Primary Care &

Tobacco

Cessation

Handbook

A Resource

for Providers
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Primary Care &

Tobacco

Cessation

Handbook

A Resource

for Providers
Acknowledgements
 

The provider manual Primary Care & Tobacco Cessation and the 

accompanying My Tobacco Cessation Workbook were developed by 

Julianne Himstreet, Pharm.D., BCPS. The author’s primary goal was to 

develop materials promoting tobacco cessation interventions, based on 

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

for use by primary care providers treating patients who use tobacco.

With permission from the HIV and Smoking Cessation (HASC) Working Group, 

several materials used in the Primary Care & Tobacco Cessation provider 

manual were modified from HIV Provider Smoking Cessation Handbook. 

The U.S. Public Health Service Clinical Practice Guideline (Fiore, 2000) 

and the treatment model described by Richard Brown (2003) provided the 

foundation for their work and therefore indirectly ours as well.1

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

in Clinical Public Health, Office of Public Health, for supporting this 

project and Leah Stockett for editing the manual and the workbook. In 

addition, much appreciation needs to be given to Dana Christofferson, Kim 

Hamlett-Berry, Pam Belperio, and Tim Chen for their editing and content 

contributions.

1 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.

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.
i

Table of Contents

I. Tobacco Use in VA’s Population ................................1

Scope Of The Problem ...................................... 4

Benefits Of Tobacco Cessation ............................. 5

The Role Of The Primary Care Provider .................. 6

Challenges To Tobacco Cessation In VA Primary

Care Patients ................................................. 6

II. Tobacco Cessation Interventions ............................ 13

Effectiveness Of Tobacco Cessation Interventions ..... 15

Establishing A Tobacco Cessation Program

For Veterans In Primary Care Clinics .................... 16

Tobacco Cessation Behavioral Interventions ............ 16

Identifying Reasons To Quit ............................... 19

III. Real‐time Scripts for Brief Tobacco

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

Approaching Patients About Tobacco Cessation ........ 25

Addressing Patient Concerns And Sample Scripts ...... 27

IV. Medications for Tobacco Cessation ........................ 33

Nicotine Pharmacology .................................... 35

Nicotine Replacement Therapy (NRT) ................... 37

Bupropion (Zyban®, Wellbutrin®) ......................... 42

Varenicline (Chantix®) ...................................... 45

V. Relapse Prevention and Tobacco

Cessation Maintenance ....................................... 57

Tobacco Use: A Chronic, Relapsing Disorder ............ 59

Management Of Withdrawal Symptoms .................. 60

VI. Establishing A Tobacco Cessation Program In Primary

Care Clinics ................................................... 65

Group Counseling Program ................................ 67
ii

Appendices ........................................................ 99

Appendix A. Evaluating Tobacco

 Cessation Programs ........................100

Appendix B. Tobacco Cessation Resources .............102
iii

Tables and Charts

Table 1. The 5 A’s of Tobacco Cessation Interventions ...... 17

Table 2. Enhancing Motivation to Quit Tobacco,

the 5 R's ................................................. 19

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

Table 4. Sample Responses to Patients’ Concerns

About Tobacco Cessation ............................. 27

Table 5. Sample Scripts for Brief Tobacco Cessation

Conversations Between Patients

and Providers ........................................... 29

Figure 1. Efficacy of Medications for

Smoking Cessation .................................... 36

Table 6. Medications for Tobacco Cessation Available

Through the VA National Formulary ................. 47

Table 7. Tobacco Withdrawal Symptoms

and Recommendations ................................ 60
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1

I. Tobacco Use in 

VA’s Population
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3

I. Tobacco Use in VA’s Population

CHAPTER SUMMARY

Scope of the problem

 In 2011, approximately 19% percent of the adult population in the

United States smoked

 Smoking accounts for more than 443,000 deaths each year in the

United States1

 Smoking is a known cause of multiple cancers, heart disease, 

stroke, complications of pregnancy, chronic obstructive pulmonary

disease (COPD), and many other diseases2,3

 Smoking prevalence in the Veteran population has been reported to

be similar to the general U.S. population with approximately 20% of

Veterans reporting smoking in 2010

 In 2008, rates of smoking among Veterans of the Iraq and 

Afghanistan wars were approximately 33%, with rates of smokeless

tobacco use at 14%5

 Tobacco dependence is a chronic disorder that often requires

repeated interventions and multiple quit attempts

Benefits of smoking cessation in primary care patients

 Smoking cessation can reduce and prevent many smoking-related

health problems

 Smoking is the most clinically important modifiable cardiovascular

risk factor for all patients

 The improvements after quitting tobacco are noticeable within the

first few days after stopping

 Every attempt to quit improves the probability of eventual success6

VA's primary care provider’s role

 Address tobacco use at every visit. Effectiveness starts with the

clinical routine of:

• Asking every patient about tobacco use

• Advising patients to quit at every visit

• Assessing all patients’ readiness to quit at every visit

• Assisting all patients willing to make a quit attempt with

counseling and cessation medications

• Arranging for follow up for patients making a quit attempt
4

I. Tobacco Use in VA’s Population

CHAPTER SUMMARY

 Approach tobacco use as a chronic illness, which includes 

monitoring repeated quit attempts and relapses

 Counsel and prescribe medications to assist with cessation

 Help patients access comprehensive care to address co-morbidities

affecting their ability to quit

 Utilize an integrated model of care and provide a consistent 

message about the importance of quitting tobacco use

 Use a team approach as it results in greater efficacy in long-term

follow up and prescribing tobacco cessation medications

Challenges to tobacco cessation in VA primary care

 Higher rates of tobacco use in many Veteran groups including 

Veterans of Iraq and Afghanistan wars, mental health patients, and 

HIV-infected patients

 Integrating tobacco cessation counseling into all patient care areas

including primary care, mental health, and specialty clinics

 Changing the delivery of tobacco cessation services to address

tobacco use and dependence in a chronic disease model

SCOPE OF THE PROBLEM

Impact of Tobacco Use on Morbidity and Mortality

Smoking is the leading cause of preventable death and disease in the United 

States.2

 Cigarette smoke contains more than 7,000 chemicals, including 

hundreds of chemicals that are toxic and approximately 69 that can cause 

cancer.7 It is a chronic disorder that often requires repeated interventions and 

multiple attempts to quit.

 In the United States, the current prevalence of tobacco use among 

adults has dropped from 44% in the 1960s to approximately 19% in 

2011.1,7

 The adverse health effects from cigarette smoking account for an 

estimated 443,000 annual deaths, or nearly one of every five deaths 

in the United States.7,9

 More deaths are caused each year by tobacco use than by all deaths 

from human immunodeficiency virus (HIV), illegal drug use, alcohol 

use, motor vehicle injuries, suicides, and murders combined.7,9
5

I. Tobacco Use in VA’s Population

 Smoking causes an estimated 90% of all lung cancer deaths in men

and 80% of all lung cancer deaths in women.3

 An estimated 90% of all deaths from chronic obstructive lung disease

are caused by smoking.3

 The risk of heart attack and stroke are much higher in tobacco users

compared to people who do not use tobacco.

 Smoking-attributable health costs are estimated at $96 billion per 

year in direct medical expenses and $97 billion in lost productivity.11

 Light smoking is dangerous to the health of those who smoke. The 

Surgeon General’s 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.7 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.

BENEFITS OF TOBACCO CESSATION

Smoking cessation can reduce and prevent many smoking-related health

problems. The benefits of quitting tobacco can be noticed in the first few days

after stopping.3

 Smoking cessation lowers the risk for lung and other types of cancer 

within 10 years after stopping.

 Tobacco cessation reduces the risk of stroke, heart disease, and 

peripheral vascular disease. Coronary heart disease risk begins to

decline within 1-2 years of stopping tobacco.

 Smoking cessation reduces coughing, wheezing, and shortness of 

breath. The rate of decline in lung function that occurs with aging is

slower among persons who quit tobacco.

 Smoking cessation reduces the risk of developing chronic obstructive 

pulmonary disease (COPD).

 Smoking increases the rate of infertility in women during their 

reproductive years. Women who stop smoking during their 

reproductive years have a reduced risk of infertility and women 
6

I. Tobacco Use in VA’s Population

who stop smoking during pregnancy reduce the risk of having a low 

birth-weight baby.

 Every attempt to quit improves the probability of eventual success.6

THE ROLE OF THE PRIMARY CARE PROVIDER

Assess tobacco use at every visit with Veterans. This can be done by multiple 

providers during a visit, including but not limited to medical assistants, nurses, 

physicians, nurse practitioners, physician assistants, pharmacists, and other 

members of the health care team. It is estimated that 70% of current adult 

smokers in the United States want to quit and millions have attempted to do 

so. Tobacco dependence is a chronic disorder that often requires repeated 

interventions and multiple quit attempts. Limits should not be placed on how 

often Veterans can attend counseling sessions or receive medication. Methods 

to quit tobacco use include:

 Brief clinical interventions (≤10 minutes)

• Provider offering counseling with “advice to quit” and assistance 

with quitting

 Counseling (≥10 minutes)

• Individual

• Group

• Telephone

 Medications to help with tobacco cessation

• Nicotine replacement therapy (NRT)

• Non-nicotine medications

 Bupropion

 Varenicline

• The combination of medication and counseling is more effective 

for tobacco cessation than either medication or counseling alone.2

CHALLENGES TO TOBACCO CESSATION IN VA PRIMARY 

CARE PATIENTS

Rates of tobacco use are higher in many Veteran groups, including Veterans

of the Iraq and Afghanistan wars, mental health patients, and HIV-infected 

patients. Quitting tobacco products can be more challenging in these patient 

groups, however there are effective models of care for smoking cessation 
7

I. Tobacco Use in VA’s Population

interventions in these patients. Establishing programs to help support cessation 

attempts can increase cessation rates.

Veterans with posttraumatic stress disorder (PTSD) smoke and use tobacco at 

higher rates than Veterans without PTSD.13 An integrated model of smoking 

cessation with primary care providers and staff that provided consistent care 

for Veterans with PTSD was found to be effective and superior to standardof-care smoking cessation programs given separately from the primary care 

clinic.13‐15

 Veterans with psychiatric disorders smoke at higher rates than 

those without mental health disorders.13 Studies in populations with 

psychiatric disorders and depression suggest moderate efficacy 

of smoking cessation and little or no evidence of exacerbation of 

these disorders.14,15

 Approximately half of alcohol dependent individuals are daily 

smokers.18,19 Evidence indicates that smoking cessation interventions 

for individuals with alcohol use disorder are effective and have no 

detrimental effects on abstinence from alcohol.18 Study results are 

mixed regarding optimal timing of smoking cessation interventions 

for individuals with alcohol use disorder.20,21 Smoking status should 

be addressed for all individuals with alcohol use disorder and the 

following recommendations have been proposed:18,22,24

• 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

 HIV-infected smokers have a greater probability of non-AIDS 

related diseases such as cardiovascular and pulmonary conditions 

(pneumothorax, pneumonia, lung cancer) and non-AIDS cancers.22

Cigarette smoking is the most important modifiable cardiovascular 

risk factor among HIV-infected patients, more so even than the use 

of lipid-lowering drugs or ART.23

 Tobacco use is more prevalent in the Veterans from Operation 

Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) than 

in the general Veteran population. Veterans returning home from 

Iraq and Afghanistan report they continued to smoke as a way to 

modulate negative moods (e.g., anger dysregulation, irritability, 

stress); cope with a post deployment shift to civilian life; and 

deal with combat-related injuries, unstructured life outside of the 
8

I. Tobacco Use in VA’s Population

military, sleep disorders, and the inability to turn off the military 

mindset (e.g., hypervigilance).26

 Concurrent tobacco use is the use of cigarettes along with another 

form of tobacco like chewing tobacco, cigars or pipes. The rates of 

concurrent tobacco use are increasing and this is felt to be due at 

least in part to restrictions on cigarette smoking in indoor locations. 

In a 2008 report, 41% of active duty military personnel reported 

using at least one form of tobacco in the previous month. Heavier 

rates of smoking (more than 15 cigarettes a day) was associated with

a higher rate of using multiple forms of tobacco (cigarettes, cigars 

and chewing tobacco).27
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I. Tobacco Use in VA’s Population

References:

1. Centers for Disease Control and Prevention. (2012). Current cigarette smoking 

among adults — United States 2011. Morbidity and Mortality Weekly Report, 

61(44), 889-894. Accessed at http://www.cdc.gov/mmwr/preview/mmwrhtml/

mm6144a2.htm?s_cid= mm6144a2.htm_w

2. 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.ncbi.nlm.nih.gov/

books/NBK63952/

3. U.S. Department of Health and Human Services. (2004). The health 

consequences of smoking: a report of the Surgeon General. Accessed at http://

www.surgeongeneral.gov/library/reports/smokingconsequences/index.html

4. Department of Veterans Affairs. (2011, July). 2010 survey of veteran 

enrollees’ health and reliance on VA. Accessed at http://www.va.gov/

HEALTHPOLICYPLANNING/Soe2010/SoE_2010_Final.pdf

5. Bray, R. M., Pemberton, M. R., Hourani, L. L., Witt, M., Olmstead, K. 

L. R., Brown, J. M., Weimer, B., Lane, M. E., Marsden, M. E., Scheiffler, 

S., Vandermaas-Peeler, R., Aspinwall, K. R., Anderson, E., Spagnola, K., 

Close, K., Gratton, J. L., Calvin, S., Bradshaw, M., & RTI International. 

(2009) 2008 Department of Defense Survey of Health Related Behaviors 

Among Active Duty Military Personnel. Accessed at http://www.tricare.mil/

tma/2008HealthBehaviors.pdf

6. Prochaska, J. O., & Velicer, W. F. (1997). The transtheoretical model of health 

behavior change. American Journal of Health Promotion, 12(1); 38–48.

7. U.S. Department of Health and Human Services. (2010). How tobacco smoke 

causes disease: The biology and behavioral basis for smoking-attributable 

disease: A report of the Surgeon General. Accessed at http://www.

 ncbi.nlm.nih.gov/books/NBK53017/

8. U.S. Department of Health and Human Services (2012, June). 2011 National

Health Interview Survey (NHIS) public use data release. Accessed at ftp://

ftp.cdc.gov/pub/health_statistics/nchs/dataset_documentation/nhis/2011/

srvydesc.pdf

9. Mokdad, A. H., Marks, J. S., Stroup, D. F., & Gerberding, J. L. (2004). Actual 

causes of death in the United States. Journal of the American Medical 

Association, 291(10), 1238–1245.

10. Centers for Disease Control and Prevention. Sustaining state programs 

for tobacco control: Data highlights 2006. Accessed at http://www.

cdc.gov/tobacco/data_statistics/state_data/data_highlights/2006/pdfs/

datahighlights06rev.pdf
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I. Tobacco Use in VA’s Population

11. Centers for Disease Control and Prevention. (2008). Annual smokingattributable mortality, years of potential life lost, and productivity losses—

United States, 2000–2004. Morbidity and Mortality Weekly Report, 57(45), 12261228. Accessed at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5745a3.

htm

12. National Toxicology Program. (2011). Report on carcinogens (12th Ed.). U.S. 

Department of Health and Human Services, Public Health Service, National 

Toxicology Program. Accessed at http://ntp.niehs.nih.gov/ntp/roc/twelfth/

roc12.pdf

13. McFall, M., Saxon, A. J., Thompson, C. E., Yoshimoto, D., Malte, C., 

Straits‐Tröster, 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. Accessed 

at http://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.162.7.1311

14. Duffy, S. A., Kilbourne, A. M., Austin, K. L., Dalack, G. W., Woltmann, E. M., 

Waxmonsky, J., & Noonan, D. (2012). Risk of smoking and receipt of cessation 

services among veterans with mental isorders. Psychiatric Services, 63(4), 

325‐332. Accessed at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3323716/

15. 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

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

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

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

Journal of Preventive Medicine, 33(6 Suppl), S406-S413.

18. 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. Accessed at http://pubs.niaaa.nih.gov/

publications/arh293/162-171.htm

19. 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.

20. 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.

21. 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.

22. Aberg, J. A. (2009). Cardiovascular complications in HIV management: Past, 

present and future. Journal of Acquired Immune Deficiency Syndromes, 

50(1), 54-64. Accessed at http://www.ncbi.nlm.nih.gov/pmc/articles/ 

PMC2746916/?tool=pubmed
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I. Tobacco Use in VA’s Population

23. Grinspoon, S., & Carr, A. (2005). Cardiovascular risk and body-fat abnormalities 

in HIV-infected adults. The New England Journal of Medicine,352(16), 48-62. 

Accessed at http://www.nejm.org/doi/full/10.1056/NEJMra041811

24. 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.

25. Sherman, S. E., Yano, E. M., Lanto, A. B., Simon, B., & Rubenstein, L. V. (2001, 

February). Veterans who smoke: Do they want to quit and are we helping 

them? Paper presented at the VA Health Services Research and Development 

19th Annual Meeting, Washington, D.C.

26. Gierisch, J. M., Straits-Tröster, K., Calhoun, P. S., Beckham, J. C., Acheson, 

S., & Hamlett-Berry, K., (2012), Tobacco use among Iraq- and Afghanistanera veterans: A qualitative study of barriers, facilitators, and treatment 

preferences. Preventing Chronic Disease, 9(E58). Accessed at http://www.ncbi.

nlm.nih.gov/pmc/articles/PMC3359099/

27. Olmsted, K. L., Bray, R. M., Reyes-Guzman, C. M., Williams, J., & Kruger, H. 

(2011). Overlap in use of different types of tobacco among active duty military 

personnel. Nicotine & Tobacco Research, 13(8), 691-698.
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II. Tobacco Cessation Interventions

CHAPTER SUMMARY

 Effective interventions can be brief (3-10 minutes) or intensive 

(lasting for >10 minutes)

 Brief 3-minute interventions advising patients to quit can enhance 

abstinence rates

 Even without a tobacco cessation program, brief counseling 

and medications provided as part of ongoing health care can 

be effective

 When creating a tobacco cessation program, start small and 

manageable by selecting brief interventions appropriate for 

the setting

 Identify primary care providers and key staff with an interest in 

tobacco cessation

 Build the program by incorporating more intensive interventions 

when appropriate

 Monitor and track your patients’ progress

EFFECTIVENESS OF TOBACCO CESSATION INTERVENTIONS

Tobacco cessation interventions can be extremely effective and providers 

who perform even brief interventions of ‘advice to quit’ to patients can 

significantly increase abstinence rates. Health care providers should present 

a clear, concise, and consistent “quit” message to all their patients who use 

tobacco. The evidence on tobacco cessation interventions referenced below 

is presented in full in the U.S. Department of Health and Human Services 

(DHHS), Public Health Service (PHS), Treating Tobacco Use and Dependence: 

2008 Update (Clinical Practice Guideline).1

Any type of clinician can be effective at delivering evidence-based interventions 

to increase quit rates. There is strong evidence of a dose-effect response, as 

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 4-30 minutes can 

double a patient’s chance of abstinence 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 

double the chance of success.1

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 
16

II. Tobacco Cessation Interventions

a referral to an outside clinic, tobacco cessation program or the prescribing 

of medication alone.1 Self-help, pro-active group counseling and telephone 

counseling have all been shown to significantly increase abstinence rates 

compared to stopping “cold turkey.”

ESTABLISHING A TOBACCO CESSATION PROGRAM FOR VETERANS

IN PRIMARY CARE CLINICS

Implementing a sustainable and effective tobacco cessation program can feel 

daunting, but several key strategies can be helpful when implementing an 

effective tobacco cessation program in your primary care clinic. As you start to 

build a program in your clinic, identify providers and staff who are interested 

in tobacco 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, there 

is a Smoking Cessation Lead Clinician and a Health Behavior Coordinator at 

each VA facility who can be a valuable resource for your clinic. Please email 

publichealth@va.gov to obtain the name of the Smoking Cessation Lead 

Clinician at your VA facility.

TOBACCO CESSATION BEHAVIORAL INTERVENTIONS

This chapter describes interventions to use when talking with your patients

about their interest in tobacco 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. Challenges

and opportunities for implementing these well-established interventions with

your primary care patients and making tobacco cessation a routine part of

clinical care are also addressed.

Brief Interventions (3-10 minutes)

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

patients with information about the impact of tobacco use, assessing their 

level of motivation to quit, and helping them move to the next step in cessation 

through the provision of resources or referrals to tobacco cessation programs, 

are critical components of brief interventions. The five elements of a brief 

tobacco cessation intervention are outlined below.
17

II. Tobacco Cessation Interventions

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

ASK about smoking*

Ask patients about tobacco use at every clinic visit

 Ask about the type(s) of tobacco used and how long it has 

been used

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

*Clinical reminders and performance measures within VHA can assist with 

this element

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 the increased risk of harm to their body, 

exposure of children or pets to tobacco smoke, the expense of 

cigarettes, or pulmonary and cardiovascular comorbidities.

• Your smoking habit can increase your risk of heart attacks 

and strokes.

• Remember the time you had that terrible pneumonia?

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

cigarette expenses if you quit?

ASSESS readiness to quit

Assess patient’s readiness to quit within the next 30 days

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

• If patient is ready, assist patient using the follow-up activities 

in the ARRANGE section (p. 18).

• If the patient is not ready to quit, consider using motivational 

interviewing to increase their readiness

(See Table 2. Enhancing Motivation to Quit Tobacco, The 5 R's

on p. 19).

ASSIST patients with their quit attempt

Prepare your patient for quitting using STAR. Have them:

 Set a target quit date (TQD). Ideally, the TQD should be within two
18

II. Tobacco Cessation Interventions

weeks, but no later than within 30 days. The TQD 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 nicotine 

withdrawal symptoms.

 Remove tobacco products from their environment. Before quitting,

they should avoid smoking in places where a lot of time is spent 

(e.g., work, home, car) and make their home smoke free.

Offer pharmacotherapy and discuss the role of medications in treatment

Provide practical counseling (problem-solving/skills training)

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

telephone counseling) available within your VA facility.

 Provide a supportive clinical environment while encouraging the

patient in his or her quit attempt.

 Provide supplementary materials and other resources to keep the 

patient motivated and engaged.

ARRANGE follow-up encounters

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

VHA-based smoking cessation clinic, if s/he requests)

 Timing

• The first follow-up encounter should be around the TQD or 

within the first week

• The second follow-up encounter should be within the first 

month of the TQD

 Actions to take during follow-up encounters

• Assess medication use and any adverse reactions

• Remind patient of reasons for quitting and other resources 

available to them

• Congratulate patient on abstinence

 Provide supplementary materials and other resources such as the 

My Tobacco Cessation Workbook to keep the patient motivated 

and engaged
19

II. Tobacco Cessation Interventions

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 tobacco cessation intervention consist of:

 Determining whether tobacco users are willing to make a quit 

attempt with intensive counseling

 Conducting patient assessments that may be helpful including lung 

function, stress level, and nicotine dependence using 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 tobacco cessation treatment)

 Including problem solving/skills training and intra-treatment social 

support as part of the intervention

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

who are not quite ready to quit.

TABLE 2. ENHANCING MOTIVATION TO QUIT TOBACCO, THE 5 R'S3-6

RELEVANCE Explain why cessation is personally relevant

 Health concerns and patient’s disease status or risk

 Family situation, such as quitting for children

 Monetary cost of nicotine dependence

RISKS Ask patients to explain their perceived potential risks of tobacco 

use; discuss these risks (e.g., infertility, fetal harm, cardiovascular and 

pulmonary disease, malignancies, harm of secondhand smoke to others) 

 Increased risk of heart attack and stroke
20

II. Tobacco Cessation Interventions

 Reduced circulation in legs (peripheral artery disease), which can 

increase risk of amputation

 Increased risk of cancers like lung, bladder, pancreas, esophageal, 

stomach, and head and neck cancers

 Increased risk of osteoporosis and bone fractures

 Increased risk of lung damage leading to emphysema

 Smoking is a common cause of sexual dysfunction

REWARDS Ask patients to explain what they might gain from tobacco

cessation and highlight the rewards most relevant to the patient

 Improved taste of food

 Improved sense of smell

 Saving money

 Setting a good example for children

 Better performance of physical activities

 Improved appearance (e.g., reduced wrinkling, whiter teeth)

 Lower risk of heart disease

 Lower risk of lung disease

 Lower risk of tobacco-related cancers

Explain that:

 20 minutes after quitting, heart rate and blood pressure drop

 Two weeks to three months after quitting, circulation and lung 

function improve by 30%

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

reduced by 50%

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

who never smoked

ROADBLOCKS Ask patients to identify barriers to quitting and offer

options to address those barriers

 Withdrawal symptoms

 Fear of failure

 Weight gain

 Lack of support
21

II. Tobacco Cessation Interventions

 Depression

 Enjoyment of smoking

 Socializing with other smokers

REPETITION Discuss the R's listed above with patients visit
22

II. Tobacco Cessation Interventions

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 Medical 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: Guildford Publications, Inc.

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 

Tobacco Cessation 

Interventions
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25

III. Real-time Scripts for Brief Tobacco Cessation Interventions

CHAPTER SUMMARY

 Tobacco use and dependence can be a chronic, relapsing condition

 Consider tracking tobacco use as a vital sign

 Provide factual information to address patient concerns

 Assess patient’s tobacco use status and readiness to quit

 Advise patients about quitting

 Encourage confidence in quitting

APPROACHING PATIENTS ABOUT TOBACCO CESSATION

Though primary care providers are in an excellent position to provide tobacco 

cessation interventions with their patients who use tobacco products, it can be 

difficult and sometimes uncomfortable to approach the topic. We recommend 

treating tobacco use as a vital sign so that a patient’s tobacco use status is 

readily apparent upon their entrance into the exam room. This is an easy way 

to integrate conversations about tobacco use into the clinic visit. Tobacco use 

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 tobacco cessation.

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

the test in 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.
26

III. Real-time Scripts for Brief Tobacco Cessation Interventions

TABLE 3. FAGERSTRÖM TEST FOR NICOTINE DEPENDENCE1-2

Points* Your 

Points

1. How soon after you wake up do 

you smoke/use your first cigarette/

chew?

Less than

5 min.

3

6-30 min. 2

31-60 min. 1

After 

1 hour

0

2. Do you smoke/chew more 

frequently in the hours after waking

than during the rest of the day?

Yes 1

No 0

3. Do you find it difficult not to smoke/

chew?

Yes 1

No 0

4. Which cigarette/chew would be the

hardest to give up?

First one 

in the 

morning

1

Any other 0

5. How many cigarettes do you smoke

in a day?

10 or less 0

11-20 1

21-30 2

31 or more 3

6. Do you smoke when you're so sick

that you're home in bed?

Yes 1

No 0

NICOTINE DEPENDENCE SCORE (Points): Your Score ________

(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.
27

III. Real-time Scripts for Brief Tobacco Cessation Interventions

ADDRESSING PATIENT CONCERNS AND SAMPLE SCRIPTS

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

and tobacco cessation with your patients.

TABLE 4. SAMPLE RESPONSES TO PATIENTS’ CONCERNS ABOUT

TOBACCO CESSATION3-5

Patient Provider

I don’t want counseling, I only 

want medication.

 Counseling and 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 the evidence 

supporting the effectiveness 

of counseling and medication.

 Suggest that the patient 

augment any substandard 

therapy with counseling 

and 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.

 Studies have shown that 

medicinal nicotine is 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 

tobacco cessation.
28

III. Real-time Scripts for Brief Tobacco Cessation Interventions

Patient Provider

My life is too stressful to 

quit tobacco.

 Smoking/chewing is one 

way that many people deal 

with stress.

 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.
29

III. Real-time Scripts for Brief Tobacco Cessation Interventions

TABLE 5. SAMPLE SCRIPTS FOR BRIEF TOBACCO CESSATION

CONVERSATIONS BETWEEN PATIENTS AND PROVIDERS3-5

Questions and statements are all in the voice of the provider.

Approach your patients about smoking/chewing

Assess tobacco status

 How many cigarettes do you smoke a day? How many cans of 

chewing tobacco do you use in a week?

 Do others in your household or work environment smoke/chew?

 Have you thought about quitting?

Advise patient about quitting tobacco

Be clear

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

Make strong statements

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

your health.

 Smoking can greatly increase your chances of having a heart attack 

or stroke

 Chewing tobacco is directly linked to cancers in the mouth 

and throat.

Personalize your feedback

 Your smoking habit may be a more serious risk to your health right 

now than your diabetes.

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

you quit.

 All your hard work improving your diet and working on reducing 

your blood pressure is being undone by smoking.

 Your risk of lung disease, coronary heart disease, and other 

problems are much higher.

 You are at increased risk of developing lung disease and lung cancer 

when you smoke.

 You complain of shortness of breath; giving up cigarettes will 

improve your breathing and stamina.
30

III. Real-time Scripts for Brief Tobacco Cessation Interventions

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 quit? 

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.

 You've been really successful in managing your diabetes (or other) 

medication regimens and you can use some of those same 

skills here.

 Would you like some resources about smoking cessation that you 

can read on your own time while you decide?

Encourage confidence in quitting tobacco

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

tobacco for good?

 What would make you more confident in your ability to 

stop tobacco?

 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 tobacco?

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 you whenever you're ready.

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

the things we consider like a vital sign so I'll be asking about it
31

III. Real-time Scripts for Brief Tobacco Cessation Interventions

when you come in for your next visit. 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., counseling 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.

Express empathy

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

without tobacco.

 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.
32

III. Real-time Scripts for Brief Tobacco Cessation Interventions

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, Inc.
33

IV. Medications for

Tobacco Cessation
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35

IV. Medications for Tobacco Cessation

CHAPTER SUMMARY

 Use of medications for tobacco cessation result in better abstinence 

rates and durability than quitting “cold turkey”

 Tobacco cessation medications help address the physiological 

symptoms experienced during a quit attempt, which reduces 

cravings and the potential for relapse in the early stages of a 

quit attempt

 Medications for tobacco 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 NRT while 

maintaining tobacco 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 tobacco cessation medication 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, 

those who are heavier users, or those experiencing cravings or 

withdrawal symptoms while on the patch alone

 Consider combination therapy of nicotine patch plus nicotine 

polacrilex gum or nicotine lozenge for maximum management of 

withdrawal symptoms

NICOTINE PHARMACOLOGY

First-line FDA-approved agents for smoking cessation consist of nicotine 

replacement therapies (NRTs), which include the nicotine patch, gum, 

lozenge, oral inhaler and nasal spray; and the non-NRT agents bupropion and 

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

and the nicotine oral inhaler and nicotine nasal spray are nonformulary agents. 

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

lozenge, or bupropion is also recommended as a first-line treatment option.
36

IV. Medications for Tobacco Cessation

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 inhalation, nicotine 

reaches the brain and stimulates the release of various neurotransmitters 

including dopamine, which produces 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.

The main purpose of nicotine pharmacology is to minimize a person’s nicotine

withdrawal symptoms when they quit tobacco. 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 tobacco can persist for months or even years.
37

IV. Medications for Tobacco Cessation

NICOTINE REPLACEMENT THERAPY (NRT)

The mechanism of action of NRTs, which are ganglionic (nicotinic) cholinergicreceptor 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. The onset of action with NRT is not as rapid as that of 

nicotine obtained through a cigarette, so patients become less accustomed to 

the nearly immediate reinforcing effects of tobacco.4 The goal is to use NRT 

to taper off of nicotine over a few months. Table 6. Medications for Tobacco 

Cessation Available Through the VA National Formulary (p. 47) summarizes 

the dosing regimens, advantages and disadvantages, common adverse effects, 

and contraindications for three forms of NRT, bupropion, and varenicline.

Treatment of nicotine dependence with NRT should adhere to the following 

principles6:

 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 the patient to try 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). If the 

patient has a slip and uses tobacco while using NRT, encourage the 

patient to try to get back on track with quitting tobacco. If they 

are not using combination therapy, then this should be considered 

to help them abstain completely from tobacco. If they have a 

relapse and are back to smoking daily, then it may be best to have 

them quit the NRT and set another quit day when they are ready to 

try again.

 Selection of the type of 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.
38

IV. Medications for Tobacco Cessation

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 

symptoms of withdrawal can still be alleviated.

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

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

is applied.

 Available OTC in the community.

Nicotine polacrilex gum6‐9

 Resin complex of nicotine and polacrilin in a sugar-free 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).

 Patients should be advised to use a bite-and-park method when 

using the nicotine gum. They should bite the gum several times 

until they taste a peppery taste or feel a tingling sensation, then 

park the gum on the inside of their cheek where the nicotine will 

be absorbed. When they no longer taste the peppery taste or feel 

the tingling sensation, then they should bite the gum several times 

again and park the gum in the inside of their cheek. This should 

be repeated until they no longer taste the peppery taste. The gum 

should not be chewed continuously like regular chewing gum or 

the nicotine will not be absorbed and the patient may experience 

stomach upset and heartburn.

 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 precessation levels.

 Allows smokers to take an active coping response to nicotine
39

IV. Medications for Tobacco Cessation

withdrawal symptoms.

 Associated with less weight gain compared to placebo 

during treatment.

 Sticks to dentures, may dislodge fillings and inlays because of the 

density and texture of the gum.

 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.

Nicotine polacrilex lozenge4,6‐9

 Resin complex of nicotine and polacrilin in a flavored lozenge 

intended to be dissolved in mouth and moved from side to side in 

the mouth until fully dissolved. Lozenge contains sodium carbonate/

potassium bicarbonate buffers to increase salivary pH thereby 

enhancing absorption of nicotine across the buccal mucosa.

 Patients should be advised to place the lozenge in their cheek to 

allow the lozenge to be absorbed. They should not bite or chew 

the lozenge.

 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.

 Allows smokers to take an active coping response to nicotine 

withdrawal symptoms.

 Potential to consume too quickly, which 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.
40

IV. Medications for Tobacco Cessation

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.

 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) 
41

IV. Medications for Tobacco Cessation

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 Therapy6,9,12‐15

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

patch) along with a short-acting formulation (e.g., nicotine gum, nicotine 

lozenge, nicotine inhaler, or nicotine 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 the nicotine patch alone. Combination therapy with the nicotine patch and 

either nicotine gum or lozenge is superior to monotherapy with the nicotine 

patch in up to one year of follow up. Using a combination of nicotine 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.

Combination NRT Example Taper Schedule

 Week 1: Nicotine 21mg patches and 5 lozenges daily

 Week 2: Nicotine 21mg patches and 4 lozenges daily

 Week 3: Nicotine 21mg patches and 3 lozenges daily

 Week 4: Nicotine 21mg patches and 2 lozenges daily

 Week 5: Nicotine 21mg patches and 1 lozenge daily

 Week 6: Nicotine 14mg patches and 4 lozenges daily

 Week 7: Nicotine 14mg patches and 3 lozenges daily

 And so forth...

**Use behavioral strategies previously listed to assist with taper of NRT**
42

IV. Medications for Tobacco Cessation

Nicotine Replacement Therapy Safety6,9,16‐18

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, nicotine 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 compared to younger

subjects.

BUPROPION6,19‐23

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

inhibitor with some nicotine receptor blocking activity.19,20 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.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 
43

IV. Medications for Tobacco Cessation

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.

 Other inducers such as carbamazepine, phenobarbital, 

and phenytoin can lower bupropion levels via induction of 

bupropion metabolism.

 Bupropion and hydroxybupropion (one of its metabolites) are 

inhibitors of CYP2D6 in vitro. Since the interactions between 

bupropion and drugs metabolized by CYP2D6 have not been formally 

examined, caution is advised in the coadministration of bupropion 

with drugs metabolized by CYP2D6. If adding a drug metabolized by 

CYP2D6 (e.g., nortriptyline, imipramine, desipramine, paroxetine, 

fluoxetine, sertraline, haloperidol, risperidone, thioridazine, 

metoprolol, propafenone, flecainide) to a patient already receiving 

bupropion, consider initiating the coadministered drug at the 

lower end of the dose range. Conversely, if bupropion is added 

to a regimen containing a drug metabolized by CYP2D6, consider 

decreasing the dose of the original medication; especially for those 

concomitant medications with a narrow therapeutic index.

 MAO (monoamine oxidase) inhibitors: Wait 14 days after 

discontinuing before starting therapy with bupropion.

 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 the nicotine patch.6,23

Bupropion Safety24-26

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 
44

IV. Medications for Tobacco Cessation

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. The Food and 

Drug Administration (FDA) has provided the following recommendations for 

monitoring bupropion when used for tobacco cessation:

 It is important to discuss the possibility of serious 

neuropsychiatric symptoms in the context of the benefits of 

quitting smoking with patients before prescribing bupropion. 

Bupropion is an effective smoking cessation aid and the health 

benefits of smoking cessation are immediate and substantial.

 Healthcare professionals should monitor all patients taking 

bupropion for serious neuropsychiatric symptoms. These 

symptoms include changes in behavior, hostility, agitation, 

depressed mood, suicidal ideation, suicidal behavior, and attempted 

suicide. These symptoms have occurred in patients without 

pre-existing psychiatric illness and have worsened in some patients 

with pre-existing psychiatric illness. In most cases, neuropsychiatric 

symptoms developed during treatment with bupropion but in others, 

symptoms developed after stopping drug treatment.

 Patients should be informed that it is not unusual to have 

symptoms such as irritability, feeling anxious, depressed mood 

and trouble sleeping when they are withdrawing from nicotine, 

independent of whether they are taking bupropion.

 Patients with serious psychiatric illness such as schizophrenia, 

bipolar disorder, and major depressive disorder, may experience 

worsening of their pre-existing psychiatric illness while 

taking bupropion.

 Patients who discontinue treatment because of neuropsychiatric 

events should continue to be monitored until symptoms resolve.

Although in many cases symptoms resolved after treatment was 

stopped, there were some cases where the symptoms persisted.
45

IV. Medications for Tobacco Cessation

VARENICLINE27-30

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 

blocks nicotine from binding to the receptor and attenuates the reinforcement 

and rewarding effects of nicotine.

 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 Tobacco Cessation in VA

Within VA, varenicline is a second-line agent for tobacco 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,
46

IV. Medications for Tobacco Cessation

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

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

appear.

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.
47

IV. Medications for Tobacco Cessation

TABLE 6. MEDICATIONS FOR TOBACCO CESSATION AVAILABLE THROUGH THE VA NATIONAL FORMULARY

BUPROPION NICOTINE 

TRANSDERMAL PATCH

NICOTINE POLACRILEX 

GUM

NICOTINE POLACRILEX 

LOZENGE

VARENICLINE

Trade name and dose 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

Recommendedregimen

Bupropion SR150mg daily for 3d, 

then 150mg twice daily (8 hrs apart)Patients with cirrhosis need adjusted dose: 150mg every other dayBupropion IR100mg daily for 3d, then 100mg three times dailyPatients with cirrhosis need adjusted dose: 75mg daily

Smoking more than 10 cigarettes a day:21mg for 4-6wks,

then 14mg for 2wks,

then 7mg for 2wksSmoking 10 or fewer cigarettes a day: 14mg for 6-8wks,then 7mg for 2wks

High dependence*:4mg every 1-2 hrs for 6wks, then every 2-4hrs for 3wks, then every 4-8hrs for 3wksLow dependence:2mg every 1-2hrs for 6wks, then every 2-4hrs for 3wks, then every 4-8hrs for 3wksNo more than 24 pieces in 24hrs

High dependence*:4mg every 1-2hrs for 6wks, then every 2-4hrs for 3wks, then every 4-8hrs for 3wksLow dependence:2mg every 1-2hrs for 6wks, then every 2-4hrs for 3wks, then every 4-8hrs for 3wksNo more than 20 pieces in 24hrs

0.5mg daily for 1-3d,then 0.5mg twice daily on days 4-7, then STOP SMOKING on quit date, then 1mg twice daily for total of 

12 weeks durationCrCl<30ml/min: max dose0.5mg 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

Administration comments

•Continue treatment for 

7-12 wks (if no progress 

is made by week 7, consider

•Usually worn for 

16‐24 hrs

•Apply from shoulders 

to waist

•Chew slowly (about 10 

chews) until peppery taste then “park” between cheek and

•Dissolve slowly 

over 20-30 minutes shifting in the mouth occasionally

•Take after eating and 

with 8 ounces of water to minimize nausea

•Report depression,
48

IV. Medications for Tobacco Cessation

BUPROPION NICOTINE 

TRANSDERMAL PATCH

NICOTINE POLACRILEX

GUM

NICOTINE POLACRILEX 

LOZENGE

VARENICLINE

Administration 

comments (cont.)

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 

combinationwith nicotine patch,nicotine gum or nicotine lozenge

•Rotate sites•Takes 2-3 d for effect

after application of first patch

•Can be used in 

combination with 

nicotine gum or lozenge at the usual dose. Patch continued for 8-10 weeks with lozenge and 8-24 weeks with gum

•Can be used in 

combination with bupropion

gums until taste disappears. Repeat chew and park process for 30 minutes on each piece of gum

•Avoid acidic beverages 

(citrus juice, soft 

drinks, coffee) within 15 minutes of use

•Avoid eating or 

drinking while using the gum

•Can be used in 

combination with nicotine patch or bupropion; most patients will require 6-8 pieces of gum/day as needed when used in combination. Gum can be continued for 26-52 weeks when initiated as combination therapy

•Do not chew or 

swallow (increased risk 

of 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 with 

nicotine patch or bupropion; most patients will require 6-8 lozenges/day as needed when used in combination. Lozenges can be continued for 12 weeks duration when initiated as combination therapy

suicidal ideation, unusual behavior, or worsening psychiatric illness

•An additional 12 wks 

of treatment in 

patients who have successfully stopped smoking may increase the likelihood of long-term abstinence

Advantages (+) and disadvantages 

(‐)

(+) better adherence;ease of use; can be combined with NRT; 

(+) best adherence; easy to use; consistent rate of exposure; 

(+) can titrate to adjust for cravings or sudden urges; oral substitute for cigarettes; can be

(+) ease of use; discreet; higher immediate levels; can

(+) better adherence; ease of use; consistentrate of exposure; superior rate of
49

IV. Medications for Tobacco Cessation

BUPROPION NICOTINE 

TRANSDERMAL PATCH

NICOTINE POLACRILEX 

GUM

NICOTINE POLACRILEX 

LOZENGE

VARENICLINE

Advantages (+) and disadvantages (‐) (cont.)

consistent rate of exposure; helps with 

withdrawal symptoms(-) many drug interactions; CNS side effects; must be adjusted for hepatic insufficiency; increased risk of seizures

unobtrusive; can be combined as needed with gum, lozenge, or bupropion for 

better efficacy(-) less effective for cravings; difficult to control titration; absorption increased at elevated temperatures

combined with nicotine patch or bupropion for better efficacy(-) difficult for those with poor dentition or dentures; must use proper chewing technique; must abstain from drinking and eating during gum use; swallowing the nicotine causes GI side effects

titrate to adjust for cravings; reduces selfreported withdrawal 

symptoms; can be combined with nicotine patch or bupropion for better efficacy(‐) must abstain from drinking/eating during lozenge use

abstinence compared to bupropion and placebo(‐) potential for serious neurologic and psychiatric side effects (esp. in those with underlying psychiatric disease); dose adjust for renal insufficiency (CrCl<30); high incidence of nausea

Adverse effects •Agitation

•Anxiety

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

reactions

•Seizures (risk 1:1000)

•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•Nausea and vomitingConsider dose reduction in patients 

with nausea, insomnia, headache
50

IV. Medications for Tobacco Cessation

BUPROPION NICOTINE 

TRANSDERMAL PATCH

NICOTINE POLACRILEX 

GUM

NICOTINE POLACRILEX 

LOZENGE

VARENICLINE

VA national formulary

Open formulary, no restrictions

Open formulary, no restrictions

Open formulary, no restrictions

Open formulary, no restrictions

Yes, must meet criteria for use.

Criteria available at https://vaww.cmopnational.va.gov/cmop/PBM/Clinical%20Guidance/Criteria%20For%20Use/Varenicline%20Criteria%20for%20Prescribing.docAvailable to patients without active mental health disorders who have had >1 relapse on NRT or bupropion

Contraindications & relative contraindications

Contraindications:•History of seizures•Predisposition to 

seizures (severe head 

trauma, CNS tumor, hepatic cirrhosis)

•Abrupt withdrawal 

from heavy alcohol or sedative use

Relative Contraindications:•Hypersensitivity•Pregnancy category D•Use within 14 days post MI, or serious or worsening angina•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. If patient has a relapse, then suggest patient stop using NRT and restart once they are ready to try quitting again.

Relative Contraindications:•Serious 

neuropsychiatric 

disorders(including suicidal and homicidal ideation)

•History of suicidal, 

homicidal, or assaultive behavior in the past 12 weeks
51

IV. Medications for Tobacco Cessation

BUPROPION NICOTINE 

TRANSDERMAL PATCH

NICOTINE POLACRILEX 

GUM

NICOTINE POLACRILEX 

LOZENGE

VARENICLINE

Contraindications & relative contraindications (cont.)

•MAO inhibitor 

within 14 d

•Bulimia, anorexia 

nervosa

•Hypersensitivity•Pregnancy category C

•TMJ syndrome (gum only) •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 with 

nicotine gum/lozenge or bupropion for significantly better abstinence rates and durability

•Using the 21 mg patch 

yields roughly 40-50% the plasma nicotine levels of smoking 1.5 packs per day

•May be used In 

combination with 

nicotine patch or bupropion for significantly better abstinence rates and durability

•Using 2 mg dose 

every 1-2 hours yields roughly 40% the plasma nicotine levels of smoking 1 pack per day

•May be used In 

combination with nicotine patch or bupropion for significantly better abstinence rates and durability

•Delivers about 25% 

more nicotine than does an equivalent dose of nicotine gum

•Should not be used as 

first-line therapy

•Ask about psychiatric 

history prior to prescribing

•Monitor for signs 

and symptoms of psychiatric illness during use

•Monitor serum 

creatinine; if renal function decreases dose reductions may be 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.
52

IV. Medications for Tobacco Cessation

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trials of varenicline: A pooled analysis. Drug Safety, 33(4), 289-301. doi: 

10.2165/11319180-000000000-00000

34. Williams, K. E., Reeves, K. R., Billing, C. B., Jr., & Gong, J. (2007). A doubleblind study evaluating the long-term safety of varenicline for smoking 

cessation. Current Medical Research and Opinion, 23(4), 793‐801.
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V. Relapse Prevention

and Tobacco Cessation

Maintenance
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V. Relapse Prevention and Tobacco Cessation Maintenance

CHAPTER SUMMARY

 Tobacco use is a chronic, relapsing disorder

 Multiple quit attempts and interventions may be necessary

 Relapse is NOT uncommon

 Continue to address tobacco use status at every visit and provide

ongoing support

 Offer retreatment with medication and counseling

 Provide patients with options for the management of 

withdrawal symptoms

TOBACCO USE: A CHRONIC, RELAPSING DISORDER

Patients who have recently quit using tobacco 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 use 

of an evidence-based tobacco cessation treatment from the start, including a 

combination of tobacco cessation medications and behavioral counseling, as 

described in previous chapters.

For patients who have recently quit using tobacco, 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 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 tobacco cessation program for additional support. 

Additional support available from VA is summarized on the VA Tobacco & 

Health webpage (www.publichealth.va.gov/smoking). Other resources include

the VA telephone quitline, which can be reached at 1-855-QUIT VET (1-855-

784-8838) M-F, 8 am-10 pm, ET (counseling is also available in Spanish), and the 

SmokefreeVET text support program (text the word VET to 47848 or sign up at 

www.smokefree.gov/VET).
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V. Relapse Prevention and Tobacco Cessation Maintenance

MANAGEMENT OF WITHDRAWAL SYMPTOMS

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

encountered during their quit attempt and 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, retreatment 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 tobacco.

TABLE 7. TOBACCO WITHDRAWAL SYMPTOMS* AND

RECOMMENDATIONS

Withdrawal Symptom Recommendation

 Chest tightness

(tension 

created by the 

body’s need 

for nicotine)

 Practice relaxation techniques

 Nicotine replacement therapy might

be helpful

 Stomach pain

 Constipation

 Gas

 Drink fluids

 Avoid stress

 Increase fiber in diet

 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.
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V. Relapse Prevention and Tobacco Cessation Maintenance

Withdrawal Symptom Recommendation

 Cravings/

urges (nicotine

withdrawal/

habit) (cont.)

Believe it or not, the urge will fade after 5 to 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 sugar-free candy or sugarfree gum, especially if you are watching your 

weight. You could eat 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.
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V. Relapse Prevention and Tobacco Cessation Maintenance

Withdrawal Symptom Recommendation

 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

 Nicotine replacement therapy may 

be helpful

 Hunger 

(cravings for a

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

 Irritability 

(body’s craving 

for nicotine)

 Exercise

 Practice relaxation techniques

 Take a hot bath
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V. Relapse Prevention and Tobacco Cessation Maintenance

Withdrawal Symptom Recommendation

 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 and urges are the only symptoms that can return even after 

one year of tobacco cessation.
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V. Relapse Prevention and Tobacco Cessation Maintenance

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. Accessed at http://www.healthquality.va.gov/

tuc/phs_2008_full.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. Accessed at http://

www.publichealth.va.gov/docs/smoking/cessationguidelinepart2_508.pdf
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VI. Establishing A 

Tobacco Cessation 

Program In Primary 

Care Clinics
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

CHAPTER SUMMARY

Group counseling program

 Class 1: Introduction

 Class 2: Why do I use tobacco and nicotine addiction

 Class 3: Medications to help you quit tobacco and getting ready for 

quit day

 Class 4: Quit day

 Class 5-7: Follow-up classes

GROUP COUNSELING PROGRAM

This chapter offers suggestions on how to moderate a tobacco cessation 

group counseling program using the guidance below and My Tobacco Cessation 

Workbook: A Resource for Veterans. The participant manual is designed to 

be used in a group format for patients in primary care clinics. The program 

is flexible when choosing which chapters to use in each group session. To 

encourage an environment that supports motivational interviewing, topics for 

discussion can be introduced at the beginning of each session. The class can 

then have input on the topics they would like emphasized. Classes should be 

instructed in a format that encourages discussion among the group members. 

Participants have the opportunity to choose the topics they would like to focus 

on for the session. Group moderators should feel free to incorporate these 

suggestions or make changes that they find appropriate. However, providers 

should ensure that changes to the program follow the guidelines provided in 

the 2008 U.S. Public Health Service Clinical Practice Guideline Treating Tobacco 

Use and Dependence.

It is recommended that the group program consist of 5-7 classes, each lasting 

60 minutes in duration. The program could be extended to 8-10 classes to allow 

coverage of all topics in adequate detail and to have a longer follow-up period.
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

Classes At A Glance

Class Corresponding Chapter In 

Participant's Manual

Topic

1 Chapter 1  Introduction

2 Chapters 2 & 3

 Why do I use tobacco?

 Nicotine addiction

3 Chapters 4 & 5

 Medications to help you 

quit tobacco

 Getting ready for 

quit day!

4 Chapter 6  Quit day

5-7 Chapters 7-9

 The first two weeks after 

quit day

 How do I stay 

off tobacco?

 Living as a nonsmoker

Additional classes can be added to allow group support for the first few months 

after quit day. The duration of follow-up classes can be extended for a longer 

period of time if the instructor feels this is necessary. Another consideration 

for follow up could be to do telephone follow up at one month and two months 

after quit day and potentially adding follow up at six and 12 months to evaluate 

long-term cessation.

A more detailed look at the classes is reviewed below.

Class 1

Covers Chapter 1: Introduction

Room Set Up

This group program would be best delivered in a room with chairs arranged in 

a circle. A dry erase board is useful when having a group discussion to write 

down ideas from the group.

At the beginning of the session, take time to do introductions and give some 

background into what participants can expect from the program. Introduce 

yourself to the group and include your experience in providing tobacco 
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

cessation counseling. Discuss if you have smoked in the past and if so, how 

you quit tobacco. If you have never smoked cigarettes, you are still able to 

moderate this program. Just be honest with the group and let them know 

that you will be providing information and counseling that is based on strong 

evidence to help people quit tobacco. If you are currently a tobacco user, it is 

advised that you not be an instructor for this group.

Background For Providing Tobacco Cessation Counseling

Review with participants that research has shown that providing tobacco 

cessation counseling in addition to medications for tobacco cessation is the 

most effective way to help people quit smoking. While the research is not as 

strong for the use of tobacco cessation counseling and medication for people 

who use chewing tobacco, cigars or pipes, it is felt that these measures may 

still help people quit. The program can be used by all types of tobacco users. 

Discuss that on average, it takes 6-8 tries for people to quit tobacco. It is 

important to highlight that participants should not be frustrated if they have 

tried to quit in the past and have not been successful. Each time a person tries 

to quit tobacco they learn a little more about how to quit. These lessons can 

be applied in future quit attempts. Review that tobacco use can be thought of 

as a chronic disease like hypertension or diabetes and that tobacco users can 

rotate between using tobacco and not using tobacco many times before they 

quit for good.

Next, have the group introduce themselves and state what type of tobacco they 

use, how much daily, and when they started using tobacco. This information 

is good to enter into your progress notes for the class. Note if participants are 

using chewing tobacco. If participants are using chewing tobacco, try to say 

“tobacco” rather than “cigarettes” when instructing the program so everyone 

feels included.

It is a good idea to set up “rules” for the program. Examples include respecting 

other group participants, keeping information that is said in the group 

confidential, no tobacco breaks during class, and limiting topics of discussion 

to tobacco cessation. It is beneficial to keep political talk out of the group 

sessions. Also ask the group for rules they would like to include. Participants 

can sign confidentiality agreements at the first class to be scanned into their 

charts.

Give A Brief Summary Of The Program, Reviewing The Topics For Discussion For 

Each Of The Classes

A discussion about the regional tobacco use for the state where you live is a 

good way to start participants talking in the group. You can find your state-
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

specific prevalence of cigarette and smokeless tobacco use on the Centers 

for Disease Control and Prevention (CDC) website at: http://www.cdc.gov/

tobacco/data_statistics/state_data/index.htm. The prevalence of tobacco use 

among VA patients is very similar to the state-specific data, but in some cases 

might be slightly higher.

The next topic of discussion is the participants’ reasons to quit tobacco. 

Explain that it is important to start thinking about why they want to quit and to 

keep these reasons at the forefront of their minds as they embark on this quit 

attempt. Ask the participants to give one reason they have for quitting tobacco 

to facilitate a discussion. If participants offer “my health” as a reason, ask 

them to be specific about what part of their health they are concerned about 

and list each health reason separately. Being specific about health reasons will 

make it more personalized for the group members.

Ask participants to review why they use tobacco. Again have them go around 

the room and give one reason they use tobacco. Reassure participants that it is 

ok to admit that they like to smoke or chew (or both) and this does not impact 

whether they will be successful in stopping tobacco. Once they have reviewed 

their reasons to use tobacco, have them look at the participant manual pages 

(p. 3-4) listing their reasons to quit and their reasons to use tobacco. Ask: Do 

your reasons to quit outweigh your reasons to continue to use tobacco? If the 

answer is yes, then they are ready to quit tobacco.

Next, ask the participants if they have tried to quit tobacco in the past. Then 

have them think about what caused them to go back to using tobacco. Introduce 

this as a barrier to quitting. Barriers can be thought of as “speed bumps” that 

can get in the way of quitting successfully. The barriers can also become a 

“back door” that is left open to justify going back to smoking or chewing. It is 

helpful to close these “back doors” so there is no reason to return to tobacco. 

Have the class give one barrier they feel might hinder their chances of quitting 

tobacco. Participants can mark off their barriers to quitting on page 5 of the 

participant manual. Discuss each barrier and have the group think of ways to 

manage each barrier without using tobacco.

Class 2

Covers Chapter 2: Why Do I Use Tobacco? & Chapter 3: Nicotine Addiction

Why Do I Use Tobacco?

Review the types of behaviors related to tobacco use:

1. Learned behavior: Ask the class where they learned to use tobacco. 

The list could include family, friends, TV/movies, magazines, and 
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

military life. Then go over the calculation of how often they puff on 

a cigarette a day and mention how many puffs this would equal in 

a year.

If you look at smoking one pack a day for 40 years you would have

taken approximately three million puffs from cigarettes.

Example My Experience

If you smoke 1 pack per day

 I smoke ____ packs/

cigarettes per day

Estimate 10 puffs on 

each cigarette

 Estimate 10 puffs on 

each cigarette

10 puffs/cigarette x 20 cigarettes/

day = 200 puffs each day

200 puffs/day x 365 days/year =

73,000 puffs/year

 10 puffs/cigarette x ___

cigarettes/day = ____ puffs 

each day

2. Triggered behavior: Have the class discuss their triggers and have 

them mark these off in the participant manual (p. 8‐9). Then pose 

a challenge: Ask each participant to pick one trigger they have 

each day. An example of a trigger could be after breakfast. The 

challenge is to avoid smoking or chewing tobacco for 10 minutes 

after that trigger for the first day. If they are successful in waiting 

10 minutes, then they are encouraged to add 10 minutes a day until 

they have reached not smoking for 60 minutes after the trigger. 

They should only attempt one trigger once in a day to start. If they 

are successful with the first trigger, then the next week they can try 

a new trigger. Have participants think of things they can do instead 

of smoking. Examples could be taking a walk, deep breathing, using 

sugar-free candy or gum, chewing on a straw or toothpick, reading a 

book, doing yard work, or brushing their teeth. This can help them 

be more successful at avoiding using tobacco use around the trigger.

3. Automatic behavior: Review that tobacco use can develop over 

time into an automatic behavior where they use tobacco without 

even thinking about it. To help reduce the automatic behavior, 

suggest they move their tobacco to a different location. This could 

mean putting the pack of cigarettes on the kitchen counter instead 

of in their pocket. They could also bring only one cigarette with 
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

them when going outside to smoke instead of the entire pack. This 

way they have to go back inside to get more if they want more than 

one cigarette. This may help them reduce the amount of daily use. 

The other tip is to try using Table 2. Tobacco Tracker (p. 13) of the 

participant manual. For this exercise, participants mark off each 

cigarette they smoke or each time they chew, noting their mood 

before using tobacco and their need for the tobacco. They can mark 

off 1⁄2 cigarettes, if they are smoking only 1⁄2 of the cigarette at a 

time. By writing down each time they use tobacco, it can help them 

see patterns in their use and whether they smoke due to emotional 

changes or from boredom. They may also find that they can put 

off having a cigarette for a while and this may help reduce their 

daily consumption.

Nicotine Addiction

Nicotine is a substance found naturally in tobacco that causes feelings of pleasure, 

relaxation or stimulation, and stress reduction. Many people mistakenly think 

that nicotine is the substance that causes cancer, lung disease and the other 

toxicities related to tobacco use. Explain that the body is harmed by the many 

other substances found in tobacco and those compounds are formed when they 

are burned. Advise that tobacco, even when grown organically and harvested 

and dried without chemicals, is harmful to the body and still contains cancercausing substances. There are more than 7,000 chemicals in tobacco smoke 

that cause cell damage, cell death, and cancer. Some of the compounds that 

are harmful to humans include:

 Carbon monoxide

 Hydrogen cyanide

 Ammonia

 Lead

 Cadmium

 Polonium-210

 Arsenic

 Benzene

 Formaldehyde

Nicotine is one of the most addictive substances available on earth; this is why 

it is so hard to stop smoking. Explain that you feel a need for a cigarette when 
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

the level of nicotine in your body starts to drop. If you go for long periods of 

time between cigarettes or after sleeping during the night without cigarettes, 

you will have a strong craving to smoke. This is because the amount of nicotine 

in your body has dropped and since your body is used to having nicotine, it will 

want more.

Now ask class participants if they have tried to quit tobacco in the past and 

what withdrawal symptoms they have experienced. Some common withdrawal 

symptoms include:

 Irritability/frustration/anger

 Anxiety

 Difficulty concentrating

 Restlessness

 Depressed mood

 Difficulty sleeping

 Increased appetite

 Cravings

 Coughing

 Runny nose

Explain that most of these symptoms start on the first or second day after 

stopping tobacco. They are at the worst in the first week and get better with 

time. Most symptoms will disappear after 2-4 weeks. Irritability and difficulty 

sleeping will usually be gone after 2-4 weeks, but the urge to smoke can stay 

for a long time. The urge will be stronger at first and seem to last for minutes. 

However, after the first 2-4 weeks, the urges become shorter. For most people 

the urge lasts only seconds after they have been off tobacco for a month or 

longer. Nicotine withdrawal symptoms can be managed by some medicines and 

with behavioral coping strategies. Medications to help with tobacco cessation 

will be discussed during Class 3.
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

Here are some suggestions to deal with the withdrawal symptoms:

Withdrawal Symptom Recommendation

 Irritability  Avoid Stress

 Practice relaxation techniques

 Exercise

 Depressed 

mood

 Do something fun

 Get support from family and friends

 Discuss with your medical provider

 Difficulty 

concentrating

 Avoid stress

 Plan your workload accordingly

 Dizziness  Get up slowly from sitting position

 Chest tightness  Practice relaxation techniques

 Fatigue  Get more sleep

 Take naps

 Don't push yourself

 Hunger  Drink lots of water

 Eat low-calorie snacks

 Stomach pain, 

constipation, 

gas

 Drink fluids

 Eat fruits and vegetables

 Cough, dry 

throat, runny 

nose

 Drink fluids

 Eat sugar-free candy

 Use cough drops

 Difficulty 

sleeping

 Reduce caffeine consumption (e.g., reduce 

daily intake by 50%)

 Stress  Practice relaxation techniques

 Avoid Stress

 Exercise

 Plan your workload accordingly
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

Withdrawal Symptom Recommendation

 Craving/urge 

for tobacco

 Practice DEADS Strategy (see p. 47 of 

participant manual)

 Use nicotine replacement therapy

Administer the Fagerström Test for Nicotine Dependence, go over the questions 

with the group, and have them discuss some of their answers.

Fagerström Test for 

Nicotine Dependence

Points* Your 

Points

1. How soon after you wake 

up do you smoke/use your 

first cigarette/chew?

Less than 

5 min.

3

6-30 min. 2

31-60 min. 1

After 1 hr. 0

2. Do you smoke/chew more 

frequently in the hours 

after waking than during 

the rest of the day?

Yes 1

No 0

3. Do you find it difficult not

to smoke/chew?

Yes 1

No 0

4. Which cigarette/chew 

would be the hardest to 

give up?

First one 

in the 

morning

1

Any other 0

5. How many cigarettes do

you smoke in a day?

10 or less 0

11-20 1

21-30 2

31 or more 3

6. Do you smoke when you're

so sick that you're home 

in bed?

Yes 1

No 0
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

NICOTINE DEPENDENCE SCORE (Points): Your Score ________

(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.

Explain what their scores mean. The higher the number (up to 10) suggests a 

higher level of nicotine addiction. In the end, whether the score is high or low, 

quitting tobacco will still require hard work.

How Tobacco Affects Your Body

Review with participants how tobacco affects the body, starting from the head 

and going to the toes. To encourage class participation, write each body part 

(e.g., head) on a board and ask the class the effect of tobacco on each of the 

parts.

Head

 Stroke (blockage or breaking of a blood vessel in the brain)

 Mouth and throat cancers

 Cavities and loss of teeth

 Bad breath

 Decreased night vision

 Yellow staining of skin and teeth

 Nose congestion and infections

 Wrinkles
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

Lungs

 Cancer (up to 85% of all lung cancers are from smoking)

 Emphysema and chronic bronchitis

 Worsening of asthma

 Lung infections

Heart

 Congestive heart failure

 Heart attacks

 Increased blood pressure and heart rate

Stomach/intestines

 Cancers

 Ulcers

 Heartburn

Pancreas

 Cancer

Circulation in arms, legs and feet

 Reduced circulation in arms, legs and feet that sometimes leads to 

amputations in severe cases

Bones

 Increased bone thinning leading to a higher risk of broken bones

Genitals/urinary system

 Cancers in kidneys, bladder and reproductive organs

 Erectile dysfunction in men

 Sexual dysfunction in women
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

Secondhand Smoke

Review the effects of secondhand smoke on adults, children, and pets.

Adults exposed to secondhand smoke may:

 Have more breathing problems

 Get colds or flu more easily

 Have higher chances of heart disease and cancer

 Die younger than people not exposed to secondhand smoke

Children exposed to secondhand smoke may have:

 More breathing problems like asthma

 More ear infections

 More lung infections like pneumonia

 More dental problems like cavities

Pregnant women and infants exposed to secondhand smoke may have:

 A higher risk of giving birth to a low birth-weight baby

 A higher risk of sudden infant death syndrome (SIDS)

Pets exposed to secondhand smoke may have:

 Higher risk of oral cancer, lung cancer and lymphomas (cats)

 Higher risk of lung and nasal cancers (dogs)

 Higher risk of lung cancer (birds)

 A fatal nicotine overdose if your pet eats a cigarette

After reviewing the harmful effects of tobacco, it is time to review how the 

body heals after stopping tobacco. Review the section Recovery Of Your Body 

After Stopping Tobacco (p. 26-27) in the participant’s manual. Start with 20 

minutes after stopping and end at 20 years. It can be mentioned that the 

benefits of lowered blood pressure and heart rate occurring 20 minutes after 

quitting can be experienced by participants as they sit in the group.

20 minutes after you quit

Reduction in your heart rate and blood pressure; the temperature of your 

hands and feet will start returning to normal.
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

12 hours after you quit

Carbon monoxide level in your blood drops.

24 hours after you quit

Anxiety and irritability may start due to withdrawal from nicotine. These

symptoms get better the longer you are off tobacco.

2—3 days after you quit

Nerve endings in your body start to regenerate and you may notice a 

return in your taste and smell. Anger, anxiety and irritability from nicotine 

withdrawal may be at the worst level during this time. Nicotine replacement 

with nicotine gum or lozenges may help this. Breathing may be easier now.

1 week after you quit

Tobacco cravings and urges may be less frequent and shorter in duration.

2 weeks after you quit

Blood circulation in your gums and teeth are similar to a nonsmoker. 

You should no longer have anger, anxiety and irritability from nicotine 

withdrawal. Cravings and urges should be shorter and less frequent.

1—3 months after you quit

Your heart attack risk has started to drop and your lung function is 

improving. The blood circulation in your body has improved and walking 

might be easier. Give walking a try and see if you can go farther than when 

you were smoking. If you had a cough when you smoked, the cough should be

gone now.

1—9 months after you quit

Smoking-related nasal congestion, fatigue, and shortness of breath should 

be improving. Cilia (little hairs in the lungs, throat and nose) have re-grown 

in your lungs and can clean your lungs to remove irritants and mucous, and 

reduce infections.

1 year after you quit

The risk of cardiovascular disease, heart attack, and stroke has dropped to 

less than half that of a smoker.

10—15 years after you quit

Your risk of having a stroke or heart attack has dropped to a similar rate as 

a nonsmoker.

Your risk of lung cancer is 30-50% less than a continuing smoker’s risk. Your 

risk of death from lung cancer is one-half of the risk if you were an average 

smoker (one pack per day). Your risk of pancreatic cancer is similar to a person 

who has not smoked and your risk of mouth, throat, and esophageal cancer has 

reduced significantly.
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

Your risk of tooth loss has decreased to a rate similar to someone who has 

never smoked.

20 years after you quit (women)

Your risk of death from smoking-related causes, including cancer and lung 

disease, is the same as a person who never smoked.

Class 3

Covers Chapter 4: Medications To Help You Quit Tobacco & Chapter 5: Getting 

Ready For Quit Day!

(Please refer to Chapter IV of this manual for detailed information on 

medications used for tobacco cessation.)

Medications To Help You Quit Tobacco

When presenting information about medications for tobacco cessation, 

emphasize to the participants that the medications can help them quit tobacco, 

but they are not a “magic bullet.” Research shows that using medication, in 

addition to behavioral counseling is the best method to quit tobacco. It is 

important to present the medications in an unbiased manner, understanding 

that each class participant might need to use a different regimen due to their 

medical history or current medications. If one regimen is highlighted to be 

significantly more effective than another regimen, then participants will want 

to use that regimen even if it might not be advisable with their medical history 

or current medications.

There are many ways to present the medication section to the group. One 

way to present the information would be to first present NRTs, highlighting 

the nicotine patch, nicotine gum and nicotine lozenge. Since the nicotine 

nasal spray and nicotine oral inhaler are not on the VA national formulary, it 

may not be necessary to present these in the group. The nasal spray and oral 

inhaler could be introduced to an individual patient if they have had problems 

tolerating the other NRTs and meet the criteria for nonformulary use. Refer to 

Table 6. Medications for Tobacco Cessation Available Through the VA National 

Formulary on p. 47 that covers medications.

The nicotine patch, nicotine gum and nicotine lozenge can be presented to

include the following information:

 Directions for use

 Duration of therapy

 Potential adverse effects
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

 Options for combination therapy and instructions on use of 

combination therapy

Bupropion can be presented next with the following information highlighted:

 Relative contraindications

 General dosing instructions

 Potential adverse effects

 Directions for use

 Duration of therapy

 Options for combination therapy and instructions on use of 

combination therapy

Varenicline can be presented next with the following information highlighted:

 Relative contraindications

 General dosing instructions

 Potential adverse effects

 Directions for use

 Duration of therapy

 Inform class participants that varenicline is not used in 

combination therapy

Smoking And Drug Interactions

When a person smokes, they inhale polyaromatic hydrocarbons, which can 

increase the metabolism of certain medications. Specifically the polyaromatic 

hydrocarbons cause an induction of the CYP1A2 liver enzymes. This effect is 

only seen with smoking tobacco and is not seen when using chewing tobacco 

or when using NRT.

Medications that can be affected by this include:

 Atypical antipsychotics

 Theophylline

 Warfarin

 Anxiolytics
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

 Antihypertensives

 Caffeine

When an individual stops smoking, their liver enzymes will return to normal 

functioning in 2-3 days. If they are taking the medications listed above, 

they might have increased adverse effects. If this occurs, a reduction in the 

medication dose may be needed.

If patients drink coffee or consume other caffeinated beverages, they might 

have side effects of too much caffeine if they continue their same level 

of consumption. It is recommended that a person reduce their caffeine 

consumption by 50% when they stop smoking.

Getting Ready For Quit Day!

With the group, review the following steps to get ready for quit day.

1. Plan out your tobacco usage so you will run out by your quit day. 

Make sure you remove all tobacco from your home. Look in jacket 

pockets, kitchen drawers, the freezer, your garage, or other 

frequent tobacco storage sites. Also check inside your car for any 

stashes of tobacco. Considering that the average craving for tobacco 

lasts 2-3 minutes, removing nearby tobacco products will keep you 

from being tempted. For most folks, the urge may pass before you 

can get in the car and go to a store to buy tobacco.

2. Remove all ashtrays and lighters. These can be triggers for tobacco 

once you get to quit day. Since your plan is to quit, do you really 

still need them? Remove ashtrays and lighters in the car as well.

3. Clean up your smoking area. If you smoke in one room (e.g., porch, 

garage) or in the car, clean up these locations, as they can be 

triggers for you to smoke. Remove cigarette butts, wash down 

furniture, and spray upholstery with an odor neutralizer to help 

remove the smoke smell. Getting your car cleaned or detailed may 

help. You may find you have trouble spending time in these areas for 

a while. That is ok, just take a break and come back when you have 

a few weeks being tobacco free.

4. Go to the store and stock up on tobacco substitutes. Sugar-free 

gum, sugar-free mints or candies, carrot and celery sticks or other 

vegetables, toothpicks, straws, and cinnamon sticks. These items 

can be helpful to use when you are having a craving.
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

5. Think about hobbies or other interests you have to fill up your 

day. Some hobbies/interests to consider would be puzzles, games, 

reading, exercise, fishing, woodworking, painting, drawing, and 

cooking. Make sure it is a hobby not associated with tobacco use.

Encourage participants to consider packing an emergency kit for their first long 

car trip or a pending adventure. Such a kit would contain:

 Sugar-free candy

 Sugar-free gum

 Toothpicks

 Straws

 Vegetables and fruit

 Water

 Cinnamon sticks

 Throat lozenges

Planning For Quit Day

Group Activity

Page 45 of the participant manual has participants list the top situations where 

they use tobacco and what they will do instead of using tobacco. They can 

also use the information from Table 2. Tobacco Tracker (p. 13) to review their 

pattern of using tobacco. Then pick three times that they use tobacco and 

write these into the spaces on page 45. Ask the group to write down an activity 

they can do or a substitute they can use instead of using tobacco. Have the 

group share one of their times that they smoke/chew and something they will 

do at that time instead of using tobacco.

Stress And Tobacco Use

Most Veterans who use tobacco say that stress is their biggest trigger. When 

under stress, many smokers will inhale deeper and hold the smoke in longer. 

Most people feel that using tobacco helps them relax when they are feeling 

stress. It is important to explain that the feeling of relaxation is usually from 

the nicotine treating the withdrawal symptoms between cigarettes or chewing 

tobacco. Nicotine is actually a stimulant and can increase heart rate and blood 

pressure very quickly. This can result in physical stress.
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

Ask the group to think about situations that cause them to have more stress. 

They can write down these situations in their manual.

Discuss with the group the stress reduction tips listed in the participant manual 

including:

 Talking to a friend

 Deep breathing

 Going for a walk or a jog

 Doing chair exercises

 Reading a book

 Listening to relaxing music

 Working a crossword puzzle

 Playing computer games

Cravings For Tobacco

Review that it is common to have cravings for tobacco after quit day. Almost 

all people have tobacco cravings when they quit. Explain that having a craving 

for tobacco should never be thought of as a relapse.

Introduce the DEADS Strategy (see p.60‐61):

 Delay

 Escape

 Avoid

 Distract

 Substitute

Get Help From Family And Friends

Finding a support person can be helpful. It could be a family member, a friend,

a neighbor, or someone from work. It is best to choose someone who does not

smoke. How can your support person help you?

 Listen when you want to talk
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

 Call to see how you are doing

 Offer to help you with chores, errands, childcare, shopping, etc.

 Talk about problems and how to solve them

 Cheer you on

You can help your support person in the following ways:

 Let them know what will help you

 Let them know when you will be quitting tobacco

 Plan on when you want to talk to them after quit day

 Plan fun activities that can keep you from thinking about tobacco

 Teach your support person about quitting tobacco, especially if they 

have not used tobacco themselves

 If you are keeping your quit attempt a secret, then let your support 

person know this

 Thank your support person for helping you quit tobacco

Class 4

Covers Chapter 6: Quit Day

Quit Day

Celebrate the quit day! Congratulate everyone in class for making it to this 

day. Take time to go around the group and ask everyone when they last 

smoked or chewed tobacco. Congratulate those who have quit so far and give 

encouragement to those who have not quit. Provide assistance to those who 

have not yet quit. Review briefly getting ready for quit day again and suggest 

they try quitting tomorrow if they are ready.

Review The Following:

It Is Time To Make Some Changes:

 Change your routine

 Switch the order of your morning

 Be active — take a walk

 Have your morning coffee in a new mug
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

 Drink less caffeine

 Drive to work on a new route

 Take your work break inside

 Get up from the table as soon as you finish eating

 Sit in a different chair to watch TV or read the newspaper 

Keep Busy:

 Do something fun like see a movie

 Exercise for 20-30 minutes a day

 Wash your clothes and sheets 

 Use substitutes to keep your mouth busy

 Meet with friends who don’t smoke

 Go to nonsmoking places like the library

 Drink more water

 Stay away from places where you smoked 

Don’t:

 Feel like smoking has been taken away from you, remember you are 

better off without it.

 Test yourself by trying a cigarette. This can lead to a full relapse.

 Forget there will be difficult times when you stop smoking: be proud 

of how well you are doing!

 Drink alcohol and go to bars for a while; this can be too tempting 

and you may want to smoke.

 Forget to bring nicotine lozenges or nicotine gum with you when you 

need to go places or do things where you used to smoke.

Handling Nicotine Cravings

Review that nicotine cravings at first seem like they last minutes and happen 

frequently. The cravings will reduce in intensity and frequency with more time 

off tobacco. Review the DEADS Strategy (p. 60-61). Also remind participants 
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

that have been using nicotine gum or lozenges in combination therapy that 

these are used to help reduce nicotine cravings.

Spend a few minutes reviewing deep breathing exercises and suggest using 

these to help with nicotine cravings.

Discuss how exercise can be used to help reduce nicotine cravings. For 

participants who do not currently exercise, emphasize that they start very 

slowly at about five minutes and slowly increase as tolerated. Review activities 

they can try:

 Walking or jogging

 Tennis

 Dancing

 Golfing without a cart 

 Aerobic exercise classes

 Cycling

 Gardening and pushing a lawn mower

 Yoga

 Swimming 

 Water walking

 Weight machines

 Aqua aerobics

Healthy Eating

This can be particularly helpful if participants are concerned about weight gain 

after quitting tobacco.

Suggestions to review:

 Weight gain is typically small from quitting tobacco, about 5-10 

pounds on average.

 Eating more healthy foods and staying active can minimize weight 

gain after stopping tobacco.
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

 Eat more fresh fruits and vegetables. If you cannot afford fresh 

fruit/vegetables, then try buying them frozen.

 Drink more water, which will help you feel full and reduce 

weight gain.

 Eat carrot and celery sticks to help with the hand-to-mouth habit 

from smoking.

 Eat crunchy foods like pretzels, rice cakes, or air popped popcorn, 

so your mouth has to work.

 If craving a sweet, eat a small square of dark chocolate or a low-fat 

frozen yogurt.

 Eat smaller meals, but more often. If you eat snacks in between 

meals, you are less likely to overeat. This can help prevent weight 

gain as well.

Congratulate the class one more time to finish the session and wish them luck 

for the next week.

Classes 5-7: Follow-up classes

Covers Chapter 7: The first two weeks after quit day, Chapter 8: How do I stay 

off tobacco? & Chapter 9: Living as a nonsmoker)

The ideal time for the first follow-up class is in the first week after quit day. 

Subsequent follow-up classes can be done weekly or could be extended to 

every two weeks.

The First Two Weeks After Quit Day

The first portion of each follow-up class can be used to ask each class member 

to share how they have done since quit day. Ask the class to comment on the 

following:

 Have you had any slips since quit day?

• If you had a slip, what caused it?

• Did you continue to smoke or did you stop after the slip?

• What could you do in the future to prevent having a slip?

 What benefits have you noticed since quit day?

• Examples of some benefits they may have noticed so far:

 Improved breathing
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

 More energy

 Improved sense of taste and smell

 Yellow staining almost gone from fingers and sides of mouth

 Feeling in control instead of the cigarette being in control 

 MORE MONEY!

Reward Yourself

Discuss that rewarding yourself along the way when you quit tobacco can help

you stay motivated. Review examples of rewards:

 Buy yourself something special to celebrate quitting

 Splurge on a massage or dinner at a new restaurant

 See a movie or sporting event

 Start a new hobby

 Begin exercising

 Use your savings to pay off your bills

 Go on a nice trip after being a nonsmoker for six months

Ask the group if they have some rewards they plan to do after quit day. Review 

page 61 of the participant manual and the cost savings from quitting tobacco. 

Have the group calculate their savings.

If participants have problems with triggers and urges for tobacco, review the 

section:

How Do I Stay Off Tobacco?

Watch Out For Triggers

 Go back to your list of triggers on pages 8-9.

 What triggers are the most common now that you have quit?

 How have you kept from using tobacco when you have a trigger?
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

Resist The Urges

Remember, the urge to use tobacco will go away whether you smoke/chew

or not. Try to avoid using tobacco and the urges will slowly lose their power 

over you.

Go back to page 45 when you were planning for quit day. On that page you 

wrote down what you could do instead of smoking when you had a craving for 

tobacco. Have these strategies worked? 

Make a new list if your strategies are not working.

 Instead of using tobacco I could:

• Go for a walk

• Chew gum

• Eat a sugar-free mint or candy

• Talk to a friend

• Listen to music

• Play with your dog/cat

• Try deep breathing

No matter what, don’t think “Just one won’t hurt”...yes it can hurt and 

cause you to go back to smoking daily. You have worked so hard!

Keep things simple. Work through this one day at a time.

Planning For The Future

It is time to start looking at your calendar and see if there are any big events 

coming up that might be a trigger for you to use tobacco. Examples of some 

events that could cause triggers:

 Weddings

 Holidays

 Anniversaries

 Birthdays

 Family or group events

 Sporting events
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

 Hunting season

 Fishing season

List some upcoming events where you might be triggered to use tobacco.

What could you do instead of smoking at these events?

Slip Prevention

This is an important section to review with participants. Include an explanation 

of what a slip is and how to prevent slips. Use the information below to assist 

with the discussion.

What is a slip? This is when you smoke a couple cigarettes and then go back to 

not smoking. This is not a full relapse but can lead to a relapse if not corrected 

quickly.

To prevent slips:

 Be aware of triggers—during these times you will crave tobacco 

more often

 Do not get overconfident—you may think that you can smoke just 

one and go back to being a nonsmoker. Many people relapse and go 

back to full-time smoking after just one cigarette.

 Think about the benefits you have experienced and feel good about

your progress

To continue your success, try to:

 Be aware of your triggers

 Not get discouraged if you slip and stay the course of becoming 

tobacco free

 Stay positive and praise your achievements

 Focus on the benefits of quitting and beginning a healthier lifestyle

What if I have slipped?

Don’t get discouraged! One cigarette is better than smoking the whole pack. 

Get back on track quickly.

 Slips can quickly lead to a relapse
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

 If you bought a pack, throw it away and destroy it so you will not be 

tempted to dig it out of the garbage

 Continue to use medications as prescribed

Figure out what caused the slip:

 If you can identify what caused the slip, you can try to prevent this 

from happening in the future

 If stress is the cause, review your stress reduction strategies 

such as:

• Deep breathing

• Going for a walk

• Removing yourself from the stressful situation

• Using nicotine lozenges or nicotine gum if you were prescribed 

these medications. If you were not prescribed these, ask your 

provider if these would be appropriate for you.

Don’t let one slip take you back to smoking again!

What if I am back to daily smoking?

If you go back to daily smoking then this is called a relapse. If you relapse, get

back on track as soon as you can.

 Stop your medications until you are ready to quit again

 Set a new quit day in the next two weeks

 Review what led you to start smoking again

 Plan out your cigarettes so you will not have any left once you get to 

your new quit day

 Throw out ashtrays and lighters on quit day

 Talk to your provider about the medication you used for 

stopping tobacco

• You might want to consider a change in medication if the 

medication did not seem to help you or if you had adverse effects 

from the medication.

• If the medication did help you, then you can retry the 

same medication.
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

Don’t tell yourself negative messages like:

 “It’s no use, I can’t quit. I may as well give up because I smoked!”

• In reality, it takes people on average 6-8 tries to quit for good.

 “I smoked because I’m weak and don’t have the willpower.”

• This is not about willpower. It’s more about learning from the 

relapse to make sure you don’t fall back again. You learn more 

about your addiction and the best way for you to quit the more 

times you try.

 “I’m too old to quit smoking; it is too late for me anyway.”

• Everyone can benefit from stopping smoking no matter their age 

or current health status.

• Even people with very severe lung disease can see improvements 

by stopping smoking.

Living As A Nonsmoker

For each follow-up class, go around the room and have each member comment 

on the progress of their quit attempt. Have each member comment on the

following:

 Have you had any slips since quit day?

• If you had a slip, what caused it?

• Did you continue to smoke or did you stop after the slip?

• What could you do in the future to prevent having a slip?

 What benefits have you noticed since quit day?

• Examples of some benefits they could have noticed so far:

 Improved breathing

 More energy

 Improved sense of taste and smell

 Yellow staining almost gone from fingers and sides of mouth

 Feeling in control instead of the cigarette being in control 

 MORE MONEY!

Review with the group tips to maintain cessation from tobacco products. Use 

the information to assist with the discussion. Congratulate everyone in the 
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

group on their progress in quitting tobacco. For those who are still smoking, 

provide continued encouragement to help them quit completely. One strategy 

is to set another quit day and try again. For those who have quit completely, 

encourage continued cessation by reviewing the following:

 Avoid smoking and chewing

• Smoking or chewing even one time can lead to relapse. 

Sometimes you might think that “it is only one” but many people 

have relapsed from “just one.”

• Avoid cigars also, this can lead you back to smoking or chewing 

and cause a relapse.

 Try to be around people who do not smoke

• It can be challenging to stay off tobacco when you are around 

people who still smoke. Try to be around nonsmokers if you can 

do this. If you must be around people who smoke, let them know 

you have quit smoking and ask them not to offer you any tobacco. 

You can also be around them in places where they can’t smoke.

• Bring your emergency kit and other items to help distract you 

from wanting to use tobacco.

 Continue to use substitutions and distractions

• Use your emergency kit or some sugar-free candy or gum

• Have a book, the newspaper, or a puzzle book to do when you 

have extra time on your hands

 Don’t be afraid to ask for help

• If you have been working with your primary care provider or 

tobacco cessation counselor to quit, contact them if you are 

struggling to remain off tobacco

• Ask for help from friends and family 

• Call the tobacco quit line at 1-855-QUIT VET

 If you have been using medication to help you quit, take it for the 

entire course of treatment

• You may feel ready to stop the medication early, but try not 

to do this. The medication may work better if you finish the 

entire course.
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

• If you need the medication for a longer period of time, talk to 

your primary care provider or tobacco cessation counselor.

 Congratulate yourself every day

• You have done an amazing job and you deserve it!

Remind Participants: If you feel like using tobacco again, remember why 

you quit.

Go back to page 3 and look at your reasons for quitting tobacco. Check off the

things you are enjoying now that you have quit tobacco:

 I have more energy

 I can breathe better

 I am not wheezing

 I sleep better

 I can walk farther

 I have saved money

 I don’t have to stand outside 

to smoke

 I can say I am a nonsmoker

 I am setting a good 

example for my children/

grandchildren

 I smell better

 I can taste my food

 I have lowered my risk 

of cancer

 I have lowered my risk of 

heart disease

 I have less stress since I 

quit tobacco

 I am in control now

 I am proud of myself
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

Dealing With Stress

Here are more tips on how to deal with stress. We all have stress, so remember 

that there are ways to deal with stress other than using tobacco.

Do what is best for you

 Give yourself extra time to get to work or appointments

 Make time to do things you want to do

 Learn to say “no” to things you don’t want or don’t have time to do

 Eat healthy foods

 Get enough sleep

 Reward yourself

Have fun

 Enjoy your hobbies

 Go for a walk, go swimming, or get on your bike

 Go to a movie

 Play with your favorite pet

 Go outside

Spend time with others

 Visit or call a friend

 Go out to eat

 Spend time with family members

 Cook a special meal for your spouse or friend

 Go to a fun event

Keep busy

 Go dancing

 Work on your yard

 Fix or build something
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics

 Clean your home

 Listen to music

Find time to relax and have quiet time

 Read a book or magazine

 Listen to music

 Take a bath

 Practice deep breathing

 Meditate

 Daydream

 Take a yoga class
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99

Appendices

Appendix A. Evaluating Tobacco 

Cessation Programs

Appendix B. Tobacco Cessation

Resources
100

Appendices

Appendix A. Evaluating Tobacco 

Cessation Programs

To assess the effectiveness of your program, track the outcome measures 

related to its objectives. The use of these outcome measures as performance 

measures will elicit more participation support among your fellow clinicians. 

Below is a list of tobacco cessation program performance measures you may 

want to track yearly, quarterly, monthly, weekly, and/or daily.

 Number of patients seen in your clinic

 Number of patients identified as a smoker in CPRS (Tobacco Use

Disorder ICD-9 Code 305.1)

 Number of patients identified as smoker when prompted by 

a provider

 Number of patients in each dependence level, as defined by 

Fagerström Test for Nicotine Dependence

• (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

 Number of patients reporting abstinence (supported by cotinine 

level, CO2 — optional)

• Continuous abstinence (1, 3, 6, and 12 months)

• 7 day point prevalence (not smoking during the last 7 days)

 Number of patients referred to the smoking cessation program

 Number of encounters/visits completed

 Number of patients enrolled in the clinic

 Number of quit attempts

 Number of patients prescribed the different types of medication 

regimens and their outcomes (abstinence)
101

Appendices

• Combination NRTs such as the patch + lozenges

• Combination bupropion + NRT (e.g., nicotine patch)

• NRT monotherapy

• Varenicline

 Number and details of counseling sessions

• Face-to-face

• Telephone

• Duration and frequency

• Provider who delivered the intervention

To track the effectiveness of your facility in providing tobacco cessation 

assistance, below is a checklist of performance measures you may want to 

track yearly, quarterly, monthly, weekly, and/or daily.

 Number of tobacco users screened for their interest in a tobacco 

cessation program

 Number of tobacco users ready for a screening visit with a tobacco 

cessation counselor following this visit

 Number of tobacco cessation medication prescriptions ordered 

by providers

 Number of patients prescribed specific medication regimens and 

their outcomes (i.e., abstinent at 1 month, 3 months, 6 months, 

12 months)

 Number of counseling sessions, frequency, duration, provider who 

delivered interventions
102

Appendices

Appendix B. Tobacco Cessation Resources

Web And Telephone Resources

 VHA Tobacco & Health

www.publichealth.va.gov/smoking

 Quit VET, Veterans Smoking Quitline

1-855-QUIT VET (1-855-784-8838)

8am-10pm, Monday-Friday (ET)

Counseling is available in Spanish

 SmokefreeVET Text Message Program

Text the word VET to 47848 or sign up online:

www.smokefree.gov/VET

 Stay Quit Coach smartphone app

http://mobilehealth.va.gov/app/stay-quit-coach

 Smokefree.gov

www.smokefree.gov

 Women.smokefree.gov

www.women.smokefree.gov

 Womenshealth.gov

www.womenshealth.gov/smoking-how-to-quit

 My HealtheVet

www.myhealth.va.gov

 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/health-care-information/topics/topic-tobacco-use.html

 Office of the Surgeon General

www.surgeongeneral.gov/tobacco

 Healthfinder Tobacco Resources Page

www.healthfinder.gov/scripts/SearchContext.asp?topic=860
103

Appendices

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

 Center for Disease Control and Prevention

www.cdc.gov/tobacco/basic_information/smokeless

Web Resources and Online Trainings for Health Care Providers

 VHA Smoking and Tobacco Use Cessation intranet

http://vaww.publichealth.va.gov/smoking

 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

 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/clinicians/update/

treating_tobacco_use08.pdf
104

Appendices

 VA Center for Integrated Healthcare

Tobacco Use Cessation: A Brief Primary Care Intervention (A Training 

Manual for Integrated Primary Care Behavioral Health Providers and 

other Tobacco Cessation Providers)

http://www.mentalhealth.va.gov/coe/cih-visn2/

documents/provider_education_handouts/

tobacco_use_cessation_brief_intervention_manual_version_3.pdf

 U.S. Department of Veterans Affairs

Integrated care for smoking cessation: Treatment for Veterans with 

PTSD (For a copy of this manual, contact VA’s Clinical Public Health 

at publichealth@va.gov)

 Online Trainings

The University of Wisconsin School of Medicine and Public Health 

offers a free online, 1-hour CME program on treating tobacco use 

and dependence. Participants will learn best evidence-based 

practices as culled from the DHHS Public Health Service (2008) 

Treating Tobacco Use and Dependence (Clinical Practice Guideline). 

Visit http://cme.uwisc.org/index.pl for further information.
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Sponsored by

U.S. Department of Veterans Affairs

Veterans Health Administration

Clinical Public Health

U.S. Department of Veterans Affairs

Veterans Health Administration

Washington, DC 20420

Primary Care & Tobacco Cessation Handbook:

A Resource for Providers

May 2014

IB 10-565; P96622