

(body’s craving

for nicotine) 

 Exercise

 Practice relaxation techniques 

 Take a hot bath 

 Stress  Exercise 

 Practice relaxation techniques 

 Avoid known stressful situations 

 Plan workload accordingly 

*Most withdrawal symptoms go away after a few days to 1-2 months at the 

most. Cravings/urges are the only symptoms that can return even after one 

year of smoking cessation. 
78 

pg 

References 

1.	 Fiore, M. C., Jaén, C. R., Baker, T. B., Bailey, W. C., Benowitz, N. L., 

Curry, S. J., Dorfman, S. F., Froelicher, E. S., Goldstein, M. G., Healton, C. G.,

Henderson, P. Nez, Heyman, R. B., Koh, H. K., Kottke, T. E., Lando, H. A., 

Mecklenburg, R. E., Mermelstein, R. J., Mullen, P. D., Orleans, C. Tracy, 

Robinson, L., Stitzer, M. L., Tommasello, A. C., Villejo, L., & Wewers, M. E. 

(2008, May). Treating tobacco use and dependence: 2008 update. Clinical 

practice guideline. Rockville, MD: U.S. Department of Health and Human 

Services, Public Health Service. Retrieved from http://www.surgeongeneral.

gov/tobacco/treating_tobacco_use08.pdf

2.	 U.S. Department of Veterans Affairs, Office of Public Health and Environmental

Hazards. (2010, July). VHA tobacco use cessation treatment guidance part 2: 

Assisting with tobacco cessation — medication options. Retrieved from http:// 

www.publichealth.va.gov/docs/smoking/cessationguidelinepart2_508.pdf
79 

 

Appendices 

Appendix A. Sample Intensive 

Smoking Cessation 

Counseling Programs 

Appendix B. Web and Telephone 

Tobacco Cessation 

Resources 
80 

pp

 

 

 

Appendix A. Sample Intensive Smoking

Cessation Counseling Programs
 

SUMMARY 

Research suggests that intensive tobacco cessation programs can double 

a patient’s chance of quitting smoking.1 Programs that consistently identify 

smokers, raise awareness of the need to quit smoking, and encourage smoking 

cessation have been shown to increase abstinence. Such programs can be 

delivered by phone, face to face, or in groups and offered by all members of 

the healthcare team.1 

In VA, not all clinics can provide the recommended comprehensive programs 

as outlined in this handbook. In light of this reality, below are examples of 

different levels of intensive smoking cessation counseling programs considerate 

of staff and time constraints. For clinics that have minimal staff, conducting 

brief interventions (see Chapter 3) and referring patients to 1-855-QUIT-VET 

(1-855-784-8838) will assist your patients in their cessation efforts. 

The types of smoking cessation programs detailed in this section are: 

 One-on-one counseling 

 Group counseling 

 Telephone counseling 

Before initiating a program, please address the following items: 

£Identify existing smoking cessation programs 

£Identify the smoking cessation lead clinician 

(Email publichealth@va.gov to obtain the name of this clinician at your 

VA facility) and/or the health behavior coordinator at your facility 

£Identify the process at your facility to initiate a new program (i.e., this 

could include adding privileges to existing scopes of practice) 
81 

pp

£Determine time allocated for a smoking cessation program and level of 

intervention that will work best: 

•	 Brief 

 Less than three minutes 

 3-10 minutes 

•	 Intensive 

 10–30 minutes 

 More than 30 minutes 

£Determine the type of program (e.g., one-on-one counseling, group
 

counseling, telephone counseling) to offer taking into account what
 

is the best fit for your facility, the duration of follow-up allowed 

(should be at least six months), and who can provide medications 

(e.g., physicians, pharmacists, nurse practitioners) 

£Setting up the program (after facility approval process) 

•	 Meet with coding and billing to establish program 

•	 Ensure that the clinic is set up with a stop code “707” so 

patients will not be billed for smoking cessation counseling as 

federal policy prohibits charging co-payment to Veterans for 

outpatient smoking cessation counseling 

•	 Use appropriate diagnostic and clinic codes for smoking 

cessation counseling 

 Diagnostic Code: Tobacco Use Disorder (305.1) 

 Procedure Code (CPT): Will depend on the length 

of appointment and discipline (discuss with local DSS expert) 

£Develop clinic note templates (or adapt existing templates) specifically 

addressing smoking cessation so that the patient's progress and 

response to interventions is easily documented and tracked in the 

patient's medical chart 

Regardless of which type of intervention you choose, smoking cessation 

programs for female Veterans should have the following goals in common: 

 Educate providers about the risks of cigarette smoking for women 

 Adopt a standard of care that includes identifying and tracking
 

patients who smoke, and encouraging smoking cessation
 

among them
 
82 

pp

 Identify and denote in Vista/CPRS all patients who are current
 

cigarette smokers
 

 Offer every patient who is a current smoker: 

•	 Motivational interviewing (conducted by their primary 

care provider) 

•	 If available, enrollment in an intensive smoking cessation program 

at your facility 

•	 At the minimum, brief counseling and medication, and refer to 

1-855-QUIT-VET (1-855-784-8838) 

 Establish a bimonthly open house where patients who smoke
 

can learn more about evidence-based cessation techniques and
 

opportunities for cessation support through the clinic
 

EXAMPLES OF INTENSIVE SMOKING CESSATION COUSELING 

ONE-ON-ONE (INDIVIDUAL) COUNSELING 

Whether conducted in a 4-session or 8-session program, one-on-one counseling 

will require these common elements: 

 Designate time in your schedule each week for a certain number of 

appointment slots 

 Create a referral process to smoking cessation counseling program 

that is known to all providers 

 Create a program flier 

 Remind providers of the program 

 Be proactive 

 Schedule 15-30 minute counseling sessions with patients 

 Discuss number of sessions available (e.g., 4-6 sessions, as many
 

as needed)
 

 Discuss session spacing (e.g., biweekly, based on quit date) 

 Conduct outreach and follow up 

 Make sure patients know one-on-one counseling is available 
83 

pp

 If a patient is interested in counseling, make sure to follow up 

(e.g., offer to remind them with calls/letters about appointments) 

 Long-term follow up can increase success 

 Choose a protocol that you like that uses behavioral interventions
 

(see below for some examples)
 

Example of a 4-session one-on-one counseling intervention 

Ideally, meet with patient for 15-30 minutes at least four times in person or by 

telephone. 

Appointment 1: Prepare for the quit attempt 

Appointment 2: (should be on or before the quit date) 

•	 Review benefits of quitting 

•	 Review quit plan 

•	 Discuss concerns/fears (e.g., confidence and motivation, develop 

plan to address concern) 

•	 Discuss plan for handling urges 

•	 Introduce relaxation strategies such as diaphragmatic breathing 

Appointment 3: Maintenance (approximately one week after 

quit date) 

•	 Assess current cigarette use 

•	 Discuss maintenance strategies 

•	 Address stress management 

Appointment 4: Relapse prevention (approximately one month after 

quit date) 

•	 Assess current cigarette use 

•	 Discuss positive experiences associated with quitting smoking and 

successful methods used to quit 

•	 Assess and resolve problems encountered in quitting smoking 

and/or anticipated threats to abstinence 

•	 Discuss the difference between a slip and a relapse 

•	 Discuss strategies for managing and preventing relapse 

Note, this program is flexible and can be condensed or expanded depending 

on the patient’s needs. Sessions are best conducted in person, but telephone 

sessions can also be effective for Veterans who are not able to come in weekly. 
84 

pp

 

Example of an 8-session one-on-one counseling intervention 

This intervention uses a patient workbook based on McFall's model,2

 which is a 

one-on-one integrated smoking cessation program for patients with PTSD. The 

intervention as it appears here has been modified for female smokers. The 

patient workbook, My Smoking Cessation Workbook, consists of the following 

worksheets and sections: 

 STEP 1: Setting My Quit Date! 

 STEP 2: Identifying My Smoking Triggers and Beginning to Delink 

 STEP 3: Identifying My Reasons to Quit and My Support System 

 STEP 4: Talking to My Provider to Identify Smoking Cessation
 

Medications to Use with My Quit Plan
 

 STEP 5: Getting Ready to Quit 

 STEP 6: Developing Strategies and Skills for Quitting 

 STEP 7: Planning to Cope with Smoking Triggers 

 STEP 8: STOP SMOKING! 

 STEP 9: My Strategies to Use Immediately After Quitting 

 STEP 10: Identifying and Coping with Nicotine Withdrawal 

 STEP 11: Preventing a Smoking Relapse 

 STEP 12: Preventing Weight Gain After Quitting 

 STEP 13: Stress and Smoking 

 STEP 14: Developing an Exercise Program 

 STEP 15: Deep Breathing Exercises 
85 

 

 

 

pp

TABLE 9. EXAMPLE OF 8-SESSION INTERVENTION
	

Timeframe Activities MONTH 1 Week 1 

Baseline assessment of level of tobacco use: Review 

workbook, check on other substance use and/or cravings and 

psychosocial stressors or issues that might interfere with quit 

program. Schedule quit date, assign homework to identify 

smoking triggers and reasons for quitting, review smoking 

cessation medications available, and establish next session. 

Week 2 

Preparing to quit: Review workbook and discuss triggers 

and ways to mediate, check on other substance use/ 

cravings/stressors, assign homework on getting support and 

completing Getting Ready to Quit Worksheet and My Action 

Plan for Coping with Smoking Triggers Worksheet. Confirm 

quit date, order bupropion/varenicline if going to be used, 

and schedule next session. 

Week 3 

Strategies and skills for quitting: Review homework 

assignment, check on other substance use or cravings, 

assign homework on planning strategies to use after quitting 

and coping with nicotine withdrawal, confirm quit date, 

encourage abstinence, order NRT medications and provide 

instructions for use, and schedule next session. 

Week 4 

Planning ahead: This session should be conducted shortly 

after quit date and should focus on preventing smoking 

relapse, support for continued abstinence, and correct use of 

medications. Encourage continued abstinence and schedule 

next session. 

Week 5 

Preventing smoking relapse: Discuss cessation program and 

check for cravings and/or relapse and discuss interventions if 

present. Support continued abstinence and assign homework 

on weight control following smoking cessation. Schedule 

next session. 

MONTH 2 

Weight control after smoking cessation: Review homework 

assignment and encourage Veteran to adopt healthier eating 

habits that will assist in smoking cessation and weight 

control. Assign homework on benefits of physical exercise 

in a cessation program. Support continued abstinence and 

schedule next session. 
pp

Timeframe	 Activities MONTH 3

Physical exercise: Review homework and discuss how 

exercise can help the Veteran remain smoke free. Encourage 

establishment of an exercise regimen. Check on cravings/ 

relapse and support continued abstinence. Schedule final 

visit. 

MONTH 4

Feedback and graduation: Review homework and encourage 

Veteran to continue making healthier lifestyle choices to 

support their new smoke-free status. Support continued 

abstinence and provide graduation certificate. 

Note. Adapted with permission from Tobacco use cessation: A brief primary 

care intervention (A training manual for integrated primary care behavioral 

health providers and other tobacco cessation providers), 2010, VA Center for 

Integrated Healthcare. 

This program is flexible and can be condensed or expanded depending on an 

individual Veteran's needs. These sessions are best conducted in person, but 

telephone sessions can also be effective for Veterans who are not able to come 

in weekly. Topics for each session are general guidelines and follow the patient 

workbook, but can be condensed into fewer sessions. 

GROUP COUNSELING 

Smoking cessation quit groups are generally one hour and can be conducted 

by any healthcare provider including physicians, pharmacists, social workers, 

psychologists, psychology interns, or nurses. It is important that the groups be 

advertised and held in or near the clinic where women Veterans receive their 

primary care. 

Drop-in Support Groups 

 Schedule a weekly, 1-hour block of time 

•	 Just before a women's clinic time is often most convenient 

for patients 

 Recruit 

•	 Post fliers in clinic and have providers distribute to patients 

•	 Make sure your patients are aware that there is a drop-in group 

and provide reminder calls/letters if the patient requests 

86 
87 

pp

 Offer an open structure 

•	 Patients do not need to make an appointment to attend a 

drop-in group 

•	 Patients attending the group can be in any stage of quitting, 

including preparing to quit 

•	 At the group, check in with each participant about their smoking, 

barriers to cessation, challenges, and lessons learned 

•	 Prepare a group topic that can be tied into what patients are 

interested in discussing that day 

•	 Maintain an open stance by letting participants' stated needs and 

discussion topics drive the focus of each group session 

On-going Structured Group Therapy 

 Schedule a weekly, 1-hour block of time 

 Recruit 

•	 Post fliers in clinic and have providers distribute to patients 

•	 Make sure your patients are aware that there is an on-going group 

and provide reminder calls/letters if the patient requests 

 Choose a program that will fit your schedule (e.g., weekly sessions, 

biweekly) 

 Cycle through crucial group topics every 6-8 weeks (other topics can 

be added): 

•	 Psycho education about nicotine dependence 

•	 Health consequences of smoking and benefits of quitting 

•	 Motivation to quit/setting a quit date 

•	 Managing withdrawal symptoms and concerns about weight gain 

•	 Mood and stress management 

•	 Coping with urges to smoke 

 Address social support 

•	 Relapse prevention 
88 

pp

TELEPHONE COUNSELING 

Personalized telephone counseling initiated by your clinic or facility can 

be conducted by physicians, pharmacists, social workers, psychologists, 

psychology interns, or nurses. 

A toolkit for a telephone counseling clinic based on a pharmacist provider

is available; however, it can be modified as needed for other providers.

Visit http://vaww.publichealth.va.gov/smoking/clinical.asp for the Pharmacy

Managed Telephone Tobacco Cessation Clinic (PMTTCC) toolkit. 

All telephone counseling programs should include the following components: 

 Schedule your telephone clinic for a block of time each week 

 Create a referral process to telephone counseling that is known to 

all providers 

•	 Create a program flier 

•	 Remind providers the program is available 

•	 Encourage active and ongoing recruitment 

 Describe to patients the purpose, nature, and structure of
 

telephone counseling
 

•	 Include specific smoking cessation strategies from the Clinical 

Practice Guidelines and this handbook 

 Conduct a program assessment, outreach, and follow up 
89 

pp

 

 

 

 

References 

1.	 Fiore, M. C., Jaén, C. R., Baker, T. B., Bailey, W. C., Benowitz, N. L., 

Curry, S. J., Dorfman, S. F., Froelicher, E. S., Goldstein, M. G., Healton, C. G., 

Henderson, P. Nez, Heyman, R. B., Koh, H. K., Kottke, T. E., Lando, H. A., 

Mecklenburg, R. E., Mermelstein, R. J., Mullen, P. D., Orleans, C. Tracy, 

Robinson, L., Stitzer, M. L., Tommasello, A. C., Villejo, L., & Wewers, M. E. 

(2008, May). Treating tobacco use and dependence: 2008 update. Clinical 

practice guideline. Rockville, MD: U.S. Department of Health and Human 

Services, Public Health Service. Retrieved from http://www.healthquality. 

va.gov/tuc/phs_2008_full.pdf 

2.	 McFall, M., Saxon, A. J., Thompson, C. E., Yoshimoto, D., Malte, C.,
	

Straits-Troster, K., Kanter, E., Zhou, X. H., Dougherty, C. M., & Steele, B.
	

(2005). Improving the rates of quitting smoking for veterans with 

posttraumatic stress disorder. The American Journal of Psychiatry, 

162(7), 1311-1319. Retrieved from http://ajp.psychiatryonline.org/article. 

aspx?volume=162&page=1311 
90 

pp

Appendix B. Web and Telephone Tobacco

Cessation Resources
 

VA INTRANET RESOURCES 

Provide your women Veterans with resources to stop smoking such as the I 

QUIT: Strategies to Help Women Quit Smoking booklet and pocket guide. You 

can also order posters for display in your facility about the health effects of 

secondhand smoke. Print publications and ordering information can be found 

at: http://vaww.publichealth.va.gov/smoking/publications.asp 

WEB AND TELEPHONE RESOURCES 

 VHA Tobacco and Health
 

www.publichealth.va.gov/smoking
 

 Quit VET, Veterans Smoking Quitline.
 

1-855-QUIT-VET (1-855-784-8838)
 

Monday-Friday 

Counseling is availabe in English and Spanish 

 SmokefreeVET Text Message Program
 

Text the word VET to 47848
 

www.smokefree.gov/VET 

SmokefreeVET en Español 

Envie la palabra VETesp al 47848 

www.smokefree.gov/VETespanol 

 Stay Quit Coach smartphone app
 

www.ptsd.va.gov/public/materials/apps/index.asp
 

 Women.smokefree.gov
 

www.women.smokefree.gov
 

 Womenshealth.gov
 

www.womenshealth.gov/smoking-how-to-quit
 

 Pregnancy and smoking 

www.cdc.gov/Features/PregnantDontSmoke/ 

www.cdc.gov/reproductivehealth/TobaccoUsePregnancy 

betobaccofree.hhs.gov/health-effects/pregnancy/index.html 

women.smokefree.gov/pregnancy-motherhood.aspx 
91 

pp

 SmokefreeMOM Text Message Program
	

Text the word MOM to 222888
	

http://women.smokefree.gov/smokefreemom.aspx 

 My HealtheVet
 

www.myhealth.va.gov
 

 Spit Tobacco Resources 

• Spit Tobacco: A Guide to Quitting 

www.nidcr.nih.gov/OralHealth/Topics/SmokelessTobacco/ 

SmokelessTobaccoAGuideforQuitting.htm 

• U.S. Food and Drug Administration 

www.fda.gov/TobaccoProducts/ucm173429.htm 

 Centers for Disease Control and Prevention
 

www.cdc.gov/tobacco and
 

www.cdc.gov/tobacco/data_statistics/sgr/2010/consumer_booklet 

 U.S. Department of Health and Human Services

 http://www.ahrq.gov/professionals/clinicians-providers/guideline-

 recommendations/tobacco/clinicians/tearsheets/helpsmokers.html

 Office of the Surgeon General 

www.surgeongeneral.gov/tobacco 

 Healthfinder Tobacco Resources Page
	

www.healthfinder.gov/scripts/SearchContext.asp?topic=860
	

WEB RESOURCES AND ONLINE TRAININGS FOR HEALTH 

CARE PROVIDERS 

 VHA Smoking and Tobacco Use Cessation intranet
 

http://vaww.publichealth.va.gov/smoking
 

 VHA Model of Pharmacy Managed Telephone Tobacco Cessation 

Clinic (PMTTCC) 

vaww.publichealth.va.gov/PUBLICHEALTH/docs/smoking/pmttctoolkit.pdf

 National Institutes of Health — National Institute of Drug Abuse — 

Smoking Cessation 

http://health.nih.gov/topic/SmokingCessation 

 Health Resources and Services Administration
 

www.hrsa.gov/stopsmoking
 
92 

pp

 Centers for Disease Control and Prevention — Smoking and 

Tobacco Use 

www.cdc.gov/tobacco 

 American Lung Association 

www.lung.org 

 American Cancer Society 

www.cancer.org 

 American Heart Association 

www.heart.org 

 Surgeon General’s Report 

How Tobacco Causes Disease: The Biological and Behavioral Basis for 

Smoking-Attributable Disease (2010) 

http://www.ncbi.nlm.nih.gov/books/NBK53017/

 U.S. Department of Health and Human Services, Public 

Health Service 

Treating Tobacco Use and Dependence: 2008 Update (Clinical 

Practice Guideline) 

http://www.ahrq.gov/professionals/clinicians-providers/

 guidelines-recommendations/tobacco/index.html
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Women & Smoking Cessation Handboo

A Resource for Providers 

June 2014 

IB 10 628; P96663