HIV Provider 

Smoking

Cessation

Handbook

A Resource

for Providers

HIV Provider 

Smoking

Cessation

Handbook

A Resource

for Providers
The provider manual HIV Provider Smoking Cessation Handbook and the 

accompanying My Smoking Cessation Workbook were developed by the 

HIV and Smoking Cessation (HASC) Working Group of the Veterans Affairs 

Clinical Public Health (CPH). The authors primary goal was to develop 

materials promoting smoking cessation interventions, based on published 

principles of evidence- and consensus-based clinical practice, for use by 

HIV-care providers treating HIV+ patients who smoke.

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

materials used in these publications were modified from smoking cessation 

workbooks they developed for providers of patients with post traumatic 

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

Network Mental Illness Research, Education & Clinical Center of Excellence 

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

Care System. The 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 the Office of Public Health 

Policy and Prevention of CPH, for supporting this project; Hannah-Cohen 

Blair and Michelle Allen, research assistants, for their help organizing 

materials; and Leah Stockett for editing the manual and the workbook. 

As well, the HASC Working Group: Ann Labriola, Pam Belperio, Maggie 

Chartier, Tim Chen, Linda Allen, Mai Vu, Hannah Cohen-Blair, Jane Burgess, 

Maggie Czarnogorski, Scott Johns, and Kim Hamlett-Berry.

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.

Acknowledgements
i

Table of Contents

I. HIV and Smoking .................................................1

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

Benefits of Smoking Cessation in

HIV-Infected Smokers ....................................... 5

The HIV Care Provider’s Role .............................. 6

Challenges to Cessation in

HIV-Infected Smokers ....................................... 7

II. Smoking Cessation Interventions............................ 15

Effectiveness of Smoking

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

Starting a Smoking Cessation Program for 

HIV‐Infected Veterans...................................... 18

Smoking Cessation Behavioral Interventions............ 18

Identifying Reasons to Quit ............................... 21

III. Real‐time Scripts for Brief Smoking

Cessation Interventions...................................... 25

Approaching Your Patients about

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

Addressing Patient Concerns.............................. 28

IV. Medications for Smoking Cessation ........................ 35

Nicotine Pharmacology .................................... 38

Nicotine Replacement Therapy (NRT) ................... 39

Bupropion....................................................44

Varenicline .................................................. 46

V. Relapse Prevention and Smoking

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

Smoking is a Chronic, Relapsing Disorder ............... 59

Management of Withdrawal Symptoms .................. 60
ii

Appendices ........................................................ 65

Appendix A. Sample Smoking

Cessation Programs ........................................ 66

One-on-one counseling ............................... 68

Group Counseling...................................... 72

Telephone Counseling................................. 74

Appendix B. Evaluating Smoking

Cessation Programs ........................................ 89

Appendix C. Educational Materials and

Additional Resources for Patients ........................ 91

Smoking and HIV Fact Sheet ......................... 91

Web and Telephone Resources ...................... 94

Appendix D. Educational Materials and

Additional Resources for Providers....................... 96

The 5 A’s of Smoking

Cessation Interventions............................... 96

The 5 R’s of Enhancing Motivation

to Quit Tobacco........................................ 97

Sample: Smoking Cessation Program

Screening Form ........................................ 99

Sample: HIV Clinic Form.............................100

Web Resources and Online Trainings............... 101

Appendix E. FAQs..........................................103
iii

Tables and Figures

 Table 1. The 5 A’s of Brief Smoking

Cessation Interventions .............................. 19

 Table 2. Enhancing Motivation to Quit Tobacco ............. 21

 Table 3. Fagerström Test for Nicotine Dependence ........ 28

 Table 4. Sample Responses to Patients’ Concerns

About Smoking Cessation ............................ 29

 Table 5. Sample Scripts for Brief Smoking

Cessation Conversations Between

Patients and Providers ............................... 31

Figure 1. Efficacy of Medications for

Smoking Cessation .................................... 38

 Table 6. Medications for Smoking Cessation

Available Through the VA

National Formulary ................................... 48

 Table 7. Smoking Withdrawal Symptoms 

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

 Table 8. Eight-Session Smoking Cessation 

Intervention Schedule ................................ 71

 Table 9: PMTTCC Script for Initial Call

(20-30 minutes)........................................ 75

1

I. HIV and Smoking

3

I. HIV and Smoking

CHAPTER SUMMARY

Scope of the problem

 The incidence of smoking in HIV-infected Veterans is high and 

likely underreported

 Tobacco dependence is a chronic disorder that often requires 

repeated intervention and multiple attempts to quit

 Overall health consequences of smoking for those with HIV disease 

are more severe:

• Greater probability of cardiovascular and 

pulmonary conditions

• Greater risk of AIDS and non AIDS‐related illnesses

 Smoking increases the all-cause mortality of HIV-infected 

current smokers

Benefits of smoking cessation in HIV-infected smokers

 Smoking cessation can reduce and prevent many smoking-related 

health problems

 Smoking is the most clinically important modifiable cardiovascular 

risk factor for HIV-infected smokers

 HIV-related symptoms decrease as early as three months after 

smoking cessation

 Every attempt to quit improves probability of eventual success

The HIV care provider’s role

 Address smoking at every visit. Effectiveness starts with the 

clinical routine of:

• Documenting a patient’s smoking status

• Advising patients to quit and inquiring about their readiness 

at every visit

• Approaching smoking as a chronic illness, which includes 

monitoring repeated quit attempts and relapses

• Counseling and prescribing a combination of two smoking 

cessation medications

 Help patients access comprehensive care to address co-morbidities 

hindering their ability to quit

 Utilize an integrated model of care and provide a consistent 

message about smoking
4

I. HIV and Smoking

CHAPTER SUMMARY

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

follow up and represcribing smoking cessation medications

Challenges to smoking cessation in HIV-infected smokers

 Higher incidence of co-morbidities such as post-traumatic stress 

disorder (PTSD), depression, other psychiatric conditions, and 

substance and alcohol abuse

 Complications related to smoking habits may be a more serious 

immediate risk than HIV disease itself

 Culture of smoking higher in the military and among Veterans

SCOPE OF THE PROBLEM

Impact of Smoking on Morbidity and Mortality

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

States.1-2 It is a chronic disorder that often requires repeated interventions 

and multiple attempts to quit. For HIV-infected individuals, smoking has an 

even greater health impact than for smokers in the general population or 

HIV‐infected nonsmokers3-4:

 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.3-7

 HIV-infected smokers have more AIDS-related illness such 

as Pneumocystis jiroveci pneumonia, tuberculosis, and oral 

candidiasis.8-10

 HIV-infected smokers may have a decreased response to 

antiretroviral therapy (ART) and more rapid progression to AIDS.11-12

 There may be an association between smoking and immunologic and 

virologic failure.13

 Cigarette smoking has been found to be an independent predictor of 

non-adherence to ART.14

 Studies have shown that HIV-infected individuals, including Veterans, 

who are current smokers have a significantly higher all-cause 

mortality than those who never smoked.15-16
5

I. HIV and Smoking

ART has changed the prognosis for HIV-infected individuals from a fatal diagnosis 

to a manageable chronic illness.17-18 HIV-infected patients who adhere to ART 

are less likely to die from AIDS-related illnesses than from non‐AIDS‐related 

disease.18 Efforts to improve the health status and quality of life of individuals 

living with HIV is one of the highest treatment priorities. Such efforts need to 

include strategies for effective smoking cessation counseling and treatment.3,18

Incidence of Cigarette Smoking in the U.S. HIV-infected Population and 

HIV-infected Veterans

Approximately 20% of the general U.S. population over 18 years old is a current 

smoker.19 The incidence of HIV-infected current smokers is thought to be much 

higher:

 HIV-infected individuals are 2-3 times more likely to be smokers than 

those who do not have the disease, with prevalence of smoking in 

the general HIV-infected population reported between 40-70%.20-23

 The incidence of smoking in HIV-infected Veterans is also high 

and likely underreported. According to 2010 VHA reports of the 

25,000 Veterans with HIV in VA care, 47% have smoked cigarettes at 

some time and approximately 25% are current smokers. However, 

self-report surveys indicate that more than 70% of these Veterans 

have smoked at some time and 46-51% are current smokers. These 

percentages may be even higher for combat Veterans.24-27

BENEFITS OF SMOKING CESSATION IN HIV-INFECTED SMOKERS

Smoking cessation can reduce and reverse many of the well-known negative 

effects of tobacco use.28 There are also specific benefits for HIV-infected 

patients who quit smoking:

 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.29

 The risk of cardiovascular events in HIV-infected patients decreases 

with increased time since smoking cessation.30

 The evaluation of a smoking cessation program at a 3-month follow 

up found that HIV-related symptom burden decreased as the amount 

of time without smoking increased.31

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

I. HIV and Smoking

Effective Smoking Cessation Strategies

Effective smoking cessation treatments that can significantly increase rates of 

long-term abstinence have been developed and tested.1,32 Patient success in 

quitting and staying smoke-free can be dramatically increased by implementing 

interventions that:

 Increase patient and staff awareness and education

 Use smoking cessation counseling plus smoking cessation medication

 Use two, rather than one, forms of smoking cessation medication

 Consistently identify (through documentation in the Computerized 

Patient Record System [CPRS]) and treat smokers

 Integrate smoking cessation into primary care

THE HIV CARE PROVIDER’S ROLE

HIV care providers have been slow to routinely assess their patients’ smoking 

status and monitor their quit attempts when compared to general primary care 

providers.22,33-34 In a study of VA HIV care providers35 they were:

 Less likely to identify their patients as current smokers

 Had lower confidence in their ability to influence the smoking habits 

of patients in their care

 Less likely to recognize current smoking in patients who reported 

dyspnea/cough, or with smoking-related diseases such as chronic 

obstructive pulmonary disease, coronary artery disease, and 

bacterial pneumonia

In an informal survey of providers at clinics for HIV-infected Veterans and studies 

of HIV care providers, it was shown that fewer than 50% of these providers 

followed the U.S. Department of Health and Human Services’ Treating Tobacco 

Use and Dependence: 2008 Update (Clinical Practice Guideline) of providing 

patients with smoking cessation interventions such as counseling, referring them 

to a cessation program, or providing them with cessation medications.22,25,35

What We Can Do for HIV-infected Patients Who Smoke

Researchers cite the importance of developing smoking cessation strategies 

specifically for HIV-infected smokers.36-38 Studies have shown the efficacy of 

integrating smoking cessation counseling into primary care and into clinics 

serving special populations such as those with PTSD and HIV disease.39-43 HIV 
7

I. HIV and Smoking

care providers can play a key role in helping their HIV+ patients quit smoking 

by:

 Recommending quitting, assessing readiness to quit, giving patients 

information about the risk of smoking and HIV disease and smoking 

cessation materials and monitoring quit attempts and smoking 

relapses. Smokers cite a physician’s advice to quit as an important 

motivating factor for attempting to quit.28

 Administering two smoking cessation medications in combination 

with counseling.

 Assisting patients in resolving co-morbidities that may hinder their 

ability to quit smoking.

 Making referrals to specialists (e.g., mental health and substance 

abuse treatment providers, social workers) as needed.

 Re-prescribing smoking cessation medications after relapse.

CHALLENGES TO CESSATION IN HIV-INFECTED SMOKERS

HIV-infected individuals who smoke have a higher incidence of co-morbidities 

such as PTSD, depression and other psychiatric conditions, as well as substance 

and alcohol abuse.44-49 Some providers are hesitant to attempt smoking 

cessation in patients with serious co-morbidities, while others and some 

HIV‐infected smokers have misconceptions about the impact of light smoking 

in those with HIV disease. Several studies suggest that smoking cessation 

is possible in populations with serious co-morbidities, including HIV-infected 

individuals.

 For Veterans with PTSD who smoke, an integrated model of 

smoking cessation with primary care providers and staff that 

provided consistent care was found to be effective and superior to 

standard‐of‐care smoking cessation programs given separately from 

the primary care clinic.40,42

 Studies in populations with psychiatric disorders and depression 

suggest at least moderate efficacy of smoking cessation and little 

evidence of exacerbation of these disorders.50-51

 Approximately half of alcohol dependent individuals are daily 

smokers and a number of studies have evaluated concurrent 

treatment of nicotine dependence and alcohol use disorders.52 

Overall, evidence indicates that smoking cessation interventions 

for individuals with alcohol use disorders are effective and have no 

detrimental effects on abstinence from alcohol.53 Study results are 
8

I. HIV and Smoking

mixed regarding optimal timing of smoking cessation interventions 

for alcohol use disordered individuals.54-55 Smoking status should 

be addressed for all individuals with alcohol use disorders and the 

following recommendations have been proposed:52,56

• 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 patients and their providers should know that the 

complications of their smoking habit may be a more serious risk to 

them than their HIV disease especially if patients are compliant with 

ART and otherwise well.

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

Surgeon General’s report on how tobacco causes diseases 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.57 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.

Though the Department of Defense and the VA Veterans Health Administration 

have worked hard to reduce tobacco use, smoking remains widespread 

and deeply rooted in military culture and among Veterans.58 In one study, 

HIV‐infected Veterans who smoked were shown to socialize with other smokers 

to a greater extent than with non-smokers.25 Smoking cessation strategies need 

to continue to focus on changing the culture of smoking and find alternative and 

more positive forms of social interactions for Veterans that exclude tobacco 

use.
9

I. HIV and Smoking

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critical component of medical management in chronic disease populations. 

American Journal of Preventive Medicine, 33(6 Suppl), S414-S422. doi: 

10.1016/j.amepre.2007.09.013

38. Borrelli, B. (2010). Smoking cessation: Next steps for special populations 

research and innovative treatments. Journal of Consulting and Clinical 

Psychology, 78(1), 1-12. doi: 10.1037/a0018327

39. Goldstein, A., Gee, S., & Mirkin, R. (2005, Spring). Tobacco dependence 

program: A multi-faceted systems approach to reduce tobacco use among 

Kaiser Permanente members in northern California. The Permanente Journal, 

9(2), 9-18. Retrieved from http://www.thepermanentejournal.org/files/PDF/

Spring2005.pdf

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

Straits‐Troster, K., Kanter, E., Zhou, X. H., Dougherty, C. M., & Steele, B. 

(2005). Improving the rates of quitting smoking for veterans with 

posttraumatic stress disorder. The American Journal of Psychiatry, 

162(7), 1311-1319. Retrieved from http://ajp.psychiatryonline.org/article.

aspx?volume=162&page=1311

41. Thompson, R. S., Michnich, M. E., Friedlander, L., Gilson, B., Grothaus, L. C., & 

Storer, B. (1988). Effectiveness of smoking cessation interventions integrated 

into primary care practice. Medical Care, 26(1), 62-76.

42. 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. JAMA, 304(22), 2485-2493. doi: 

10.1001/jama.2010.1769
13

I. HIV and Smoking

43. Tashima, K., Niaura, R., Richardson, E., Stanton, C., De Dios, M., & Kojic, M. 

(2009). Positive paths: A motivational intervention for smoking among HIV+ 

smokers [Abstract #148]. Conference on Retroviruses and Opportunistic 

Infections, Montréal, Canada. Abstract retrieved from http://retroconference.

org/2009/

44. Collie, C. F., Clancy, C. P., Yeatts, B. P., & Beckham, J. C. (2006). 

Posttraumatic stress disorder and smoking cessation in veteran smokers. 

Journal of Trauma Practice, 3(4), 37-63.

45. Lasser, K., Boyd, J. W., Woolhander, S., Himmelstein, D. U., McCormick, D., & 

Bor, D. H. (2000). Smoking and mental illness: A population-based prevalence 

study. JAMA, 284(20), 2606-2610. Retrieved from http://jama.ama-assn.org/

content/284/20/2606.long

46. Feldner, M. T., Babson, K. A., & Zvolensky, M. J. (2007). Smoking, traumatic 

event exposure, and post-traumatic stress: Critical review of the empirical 

literature. Clinical Psychology Review, 27(1) 14-45. Retrieved from http://

www.ncbi.nlm.nih.gov/pmc/articles/PMC2575106/?tool=pubmed

47. Humfleet, G. L., Delucchi, K., Kelley, K., Hall, S. M., Dilley, J., & Harrison, G. 

(2009). Characteristics of HIV-positive cigarette smokers: A sample of 

smokers facing multiple challenges. AIDS Education & Prevention, 21(3 

Suppl), 54-64. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/

PMC2752468/?tool=pubmed

48. Justice, A. C., Lasky, E., McGinnis, K. A., Skanderson, M., Conigliaro, 

J., Fultz, S. L., Crothers, K., Rabeneck, L., Rodriquez-Barradas, M., 

Weissman, S. B., Bryant, K., & VACS 3 Project Team. (2006). Medical disease 

and alcohol use among veterans with human immunodeficiency infection: A 

comparison of disease measurement strategies. Medical Care, 44(8 Suppl 2), 

S52-S60. doi: 10.1097/01.mlr.0000228003.08925.8c

49. Pence, B. W., Miller, W. C., Whetten, K., Eron, J. J., & Gaynes, B. N. (2006). 

Prevalence of DSM-IV-defined mood, anxiety, and substance use disorders in 

an HIV clinic in the Southeastern United States. Journal of Acquired Immune 

Deficiency Syndromes, 42(3), 298-306. doi: 10.1097/01.qai.0000219773.82055.aa

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

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

doi: 10.1177/1753465809102662

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

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

10.1016/j.amepre.2007.09.004

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

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

National Epidemiologic Survey on Alcohol and Related Conditions. Alcohol 

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

publications/arh293/162-171.htm

53. 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.
14

I. HIV and Smoking

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

cessation interventions with individuals in substance abuse treatment or 

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

10.1037/0022-006X.72.6.1144

55. 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.

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

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

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

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

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

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

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

tobaccosmoke/index.html

58. 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.
15

II. Smoking Cessation 

Interventions

17

II. Smoking Cessation Interventions

CHAPTER SUMMARY

Effectiveness of smoking cessation interventions

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

(lasting for >10 minutes)

 Brief 3-minute interventions advising patients to quit can enhance 

abstinence rates

 Even without a smoking cessation program, brief counseling 

and medications provided as part of ongoing health care can 

be effective

Starting a smoking cessation program for HIV-infected Veterans

 Identify HIV care providers and key staff with an interest in 

smoking cessation

 Start small and manageable by selecting brief interventions 

appropriate for the setting

 Build the program by incorporating more intensive interventions 

when appropriate

 Monitor and track your patients’ progress

EFFECTIVENESS OF SMOKING CESSATION INTERVENTIONS

Smoking cessation interventions can be extremely effective and providers 

who perform even brief interventions of advice to quit can significantly 

enhance abstinence rates. Care providers should present a clear, concise, and 

consistent “quit” message to all their patients who smoke. The evidence on 

smoking 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 provider can be effective at increasing quit rates. Strong evidence 

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

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

length and number of individual treatment sessions.1 Cessation counseling 

lasting between 4-30 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 chances of success.1
18

II. Smoking Cessation Interventions

Self-help, pro-active group counseling and telephone counseling have all been 

shown to significantly increase abstinence rates compared to stopping “cold 

turkey.”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 a referral to an outside clinic smoking cessation program or the 

prescribing of medication alone.

STARTING A SMOKING CESSATION PROGRAM FOR 

HIV‐INFECTED VETERANS

Implementing a sustainable and effective smoking cessation program can feel 

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

effective smoking cessation program in your HIV clinic.

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

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

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

providers become interested, you can start to implement more intensive 

cessation interventions. Monitoring and tracking patients’ progress over time 

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

Finally, there is a smoking cessation lead clinician at each VA facility who can 

be a valuable resource for your clinic. Please email publichealth@va.gov to 

obtain the name of this clinician at your VA facility.

SMOKING CESSATION BEHAVIORAL INTERVENTIONS

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

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

interventions have been used for smoking cessation in health care settings and 

range from 3-10 minute conversations, to intensive counseling that can last an 

hour. Also addressed are challenges and opportunities for implementing these 

well-established interventions with your HIV-infected patients and making 

smoking cessation a routine part of the clinical care you provide.

Brief Interventions (3-10 minutes)

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

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

AIDS, 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 

smoking cessation programs, are critical components of brief interventions. 

Below the five elements of a brief smoking cessation intervention are outlined.
19

II. Smoking Cessation Interventions

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

ASK about smoking*

Ask patients about smoking at every clinic visit

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

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

*Clinical reminders and performance measures within VHA can assist with 

this intervention

ADVISE patient to quit

Provide clear, strong, and personalized suggestions

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

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

can do to protect your health.

 Personalized: Associate smoking with something that is important 

to the patient, such as the increased risk of harm with HIV, 

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

cigarettes, or pulmonary and cardiovascular comorbidities.

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

right now than your HIV disease.

• 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. 20).

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

interviewing to increase their readiness

(see Table 2. Enhancing Motivation to Quit Tobacco (p. 21)).

ASSIST patients with their quit attempt

Prepare your patient for quitting (STAR)

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

weeks, but no later than within 30 days. The TQD should be a date
20

II. Smoking Cessation Interventions

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 the environment. Before quitting, 

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

home, car). Make your home smoke free.

Offer pharmacotherapy

Provide practical counseling (problem-solving/skills training)

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

telephone counseling) available within your VA facility.

Provide intra-treatment social support

 Provide a supportive clinical environment while encouraging the 

patient in his or her quit attempt.

Provide supplementary materials and other resources to keep 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
21

II. Smoking Cessation Interventions

the My Smoking Cessation Workbook to keep patient motivated 

and engaged

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

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

cessation services.

Intensive Intervention (>10 minutes)1

The components of an intensive smoking cessation intervention consist of:

 Determining whether smokers are willing to make a quit attempt 

with intensive counseling

 Conducting patient assessments that may be helpful including 

lung function, stress level, and the Fagerström Test for 

Nicotine Dependence (See Table 3. Fagerström Test for 

Nicotine Dependence on p. 28)

 When possible, conducting sessions longer than 10 minutes and 

including ≥ 4 sessions

 Combining behavioral counseling and medication (essential to 

successful smoking cessation treatment)

 Including problem solving/skills training and intra-treatment social 

support as part of the intervention

For sample programs and examples of intensive smoking cessation counseling, 

please see Appendix A.

IDENTIFYING REASONS TO QUIT

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

intervention, based on motivational interviewing, can help motivate patients 

to quit who are not quite ready.

TABLE 2. ENHANCING MOTIVATION TO QUIT TOBACCO3-6

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
22

II. Smoking Cessation Interventions

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

discuss these risks (e.g., infertility, fetal harm, CV and pulmonary 

disease, malignancies, harms of secondhand smoke to others) and 

HIV‐specific risks such as:

 HIV-infected smokers may have a decreased response to ART and a 

more rapid progression to AIDS

 Smoking cigarettes can make it harder to fight off 

HIV‐related infections

 Overall mortality (death rate) is increased in HIV-infected patients 

who smoke

 Women with HIV who smoke have a greater risk of contracting 

human papillomavirus (HPV), which can cause cancer of the cervix

 For a smoker with the co-morbid conditions of HIV and Hepatitis C, 

the liver can be seriously harmed

 Smoking is a common cause of sexual dysfunction

REWARDS Ask patients to explain what they might gain from smoking 

cessation and highlight the rewards most relevant to the patient, 

including those that are HIV specific

 Better chance of avoiding HIV-related infections

 Better chance of responding to ART

 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)

 Lowered risk of heart disease

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%
23

II. Smoking Cessation Interventions

 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

 Depression

 Enjoyment of smoking

 Socializing with other smokers

REPETITION Discuss the 5 R issues listed above with patients at each visit
24

II. Smoking 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. JAMA, 

294(4), 482-487. doi: 10.1001/jama.294.4.482

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

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

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

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

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

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

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

smoking reduction with nicotine replacement therapy and motivational advice 

increase future cessation among smokers unmotivated to quit. Journal 

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

006X.72.3.371

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

for practioners. Edinburgh, England: Churchill Livingstone.
25

III. Real‐time 

Scripts for Brief 

Smoking Cessation 

Interventions

27

III. Real‐time Scripts for Brief Smoking Cessation Interventions

CHAPTER SUMMARY

How to approach your patients about smoking cessation

 Smoking can be a chronic, relapsing condition

 Consider tracking smoking as a vital sign

 Administer the Fagerström Test for Nicotine Dependence

Address patient concerns

 Provide factual information to address each concern

Sample scripts for brief interventions

 Assess smoking status

 Advise patients about quitting

 Assess readiness to quit

 Encourage confidence in quitting

APPROACHING YOUR PATIENTS ABOUT SMOKING CESSATION

Though HIV care providers are in excellent position to provide smoking 

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

sometimes uncomfortable to approach the topic. We recommend treating 

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

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

you and your patient to integrate conversations about cigarette smoking into 

your clinic visit. Smoking can be a chronic, relapsing condition that at times 

requires varying levels of intervention. We encourage you to go as far as you 

can with each patient at each visit as you help lay the groundwork for smoking 

cessation.

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

using the test in Table 3. Fagerström Test for Nicotine Dependence (p. 28). The 

level of your patient’s nicotine dependence has important indications for the 

regimen that should be suggested for treatment.
28

III. Real‐time Scripts for Brief Smoking Cessation Interventions

TABLE 3. FAGERSTRÖM TEST FOR NICOTINE DEPENDENCE1-2

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

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

After 60 minutes (0 pts.)

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

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

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

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

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

4. How many cigarettes a day do you smoke?

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

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

than during the rest of the day?

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

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

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

NICOTINE DEPENDENCE SCORE (Points):

(0-2 pts.) Very low dependence

(3-4 pts.) Low dependence

(5 pts.) Medium dependence

(6-7 pts.) High dependence

(8-10 pts.) Very high dependence

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

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

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

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

ADDRESSING PATIENT CONCERNS

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

smoking and smoking cessation with your patients. For a complete step-bystep guide, please consult Appendix A.
29

III. Real‐time Scripts for Brief Smoking Cessation Interventions

TABLE 4. SAMPLE RESPONSES TO PATIENTS’ CONCERNS ABOUT 

SMOKING CESSATION3-5

Patient Provider

I don’t want counseling, I only 

want medication.

 Counseling + medication 

works better than 

medication alone.

 Counseling will provide 

you with practical skills to 

support the behavior changes 

necessary to quit.

I want to try acupuncture, 

hypnosis, or laser therapy.

 Reinforce that evidence 

supporting the effectiveness 

of counseling + medication.

 Suggest that the patient 

augment any substandard 

therapy with counseling 

+ medication.

I am concerned that I will gain 

weight once I quit smoking.

 Start to increase physical 

activity as soon as possible.

 Consider taking a walk 

instead of a cigarette break.

I don’t understand how nicotine 

replacement therapies (NRTs) 

could be harmless if nicotine is 

also one of the harmful drugs 

in cigarettes.

 Studies have shown that 

medicinal nicotine is safe.

 What is harmful in 

cigarettes are the 4,000 

other chemicals, including 

40 carcinogens.

 Medicinal nicotine in 

dosages approved for 

NRT medications are 

proven to greatly reduce 

withdrawal symptoms during 

smoking cessation.
30

III. Real‐time Scripts for Brief Smoking Cessation Interventions

Patient Provider

My life is too stressful to 

quit smoking.

 Smoking 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.

I am HIV-positive; my life is 

hard enough.

 Between all my medications 

and feeling alone, 

cigarettes are the high 

point of my day.

 I am going to die soon 

anyway, so why quit now?

 Smoking is even more 

dangerous for HIV-infected 

people, as it can be 

responsible for increasing 

the chances of AIDS-related 

infections and cancers. 

Smoking can also prevent 

your HIV medications from 

working as well to fight your 

HIV-infection and keeping 

your immune system strong.

 Thanks to ART, HIV-infected 

people now can live as long 

as HIV-negative people. 

You are jeopardizing your 

health and long life by 

smoking cigarettes.
31

III. Real‐time Scripts for Brief Smoking Cessation Interventions

TABLE 5. SAMPLE SCRIPTS FOR BRIEF SMOKING CESSATION 

CONVERSATIONS BETWEEN PATIENTS AND PROVIDERS3-5

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

Approach your patients about smoking

Assess smoking status

 How many cigarettes do you smoke a day?

 Do others in your household or work environment smoke?

 Have you thought about quitting?

Advise patient about quitting smoking

Be clear

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

Make strong statements

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

your health.

 Smoking is much more likely to kill you than your HIV.

Personalize your feedback

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

now than your HIV disease.

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

you quit.

 All your hard work with your HIV medications is being undone 

by smoking.

 Your risk of lung disease, CHD, and other problems are much higher.

 You are at increased risk of developing AIDS and other health 

problems when you smoke.

 The overall mortality for people with HIV who smoke is much 

higher than for people with HIV who are non-smokers.

 You complain of shortness of breath; giving up cigarettes will 

improve your breathing and stamina.

Assess patient’s readiness to quit

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

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

time I see you?
32

III. Real‐time Scripts for Brief Smoking Cessation Interventions

Assess and build motivation

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

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

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

for you to change?

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

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

of you being able to do this.

Support self-efficacy

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

strategy last time you quit.

 You've been really successful in managing HIV 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?

Encouraging confidence in quitting smoking

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

smoking for good?

 What would make you more confident in your ability to 

stop smoking?

 What did you learn from your past quit attempts?

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

new attempt?

 Is there anything you found helpful in previous attempts to 

stop smoking?

Emphasize personal choice and responsibility

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

here to help 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 

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

a change.

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

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

would you be interested in trying first?

 If you would like, I can tell you some strategies that will help you
33

III. Real‐time Scripts for Brief Smoking Cessation Interventions

address those concerns.

Expressing empathy

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

without cigarettes.

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

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

quit or start to cut down.
34

III. Real‐time Scripts for Brief Smoking 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.
35

IV. Medications for 

Smoking Cessation

37

IV. Medications for Smoking Cessation

CHAPTER SUMMARY

Nicotine pharmacology

 Use of medications for smoking cessation result in better 

abstinence rates and durability then quitting “cold turkey”

 Medications for smoking cessation are most successful when 

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

and tracking)

 Use Table 3. Fagerström Test for Nicotine Dependence (p. 28) to 

guide prescribing

 The goal of titration is to eliminate the need for NRT while 

maintaining smoking abstinence

 Nicotine pharmacology considers the dose response and manages 

withdrawal symptoms, which commonly include irritability, 

impatience, anxiety, difficulty concentrating, restlessness, hunger, 

depression, insomnia, and cravings

 Selection of the smoking cessation medication should be based on 

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

concomitant medical conditions

 Consider combination therapy in patients with high dependence, 

those who are heavier smokers, or those experiencing cravings or 

withdrawal symptoms while on the patch alone

Nicotine replacement therapy (NRT)

 Nicotine transdermal patch

 Nicotine polacrilex gum

 Nicotine polacrilex lozenge

 Nicotine nasal spray*

 Nicotine oral vapor inhaler*

 Consider combination therapy of nicotine patch plus polacrilex gum 

or lozenge for maximum management of withdrawal symptoms

Non-NRT agents

 Buproprion

• Levels of bupropion may be reduced when patient takes 

ritonavir or elfavirenz

 Varenicline (second-line agent within VA)

*Not on VA national formulary
38

IV. Medications for Smoking Cessation

NICOTINE PHARMACOLOGY

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

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

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

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

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

It is important to note that neither NRTs nor varenicline interact with ART, 

however, bupropion levels may be reduced when prescribed in patients 

receiving ritonavir, lopinavir/ritonavir, efavirenz, and/or tipranavir.

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

0

5

10

15

20

25

30

35

40

Patch+Gum/Lozenge

Bupropion+Lozenge

Varenicline 2mg

Patch+Bupropion

Gum (>14 wks)

Bupropion

Lozenge

Patch

Gum (<14 wks)

Placebo

% Abstinent at 6 months

13.8

23.4 23.6 24.2 26.1

33.2

28.9 29.9

36.5

19

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 induces nearly immediate feelings of 

pleasure and relieves nicotine-withdrawal symptoms. This rapid dose response 
39

IV. Medications for Smoking Cessation

reinforces the need to repeat the intake of nicotine, thereby perpetuating 

smoking behavior.

When nicotine is discontinued, individuals may develop withdrawal symptoms 

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

hunger, depression, insomnia, and cravings.

Most physical withdrawal symptoms generally manifest within 24–48 hours 

after quitting and gradually dissipate over 2-4 weeks; however, strong cravings 

for cigarettes can persist for months or even years.

NICOTINE REPLACEMENT THERAPY (NRT)

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

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

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

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

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

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

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

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

nicotine or components and all agents have the potential for nicotine overdose. 

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

Formulary summarizes the dosing regimens, advantages and disadvantages, 

common adverse effects, and contraindications for three forms of NRT, 

bupropion, and varenicline.

Nicotine transdermal patch4-6

 Although the patch has the slowest onset of all the nicotine 

preparations, it offers more consistent levels of nicotine over a 

sustained period of time resulting in fewer blood level fluctuations. 

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

within 3-12 hours.

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

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

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

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

alleviate symptoms of withdrawal.

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

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

patch is applied.
40

IV. Medications for Smoking Cessation

 Available OTC in the community without a prescription; advise 

patients not to combine products obtained in the community with 

products dispensed from VA without discussing with their providers.

Nicotine polacrilex gum6-9

 Resin complex of nicotine and polacrilin in a sugarfree chewing 

gum base. Gum has a distinct peppery taste and contains 

sodium carbonate/bicarbonate buffers to increase salivary pH 

thereby enhancing absorption of nicotine across the buccal 

mucosa. The amount of nicotine absorbed from each piece is 

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

formulations, respectively).

 Nicotine plasma levels peak approximately 30 minutes after 

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

Provides plasma nicotine concentrations approximately 30-64% of 

pre‐cessation levels.

 Allows smokers to take an active coping response to nicotine 

withdrawal symptoms.

 Associated with less weight gain compared to placebo 

during treatment.

 Sticks to dentures, may dislodge fillings and inlays because of 

its density.

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

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

inhibit the absorption of nicotine and should be avoided within 

15‐20 minutes of use.

 Available OTC in the community; advise patients not to combine 

products obtained in the community with products dispensed from 

VA without discussing with their providers.

Nicotine polacrilex lozenge4,6-9

 Resin complex of nicotine and polacrilin in a flavored lozenge 

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

until fully dissolved. Lozenge contains sodium carbonate/potassium 

bicarbonate buffers to increase salivary pH thereby enhancing 

absorption of nicotine across the buccal mucosa.

 Nicotine plasma levels peak in approximately 30 minutes and slowly 

decline over 2-3 hours. Because the lozenge dissolves completely, it 
41

IV. Medications for Smoking Cessation

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 may cause symptoms of high 

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

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

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

inhibit the absorption of nicotine and should be avoided within 

15‐20 minutes of use.

 Available OTC in the community; advise patients not to combine 

products obtained in the community with products dispensed from 

VA without discussing with their providers.

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

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

administration to nasal mucosa. Each actuation delivers a 50 mcL 

spray containing 0.5 mg of nicotine.

 Peak concentrations occur more rapidly than with other NRT 

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

kinetics of nicotine seen with cigarette use; approximately 53% 

is absorbed.

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

fluctuations of nicotine levels, the nasal spray has the highest 

potential for developing dependence.

 Local irritant adverse effects including nasal and throat irritation, 

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

effects frequently dissipate after the first week of use.

 Not recommended for patients with known chronic nasal disorders 

or severe reactive airway disease.

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

 Consists of a plastic mouthpiece and cartridge that delivers nicotine 

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

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

mouth and throat (not the lungs).
42

IV. Medications for Smoking Cessation

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

menthol. Plastic spikes on the mouthpiece pierce the foil allowing 

the release of 4mg of nicotine vapor following intensive inhalation of 

which about 2mg 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) 

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 Therapy6,9,12-13

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

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

nasal spray). A nicotine patch provides a passive sustained form of nicotine 

delivery and is used to prevent the onset of severe withdrawal symptoms.

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

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

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

around other smokers).

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

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

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

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

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

abstinence (OR = 3.6, 95% CI 2.5-5.2). Similarly, studies evaluating the nicotine 
43

IV. Medications for Smoking Cessation

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

abstinence rates of up to 40% at six months.

Example Titration Schedule

 Week 1: Nicotine 21mg patches and 5 lozenges

 Week 2: Nicotine 21mg patches and 4 lozenges

 Week 3: Nicotine 21mg patches and 3 lozenges

 Week 4: Nicotine 21mg patches and 2 lozenges

 Week 5: Nicotine 21mg patches and 1 lozenge

 Week 6: Nicotine 14mg patches and 4 lozenges

 Week 7: Nicotine 14mg patches and 3 lozenges

 And so forth...

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

NRT Safety6,9,14-16

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

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

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

with careful monitoring. Large randomized trials have found no significant 

increase in the incidence of cardiovascular events or mortality among patients 

with cardiovascular disease receiving NRT when compared to placebo. A 

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

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

or death. Serum concentrations of nicotine achieved with the recommended 

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

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

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

Other conditions for which NRT should be used with caution include 

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

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

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

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

pregnancy.

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

However, one small pharmacokinetic study concluded that though there were 

statistically significant differences, the disposition of nicotine does not seem to 

be changed to a clinically important extent in the elderly compared to younger 

subjects.
44

IV. Medications for Smoking Cessation

NRT Use6

Treatment of nicotine dependence with NRT should adhere to the following 

principles:

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

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

cigarettes. Providers should always assess the patient’s nicotine 

dependence before prescribing cessation aids.

(See Table 3. Fagerström Test for Nicotine Dependence on p. 28)

 Treat withdrawal symptoms: The nicotine replacement dose should 

be sufficient to prevent or minimize craving for tobacco products.

 Avoid adverse reactions: The nicotine replacement dose should 

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

headache, nausea, palpitations) do not occur.

 Advise patient not to use cigarettes while using NRT: Encourage 

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

which may indicate reevaluation of dosage and type of NRT 

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

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

addiction to tobacco, product preference, and concomitant medical 

conditions: Consider combination therapy in patients with high 

dependence or in those who are heavy smokers.

BUPROPION6,17-21

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

with some nicotine receptor blocking activity.17-18 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.19

 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 

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

dose should be considered.
45

IV. Medications for Smoking Cessation

 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.

• Ritonavir at boosting doses of 100 mg twice daily or in 

co‐formulation with lopinavir (as KALETRA®) can reduce 

bupropion levels by approximately 20-80%.

• 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.20

 Bupropion may be associated with less weight gain.

 Bupropion may be used in combination with the nicotine patch.6,21

Bupropion Safety22-24

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 
46

IV. Medications for Smoking 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.

VARENICLINE25-28

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.25-26 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.28
47

IV. Medications for Smoking Cessation

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

NRT or bupropion for smoking cessation has not been studied 

extensively and is not recommended.

Varenicline for Smoking Cessation in VA

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

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

can be found on the PBM website (http://vaww.national.cmop.va.gov/PBM/

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

Prescribing.doc).29

Varenicline Safety24,30-32

Varenicline carries a boxed warning about the risk for serious neuropsychiatric 

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

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

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

appear.

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.
48

IV. Medications for Smoking Cessation

TABLE 6. MEDICATIONS FOR SMOKING 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®) 150mg, 300mg tabBupropion IR 100mg tab

Nicoderm®/Habitrol®7mg, 14mg, 21mg

Nicorette® Gum2mg, 4mg

Commit® Lozenge2mg, 4mg

CHANTIX®0.5mg, 1mg tablet

Recommended regimen

Bupropion SR150mg qd x 3d, then 150mg bid (8 hrs apart)Patients with cirrhosis need adjusted dose: 150mg qodBupropion IR100mg qd x 3d,then 100mg tidPatients with cirrhosis need adjusted dose: 75mg qd

High dependence*21mg x 4-6wks,then 14mg x 2wks,then 7mg x 2wksLow dependence14mg x 6-8wks,then 7mg x 2wks

High dependence*4mg q1-2hrs x 6wks,then q2-4hrs x 4wks, then q4-6hrs x 2wksLow dependence2mg q1-2hrs x 6wks,then q2-4hrs x 3wks,then q4-6hrs x 3wks•No more than 

24 pieces/24hrs

High dependence*4mgLow dependence2mg•Suck 1 lozenge

q1-2hrs x 6wks,then 1 q2-4hrs x 3wks, then 1 q4-8hrs x 3wks

•No more than 20 

lozenges/24hrs or 5 lozenges/6hrs

0.5mg qd day 1-3,then 0.5mg bid day 4-7, then STOP SMOKING on quit date, then 1mg bid for total of 12 weeks durationCrCl<30: max dose is 0.5mg bidESRD or HD: 0.5mg qd

Start instructions 1-2 weeks before 

quit date

On quit date On quit date On quit date 1-2 weeks before 

quit date

Administration comments

•Continue treatment for 

7-12 wks(if no progress is made by week 7, consider discontinuing therapy)

•Usually worn for 

16‐24 hrs

•Apply from neck 

to waist

•Chew slowly (about 10 

chews) until peppery taste then “park” between teeth and gums until taste dissipates. Repeat

•Dissolve slowly over 

20-30 minutes shifting in mouth occasionally

•Do not chew or 

swallow (increased risk

•Take after eating and 

with 8 ounces of water to minimize nausea

•Report depression, 

suicidal ideation,
49

IV. Medications for Smoking Cessation

BUPROPION NICOTINE 

TRANSDERMAL PATCH

NICOTINE POLACRILEX 

GUM

NICOTINE POLACRILEX 

LOZENGE

VARENICLINE

Administration comments (cont.)

•If insomnia, take PM 

dose in afternoon

•Dose tapering 

is not required upon discontinuation

•Alert patients 

to potential for drug interactions

•Do not crush or 

chew tablets

•Can be used in 

combination with patch

•Rotate sites•Takes 2-3 d for effect 

after application of first patch

•Can be used in 

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

process on and off for 30 mins/piece

•Can be used in 

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

of GI side effects)

•Avoid acidic beverages 

(citrus juice, soft drinks), within 15 minutes of use

•Can be used in 

combination with patch; most patients will require 6-8 pieces/day PRN when used in combination. Lozenge continued for 12 weeks duration when used in combination

unusual changes in behavior, or worsening of pre‐existing psychiatric illness

•An additional 12 wks 

of treatment in patients who have successfully stopped smoking may increase the likelihood of long‐term abstinence

ART interactions Efavirenz, ritonavir, and 

tipranavir may decrease bupropion levels 40-50%; monitor for depression and titrate to clinical effect

None None None Does not interact 

with the cytochrome P450 system; no ART interactions identified to date

Advantages (+) and disadvantages (-)

(+) better compliance; ease of use; can be combined with patch; consistent rate of exposure; helps with withdrawal symptoms

(+) best adherence; easy to use; consistent rate of exposure; unobtrusive; can be combined with PRN gum

(+) can titrate to adjust for cravings or sudden urges; oral substitute for cigarettes; can be combined with patch for better efficacy

(+) easy to use; discreet; higher immediate levels; can titrate to adjust for cravings; reduces selfreported withdrawal

(+) better compliance; ease of use; consistent rate of exposure; superior rate of abstinence compared to bupropion and placebo
50

IV. Medications for Smoking Cessation

BUPROPION NICOTINE 

TRANSDERMAL PATCH

NICOTINE POLACRILEX 

GUM

NICOTINE POLACRILEX 

LOZENGE

VARENICLINE

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

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

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

(-) difficult for those with poor dentition/dentures; must use proper chewing technique; must abstain from drinking/eating during gum use; swallowing the nicotine causes GI side effects

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

(-) potential for serious neurologic and psychiatric side effects (esp. in those with underlying psychiatric disease); dose adjust for renal insuf (CrCl<30); high incidence of nausea

Adverse effects •Agitation

•Anxiety•Disturbed 

concentration

•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/tingling

•Heartburn, 

indigestion, nausea (if chewed)

•Headache•Nausea, diarrhea•Flatulence

•Dream disorders•Headache•Insomnia•Abnormal behavior•Agitation•Depressed mood•Suicidal thoughts•Constipation•Flatulence•Nausea and vomitingConsider dose reduction in patients sensitive to adverse effects (e.g., nausea, insomnia)
51

IV. Medications for Smoking Cessation

BUPROPION NICOTINE 

TRANSDERMAL PATCH

NICOTINE POLACRILEX 

GUM

NICOTINE POLACRILEX 

LOZENGE

VARENICLINE

VA national formulary restrictions

None None None None Yes, must meet criteria 

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

Contraindications & relative contraindications

Contraindications:•History of seizures•Predisposition to 

seizures (i.e., severe head trauma, CNS tumor, hepatic cirrhosis, diabetes treated with insulin or oral hypoglycemics)

Relative Contraindications:•Hypersensitivity•Pregnancy category D•Use within 14 days post MI, or serious or worsening angina•Patients should be advised not to smoke while on nicotine 

replacement therapy

•TMJ syndrome (gum only)

Relative Contraindications:•Serious 

neuropsychiatric disorders(including suicidal and homicidal ideation)

•History of suicidal, 

homicidal, or
52

IV. Medications for Smoking Cessation

BUPROPION NICOTINE 

TRANSDERMAL PATCH

NICOTINE POLACRILEX 

GUM

NICOTINE POLACRILEX 

LOZENGE

VARENICLINE

Contraindications & relative contraindications (cont.)

•Abrupt withdrawal 

from heavy alcohol use/sedatives

•MAO inhibitor 

within 14 d

•Bulimia, anorexia 

nervosa

•Hypersensitivity•Pregnancy category C

assaultive behavior in the past 12 weeks

•Untreated or unstable 

mental disorder (e.g., bipolar, or psychotic disorder, major depressive disorder, PTSD)

•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/

symptoms during use

•May be used In 

combination with nicotine gum or lozenge 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 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 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/

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.
53

IV. Medications for Smoking Cessation

References

1. Benowitz, N. L. (1990). Clinical pharmacology of inhaled drugs of abuse: 

Implications in understanding nicotine dependence. In C. Chiang, & R. Hawks 

(Eds.), Research findings on smoking of abused substances [NIDA Research 

Monograph 99]. Rockville, MD: U.S. Department of Health and Human Services. 

Retrieved from http://archives.drugabuse.gov/pdf/monographs/99.pdf

2. Benowitz, N. L. (1992). Cigarette smoking and nicotine addiction. The 

Medical Clinics of North America, 76(2), 415–437.

3. Benowitz, N. L. (2008). Clinical pharmacology of nicotine: Implications 

for understanding, preventing, and treating tobacco addiction. Clinical 

Pharmacology & Therapeutics, 83(4), 531–541. doi: 10.1038/clpt.2008.3

4. Choi, J. H., Dresler, C. M., Norton, M. R., & Strahs, K. R. (2003). 

Pharmacokinetics of a nicotine polacrilex lozenge. Nicotine & Tobacco 

Research, 5(5), 635–644. doi: 10.1080/1462220031000158690

5. Palmer, K. J., Buckley, M. M., & Faulds, D. (1992). Transdermal nicotine. 

A review of its pharmacodynamic and pharmacokinetic properties, and 

therapeutic efficacy as an aid to smoking cessation. Drugs, 44(3), 498–529.

6. 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

7. U.S. Department of Health and Human Services, Public Health Service. (2000). 

Treating tobacco use and dependence. Clinical practice guideline.

8. Silagy, C., Lancaster, T., Stead, L., Mant, D., & Fowler, G. (2004). Nicotine 

replacement therapy for smoking cessation. Cochrane Database of Systematic 

Reviews, (3), CD000146. doi: 10.1002/14651858.CD000146.pub2

9. Stead, L. F., Perera, R., Bullen, C., Mant, D., & Lancaster, T. (2008). Nicotine 

replacement therapy for smoking cessation. Cochrane Database of Systematic 

Reviews, (1), CD000146. doi: 10.1002/14651858.CD000146.pub3

10. Schneider, N. G., Lunell, E., Olmstead, R. E., & Fagerström, K. O. (1996). 

Clinical pharmacokinetics of nasal nicotine delivery. A review and comparison 

to other nicotine systems. Clinical Pharmacokinetics, 31(1), 65–80.

11. Schneider, N. G., Olmstead, R. E., Franzon, M. A., & Lunell, E. (2001). The 

nicotine inhaler: Clinical pharmacokinetics and comparison with other nicotine 

treatments. Clinical Pharmacokinetics, 40(9), 661–684.

12. Piper, M. E., Smith, S. S., Schlam, T. R., Fiore, M. C., Jorenby, D. E., Fraser, D., 

& Baker, T. B. (2009). A randomized placebo-controlled clinical trial of 

5 smoking cessation pharmacotherapies. Archives of General Psychiatry, 

66(11), 1253-1262. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/

PMC2933113/?tool=pubmed]
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13. Smith, S. S., McCarthy, D. E., Japunitch, S. J., Christiansen, B., Piper, M. E., 

Jorenby, D. E., Fraser, D. L., Fiore, M. C., Baker, T. B., & Jackson, T. C. 

(2009). Comparative effectiveness of 5 smoking cessation pharmacotherapies 

in primary care clinics. Archives of Internal Medicine, 169(22), 

2148‐2155. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/

PMC2891174/?tool=pubmed

14. Benowitz, N. L. (2003). Cigarette smoking and cardiovascular disease: 

Pathophysiology and implications for treatment. Progress in Cardiovascular 

Diseases, 46(1), 91–111. doi: 10.1016/S0033-0620(03)00087-2

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

Steele, B. G., Sherman, S. E., Cleveland, M., Antonuccio, D. O., Hartman, N., 

& McGovern, P. G. (1996). The safety of transdermal nicotine as an aid to 

smoking cessation in patients with cardiac disease. The New England Journal 

of Medicine, 335(24), 1792–1798. Retrieved from http://www.nejm.org/doi/

full/10.1056/NEJM199612123352402

16. Lee, A. H., & Afessa, B. (2007). The association of nicotine replacement 

therapy with mortality in a medical intensive care unit. Critical Care Medicine, 

35(6), 1517–1521. doi: 10.1097/01.CCM.0000266537.86437.38

17. GlaxoSmithKline. (2010, September). Zyban® (bupropion hydrochloride) 

sustained-release tables [Package insert]. Greenville, NC: GlaxoSmithKline 

Research Triangle Park.

18. Slemmer, J. E., Martin, B. R., & Damaj, M. I. (2000). Bupropion is a 

nicotinic antagonist. The Journal of Pharmacology and Experimental 

Therapeutics, 295(1), 321-327. Retrieved from http://jpet.aspetjournals.org/

content/295/1/321.long

19. Hurt, R. D., Sachs, D. P., Glover, E. D., Offord, K. P., Johnston, J. A., 

Dale, L. C., Khayrallah, M. A., Schroeder, D. R., Glover, P. N., Sullivan, C. R., 

Croghan, I. T., & Sullivan, P. M. (1997). A comparison of sustained-release 

bupropion and placebo for smoking cessation. The New England Journal of 

Medicine, 337(17), 1195-1202. Retrieved from http://www.nejm.org/doi/

full/10.1056/NEJM199710233371703

20. Hays, J. T., Hurt, R. D., Rigotti, N. A., Niaura, R., Gonzales, D., Durcan, M. J., 

Sachs, D. P., Wolter, T. D., Buist, A. S., Johnston, J. A., & White, J. D. 

(2001). Sustained-release bupropion for pharmacologic relapse prevention 

after smoking cessation. A randomized, controlled trial. Annals of Internal 

Medicine, 135(6), 423-433.

21. Jorenby, D. E., Leischon, S. J., Nides, M. A., Rennard, S. I., Johnston, J. A., 

Hughes, A. R., Smith, S. S., Muramoto, M. L., Daughton, D. M., Doan, K., 

Fiore, M. C., & Baker, T. B. (1999). A controlled trial of sustained-release 

bupropion, a nicotinic patch, or both for smoking cessation. The New England 

Journal of Medicine, 340(9), 685-691. Retrieved from http://www.nejm.org/

doi/full/10.1056/NEJM199903043400903

22. Rigotti, N. A., Thorndike, A. N., Regan, S., McKool, K., Pastemak, R. C., 

Chang, Y., Swartz, S., Torres-Finnerty, N., Emmons, K. M., & Singer, D. E. 

(2006). Bupropion for smokers hospitalized with acute cardiovascular 

disease. The American Journal of Medicine, 119(12), 1080-1087. doi: 10.1016/j.

amjmed.2006.04.024
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23. Tonstad, S., Farsang, C., Klaene, G., Lewis, K., Manolis, A., Perruchoud, A. P., 

Silagy, C., van Spiegel, P. I., Astbury, C., & Sweet, R. (2003). Bupropion SR 

for smoking cessation in smokers with cardiovascular disease: A multicentre, 

randomised study. European Heart Journal, 249(10), 946-955. Retrieved from 

http://eurheartj.oxfordjournals.org/content/24/10/946.long

24. U.S. Food and Drug Administration. (2009, July 1). Information for healthcare 

professionals: Varenicline (marketed as Chantix) and bupropion (marketed as 

Zyban, Wellbutrin, and generics) [FDA alert]. Retrieved from www.fda.gov/

Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/

DrugSafetyInformationforHeathcareProfessionals/ucm169986.htm

25. Coe, J. W., Brooks, P. R., Vetelino, M. G., Wirtz, M. C., Arnold, E. P., Huang, J., 

Sands, S. B., Davis, T. I., Lebel, L. A., Fox, C. B., Shrikhande, A., Heym, J. H., 

Schaeffer, E., Rollema, H., Lu, Y., Mansbach, R. S., Chambers, L. K., 

Rovetti, C. C., Schultz, F. D. 3rd, & O’Neill, B. T. (2005). Varenicline: An 

alpha4beta2 nicotinic receptor partial agonist for smoking cessation. Journal 

of Medicinal Chemistry, 48(10), 3474-3477. doi: 10.1021/jm050069n

26. Pfizer Labs. (2010). CHANTIX® (varenicline). New York (NY): Pfizer Labs. 

Retrieved from http://www.chantix.com

27. Cahill, K., Stead, L., & Lancaster, T. (2011). Nicotine receptor partial agonists 

for smoking cessation. Cochrane Database of Systematic Reviews, (2), 

CD006103. doi: 10.1002/14651858.CD006103.pub5

28. Tonstad, S., Tønnesen, P., Hajek, P., Williams, K. E., Billing, C. B., 

Reeves, K. R., & Varenicline Phase 3 Study Group. (2006). Effect of 

maintenance therapy with varenicline on smoking cessation: A randomized 

controlled trial. JAMA, 296(1), 64-71. doi: 10.1001/jama.296.1.64

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

Services and the Medical Advisory Panel. (2010). National PBM Varenicline 

Criteria for Prescribing Updated February 2010. Retrieved from http://

vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Criteria%20For%20Use/

Varenicline%20Criteria%20for%20Prescribing.doc

30. Hays, J. T., & Ebbert, J. O. (2008). Varenicline for tobacco dependence. The 

New England Journal of Medicine, 359(19), 2018-2024. Retrieved from http://

www.ncbi.nlm.nih.gov/pmc/articles/PMC2959114/?tool=pubmed

31. Tonstad, S., Davies, S., Flammer, M., & Hughes, J. (2010). Psychiatric 

adverse events in randomized, double-blind, placebo-controlled clinical 

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

10.2165/11319180-000000000-00000

32. Williams, K. E., Reeves, K. R., Billing, C. B., Jr., & Gong, J. (2007). A 

double-blind study evaluating the long-term safety of varenicline for smoking 

cessation. Current Medical Research and Opinion, 23(4), 793-801.

57

V. Relapse Prevention 

and Smoking Cessation 

Maintenance

59

V. Relapse Prevention and Smoking Cessation Maintenance

CHAPTER SUMMARY

 Smoking is a chronic, relapsing disorder

 Multiple quit attempts and interventions may be necessary

 Relapse is NOT uncommon

 Continue to address smoking status at every visit and provide 

ongoing support

 Offer retreatment with medication and counseling

 Provide patients with options for the management of 

withdrawal symptoms

SMOKING IS A CHRONIC, RELAPSING DISORDER

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

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

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

attempting to identify strategies or interventions that are effective to prevent 

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

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

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

including a combination of smoking cessation medications and behavioral 

counseling, as described in previous chapters.

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

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

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

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

questions about noticeable benefits they have experienced since quitting. 

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

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

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

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

Additional support such as the DoD website "Quit Tobacco. Make Everyone 

Proud" (www.ucanquit2.org) provides online assistance such as a live chat. 

Additional support can be found in the form of telephone quitlines. It may also 

be helpful to consider extending the use of smoking cessation medications to 

help reduce withdrawal symptoms.1
60

V. Relapse Prevention and Smoking 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 smoking.

TABLE 7. SMOKING WITHDRAWAL SYMPTOMS* AND 

RECOMMENDATIONS

Withdrawal 

Symptoms

Recommendation

 Chest tightness 

(tension 

created by 

body’s need 

for nicotine)

 Practice relaxation techniques

 NRTs

 Stomach pain

 Constipation

 Gas (decrease 

of intestinal 

movement)

 Drink fluids

 Avoid stress

 Cravings 

(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
61

V. Relapse Prevention and Smoking Cessation Maintenance

Withdrawal 

Symptoms

Recommendation

 Cravings 

(nicotine 

withdrawal/ 

habit) (cont.)

something else, is easier than you may expect. 

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 sugarless candy or 

sugarless 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.
62

V. Relapse Prevention and Smoking Cessation Maintenance

Withdrawal 

Symptoms

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

 NRTs may help

 Hunger 

(cravings for 

cigarette can 

be mistaken 

for hunger)

 Drink lots of water

 Eat low-calorie snacks

 Insomnia 

(nicotine 

affects 

brain wave 

function and 

sleep patterns)

 Limit caffeine (reduce by 50%)

 Practice relaxation techniques

 Irritability 

(body’s craving 

for nicotine)

 Exercise

 Practice relaxation techniques

 Take a hot bath
63

V. Relapse Prevention and Smoking Cessation Maintenance

Withdrawal 

Symptoms

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/urges are the only symptoms that can return even after one 

year of smoking cessation.
64

V. Relapse Prevention and Smoking 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. Retrieved from 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. Retrieved from http://

www.publichealth.va.gov/docs/smoking/cessationguidelinepart2_508.pdf
65

Appendices

Appendix A. Sample Smoking 

Cessation Programs

Appendix B. Evaluating Smoking 

Cessation Programs

Appendix C. Educational 

Materials and 

Additional Resources 

for Patients

Appendix D. Educational 

Materials and 

Additional Resources 

for Providers

Appendix E. FAQs
66

Appendices

Appendix A. Sample Smoking 

Cessation Programs

SUMMARY

Research suggests that in selected populations with complex problems and 

high rates of smoking such as HIV-positive Veterans, an intensive one-on-one 

integrated model of smoking cessation treatment with primary care providers 

may be superior to standard smoking cessation programs conducted outside 

of primary care clinics.1 In VA HIV clinics, staff sizes range from a full staff of 

physicians, nurse practitioners, social workers, and support personnel, to one 

full-time nurse practitioner with part-time physician support. Subsequently, 

not all clinics can provide the recommended comprehensive program. In light 

of this reality, below are examples of different levels of intensive smoking 

cessation counseling programs for implementation depending on staff and time 

constraints. Programs that consistently identify smokers, raise awareness of 

the need to quit smoking, and encourage smoking cessation have been shown 

to increase abstinence. For those clinics that have minimal staff, conducting 

brief interventions (see Chapter III) and referring patients to a quit group and/

or encouraging self-help (e.g., www.smokefree.gov, 1-800-QUIT-NOW) will 

assist your patients in their cessation efforts.

The types of smoking cessation programs detailed in this section are:

 One-on-one counseling

 Group counseling

 Telephone counseling

Before initiating a program, please refer to the following checklist:

£Identify existing smoking cessation programs

£Identify the smoking cessation lead clinician (Please email 

publichealth@va.gov to obtain the name of this clinician at your VA 

facility) and/or the Health Behavior Coordinator at your facility

£Identify the process at your facility to initiate a new program (this 

could include adding privileges to existing scopes of practice)
67

Appendices

£Determine time allocated for program and level of intervention that 

will work best:

• Brief

 Less than three minutes

 3-10 minutes

• Intensive

 10–30 minutes

 More than 30 minutes

£Determine type of program (e.g., telephone, group format, one‐on‐one 

counseling) to offer taking into account what is the best fit for your 

facility, the duration of follow-up allowed (should be at least six 

months), and who can provide medications (physicians, pharmacists, 

nurse practitioners)

£Setting up the clinic (after facility approval process)

• Meet with coding and billing to establish clinic

• Ensure that the clinic is set up with a stop code “707” so 

patients will not be billed for smoking cessation counseling as 

federal policy prohibits charging co-payment to Veterans for 

outpatient smoking cessation counseling

• Use appropriate diagnostic and clinic codes for smoking 

cessation counseling

 Diagnostic Code: Tobacco Use Disorder (305.1)

 Procedure Code (CPT): Will depend on the length 

of appointment

- Use 99406 for an intermediate visit between 3-10 minutes

- Use 99407 for an intensive visit lasting longer than 10 minutes 

• Although specific clinic names and note titles will vary by 

individual clinics, appointments for this intervention should be 

entered in the standard clinic used for patients receiving their 

HIV care. Similarly, note titles should reflect services provided in 

HIV clinic rather than specialty tobacco cessation programs.

£Develop clinic note templates specifically to address smoking cessation 

so that the patient's progress and response to interventions is easily 

documented and tracked in the patient's medical chart
68

Appendices

Regardless of which type intervention you choose for your clinic, smoking 

cessation programs for HIV-infected individuals should have the following goals 

in common:

 Educate providers about the risks of cigarette smoking for 

HIV‐infected individuals

 Adopt a standard-of-care that includes identifying and tracking 

patients who smoke, and encouraging smoking cessation 

among them

 Identify and denote all current cigarette smokers in Vista/CPRS

 Offer every patient who is a current smoker:

• Motivational interviewing (conducted by their primary 

care provider)

• Information about the clinic's smoking cessation program and 

program manager contact information

• One-on-one counseling with the clinic’s smoking cessation 

counselor or a referral to a smoking cessation intervention 

program available in your clinic

 Establish a bimonthly open house where patients who smoke 

can learn more about evidence-based cessation techniques and 

opportunities for cessation support through the clinic

EXAMPLES OF INTENSIVE SMOKING CESSATION COUSELING

ONE-ON-ONE COUNSELING

One-on-one counseling, or individual counseling, whether conducted in a 

4-session or 8-session program, will require these common elements:

 Designate time in your schedule each week for a certain number of 

appointment slots

 Create a referral process to counseling that is known to all providers 

• Create a flier

• Remind providers 

• Be proactive 
69

Appendices

 Schedule 15-30 minute sessions with patients

• Combine counseling appointment times with ID appointments, 

when convenient for patients

• Discuss number of sessions available (4-6 sessions versus as many 

as needed)

• Discuss session spacing (e.g., biweekly, based on quit date)

 Outreach and follow up is important

• Make sure patients know individual counseling is available

• If a patient is interested, make sure to follow up (e.g., offer to 

remind them with calls/letters about appointments)

• Long-term follow up can increase success

 Structure of sessions

• Choose a protocol that you like that uses behavioral interventions 

(see below for some examples)

Example of a 4-session Intervention

Ideally, meet with patient for 15-30 minutes at least four times in person or by 

telephone.

Appointment 1: Prepare for the quit attempt

Appointment 2: (should be on or before the quit date)

• Review benefits of quitting

• Review quit plan 

• Discuss concerns/fears (confidence and motivation, develop plan 

to address concern)

• Discuss plan for handling urges

• Introduce relaxation strategies such as diaphragmatic breathing

Appointment 3: Maintenance (approximately one week after 

quit date)

• Assess current cigarette use

• Discuss maintenance strategies

• Address stress management
70

Appendices

Appointment 4: Relapse prevention (approximately one month after 

quit date)

• Assess current cigarette use

• Discuss positive experiences associated with quitting smoking and 

successful methods used to quit

• Assess and resolve problems encountered in quitting smoking 

and/or anticipated threats to abstinence

• Discuss the difference between a slip and a relapse

• Discuss strategies for managing and preventing relapse

Note, this program is flexible and can be condensed or expanded depending 

on the patient’s needs. Sessions are best conducted in person, but telephone 

sessions can also be effective for Veterans who are not able to come in weekly. 

Example of an 8-session Intervention

This intervention uses a patient workbook based on McFall's model,2 which is 

a one-on-one integrated smoking cessation program for patients with PTSD. 

The intervention as it appears here has been modified for the HIV-infected 

population. The patient workbook, My Smoking Cessation Workbook, consists 

of the following worksheets and sections:

 HIV and Smoking

 My Smoking Triggers Worksheet

 Breaking the Link Between Smoking and Other Habits Worksheet

 Reasons to Quit Worksheet

 My Allies in Quitting table

 Getting Ready to Quit Worksheet (strategies to reduce 

nicotine dependence)

 Strategies and Skills for Quitting Worksheet (coping with triggers 

and cravings)

 My Action Plan for Coping with Smoking Triggers Worksheet

 My Strategies to Use Immediately After Quitting

 Identifying and Coping with Nicotine Withdrawal

 Preventing a Smoking Relapse
71

Appendices

 Preventing Weight Gain After Quitting

 Developing an Exercise Program

 Next Steps

 Patient Resources

TABLE 8. EIGHT-SESSION SMOKING CESSATION INTERVENTION 

SCHEDULE

Timeframe Activities MONTH 1 Week 1

Baseline assessment of level of tobacco use: Review 

workbook, check on other substance use and/or cravings and 

psychosocial stressors or issues that might interfere with quit 

program. Schedule quit date, assign homework to identify 

smoking triggers and reasons for quitting, review smoking 

cessation medications available, and establish next session.

Week 2

Preparing to quit: Review workbook and discuss triggers 

and ways to mediate, check on other substance use/

cravings/stressors, assign homework on getting support and 

completing Getting Ready to Quit Worksheet and My Action 

Plan for Coping with Smoking Triggers Worksheet. Confirm 

quit date, order bupropion/varenicline if going to be used, 

and schedule next session.

Week 3

Strategies and skills for quitting: Review homework 

assignment, check on other substance use or cravings, 

assign homework on planning strategies to use after quitting 

and coping with nicotine withdrawal, confirm quit date, 

encourage abstinence, order NRT medications and provide 

instructions for use, and schedule next session.

Week 4

Planning ahead: This session should be conducted shortly 

after quit date and should focus on preventing smoking 

relapse, support for continued abstinence, and correct use of 

medications. Encourage continued abstinence and schedule 

next session.

Week 5

Preventing smoking relapse: Discuss cessation program and 

check for cravings and/or relapse and discuss interventions if 

present. Support continued abstinence and assign homework 

on weight control following smoking cessation. Schedule 

next session.
72

Appendices

Timeframe Activities MONTH 2

Weight control after smoking cessation: Review homework 

assignment and encourage Veteran to adopt healthier eating 

habits that will assist in smoking cessation and weight 

control. Assign homework on benefits of physical exercise 

in a cessation program. Support continued abstinence and 

schedule next session.

MONTH 3

Physical exercise: Review homework and discuss how 

exercise can help the Veteran remain smoke free. Encourage 

establishment of an exercise regimen. Check on cravings/

relapse and support continued abstinence. Schedule final 

visit.

MONTH 4

Feedback and graduation: Review homework and encourage 

Veteran to continue making healthier lifestyle choices to 

support their new smoke-free status. Support continued 

abstinence and provide graduation certificate.

Note. Adapted with permission from Tobacco use cessation: A brief primary 

care intervention (A training manual for integrated primary care behavioral 

health providers and other tobacco cessation providers), 2010, VA Center for 

Integrated Healthcare. Retrieved from www.mentalhealth.va.gov/coe/cihvisn2/Documents/Clinical/Tobacco_Use_Cessation/TUC_Manual_August_2010.

pdf

This program is flexible and can be condensed or expanded depending on an 

individual Veteran's needs. These sessions are best conducted in person, but 

telephone sessions can also be effective for Veterans who are not able to come 

in weekly. Topics for each session are general guidelines and follow the patient 

workbook, but can be condensed into fewer sessions.

GROUP COUNSELING

Smoking cessation quit groups are generally one hour and can be conducted 

by pharmacists, social workers, psychologists, psychology interns, or clinic 

nurses. It is important that the groups be advertised and held in or near the 

clinic where HIV-infected Veterans receive their primary care.

Drop-in Support Groups

 Schedule a weekly, 1-hour block of time

• Just before an HIV clinic time is often most convenient 

for patients
73

Appendices

 Recruit

• Post fliers in clinic and have providers distribute to patients

• Make sure your patients are aware that there is a drop-in group 

and provide reminder calls/letters if the patient requests

 Open structure

• Patients do not need to make an appointment to attend a 

drop‐in group

• Patients attending the group can be in any stage of quitting, 

including preparing to quit

• At the group, check in with each participant about their smoking, 

barriers to cessation, challenges, and lessons learned

• Prepare a group topic that can be tied into what patients are 

interested in discussing that day

• Maintain an open stance by letting participants' stated needs and 

discussion topics drive the focus of each group session

On-going Structured Group Therapy

 Schedule a weekly, 1-hour block of time

 Recruit

• Post fliers in clinic and have providers distribute to patients

• Make sure your patients are aware that there is an on-going group 

and provide reminder calls/letters if the patient requests

 Choose a program that will fit your schedule (weekly sessions, 

biweekly, etc.)

 Cycle through crucial group topics every 6-8 weeks (other topics can 

be added):

• Psycho education about nicotine dependence

• Health consequences of smoking in the context of HIV and 

benefits of quitting

• Motivation to quit/setting a quit date

• Managing withdrawal symptoms and concerns about weight gain

• Mood and stress management

• Coping with urges to smoke
74

Appendices

• Social support

• Relapse prevention

TELEPHONE COUNSELING

Personalized telephone counseling initiated by your clinic or facility can be 

conducted by pharmacists, social workers, psychologists, psychology interns, 

or clinic nurses. The following telephone script is based on a pharmacist 

provider; however, it can be modified as needed for other providers. State 

quitlines may offer additional counseling resources during evening and weekend 

hours when clinic staff are unavailable.

All telephone counseling programs should include the following components:

 Schedule your telephone clinic for a block of time each week

 Create a referral process to telephone counseling that is known to 

all providers

• Create a program flier

• Remind providers the program is available

• Encourage active and ongoing recruitment

 Describe to patients the purpose, nature, and structure of 

telephone counseling

• Include specific smoking cessation strategies from the clinical 

practice guidelines and this provider handbook

 Conduct a program assessment, outreach, and follow up

Elements of an Example Pharmacy Managed Telephone Tobacco 

Cessation Clinic (PMTTCC)

Assessment: Assessments are made by pharmacists at initial call. 

Initial and follow-up templates are used by all providers to ensure 

continuity of assessment.

Program Clinicians: Pharmacists trained under the Rx for Change

program are the providers for this clinic. Pharmacy technician 

can conduct routine follow-up calls but cannot make any 

clinical assessments.

Program Intensity: Proactive telephone clinic (at least 10 sessions)

• Initial call (20-30 minutes)
75

Appendices

• Follow-up calls (5-15 minutes depending on complexity)

 1-2 weeks after target quit date

 Every month for six months, at nine months and 12 months

Program Format: Proactive telephone counseling with sample 

telephone smoking cessation script. Clinic templates are used in CPRS 

and complement the script.

Type of Counseling & Behavioral Therapies: Problem solving/skills 

training and intra-treatment social support are included.

Medication: All pharmacist providers have prescribing privileges and 

all patients are offered medications.

Population: Used for all populations.

For more information on setting up a PMTTCC, please contact Dr. Timothy Chen at 

VA San Diego Tobacco Cessation Clinical Resource Center at SDCVAMCTCCRC@va.gov.

TABLE 9: PMTTCC SCRIPT FOR INITIAL CALL (20-30 MINUTES)

Determine Patient Background and Smoking History

È

Do you plan to quit within the next 30 days?

 If patient is not ready to quit within the next 30 days, consider 

providing counseling closer to the projected quit date

If so, have you set a Target Quit Date (TQD)?

 I would recommend establishing a quit date (holiday, birthday, 

weekend, day you finish last pack of cigarettes)

How long have you been smoking?

(total packs smoked in a year or years of cigarette use)

To start, could you tell me how many cigarettes per day you are 

currently smoking?

 Occasionally patients will say they cut down to 5-10 cigarettes, ask 

how long ago this was. For example, if they were smoking up to 

one ppd as of last week, then base dosing and counseling on the 

one ppd (use clinical judgment)

 1 pack per day (ppd) = 20 cigarettes

What is the most you’ve ever smoked? And how long ago?

 Main reason for this is to see patient trend for better assessment

Patient Background
76

Appendices

Have you ever tried to quit smoking in the past? If yes, how many times 

and for how long?

 If patient has quit for more than three months or six months, it is 

important to reemphasize that it can be easily repeated and the 

likelihood of long-term abstinence can be sustained especially with 

their previous successes

 Also, ask what was the reason for relapse

How did you try to quit? (cold turkey, medication, nicotine replacement 

products, or combination therapy)

Do you recall what happened with each medication? Which worked the 

best for you and how long have you used each one?

 It is important to identify what medications patients have tried 

to see if they used the medications correctly and also to see if 

they gave the product a legitimate try (i.e., using nicotine gum as 

needed or stop using after two weeks or only used three pieces 

per day are not legitimate quit attempts with the medication, thus 

should not rule out retrial of medication)

What is your reason or reasons for wanting to quit smoking?

 To provide more patient-specific counseling, reaffirm their 

reasoning for quitting while identifying other reasons specific to 

that patient (i.e., pulmonary disorders, heart disease, cancer, 

family, cost)

What are some barriers or concerns that you have when you 

consider quitting?

 Identify certain barriers that can include but are not limited to 

weight gain, irritability, inability to fight off cravings, lack of 

support from family/friends, triggers (while driving, after meals, 

alcohol, coffee in the morning), stress

 Once these barriers are identified, tailor your counseling to 

the patient

On a scale of 1-10 with 10 being the most, how confident are you in 

quitting? (10 being most confident)

On the same scale of 1-10, how important is it for you to quit? 

(10 being most important)

Patient Background
77

Appendices

Administer Fagerström Test for Nicotine Dependence

È

Fagerström Test for Nicotine Dependence

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

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

After 60 minutes (0 pts.)

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

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

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

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

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

4. How many cigarettes a day do you smoke?

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

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

than during the rest of the day?

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

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

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

NICOTINE DEPENDENCE SCORE (Points):

(0-2 pts.) Very low dependence

(3-4 pts.) Low dependence

(5 pts.) Medium dependence

(6-7 pts.) High dependence

(8-10 pts.) Very high dependence

Fagerström Test
78

Appendices

Counseling and Preparation for the Quit Attempt

È

After setting a quit date, start preparing for your quit attempt.

1. If you are using NRTs, the purpose is to get your body less addicted to 

nicotine, slowly get you more used to having less nicotine in your body 

and minimizing withdrawal symptoms.

2. The other part that is important is the behavioral part. You have been 

used to smoking ___ cigarettes for years and this has become a routine. 

The more you put into the preparation, the higher the chance you will 

be able to stop smoking. You want to create new habits.

3. Before you quit, as you are going through your day smoking, think about

when you usually smoke and identify your routine. Think about what you

can do instead of smoking. Which of your activities do not trigger 

smoking? What activities trigger smoking and if possible, can you avoid

these activities?

For example:

 If you wake up in the morning and drink coffee while smoking, 

change your routine (e.g., replace coffee with tea or a small glass 

of orange juice, go for a walk)

 Think about different ways to avoid triggers (e.g., not drinking 

coffee, not drinking alcohol, avoid people who smoke or places that 

allow smoking)

 Distract yourself by doing an activity not associated with smoking 

(e.g., exercise, video games)

 Substitute tobacco (e.g., sugar-free candy, sugar-free gum, straws, 

sunflower seeds, carrot/celery sticks)

Here are some withdrawal symptoms you might expect

Withdrawal 

Symptoms

Recommendation

 Chest tightness 

(tension 

created by 

body’s need 

for nicotine)

 Practice relaxation techniques

 NRTs

Quit Attempt
79

Appendices

Withdrawal 

Symptoms

Recommendation

 Stomach pain

 Constipation

 Gas (decrease 

of intestinal 

movement)

 Drink fluids

 Eat fruits and vegetables

 Cough

 Dry throat

 Nasal drip 

(body getting 

rid of mucus)

 Drink fluids

 Avoid stress

 Cravings 

(nicotine 

withdrawal/ 

habit)

 DEADS Strategy (See p. 80-81)

(Delay, Escape, Avoid, Distract, Substitute)

 Depressed 

mood (normal 

process for a 

short period)

 Increase pleasurable activities

 Get support from family/friends

 Discuss with provider

 Difficulty 

concentrating 

(body needs 

time to adjust 

to not having 

constant 

nicotine 

stimulation)

 Avoid stress

 Plan workload accordingly

 Dizziness

(body is getting 

extra oxygen)

 Be cautious the first few days

 Fatigue

(lack of 

stimulation 

of nicotine)

 Take naps

 Do not push yourself

 NRTs may help

Quit Attempt
80

Appendices

Withdrawal 

Symptoms

Recommendation

 Hunger 

(cravings for 

cigarette can 

be mistaken 

for hunger)

 Drink lots of water

 Eat low-calorie snacks

 Insomnia 

(nicotine 

affects 

brain wave 

function and 

sleep patterns)

 Limit caffeine (reduce by 50%)

 Practice relaxation techniques

 Irritability 

(body’s craving 

for nicotine)

 Exercise

 Practice relaxation techniques

 Take a hot bath

 Stress  Exercise

 Practice relaxation techniques

 Avoid known stressful situations

 Plan workload accordingly

*Most withdrawal symptoms go away after a few days to 1-2 months at the 

most. Cravings/urges are the only symptoms that can return even after one 

year of smoking cessation.

Here are some techniques to cope with the cravings (DEADS Strategy)

Delay: The most important thing to remember is that an urge will go away 

if you just give it time. Waiting out an urge, especially if you begin to do 

something else, is easier than you may expect. Believe it or not, the urge 

will fade after 5 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 reenter the situation, without smoking.

Quit Attempt
81

Appendices

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 that 

you enjoy doing which are incompatible with smoking. Some suggestions 

we have are 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 sugarless candy or sugarless gum, 

especially if you are watching your weight. Also, 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.

*Go over individual triggers and discuss appropriate DEADS strategies

(see Chapter V)

Differentiate to patient between "relapse" and "slips.”

 If you try to use the DEADS strategy and you have a slip, don’t 

go back into smoking. It is ok. Instead, think about what you 

techniques you tried and try a different technique the next time 

you experience an urge/craving.

 Relapse is when you return to how much you were smoking 

before quitting.

There are many health risks associated with smoking. You are making 

a great choice to quit smoking as I see that you already have health 

problems that can be worsened if you continue to smoke (be patient 

specific and focus the counseling to that patient, if they absolutely 

don’t have any health problems, discuss possible health problems by 

race/sex/family history). It is never too late to quit smoking and you will 

be able to see numerous health benefits once you do.

Risks for individuals who are HIV infected and smoke:

 Decreased response to HIV therapy and a more rapid progression 

to AIDS

 Can make it harder to fight off HIV-related infections

 Overall mortality (death rate) increases

Quit Attempt
82

Appendices

 Women with HIV who smoke have a greater risk of getting human 

papillomavirus (HPV), which can cause cancer of the cervix

 For individuals with HIV and hepatitis C, smoking can be very 

harmful to the liver

 Smoking is a common cause of sexual dysfunction

Benefits of smoking cessation for individuals who are HIV infected:

 Better chance of avoiding HIV-related infections

 Better chance of response to HIV therapy

 Food will taste better

 Better performance of physical activities

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

 In two weeks to three months, lung function can increase by 30%, 

circulation improves

 In 1-9 months, better ability to clear mucus and coughing decreases

 In one year, risk of CHD decreases by 50%

 In five years: risk of stroke is similar to someone that has 

never smoked

 In 10 years, risk of lung cancer reduced by 50% and risk of other 

cancers decreases

 In 15 years, risk of CHD is similar to someone that has 

never smoked

By quitting smoking, you can save a lot of money (i.e., $ 7.35 U.S. average 

per pack). For each day you quit smoking, you can save the money and 

after a few months, you can REWARD yourself by buying something nice 

or go on a nice vacation.

Administer Questions to Determine Best Smoking 

Cessation Therapy

È

I will ask you a couple of questions about your medical history so we can 

determine which therapy is safe for you (chart review can be done here 

as well to get this information).

Quit Attempt Medications
83

Appendices

Smoking Cessation

Medications

Medical History Questions 

and Smoking Cessation 

Medication Considerations

Nicotine Replacement

Therapies

Can you tell me if you’ve had any 

recent chest pain, heart attacks, or 

shortness of breath? Do you wear 

dentures or have any jaw problems? 

Do you have breathing problems 

such as asthma or COPD? Do you 

have any nasal conditions such as 

allergies? Are you pregnant or plan 

to be pregnant?

 NRTs should be avoided in 

recent MI (within 2 weeks)

 Nicotine gum should be 

avoided in patients with 

dentures and TMJ

 Nicotine nasal spray and 

oral inhaler should be used 

with caution in patients with 

uncontrolled airway disease

 Nicotine nasal spray should 

be avoided in patients with 

allergic rhinitis

 NRTs are pregnancy 

category D (assess risk 

v. benefit)

Bupropion (Zyban®) Do you have a history of seizures, 

anorexia, or bulimia? Do you drink 

alcohol, if so, how much? Have you 

ever had problems with alcohol in 

the past, if so, how long ago? Do 

you have any liver problems that 

you’re aware of? Are you on any 

medications for mood? Are you 

pregnant or plan to be pregnant?

 Avoid in patients with 

history of seizures, anorexia, 

or bulimia

Medications
84

Appendices

Bupropion (Zyban®)

(cont.)

 Avoid in patients at risk for 

alcohol withdrawal

 Avoid in patients with severe 

liver disease, check liver 

function tests

 If patient is on mood 

medications, make sure 

patient’s provider is aware of 

the addition of bupropion

 Bupropion is pregnancy 

category C (assess risk 

v. benefit)

Varenicline (CHANTIX®) Are you on any medications for 

mood? Do you have any suicidal 

ideations? Do you have any renal 

disease? Are you pregnant or plan 

to be pregnant?

 Avoid in patients with severe 

psychiatric illness

 Need renal adjustment

 Requires follow up every 

28 days to assess suicidal/

aggressive behavior

 Varenicline is pregnancy 

category C (assess risk 

v. benefit)

 Assess cardiac risk (avoid in 

high risk patients if possible)

Counsel Patient on Therapy Use and Follow Up

È

Assessment/Plan

 Determine the best medication for the patient and counsel the 

patient on appropriate use

 Arrange for follow-up

Medications Assessment
85

Appendices

PMTTCC INITIAL CALL TEMPLATE (see script on previous pages)

Pt Smoking Hx

Are you ready to quit within the next 30 days? (if no, advise pt to quit and call us back 

when ready)

Target quit date:

Years of tobacco use:

Current status/highest daily use in the past:

Number of quit attempts:

Medications used and what happened (duration of use, proper technique):

Reason for quitting (reaffirm patient’s reason for quitting and discuss risks to smoking 

specific to that patient):

Barriers to smoking cessation (e.g., first cigarette in the morning, stress, etc.):

On a scale from 1-10, confidence in quitting (10 most confident):

On a scale from 1-10, importance of quitting (10 most important):

Pt Medical Hx

If using NRTs:

 Recent MI/Chest Pain/SOB/Pregnancy:

 Other (Dentures, Bronchospastic Disease):

If using Bupropion:

 Hx of Seizures, Anorexia, Bulimia/Alcohol Use/Liver Dysfunction/Pregnancy/HIV:

 Psych History:

If using Varenicline:

 Psych History:

 Kidney Function:

 Pregnancy:

 Cardiovascular:

Plan for Quit Attempt

Medications ordered:

Contact number for any questions/concerns or ready for next refill:

Next follow-up date:

Preferred time of contact:

Notes (example): This patient was counseled on the use of his smoking cessation 

medication. The patient showed a satisfactory understanding of his medication regimen 

(risks and benefits), including knowing the drug name, dose, frequency, indication, and
86

Appendices

proper storage and disposal of the medication. Educated pt on risks associated with 

smoking while using nicotine replacement products or risks associated with bupropion/

varenicline; pt understands.

PMTTCC FOLLOW-UP CALL TEMPLATE

Actual quit date:

Experiencing any withdrawal symptoms: (yes or no? – most disappear from 2-4 weeks)

Withdrawal Symptoms Recommendation

 Chest tightness 

(tension created 

by body’s need 

for nicotine)

 Practice relaxation techniques

 NRTs

 Stomach pain

 Constipation

 Gas (decrease 

of intestinal 

movement)

 Drink fluids

 Eat fruits and vegetables

 Cough

 Dry throat

 Nasal drip (body 

getting rid of mucus)

 Drink fluids

 Avoid stress

 Cravings (nicotine 

withdrawal/habit)

 DEADS Strategy (See p. 80-81)

(Delay, Escape, Avoid, Distract, Substitute)

 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
87

Appendices

Withdrawal Symptoms Recommendation

 Fatigue

(lack of stimulation 

of nicotine)

 Take naps

 Do not push yourself

 NRTs may help

 Hunger (cravings 

for cigarette can be 

mistaken for hunger)

 Drink lots of water

 Eat low-calorie snacks

 Insomnia (nicotine 

affects brain 

wave function and 

sleep patterns)

 Limit caffeine (reduce by 50%)

 Practice relaxation techniques

 Irritability (body’s 

craving for nicotine)

 Exercise

 Practice relaxation techniques

 Take a hot bath

 Stress  Exercise

 Practice relaxation techniques

 Avoid known stressful situations

 Plan workload accordingly

Slips/Relapse: yes or no? (If yes, what happened, what techniques did you try, and what 

else you can try when the same situation occurs again)

On a scale of 1-10, how confident are you in staying smoke free (10 most confident):

On a scale of 1-10, how important is it for you to stay smoke free (10 most important):

NRT (or other medication) current usage:

Any adverse drug reactions with prescribed medications? (yes or no)

Reiterate behavioral counseling with patient: (provide encouragement to patient, 

re‐emphasize patient’s reason for quitting, and the rewards of smoking cessation)

Assessment/Plan:

1. Pt is doing well (or minimal slips) so will continue current therapy.

2. Pt needs change in therapy (relapsed or adverse drug reaction), refer 

to pharmacist.

Medication(s):

Will contact pt for next f/u on:

Preferred contact time:

Notes (example): Patient to contact PMTTCC line for questions/concerns.
88

Appendices

References

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

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

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

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

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

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

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

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

va.gov/tuc/phs_2008_full.pdf

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

Straits‐Troster, K., Kanter, E., Zhou, X. H., Dougherty, C. M., & Steele, B. 

(2005). Improving the rates of quitting smoking for veterans with 

posttraumatic stress disorder. The American Journal of Psychiatry, 

162(7), 1311-1319. Retrieved from http://ajp.psychiatryonline.org/article.

aspx?volume=162&page=1311
89

Appendices

Appendix B. Evaluating Smoking 

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 smoking 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)

• Combination NRTs such as the patch + lozenges

• Combination bupropion + NRT (e.g., nicotine patch)
90

Appendices

• 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 smoking cessation 

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

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

 Number of smokers whose HIV-care providers encouraged patients to 

quit/used motivational interviewing during a visit

 Number of smokers screened for their interest in a smoking 

cessation program

 Number of smokers ready for a screening visit with a smoking 

cessation counselor following this visit

 Number of smoking 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
91

Appendices

Appendix C. Educational Materials and 

Additional Resources for Patients

Please provide patients who are considering or actively pursuing smoking 

cessation with the following fact sheet and websites.

SMOKING AND HIV FACT SHEET

If you have HIV or AIDS and you smoke cigarettes, you put a lot of extra stress 

on your body. Smoking weakens your immune system making it harder for your 

body to fight off infection. Smoking is responsible for more deaths each year 

than from HIV, alcohol and drug use, car accidents, murders, and suicides 

combined. (Note. Adapted from Tobacco Smoking and HIV, California Smokers' 

Helpline, www.californiasmokershelpline.org and It's Time to Live! HIV and 

Smoking, New York State Department of Health, www.nyhealth.gov/diseases/

aids/publications)

What is Tobacco?

Tobacco is a green, leafy plant that is grown in warm climates. After it is 

picked, it is dried, ground up, and used in different ways. Nicotine is a chemical 

substance found in tobacco leaves. Addiction to nicotine is what keeps people 

smoking.

What is in a Cigarette?

Every single cigarette contains an estimated 4,800 harmful chemicals including 

11 proven to cause cancer in humans. Some of the chemicals found in cigarettes 

are:

 Acetone — found in nail polish remover

 Ammonia — household cleaner

 Formaldehyde — used to embalm dead bodies

 Arsenic — used in rat poison

 Nicotine — found in bug sprays

 Tar — used in paving roads

 Carbon monoxide — poisonous gas released in car exhaust fumes

 Cadmium — main ingredient in battery acid
92

Appendices

Smoking and HIV

Smoking can make it harder to fight off deadly infections and smoking cigarettes 

can make it harder to fight off HIV-related infections like fungal thrush, oral 

hairy leukoplakia caused by the Epstein-Barr virus, and types of pneumonia.

Health Effects of Smoking

 Heart Disease

Some HIV medications can raise the amount of fats and cholesterol 

in your blood. Fats and cholesterol clog the blood flow to your heart, 

raise your blood pressure and put more stress on your heart. These 

factors can raise your chances of heart disease, a heart attack, or a 

stroke. Smoking can make all of these problems worse.

 Oral Problems, Mouth Sores, and Mouth Cancer

People with HIV may get sores and infections (like thrush) inside the 

mouth and on the tongue and lips. Smoking can make these worse 

and can cause dental problems, gum disease, and mouth cancer.

 Immune System

HIV medications can help make your immune system stronger, 

however, smoking weakens your immune system, which makes it 

harder to fight off infections.

 Lung Diseases

People with HIV who smoke get lung cancer, bronchitis, chronic 

obstructive pulmonary disease (COPD), and other lung infections 

more than smokers who do not have HIV. Smokers with HIV are also 

at a greater risk for pneumonia (new-mone-ya) and Pneumocystis 

(new-mo-sist-iss) jiroveci pneumonia (PCP).

People with HIV who smoke are more likely to get emphysema. This 

disease hurts the walls of the lungs and makes it hard to breathe. It 

may lead to other lung infections that can cause death.

 Problems for Women

Women with HIV who smoke have a greater risk of getting human 

papillomavirus (HPV), which can cause cancer of the cervix. Smoking 

during pregnancy increases the risk of your baby dying or having 

serious health problems.

 Other Illnesses and Cancers

Smoking damages the stomach, kidneys, liver, pancreas, and 

bladder. If you have HIV and hepatitis C, smoking can be very 

harmful to your liver.
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Smoking and Stress

“This is how I deal with my HIV.”

Being HIV infected can cause stress, anxiety, and depression. You may feel that 

smoking helps you relax, takes your mind off these things, and helps you cope 

with the stress of being HIV infected. But smoking affects the “big picture” of 

your health. If you can quit smoking, you can take a big step toward staying 

healthier.

The Rewards

From 20 minutes to 20 years, the benefits of quitting smoking last a lifetime.

20 minutes after quitting

Your blood pressure drops and the circulation in your hands and feet improves.

12 hours after quitting

The carbon monoxide level in your blood returns to normal.

2 days after quitting

Your taste and smell senses improve.

2 weeks to 3 months after quitting

Your heart attack risk drops and your lung function improve.

1 to 9 Months after quitting

Your coughing and shortness of breath decrease.

1 year after quitting

Your added risk of heart disease is half that of a smoker’s.

5 to 15 years after quitting

Your risk of stroke is now equal to a non-smoker's.

10 years after quitting

If you are an average smoker (one pack a day) your lung cancer death rate 

drops by almost half. Risk of cancers of the mouth, throat, esophagus, bladder, 

kidney, and pancreas decreases.

15 years after quitting

Your added risk of heart disease is the same as a non-smoker’s.
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WEB AND TELEPHONE RESOURCES

 Quit Tobacco. Make Everyone Proud

www.ucanquit2.org

 Smokefree.gov

www.smokefree.gov

 National Quit Line

1-800-QUIT-NOW (1-800-784-8669)

24 hours a day, 7 days a week

 Women.smokefree.gov

www.women.smokefree.gov

 Womenshealth.gov

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

 VHA Smoking and Tobacco Use Cessation

www.publichealth.va.gov/smoking

 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

www.ahrq.gov/consumer/tobacco/helpsmokers.htm

 Office of the Surgeon General

www.surgeongeneral.gov/tobacco

 Healthfinder Tobacco Resources Page

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

 National Cancer Institute

www.cancer.gov

1-877-44U-QUIT (1-877-448-7878)

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

• LiveHelp chat: https://cissecure.nci.nih.gov/livehelp/welcome.asp

8am-11pm, Monday-Friday (ET)
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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
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Appendix D. Educational Materials and 

Additional Resources for Providers

The resources below provide you with additional information when helping 

your patients quit smoking.

THE 5 A’S OF SMOKING CESSATION INTERVENTIONS

ASK — 1 minute

Ask patients to describe their smoking status.

A. I NEVER smoked or smoked LESS THAN 100 cigarettes.

B. I stopped smoking more than 2 weeks ago but less than 1 year ago.

C. I stopped smoking more than 1 year ago.

D. I smoke regularly/not thinking of quitting in the next 30 days.

If B or C, reinforce their decision to quit, congratulate and encourage.

If D, document smoking status on their chart. Begin steps below.

ADVISE — 1 minute

Provide clear, strong advice to quit with personalized messages about the 

impact of smoking on health; urge every tobacco user to quit.

ASSESS — 1 minute

Assess the willingness to make a quit attempt within 30 days.

 Patient is willing to make a quit attempt in the next 14-30 days.

 Patient is not willing to make a quit attempt

(Review the 5 R’s on p. 97).

ASSIST — 3 minutes

Recommend the use of approved pharmacotherapy, refer to community 

cessation services or Internet when appropriate, and/or:

 Help the patient develop a quit plan.

 Provide problem-solving methods and skills for cessation. Provide 

social support as a part of the treatment.

 Help patient obtain extra treatment/social support for quitting in 

the smoker’s environment.
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 Recommend the use of approved pharmacotherapy.

 Provide self-help smoking cessation materials.

ARRANGE - 1 minute +

Assess smoking status every visit, reinforce/encourage cessation.

THE 5 R’S OF ENHANCING MOTIVATION TO QUIT TOBACCO

RELEVANCE - 1 minute

Ask patient about how quitting may be personally relevant.

 Longer and better quality of life

 Extra money

 People you live with will be healthier

 Decrease chance of heart attack, stroke or cancer

 If pregnant, improves chance of healthy baby

RISKS - 1 minute

Ask the patient about their perception of short-term, long-term and 

environmental risks of continued use.

 Acute (breathing, asthma, pregnancy)

 Long-term (heart, lungs, health)

REWARDS - 1 minute

Ask the patient about perceived benefits/rewards for quitting tobacco use.

 Health (self & others)

 Food tastes better

 Better sense of smell

 Feel better

 Example to others

 Additional years of life

ROADBLOCKS - 3 minutes +

Ask patient about perceived roadblocks to quitting.

 Withdrawal symptoms
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 Fear of failure

 Weight gain

 Lack of support

 Depression

 Enjoyment of tobacco

REPETITION - 1 minute +

Respectfully repeat the 5 R’s each visit, providing motivation and 

information.
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SAMPLE: SMOKING CESSATION PROGRAM SCREENING FORM

NAME: ________________________________________________________

SSN (last 4): ________________________

PHONE #: __________________________

DATE: _____________________________

1. Do you smoke cigarettes every day?

£YES

£NO

2. Are you interested in receiving help to quit smoking?

£YES

£NO

3. How soon after waking do you smoke your first cigarette?

Less than 5 minutes

5 to 30 minutes

31 to 60 minutes

4. How many cigarettes do you smoke each day?

More than 30 cigarettes

21 to 30 cigarettes

11 to 20 cigarettes

1 to 10 cigarettes

IT IS IMPORTANT FOR YOUR HEALTH THAT YOU QUIT SMOKING.

If you are not ready to quit now, we can still tell you more about our program. Please 

hand this form to the Medical Clerk and someone will contact you soon. Thank you.
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SAMPLE: HIV CLINIC FORM

HIV CLINIC SMOKER: [ ] Yes [ ] No

MD Counsel: [ ] Yes [ ] No

1. CHECK IN

PATIENT NAME: LAST 4 SSN: 

PROVIDER: APPT TIME: ARRIVAL TIME: 

2. TRIAGE / SEE PROVIDER

PROCEDURES TODAY

[ ] PNEUMOVAC [ ] PPD [ ] HEPATITIS B [ ] HEPATITIS A [ ] HEP A / B 

[ ] TETANUS/DIP [ ] INFLUENZA [ ] PENTAMIDINE [ ] OTHER 

[ ] LABS TODAY ( ) already ordered ( ) please order

CD4 CBC Minerals PSA HGBA1C 

VL CHEM 7 LPA (non-fasting) TSH OCCULT BLOOD 

U/A LFT's LPA (fasting) RPR OTHER 

[ ] FUTURE LABS DATE ( ) already ordered ( ) please order

CD4 CBC Minerals PSA HGBA1C 

VL CHEM 7 LPA (non-fasting) TSH OCCULT BLOOD 

U/A LFT's LPA (fasting) RPR OTHER 

[ ] RADIOLOGY Reason for Study 

EDUCATION - Medication Review:

Provide Literature on: HTN DM Hyperlipidemia Smoking Cessation Other

3. ENCOUNTER

DIAGNOSIS [ ] HIV [ ] Other Diagnosis #1 [ ] Other Diagnosis #2 

[ ] Established [ ] New [ ] Consult

4. PATIENT TO SEE PRIOR TO DISCHARGE FROM CLINIC TODAY

[ ] Social Worker [ ] Research Nurse:
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WEB RESOURCES AND ONLINE TRAININGS

 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

 Spit Tobacco: A Guide to Quitting

www.nidcr.nih.gov/OralHealth/Topics/SmokelessTobacco/

SmokelessTobaccoAGuideforQuitting.htm

 Smoking Cessation & HIV

www.mpaetc.org/scripts/prodView.asp?idproduct=142

 National Cancer Institute

www.cancer.gov

1-877-44U-QUIT (1-877-448-7848)

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

• LiveHelp chat: https://cissecure.nci.nih.gov/livehelp/welcome.asp

8am-11pm, Monday-Friday (ET)

 Surgeon General’s Report

How Tobacco Causes Disease: The Biological and Behavioral Basis for 

Smoking-Attributable Disease (2010)

http://www.surgeongeneral.gov/library/reports/tobaccosmoke/

full_report.pdf
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Appendices

 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/clinic/tobacco/treating_tobacco_use08.pdf

 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)

www.mentalhealth.va.gov/coe/cih-visn2/Documents/Clinical/

Tobacco_Use_Cessation/TUC_Manual_August_2010.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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Appendices

Appendix E. FAQs

Does nicotine cause cancer?

Nicotine does not cause cancer but is the addictive chemical in tobacco that 

makes it so hard to stop smoking. Tobacco smoke has over 4,000 chemicals and 

more than 50 of these chemicals are cancer causing. Nicotine in the form of 

a patch, gum, or lozenge doesn't contain any of the cancer-causing agents that 

are found in cigarettes. These products give you a reduced amount of nicotine 

to help calm your cravings and irritability so you can focus on the emotional 

and behavioral aspects of your habit.

Can I stay on nicotine gum indefinitely? What are the risks if I can't kick 

the gum habit?

Typically, people use nicotine replacement therapy for about four to six 

months. The recommended course of therapy for nicotine gum is 12 weeks 

and you should use it for the full 12 weeks to improve your chances of success. 

In one clinical trial, gum was used for as long as one year without any negative 

effects. Beyond one year, the long-term effects of nicotine exposure aren't 

clear. If you are having difficulty giving up the gum try to gradually reduce 

your dependence by substituting regular or sugar-free gum. If that doesn't 

work, you may want to seek assistance from a smoking-cessation expert who 

can help guide you through a behavioral program to change the habit part of 

your nicotine gum use. Work out a plan to wean yourself off of nicotine gum, 

and be willing to do the work it takes to achieve your goal.

What is the best way to quit smoking?

There is no one way to quit smoking, but we do know that a combination 

of behavioral counseling and the use of FDA-approved smoking cessation 

medications are the most effective elements of any treatment plan. Behavioral 

counseling may include a brief session on how to quit from your primary 

care providers or a number of sessions through a smoking cessation clinic or 

telephone counseling. But the combination of both counseling and medication 

appears to be the key. We also know that the greater the number of behavioral 

counseling sessions, the more likely you will be successful in quitting. 

I have tried quitting before and I failed. How do I know if I will be more 

successful this time?

It’s important to keep in mind that it takes even the most motivated smoker 

several quit attempts before he or she is able to quit for good. To increase 

your chances of being successful this time, have a plan. Talk with your health 

care provider about quitting and ask about getting a prescription for smoking 

cessation medications such as nicotine replacement therapy or bupropion or 
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Appendices

a combination of medications. Set a quit date and plan to throw away all 

cigarettes in your home, workplace, and car. Tell your friends and family 

about your plan and let them know that you will need their help and support. 

Think about the ways your health will improve and think about all the money 

you will save by quitting smoking. Try to think about what worked or helped 

you the last time you tried to quit and think about the challenges that you 

faced as well.

Are “light” or “low tar” or “natural” cigarettes less harmful than 

regular cigarettes?

No and in fact, there are new regulations that will prevent cigarette 

manufacturers from making these claims. They are all still harmful and carry 

the same health risks as “regular cigarettes.” Quitting is the only way to 

reduce your risk of smoking-related illnesses and premature death.

I only smoke occasionally, like when I am at parties or at a bar. What 

are the health risks of occasional smoking?

Even occasional smoking carries health risks and there really is no safe amount 

to smoke. Anytime you inhale cigarette smoke (even that from someone else 

smoking), the smoke enters the lungs and damages tissue in the lungs. Cigarette 

smoke can also restrict blood flow to the heart and increase your risk for 

heart attack. Many people who are casual or occasional smokers also convince 

themselves that they can quit whenever they want, but many of them find 

themselves becoming regular smokers. Again, there is no safe amount to smoke. 

Can hypnosis help me to quit? 

There have been a lot of studies looking at just this question and the majority 

have found that hypnosis alone isn’t effective in helping smokers quit. It is 

still important to make sure you receive behavioral counseling and use FDAapproved smoking cessation medications as part of your quit attempt. Hypnosis 

or meditation or other therapies may help you with reducing or managing the 

stress of quitting smoking, but they often aren’t enough by themselves.

What about e-cigarettes or electronic cigarettes? Can they help me quit? 

There has been a lot in the news about e-cigarettes or electronic cigarettes 

and you may have seen them on the internet. However, there are no studies 

to show that these are effective in helping smokers quit. In addition, there are 

international concerns about the safety of these products as they are currently 

not regulated. In fact, their sale is banned in a number of countries and the 

FDA has published updates to consumers about potential safety concerns. 

They are not the same as FDA-approved smoking cessation medications, which 

are known to be safe and effective in helping smokers quit.



U.S. Department of Veterans Affairs

Veterans Health Administration

Washington, DC 20420

HIV Provider Smoking Cessation Handbook:

A Resource for Providers

July 2012

IB 10-432; P96534

Sponsored by

U.S. Department of Veterans Affairs

Veterans Health Administration

Clinical Public Health