Primary Care &
Tobacco
Cessation
Handbook
A Resource
for Providers
Primary Care &
Tobacco
Cessation
Handbook
A Resource
for Providers
Acknowledgements
The provider manual Primary Care & Tobacco Cessation and the
accompanying My Tobacco Cessation Workbook were developed by
Julianne Himstreet, Pharm.D., BCPS. The author’s primary goal was to
develop materials promoting tobacco use treatment interventions, based
on published principles of evidence- and consensus-based clinical practice,
for use by primary care providers treating patients who use tobacco.
With permission from the HIV and Smoking Cessation (HASC) Working Group,
several materials used in the Primary Care & Tobacco Cessation provider
manual were modied from HIV Provider Smoking Cessation Handbook.
The U.S. Public Health Service Clinical Practice Guideline (Fiore, 2000)
and the treatment model described by Richard Brown (2003) provided the
foundation for their work and therefore indirectly ours as well.
1
Many thanks to Kim Hamlett-Berry, Director of Tobacco & Health Policy
in VHA Ofce of Mental Health and Suicide Prevention for supporting this
project and Leah Stockett for editing the manual and the workbook. In
addition, much appreciation needs to be given to Dana Christofferson, Kim
Hamlett-Berry, Pam Belperio, Tim Chen, and Jennifer Knoeppel for their
editing and content contributions.
1
1
Brown, R. A. (2003). Intensive behavioral treatment. In D. B. Abrams, R. Niaura, R. Brown,
K. M. Emmons, M. G. Goldstein, & P. M. Monti, The tobacco dependence treatment handbook: A guide
to best practices (pp. 118-177). New York, NY: Guilford Press.
Fiore, M. C., Bailey, W. C., Cohen, S. J., Dorfman, S. F., Goldstein, M. G., Gritz, E. R., Heyman, R. B.,
Jaén, C. R., Kottke, T. E., Lando, H. A., Mecklenburg, R. E., Mullen, P. D., Nett, L. N., Robinson, L.,
Stitzer, M. L., Tommasello, A. C., Villejo, L., & Wewers, M. E. (2000). Treating tobacco use and
dependence. Clinical practice guideline. Rockville, MD: U.S. Department of Health and Human
Services, Public Health Service.
i
Table of Contents
I. Tobacco Use in VA’s Population ................................1
Scope Of The Problem ...................................... 4
Benets Of Tobacco Cessation ............................. 5
The Role Of The Primary Care Provider .................. 6
Challenges To Tobacco Cessation In VA Primary
Care Patients ................................................. 6
II. Tobacco Cessation Interventions ............................ 13
Effectiveness Of Tobacco Cessation Interventions ..... 15
Establishing A Tobacco Cessation Program
For Veterans In Primary Care Clinics .................... 16
Tobacco Cessation Behavioral Interventions ............ 16
Identifying Reasons To Quit ............................... 19
III. Real‑time Scripts for Brief Tobacco
Cessation Interventions ...................................... 23
Approaching Patients About Tobacco Cessation ........ 25
Addressing Patient Concerns And Sample Scripts ...... 27
IV. Medications for Tobacco Cessation ........................ 33
Nicotine Pharmacology .................................... 35
Nicotine Replacement Therapy (NRT) ................... 37
Bupropion .................................................... 43
Varenicline .................................................. 45
V. Relapse Prevention and
Tobacco Cessation Maintenance ............................ 57
Tobacco Use: A Chronic, Relapsing Disorder ............ 59
Management Of Withdrawal Symptoms .................. 60
VI. Establishing A Tobacco Cessation Program In Primary
Care Clinics .................................................... 65
Group Counseling Program ................................ 67
ii
Appendices ........................................................ 99
Appendix A. Evaluating Tobacco
Cessation Programs ........................100
Appendix B. Tobacco Cessation Resources. ............ 102
Figures and Table
Figures
Figure 1. Efcacy of Medications for
Smoking Cessation.................................... 36
Figure 2. Combination Nicotine Replacement Therapy
(NRT) Dosing and Administration ................... 41
Figure 3. Combination NRT Tapering Strategy ............... 42
Tables
Table 1. The 5 A’s of Tobacco Cessation Interventions .... 17
Table 2. Enhancing Motivation to Quit Tobacco,
the 5 R's ............................................... 19
Table 3. Fagerström Test for Nicotine Dependence ........ 26
Table 4. Sample Responses to Patients’ Concerns
About Tobacco Cessation ............................ 27
Table 5. Sample Scripts for Brief Tobacco Cessation
Conversations Between Patients
and Providers ......................................... 29
Table 6. Tobacco Use Cessation Treatment Guidance ..... 47
Table 7. Tobacco Withdrawal Symptoms
and Recommendations ............................... 60
1
I. Tobacco Use in
VA’s Population
3
I. Tobacco Use in VA’s Population
CHAPTER SUMMARY
Scope of the problem
In 2020, approximately, 12.5 percent of the adult population in the
United States smoked cigarettes
1
Smoking accounts for more than 480,000 deaths each year in the
United States
2
Smoking is a known cause of multiple cancers, heart disease,
stroke, complications of pregnancy, chronic obstructive pulmonary
disease (COPD), and many other diseases
3,4
Smoking prevalence in the Veteran population has been reported to
be similar to the general U.S. population with approximately 13.3%
of Veterans enrolled in VA care reporting smoking in 2020
5
In 2020, 5.1% and 3.5% of VA enrollees reported smokeless tobacco
and e-cigarette use respectively
Smokeless tobacco and e-cigarette use is more prevalent among
younger Veterans enrolled in VA care. 9.8% and 8.7% of those under
age 45 reported smokeless tobacco and e-cigarette use respectively
in 2020
Tobacco dependence is a chronic, relapsing disorder that often
requires repeated interventions and multiple quit attempts
Benets of smoking cessation in primary care patients
Smoking cessation can reduce and prevent many smoking-related
health problems
Smoking is the most clinically important modiable cardiovascular
risk factor for all patients
Quitting smoking leads to reduced depression and anxiety
symptoms and improved positive mood
6
The improvements after quitting tobacco are noticeable within the
rst few days after stopping
Every attempt to quit improves the probability of eventual success
9
4
I. Tobacco Use in VA’s Population
CHAPTER SUMMARY
VA's primary care provider’s role
Address tobacco use at every visit. Effectiveness starts with the
clinical routine of:
• Asking every patient about tobacco use
• Advising patients to quit at every visit
• Assessing all patients’ readiness to quit at every visit
• Assisting all patients willing to make a quit attempt with
counseling and cessation medications
Approach tobacco use as a chronic illness, which includes
monitoring repeated quit attempts and relapses
Counsel and prescribe medications to assist with cessation
Help patients access comprehensive care to address co-morbidities
affecting their ability to quit
Utilize an integrated model of care and provide a consistent
message about the importance of quitting tobacco use
Use a team approach as it results in greater efcacy in long-term
follow up and prescribing tobacco cessation medications
Challenges to tobacco cessation in VA primary care
Higher rates of tobacco use in many Veteran groups including
Veterans of Iraq and Afghanistan wars, mental health patients,
substance use disorder patients, and HIV-infected patients
Integrating tobacco cessation counseling into all patient care areas
including primary care, mental health, and specialty clinics
Changing the delivery of tobacco cessation services to address
tobacco use and dependence in a chronic disease model
SCOPE OF THE PROBLEM
Impact of Tobacco Use on Morbidity and Mortality
Smoking is the leading cause of preventable death and disease in the United
States.
3
Cigarette smoke contains more than 7,000 chemicals, including
hundreds of chemicals that are toxic and more than 70 that can cause cancer.
10
It is a chronic disorder that often requires repeated interventions and multiple
attempts to quit.
5
I. Tobacco Use in VA’s Population
In the United States, the current prevalence of tobacco use among
adults has dropped from 44% in in the 1960s to approximately 12.5%
in 2020.
8
The adverse health effects from cigarette smoking account for more
than 480,000 annual deaths, or nearly one of every ve deaths in
the United States.
2
More deaths are caused each year by tobacco use than by all deaths
from AIDS, alcohol, motor vehicle accidents, homicide, drug use, and
suicide, combined.
11‑14
Smoking causes an estimated 90% of all lung cancer deaths in men
and 80% of all lung cancer deaths in women.
4
An estimated 90% of all deaths from chronic obstructive lung disease
are caused by smoking.
4
The risk of heart attack and stroke are much higher in tobacco users
compared to people who do not use tobacco.
Smoking-attributable health costs are estimated at $96 billion per
year in direct medical expenses and $97 billion in lost productivity.
15
Light smoking is dangerous to the health of those who smoke. The
Surgeon General’s report on how tobacco causes disease documents
in great detail how both direct smoking and secondhand smoke
causes damage not only to the lungs and heart, but to every part of
the body.
10
Researchers found that inhaling smoke from one cigarette
causes damage to the lining of blood vessels and changes to blood
platelets that increase risk of clotting, and that light smoking may
be almost as detrimental to cardiovascular health as heavy smoking.
BENEFITS OF TOBACCO CESSATION
Smoking cessation can reduce and prevent many smoking-related health
problems. The benets of quitting tobacco can be noticed in the rst few days
after stopping.
4
Smoking cessation lowers the risk for lung and other types of cancer
within 10 years after stopping.
Tobacco cessation reduces the risk of stroke, heart disease, and
peripheral vascular disease. Coronary heart disease (CHD) risk
begins to decline within 1-2 years of stopping smoking and risk of
death due to myocardial infarction and CHD is 50% lower within one
year post‑cessation.
6
I. Tobacco Use in VA’s Population
Smoking cessation reduces coughing, wheezing, and shortness of
breath. The rate of decline in lung function that occurs with aging is
slower among persons who quit tobacco.
Smoking cessation reduces the risk of developing chronic obstructive
pulmonary disease (COPD). For those already diagnosed with COPD,
smoking cessation is the most important step they can take to
control progression of their COPD.
Smoking increases the rate of infertility in women during their
reproductive years. Women who stop smoking during their
reproductive years have a reduced risk of infertility and women
who stop smoking during pregnancy reduce the risk of having a low
birth-weight baby.
Every attempt to quit improves the probability of eventual success.
10
THE ROLE OF THE PRIMARY CARE PROVIDER
Assess tobacco use at every visit with Veterans. This can be done by multiple
providers during a visit, including but not limited to medical assistants, nurses,
physicians, nurse practitioners, physician assistants, pharmacists, and other
members of the health care team. It is estimated that 70% of current adult
smokers in the United States want to quit and millions have attempted to do
so. Tobacco dependence is a chronic disorder that often requires repeated
interventions and multiple quit attempts. Limits should not be placed on how
often Veterans can attend counseling sessions or receive medication. Methods
to quit tobacco use include:
Brief clinical interventions (≤10 minutes)
• Provider offering counseling with “advice to quit” and assistance
with quitting
Counseling (≥10 minutes)
• Individual
• Group
• Telephone (VA quitline, 1-855-QUIT-VET, (1-855-784-8838))
Medications to help with tobacco cessation
• Nicotine replacement therapy (NRT)
• Non-nicotine medications
Bupropion
Varenicline
7
I. Tobacco Use in VA’s Population
The combination of medication and counseling is more effective for
tobacco cessation than either medication or counseling alone.
3
SmokefreeVET Text Message Program, visit smokefree.gov/VET
CHALLENGES TO TOBACCO CESSATION IN VA PRIMARY
CARE PATIENTS
Rates of tobacco use are higher in many Veteran groups, including
Veterans of the Iraq and Afghanistan wars, mental health patients, and
HIV-infected patients. Quitting tobacco products can be more challenging
in these patient groups, however there are effective models of care for
smoking cessation interventions in these patients. Establishing programs
to help support cessation attempts can increase cessation rates.
Veterans with posttraumatic stress disorder (PTSD) smoke and use tobacco at
higher rates than Veterans without PTSD.
14
An integrated model of smoking
cessation with primary care providers and staff that provided consistent care for
Veterans with PTSD was found to be effective and superior to standard-of-care
smoking cessation programs given separately from the primary care clinic.
14‑16
Veterans with psychiatric disorders smoke at higher rates than
those without mental health disorders.
16
Studies in populations with
psychiatric disorders and depression suggest moderate efcacy
of smoking cessation and little or no evidence of exacerbation of
these disorders.
17,18
Approximately half of alcohol dependent individuals are daily
smokers.
19,20
Evidence indicates that smoking cessation interventions
for individuals with alcohol use disorder are effective and have no
detrimental effects on abstinence from alcohol.
19
Study results are
mixed regarding optimal timing of smoking cessation interventions
for individuals with alcohol use disorder.
21,22
Smoking status should
be addressed for all individuals with alcohol use disorder and the
following recommendations have been proposed:
19,23,25
• Smoking cessation interventions should be offered to all alcohol
use disorder patients who smoke
• A menu of options about how and when to stop should be offered
• Timing of smoking cessation interventions (concurrent versus
delayed) should be based on patient preference
HIV-infected smokers have a greater probability of non-AIDS
related diseases such as cardiovascular and pulmonary conditions
(pneumothorax, pneumonia, lung cancer) and non-AIDS cancers.
23
8
I. Tobacco Use in VA’s Population
Cigarette smoking is the most important modiable cardiovascular
risk factor among HIV-infected patients, more so even than the use
of lipid-lowering drugs or ART.
24
Tobacco use is more prevalent in the Veterans from Operation
Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) than
in the general Veteran population. Veterans returning home from
Iraq and Afghanistan report they continued to smoke as a way to
modulate negative moods (e.g., anger dysregulation, irritability,
stress); cope with a post deployment shift to civilian life; and
deal with combat-related injuries, unstructured life outside of the
military, sleep disorders, and the inability to turn off the military
mindset (e.g., hypervigilance).
27
Concurrent tobacco use is the use of cigarettes along with another
form of tobacco like chewing tobacco, cigars or pipes. The rates of
concurrent tobacco use are increasing and this is felt to be due at
least in part to restrictions on cigarette smoking in indoor locations.
In a 2008 report, 41% of active duty military personnel reported
using at least one form of tobacco in the previous month. Heavier
rates of smoking (more than 15 cigarettes a day) was associated with
a higher rate of using multiple forms of tobacco (cigarettes, cigars
and chewing tobacco).
27
9
I. Tobacco Use in VA’s Population
References:
1. Centers for Disease Control and Prevention (2022). Tobacco Product Use
Among Adults – United States, 2020. Morbidity and Mortality Weekly Report,
71(11), 397-405. Retrieved from https://www.cdc.gov/mmwr/volumes/71/wr/
mm7111a1.htm?s _cid=mm7111a1_w
2. Centers for Disease Control and Prevention (2016). Health Effects of Cigarette
Smoking (Fact Sheets). Retrieved March 1, 2017 from https://www.cdc.gov/tobacco/
data_statistics/fact_sheets/health_effects/effects_cig_smoking/index.htm
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.ncbi.nlm.nih.gov/books/NBK63952/
4. U.S. Department of Health and Human Services. (2004). The health
consequences of smoking: a report of the Surgeon General. Accessed at
https://www.hhs.gov/surgeongeneral/reports-and-publications/index.html
5. U.S. Department of Veterans Affairs (2020). 2020 Survey of Veteran Enrollees’
Health and Use of Health Care, Veterans Health Administration. Retrieved from
https://vaww.va.gov/VHACSO/SOE/2020/2020_Enrollee_Data_Findings_Report-
March_2021-FINAL-508_Compliant.pdf
6. Taylor G, McNeill A, Girling A, Farley A, Lindson-Hawley N, Aveyard P. Change
in mental health after smoking cessation: systematic review and meta-analysis
[published correction appears in BMJ. 2014;348:g2216]. BMJ. 2014;348:g1151.
Published 2014 Feb 13. doi:10.1136/bmj.g1151
7. Cypel, Y. S., Hamlett-Berry, K., Barth, S. K., Christofferson, D. E., Davey, V. J.,
Eber, S., Schneiderman, A. I., Bossarte, R. M. (2016). Cigarette smoking and
sociodemographic, military, and health characteristics of Operation Enduring
Freedom and Operation Iraqi Freedom Veterans: 2009-2011 National health study
for a new generation of US veterans. Public Health Reports. 131(5); 714‑727.
8. Bray, R. M., Pemberton, M. R., Hourani, L. L., Witt, M., Olmstead, K. L.
R., Brown, J. M., Weimer, B., Lane, M. E., Marsden, M. E., Scheifer, S.,
Vandermaas-Peeler, R., Aspinwall, K. R., Anderson, E., Spagnola, K., Close,
K., Gratton, J. L., Calvin, S., Bradshaw, M., & RTI International. (2009) 2008
Department of Defense Survey of Health Related Behaviors Among Active Duty
Military Personnel.
9. Prochaska, J. O., & Velicer, W. F. (1997). The transtheoretical model of health
behavior change. American Journal of Health Promotion, 12(1); 38–48.
10. U.S. Department of Health and Human Services. (2010). How tobacco smoke
causes disease: The biology and behavioral basis for smoking-attributable
disease: A report of the Surgeon General. Accessed at http://www.ncbi.nlm.
nih.gov/books/NBK53017/
11. Centers for Disease Control and Prevention, National Center for Health Statistics.
FastStats - Statistics by Topic [webpage]. Retrieved December 7, 2016 from
10
I. Tobacco Use in VA’s Population
http://www.cdc.gov/nchs/fastats/default.htm
12. Centers for Disease Control and Prevention (2016). Increase in Drug and Opioid
Overdose Deaths — United States, 2000-2014. Morbidity and Mortality Weekly
Report, 64(50), 1378-1382. Retrieved from http://www.cdc.gov/mmwr/preview/
mmwrhtml/mm6450a3.htm
13. Substance Abuse and Mental Health Services Administration (2014). Results
from the 2013 National Survey on Drug Use and Health: Mental Health Detailed
Tables (Table 1.10B). Retrieved from https://www.samhsa.gov/data/sites/default/
les/2013MHDetTabs/NSDUH-MHDetTabs2013.pdf
14. U.S. Department of Health and Human Services (2014). The Health Consequences
of Smoking—50 Years of Progress: A Report of the Surgeon General. Centers for
Disease Control and Prevention, National Center for Chronic Disease Prevention
and Health Promotion, Ofce on Smoking and Health.
15. Centers for Disease Control and Prevention. (2008). Annual smoking-attributable
mortality, years of potential life lost, and productivity losses—United States,
2000–2004. Morbidity and Mortality Weekly Report, 57(45), 1226-1228. Accessed
at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5745a3.htm
16. McFall, M., Saxon, A. J., Thompson, C. E., Yoshimoto, D., Malte, C.,
Straits-Tröster, K., Kanter, E., Zhou, X. H., Dougherty, C. M., & Steele, B.
(2005). Improving the rates of quitting smoking for veterans with posttraumatic
stress disorder. The American Journal of Psychiatry, 162(7), 1311-1319. Accessed
at http://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.162.7.1311
17. Duffy, S. A., Kilbourne, A. M., Austin, K. L., Dalack, G. W., Woltmann, E. M.,
Waxmonsky, J., & Noonan, D. (2012). Risk of smoking and receipt of cessation
services among veterans with mental disorders. Psychiatric Services, 63(4),
325-332. Accessed at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3323716/
18. McFall, M., Saxon, A. J., Malte, C. A., Chow, B., Bailey, S., Baker, D. G.,
Beckham J. C., Boardman, K. D., Carmody, T. P., Joseph, A. M., Smith, M. W.,
Shih, M. C., Lu, Y., Holodniy, M., Lavori, P. W., & CSP 519 Study Team. (2010).
Integrating tobacco cessation into mental health care for posttraumatic stress
disorder: A randomized controlled trial. Journal of the American Medical
Association, 304(22), 2485-2493. doi:10.1001/jama.2010.1769
19. Falk, D. E., Yi, H. Y., & Hiller-Sturmhöfel, S. (2006). An epidemiologic analysis
of co-occurring alcohol and tobacco use and disorders: Findings from the
National Epidemiologic Survey on Alcohol and Related Conditions. Alcohol
Research & Health, 29(3), 162-171. Accessed at https://pubs.niaaa.nih.gov/
publications/arh312/100-110.pdf
20. 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.
21. 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.
22. 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
11
I. Tobacco Use in VA’s Population
Drugs, 65(6), 681-691.
23. Aberg, J. A. (2009). Cardiovascular complications in HIV management: Past,
present and future. Journal of Acquired Immune Deciency Syndromes,
50(1), 54-64. Accessed at http://journals.lww.com/jaids/Fulltext/2009/01010/
Cardiovascular_Complications_in_HIV_Management_.7.aspx?trendmd-shared=1
24. Grinspoon, S., & Carr, A. (2005). Cardiovascular risk and body-fat abnormalities
in HIV-infected adults. The New England Journal of Medicine,352(16), 48-62.
Accessed at http://www.nejm.org/doi/full/10.1056/NEJMra041811
25. 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.
26. Gierisch, J. M., Straits-Tröster, K., Calhoun, P. S., Beckham, J. C., Acheson,
S., & Hamlett-Berry, K., (2012), Tobacco use among Iraq- and Afghanistan-
era veterans: A qualitative study of barriers, facilitators, and treatment
preferences. Preventing Chronic Disease, 9(E58). Accessed at https://www.cdc.
gov/pcd/issues/2012/11_0131.htm
27. Olmsted, K. L., Bray, R. M., Reyes-Guzman, C. M., Williams, J., & Kruger, H.
(2011). Overlap in use of different types of tobacco among active duty military
personnel. Nicotine & Tobacco Research, 13(8), 691-698.
13
II. Tobacco Cessation
Interventions
15
II. Tobacco Cessation Interventions
CHAPTER SUMMARY
Effective interventions can be brief (3-10 minutes) or intensive
(lasting for >10 minutes)
Brief 3-minute interventions advising patients to quit can enhance
abstinence rates
Even without a tobacco cessation program, brief counseling
and medications provided as part of ongoing health care can
be effective
When creating a tobacco cessation program, start small and
manageable by selecting brief interventions appropriate for
the setting
Identify primary care providers and key staff with an interest in
tobacco cessation
Build the program by incorporating more intensive interventions
when appropriate
Monitor and track your patients’ progress
EFFECTIVENESS OF TOBACCO CESSATION INTERVENTIONS
Tobacco cessation interventions can be extremely effective and providers
who perform even brief interventions of ‘advice to quit’ to patients can
signicantly increase abstinence rates. Health care providers should present
a clear, concise, and consistent “quit” message to all their patients who use
tobacco. The evidence on tobacco cessation interventions referenced below
is presented in full in the U.S. Department of Health and Human Services
(DHHS), Public Health Service (PHS), Treating Tobacco Use and Dependence:
2008 Update (Clinical Practice Guideline).
1
Any type of clinician can be effective at delivering evidence-based interventions
to increase quit rates. There is strong evidence of a dose-effect response, as
the more intense the cessation inter vention, the greater the rate of abstinence.
Intervention intensity can be increased by extending the length and number of
individual treatment sessions.
1
Cessation counseling lasting 4-30 minutes can
double a patient’s chance of abstinence whereas counseling lasting more than
30 minutes can triple a patient’s chance of success.
1
Conducting 2-3 counseling
sessions increases abstinence rates by 1.5 fold while conducting 4-8 sessions
double the chance of success.
1
It is important to remember that brief counseling and medications provided as
part of an ongoing therapeutic relationship can be as or more effective than a
16
II. Tobacco Cessation Interventions
referral to an outside clinic, tobacco cessation program or the prescribing of
medication alone.
1
Behav ioral inter ventions such as group counseling, individual
counseling, proactive telephone counseling, physician advice, nurse advice,
and mobile phone-based interventions have all been shown to signicantly
increase abstinence rates compared to stopping "cold turkey."
ESTABLISHING A TOBACCO CESSATION PROGRAM FOR VETERANS
IN PRIMARY CARE CLINICS
Implementing a sustainable and effective tobacco cessation program can feel
daunting, but several key strategies can be helpful when implementing an
effective tobacco cessation program in your primary care clinic. As you start to
build a program in your clinic, identify providers and staff who are interested
in tobacco cessation as these “local champions” can help build momentum
for the program and get other providers involved. As more providers become
interested, you can start to implement more intensive cessation interventions.
Monitoring and tracking patients’ progress over time can provide helpful
feedback to staff so they can see the impact of their work. Finally, there is
a Smoking and Tobacco Use Cessation Lead Clinician at each VA facility who
can be a valuable resource for your clinic. Please email VHATobaccoProgram@
va.gov to obtain the name of the Lead Clinician at your VA facility.
TOBACCO CESSATION BEHAVIORAL INTERVENTIONS
This chapter describes interventions to use when talking with your patients
about their interest in tobacco cessation. These brief and intensive
interventions have been used in health care settings and range from 3-10
minute conversations to intensive counseling that can last an hour. Challenges
and opportunities for implementing these well-established interventions with
your primary care patients and making tobacco cessation a routine part of
clinical care are also addressed.
Brief Interventions (3-10 minutes)
The most important factor in tobacco cessation is engaging patients. Providing
pa
tients with information about the impact of tobacco use, assessing their
level of motivation to quit, and helping them move to the next step in cessation
through the provision of resources or referrals to tobacco cessation programs,
are critical components of brief interventions. The ve elements of a brief
tobacco cessation intervention are outlined below.
TABLE
17
II. Tobacco Cessation Interventions
TABLE 1. THE 5 A’S OF TOBACCO CESSATION INTERVENTIONS
1-3
ASK about smoking*
Ask patients about tobacco use at every clinic visit
Ask about the type(s) of tobacco used and how long it has
been used
If a patient quit years ago, congratulate and check in periodically
*Clinical reminders and performance measures within VHA can assist with
this element
ADVISE patient to quit
Provide clear, strong, and personalized suggestions
Clear: I think it is important that you quit smoking. I can help.
Strong: Quitting smoking is one of the most important things you
can do to protect your health.
Personalized: Associate smoking with something that is important
to the patient, such as the increased risk of harm to their body,
exposure of children or pets to tobacco smoke, the expense of
cigarettes, or pulmonary and cardiovascular comorbidities.
• Your smoking can increase your risk of heart attacks and
strokes.
• Remember the time you had that terrible pneumonia?
• Do you realize that you can save more than $2,000 a year on
cigarette expenses if you quit?
ASSESS readiness to quit
Assess patient’s readiness to quit within the next 30 days
Are you willing to give quitting a try in the next 30 days?
• If patient is ready, assist patient using the follow-up activities
in the ARRANGE section (p. 19).
• If the patient is not ready to quit, consider using motivational
interviewing to increase their readiness
(See Table 2. Enhancing Motivation to Quit Tobacco, The 5 R's
on p. 20).
18
II. Tobacco Cessation Interventions
TABLE 1. THE 5 A’S OF TOBACCO CESSATION INTERVENTIONS
1-3
cont.
ASSIST patients with their quit attempt
Prepare your patient for quitting using STAR. Have them:
Set a target quit date (TQD). Ideally, the TQD should be within two
weeks, but no later than within 30 days. The quit date should be a date
they feel comfortable with that gives 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 rst few weeks. These include nicotine
withdrawal symptoms.
Remove tobacco products from their environment. Before quitting,
they should avoid smoking in places where a lot of time is spent
(e.g., work, home, car) and make their home smoke free.
Offer pharmacotherapy and discuss the role of medications in treatment
Provide practical counseling (problem-solving/skills training)
Offer intensive treatment options (e.g., tobacco cessation groups,
telephone counseling) available within your VA facility.
Provide a supportive clinical environment while encouraging the
patient in his or her quit attempt.
Provide supplementary materials and other resources to keep the
patient motivated and engaged.
19
II. Tobacco Cessation Interventions
TABLE 1. THE 5 A’S OF TOBACCO CESSATION INTERVENTIONS
1-3
cont.
ARRANGE follow-up encounters
Arrange patient follow-up contact by phone or in clinic (enroll patient in a
VHA-based tobacco cessation clinic, if s/he requests)
Timing
• The rst follow-up encounter should be around the TQD or
within the rst week
• The second follow-up encounter should be within the rst
month of the TQD
Actions to take during follow-up encounters
• Assess medication use and any adverse reactions
• Remind patient of reasons for quitting and other resources
available to them
• Congratulate patient on abstinence
Provide supplementary materials and other resources such as the My
Tobacco Cessation Workbook to keep the patient motivated and engaged
• VA tobacco cessation quitline: 1-855-QUIT VET (1-855-784-
8838). Counselors are available Monday-Friday, 9AM-9PM
EST. Counseling can be provided in either English or Spanish,
depending on Veteran preference.
• SmokefreeVET text program: text the word VET to 47848 or
visit smokefree.gov/VET
• Stay Quit Coach, a smartphone app to help Veterans quit
smoking and stay quit. Visit mobile.va.gov/app/stay-quit-
coach
• Visit veterans.smokefree.gov for additional VA patient
resources
For providers with less time or comfort, the 5 A’s can be modied 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 tobacco cessation intervention consist of:
Determining whether tobacco users are willing to make a quit
attempt with intensive counseling
20
II. Tobacco Cessation Interventions
Conducting patient assessments that may be helpful including lung
function, stress level, and nicotine dependence using the Fagerström
Test for Nicotine Dependence (See Table 3. Fagerström Test for
Nicotine Dependence on p. 26)
When possible, conducting sessions longer than 10 minutes and
including ≥4 sessions
Combining behavioral counseling and medication (essential to
successful tobacco cessation treatment)
Including problem solving/skills training and intra-treatment social
support as part of the intervention
IDENTIFYING REASONS TO QUIT
It is important to help patients identify reasons for quitting. The following
intervention, based on motivational interviewing, can help motivate patients
who are not quite ready to quit.
TABLE 2. ENHANCING MOTIVATION TO QUIT TOBACCO, THE 5 R'S
3-6
RELEVANCE Discuss why cessation is personally relevant
Health concerns and patient’s disease status or risk
Family situation, such as quitting for children
Monetary cost of nicotine dependence
RISKS Ask patients to explain their perceived potential risks of tobacco
use; discuss these risks (e.g., infertility, fetal harm, cardiovascular and
pulmonary disease, malignancies, harm of secondhand smoke to others)
Increased risk of heart attack and stroke
Reduced circulation in legs (peripheral artery disease), which can
increase risk of amputation
Increased risk of cancers like lung, bladder, pancreas, esophageal,
stomach, and head and neck cancers
Increased risk of osteoporosis and bone fractures
Increased risk of lung damage leading to emphysema
Smoking is a common cause of sexual dysfunction
21
II. Tobacco Cessation Interventions
TABLE 2. ENHANCING MOTIVATION TO QUIT TOBACCO, THE 5 R'S
3-6
cont.
REWARDS Ask patients to explain what they might gain from tobacco
cessation and highlight the rewards most relevant to the patient
Improved taste of food
Improved sense of smell
Improved mood and fewer symptoms of depression and anxiety
Saving money
Setting a good example for children
Better performance of physical activities
Improved appearance (e.g., reduced wrinkling, whiter teeth)
Lower risk of heart disease
Lower risk of lung disease
Lower risk of tobacco-related cancers
Explain that:
20 minutes after quitting, heart rate and blood pressure drop
Two weeks to three months after quitting, circulation and lung
function improve by 30%
One year after quitting, risk of coronary heart disease (CHD) is
reduced by 50%
Five years after quitting, stroke risk is similar to that of someone
who never smoked
Ten years after quitting, risk of Alzheimer's disease is the same as
someone who has 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 or dipping/chewing
Socializing with other smokers
REPETITION Discuss the R's listed above with patients at each visit
22
II. Tobacco Cessation Interventions
References:
1. Fiore, M. C., Jaén, C. R., Baker, T. B., Bailey, W. C., Benowitz, N. L.,
Curry, S. J., Dorfman, S. F., Froelicher, E. S., Goldstein, M. G., Healton, C. G.,
Henderson, P. Nez, Heyman, R. B., Koh, H. K., Kottke, T. E., Lando, H. A.,
Mecklenburg, R. E., Mermelstein, R. J., Mullen, P. D., Orleans, C. Tracy,
Robinson, L., Stitzer, M. L., Tommasello, A. C., Villejo, L., & Wewers, M. E.
(2008, May). Treating tobacco use and dependence: 2008 update. Clinical
practice guideline. Rockville, MD: U.S. Department of Health and Human
Services, Public Health Service. Retrieved from https://www.ncbi.nlm.nih.gov/
books/NBK63952/
2. Schroeder, S. A. (2005). What to do with a patient who smokes. Journal of
the American Medical Association, 294(4), 482-487. doi: 10.1001/jama.294.4.482
3. Gordon, J. S., Andrews, J. A., Crews, K. M., Payne, T. J., & Severson, H. H.
(2007). The 5A’s vs 3A’s plus proactive quitline referral in private practice
dental ofces: Preliminary results. Tobacco Control, 16(4), 285-288. Retrieved
from https://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: Guilford Publications, Inc.
5. Carpenter, M. J., Hughes, J. R., Solomon, L. J., & Callas, P. W. (2004). Both
smoking reduction with nicotine replacement therapy and motivational advice
increase future cessation among smokers unmotivated to quit. Journal
of Consulting and Clinical Psychology, 72(3), 371-381. doi: 10.1037/0022-
006X.72.3.371
6. Rollnick, S. P., Mason, P., & Butler, C. (1999). Health behavior change: A guide
for practioners. Edinburgh, England: Churchill Livingstone.
23
III. Real-time
Scripts for Brief
Tobacco Cessation
Interventions
25
III. Real-time Scripts for Brief Tobacco Cessation Interventions
CHAPTER SUMMARY
Tobacco use and dependence is a chronic, relapsing condition
Consider tracking tobacco use as a vital sign
Provide factual information to address patient concerns
Assess patient’s tobacco use status and readiness to quit
Advise patients about quitting
Encourage condence in quitting
APPROACHING PATIENTS ABOUT TOBACCO CESSATION
Though primary care providers are in an excellent position to provide tobacco
cessation interventions with their patients who use tobacco products, it can be
difcult and sometimes uncomfortable to approach the topic. We recommend
treating tobacco use as a vital sign so that a patient’s tobacco use status is
readily apparent upon their entrance into the exam room. This is an easy
way to integrate conversations about tobacco use into the clinic visit. Tobacco
use is a chronic, relapsing condition that at times requires varying levels of
intervention. We encourage you to go as far as you can with each patient at
each visit as you help lay the groundwork for tobacco cessation.
In order to assess your patient’s level of nicotine dependence, we suggest using
the test in Table 3. Fagerström Test for Nicotine Dependence (p. 26). The
level of your patient’s nicotine dependence has important indications for the
regimen that should be suggested for treatment.
26
III. Real-time Scripts for Brief Tobacco Cessation Interventions
TABLE 3. FAGERSTRÖM TEST FOR NICOTINE DEPENDENCE
1-2
Points* Your
Points
1. How soon after you wake up do
you smoke/use your rst cigarette/
chew?
Less than
5 min.
3
6-30 min. 2
31-60 min. 1
After
1 hour
0
2. Do you smoke/chew more
frequently in the hours after waking
than during the rest of the day?
Yes 1
No 0
3. Do you nd it difcult not to smoke/
chew?
Yes 1
No 0
4. Which cigarette/chew would be the
hardest to give up?
First one
in the
morning
1
Any other 0
5. How many cigarettes do you smoke
in a day?
10 or less 0
11-20 1
21-30 2
31 or more 3
6. Do you smoke when you're so sick
that you're home in bed?
Yes 1
No 0
NICOTINE DEPENDENCE SCORE (Points): Your Score ________
(0-2 pts.) Very low dependence
(3-4 pts.) Low dependence
(5 pts.) Medium dependence
(6-7 pts.) High dependence
(8-10 pts.) Very high dependence
Note. Adapted with permission from “The Fagerström Test for Nicotine
Dependence: a revision of the Fagerström Tolerance Questionnaire,” by
T. F. Heatherton, L. T. Kozlowski, R. C. Frecker & K. O. Fagerström, 1991,
British Journal of Addiction, 86(9), 1119-1127. Copyrighted.
27
III. Real-time Scripts for Brief Tobacco Cessation Interventions
ADDRESSING PATIENT CONCERNS AND SAMPLE SCRIPTS
In the following tables, you will nd helpful methods for discussing tobacco use
and tobacco cessation with your patients.
TABLE 4. SAMPLE RESPONSES TO PATIENTS’ CONCERNS ABOUT
TOBACCO CESSATION
3-5
Patient Provider
I don’t want counseling, I only
want medication.
Counseling and medication
works better than
medication alone.
Counseling will provide
you with practical skills to
support the behavior changes
necessary to quit.
I want to try acupuncture,
hypnosis, or laser therapy.
We know that a combination
of medication and counseling
is the most effective
treatment for tobacco use.
There is insufcient evidence
to show that these therapies
are effective treatment. If
you choose to use one of
these therapies, consider
also using medication and/or
behavioral counseling.
I am concerned that I will gain
weight once I quit smoking.
The health benets of
stopping smoking outweigh
any harms caused by weight
gain.
Making healthy meal choices
and limiting your intake of
sweets and sugary drinks
when you stop smoking will
help to prevent weight gain.
Start to increase physical
activity as soon as possible.
Consider taking a walk instead
of a cigarette break.
28
III. Real-time Scripts for Brief Tobacco Cessation Interventions
TABLE 4. SAMPLE RESPONSES TO PATIENTS’ CONCERNS ABOUT TOBACCO CESSATION
3-5
cont.
Patient Provider
I don’t understand how nicotine
replacement therapies (NRTs)
could be harmless if nicotine is
also one of the harmful drugs
in cigarettes.
Studies have shown that
medicinal nicotine is safe.
What is harmful in cigarettes
are the 7,000 other chemicals,
including more than 70
carcinogens.
Medicinal nicotine in dosages
approved for NRT medications
are proven to greatly reduce
withdrawal symptoms during
tobacco cessation.
My life is too stressful to
quit tobacco.
Smoking/chewing is one
way that many people deal
with stress.
Counseling will help you
develop new and healthier
ways to cope with your stress.
I have been smoking for 30 years
and I have no health problems.
Plus, my grandmother smoked all
her life and she lived to be 100.
Some people who smoke do
not develop obvious health
consequences, however about
50% of people who smoke
will die from health problems
directly caused by smoking.
The average smoker
lives 10 years less than a
non‑smoker.
29
III. Real-time Scripts for Brief Tobacco Cessation Interventions
TABLE 5. SAMPLE SCRIPTS* FOR BRIEF TOBACCO CESSATION
CONVERSATIONS BETWEEN PATIENTS AND PROVIDERS
3-5
Approach your patients about smoking/chewing
Assess tobacco status
How many cigarettes do you smoke a day? How many cans of
chewing tobacco do you use in a week?
Do others in your household or work environment smoke/chew?
Have you thought about quitting?
Advise patient about quitting tobacco
Be clear
I think it is important that you quit smoking/chewing. I can help.
Make strong statements
Quitting smoking is one of the most important things you can do for
your health.
Smoking can greatly increase your chances of having a heart attack
or stroke.
Chewing tobacco is directly linked to cancers in the mouth
and throat.
Personalize your feedback
Your smoking may be a more serious risk to your health right now
than your diabetes.
You can save more than $2,000 a year on cigarette expenses if
you quit.
All your hard work improving your diet and working on reducing
your blood pressure is being undone by smoking.
Your risk of lung disease, coronary heart disease, and other
problems are much higher.
You are at increased risk of developing lung disease and lung cancer
when you smoke.
You complain of shortness of breath; giving up cigarettes will
improve your breathing and stamina.
*Questions and statements are all in the voice of the provider.
30
III. Real-time Scripts for Brief Tobacco Cessation Interventions
TABLE 5. SAMPLE SCRIPTS* FOR BRIEF TOBACCO CESSATION CONVERSATIONS
BETWEEN PATIENTS AND PROVIDERS
3-5
cont.
Assess patient’s readiness to quit
Are you willing to give quitting a try in the next 30 days?
Lets get specic, how much do you want to cut back by the next
time I see you?
Assess and build motivation
How condent do you feel (on a scale of 1-10) that you can quit?
What would move that number further up the scale for you?
What would have to happen for it to become much more important
for you to change?
I believe you can do this. It's a tough thing to give up. Let's think
about what some of the main barriers are that might get in the way
of you being able to do this.
Support self-efcacy
So, getting support from your non-smoking friends was a helpful
strategy last time you quit.
You've been really successful in managing your diabetes (or other)
medication regimens and you can use some of those same
skills here.
Would you like some resources about smoking cessation that you
can read on your own time while you decide?
*Questions and statements are all in the voice of the provider.
31
III. Real-time Scripts for Brief Tobacco Cessation Interventions
TABLE 5. SAMPLE SCRIPTS* FOR BRIEF TOBACCO CESSATION CONVERSATIONS
BETWEEN PATIENTS AND PROVIDERS
3-5
cont.
Encourage condence in quitting tobacco
On a 10-point scale, how condent are you in your ability to stop
tobacco for good?
What would make you more condent in your ability to
stop tobacco?
What did you learn from your past quit attempts?
How might your past relapses be able to help you with this
new attempt?
Is there anything you found helpful in previous attempts to
stop tobacco?
Emphasize personal choice and responsibility
It is up to you to decide when you're ready and how to quit. I'm
here to help you whenever you're ready.
It sounds like you're not ready to think about quitting. It's one of
the things we consider like a vital sign so I'll be asking about it
when you come in for your next visit. Just let me know when you
feel ready to make a change.
You're interested in quitting, that's an important step. Here's
what we have available to help you (e.g., counseling services,
medications). What would you be interested in trying rst? If you
would like, I can tell you some strategies that will help you address
those concerns.
Express empathy
Lots of people worry about how they'll be able to manage
without tobacco.
Sounds like you're not ready to quit today, I know this is a tough
decision. I'm here to help you whenever you decide you're ready to
quit or start to cut down.
*Questions and statements are all in the voice of the provider.
32
III. Real-time Scripts for Brief Tobacco Cessation Interventions
References:
1. John, U., Meyer, C., Schumann, A., Hapke, U., Rumpf, H. J., Adam, C.,
Alte, D., & Lüdemann, J. (2004). A short form of the Fagerström Test for
Nicotine Dependence and the Heaviness of Smoking Index in two adult
population samples. Addictive Behaviors, 29(6), 1207-1212. doi: 10.1016/j.
addbeh.2004.03.019
2. Kozlowski, L. T., Porter, C. Q., Orleans, C. T., Pope, M. A., & Heatherton, T.
(1994). Predicting smoking cessation with self-reported measures of nicotine
dependence: FTQ, FTND, and HIS. Drug and Alcohol Dependence 34(3),
211-216. doi: 10.1016/0376-8716(94)90158-9
3. Fiore, M. C., Jaén, C. R., Baker, T. B., Bailey, W. C., Benowitz, N. L.,
Curry, S. J., Dorfman, S. F., Froelicher, E. S., Goldstein, M. G., Healton, C. G.,
Henderson, P. Nez, Heyman, R. B., Koh, H. K., Kottke, T. E., Lando, H. A.,
Mecklenburg, R. E., Mermelstein, R. J., Mullen, P. D., Orleans, C. Tracy,
Robinson, L., Stitzer, M. L., Tommasello, A. C., Villejo, L., & Wewers, M. E.
(2008, May). Treating tobacco use and dependence: 2008 update. Clinical
practice guideline. Rockville, MD: U.S. Department of Health and Human
Services, Public Health Service. Retrieved from https://www.ncbi.nlm.nih.gov/
books/NBK63952/
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: Guilford Publications, Inc.
33
IV. Medications for
Tobacco Cessation
35
IV. Medications for Tobacco Cessation
CHAPTER SUMMARY
Use of medications for tobacco cessation results in better
abstinence rates and durability
Tobacco cessation medications help address the physiological
symptoms experienced during a quit attempt, which reduces
cravings and the potential for relapse in the early stages of a
quit attempt
Medications for tobacco cessation are most successful when
combined with other interventions (e.g., counseling, monitoring and
tracking). Use Table 3. Fagerström Test for Nicotine Dependence
(p. 26) to guide prescribing
The goal of titration is to eliminate the need for NRT while
maintaining tobacco abstinence
Nicotine pharmacology considers the dose response and manages
withdrawal symptoms, which commonly include irritability,
impatience, anxiety, difculty concentrating, restlessness, hunger,
depression, insomnia, and cravings
Selection of the tobacco cessation medication should be based on
the person’s level of addiction to tobacco, product preference, and
concomitant medical conditions
Combination therapy is more effective than monotherapy.
Combination therapy should be offered to patients with high
dependence, those who are heavier users, or those experiencing
cravings or withdrawal symptoms while on the patch alone
Consider combination therapy of nicotine patch plus nicotine
polacrilex gum or nicotine lozenge for maximum management of
withdrawal symptoms
NICOTINE PHARMACOLOGY
First-line agents approved for tobacco cessation consist of nicotine replacement
therapies (NRT), including the nicotine patch, gum, lozenge, oral inhaler and
nasal spray; and the non-NRT agents bupropion and varenicline. Combination
therapy using the nicotine patch plus either nicotine gum, nicotine lozenge,
or bupropion is also recommended as a rst-line treatment option. The
nicotine patch plus either nicotine gum, nicotine lozenge, or bupropion is also
recommended as a rst-line treatment option.
36
IV. Medications for Tobacco Cessation
FIGURE 1. EFFICACY OF MEDICATIONS FOR SMOKING CESSATION
6,9,12-13
Nicotine Withdrawal
3
Once absorbed, nicotine induces a variety of central nervous system,
cardiovascular, and metabolic effects.
1‑3
Within seconds after inhalation, nicotine
reaches the brain and stimulates the release of various neurotransmitters
including dopamine, which produces nearly immediate feelings of pleasure and
relieves nicotine-withdrawal symptoms. This rapid dose response reinforces the
need to repeat the intake of nicotine, thereby perpetuating smoking behavior.
The main purpose of nicotine pharmacology is to minimize a person’s nicotine
withdrawal symptoms when they quit tobacco. When nicotine is discontinued,
individuals may develop withdrawal symptoms such as irritability, impatience,
anxiety, difculty concentrating, restlessness, hunger, depression, insomnia,
and cravings. Most physical withdrawal symptoms generally manifest within
24-48 hours after quitting and gradually dissipate over 2-4 weeks; however,
strong cravings for tobacco can persist for months or even years.
37
IV. Medications for Tobacco Cessation
NICOTINE REPLACEMENT THERAPY (NRT)
The mechanism of action of NRTs, which are ganglionic (nicotinic) 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. The onset of action with NRT is not as rapid as that of
nicotine obtained through a cigarette, so patients become less accustomed to
the nearly immediate reinforcing effects of tobacco.
4
The goal is to use NRT to
taper off of nicotine over a few months. Table 6. VHA Tobacco Use Cesssation
Treatment Guidance (p. 47) summarizes the dosing regimens, advantages and
disadvantages, common adverse effects, and contraindications for the ve
forms of NRT, bupropion, and varenicline.
Treatment of nicotine dependence with NRT should adhere to the following
principles
6
:
Dose to effect: The initial dose should be sufcient to provide
the patient with a nicotine dose similar to that seen prior
to stopping cigarettes. Providers should always assess the
patient’s nicotine dependence before prescribing cessation aids.
(See Table 3. Fagerström Test for Nicotine Dependence on p. 26).
Treat withdrawal symptoms—the nicotine replacement dose should
be sufcient 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.
Follow up with provider if severe cravings continue. Severe cravings
may indicate reevaluation of dosage and type of NRT is needed
(consider use of combination NRT, such as the patch and gum). If
the patient has a slip and uses tobacco while using NRT, encourage
the patient to try to get back on track with quitting tobacco. If they
are not using combination therapy, then this should be considered
to help them abstain completely from tobacco. If they have a
relapse and are back to smoking daily, then it may be best to have
them quit the NRT and set another quit day when they are ready to
try again.
Selection of the type of NRT should be based on the person’s level
of addiction to tobacco, product preference, and concomitant
medical conditions: Combination therapy is recommended in
patients with high dependence or in those who are heavy smokers.
38
IV. Medications for Tobacco Cessation
Nicotine transdermal patch
4-6
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 uctuations. 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 rst patch; following removal of the transdermal patch, the
apparent half-life averages 3-6 hours. Plasma nicotine levels are
about 50% lower than those achieved with cigarette smoking, but
symptoms of withdrawal can still be alleviated.
Can be applied anywhere on the upper body, including arms and back,
avoid hairy areas; rotate the patch site each time a new patch is applied.
Available OTC in the community.
Nicotine polacrilex gum
6-9
Resin complex of nicotine and polacrilin in a sugar-free chewing gum
base. Gum has a distinct peppery taste and contains sodium carbonate/
bicarbonate buffers to increase salivary pH thereby enhancing
absorption of nicotine across the buccal mucosa. The amount of nicotine
absorbed from each piece is variable (approximately 1.1 mg and 2.9 mg
from the 2 mg and 4 mg formulations, respectively).
Patients should be advised to use a bite-and-park method when using
the nicotine gum. They should bite the gum several times until they
taste a peppery taste or feel a tingling sensation, then park the gum
on the inside of their cheek where the nicotine will be absorbed. When
they no longer taste the peppery taste or feel the tingling sensation,
then they should bite the gum several times again and park the gum in
the inside of their cheek. This should be repeated until they no longer
taste the peppery taste. The gum should not be chewed continuously
like regular chewing gum or the nicotine will not be absorbed and the
patient may experience stomach upset and heartburn.
Nicotine plasma levels peak approximately 30 minutes after chewing
a piece of gum and slowly decline over 2-3 hours. Provides plasma
nicotine concentrations approximately 30-64% of precessation levels.
Allows smokers to take an active coping response to nicotine
withdrawal symptoms.
Associated with less weight gain compared to placebo
during treatment.
39
IV. Medications for Tobacco Cessation
Sticks to dentures, may dislodge llings and inlays because of the
density and texture of the gum.
Patients should be advised not to eat or drink for 15 minutes before,
during or after using. Acidic beverages (e.g., coffee, juice) inhibit the
absorption of nicotine and should be avoided within 15-20 minutes of use.
Available OTC in the community.
Nicotine polacrilex lozenge
4,6-9
Resin complex of nicotine and polacrilin in a avored lozenge
intended to be dissolved in mouth and moved from side to side in
the mouth until fully dissolved. Lozenge contains sodium carbonate/
potassium bicarbonate buffers to increase salivary pH thereby
enhancing absorption of nicotine across the buccal mucosa.
Patients should be advised to place the lozenge in their cheek to
allow the lozenge to be absorbed. They should not bite or chew
the lozenge.
Nicotine plasma levels peak in approximately 30 minutes and slowly
decline over 2-3 hours. Because the lozenge dissolves completely, it
delivers about 25% more nicotine than does an equivalent dose of
nicotine gum.
Allows smokers to take an active coping response to nicotine
withdrawal symptoms.
Potential to consume too quickly, which may cause symptoms of high
nicotine levels (e.g., nausea, gastrointestinal upset).
Patients should be advised not to eat or drink for 15 minutes
before, during or after using. Acidic beverages (e.g., coffee, juice)
inhibit the absorption of nicotine and should be avoided within
15‑20 minutes of use.
Available OTC in the community.
Nicotine nasal spray
6-10
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.
40
IV. Medications for Tobacco Cessation
Due to its faster onset, capacity for self-titration, and rapid
uctuations 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 rst week of use.
Not recommended for patients with known chronic nasal disorders
or severe reactive airway disease.
Nicotine oral inhaler
6-9,11
Consists of a plastic mouthpiece and cartridge that delivers nicotine
as an inhaled vapor from a porous plug containing nicotine. When
puffed, nicotine is vaporized and absorbed across the mucosa of the
mouth and throat (not the lungs).
Each foil sealed cartridge contains 10 mg of nicotine and 1 mg of
menthol. Plastic spikes on the mouthpiece pierce the foil allowing
the release of 4 mg of nicotine vapor following intensive inhalation
of which about 2 mg is absorbed.
Peak plasma concentrations occur within 15-30 minutes and then
slowly decline.
High residual level of nicotine in discarded cartridge can be
dangerous to children and pets.
High incidence of mouth and throat irritation.
Use cautiously in patients with severe reactive airway disease.
Delivery of nicotine from the inhaler declines signicantly 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.
41
IV. Medications for Tobacco Cessation
Combination Nicotine Replacement Therapy
6,9,12-15
FIGURE 2. COMBINATION NICOTINE REPLACEMENT THERAPY (NRT)
DOSING AND ADMINISTRATION
Combination NRT involves the use of a long-acting formulation (e.g., nicotine
patch) along with a short-acting formulation (e.g., nicotine gum, nicotine
lozenge, nicotine inhaler, or nicotine nasal spray) It is considered the standard
treatment when using tobacco cessation medications.
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
42
IV. Medications for Tobacco Cessation
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 short-
acting NRT formulations signicantly increases quit rates relative to placebo
and the nicotine patch alone. Combination therapy with the nicotine patch and
either nicotine gum or lozenge is superior to monotherapy with the nicotine
patch in up to one year of follow up. Using a combination of nicotine patch plus
long-term nicotine gum (>14 weeks) has been shown to more than triple the
likelihood of long-term abstinence (OR = 3.6, 95% CI 2.5-5.2). Similarly, studies
evaluating the nicotine patch in combination with the nicotine lozenge for
12 weeks have resulted in abstinence rates of up to 40% at six months.
FIGURE 3. COMBINATION NRT TAPERING STRATEGY
Nicotine Replacement Therapy Safety
6,9,16-18
Nicotine can increase one’s heart rate, blood pressure, and myocardial
contractility, and also act as a coronary vasoconstrictor. In patients with
stable coronary artery disease, NRT can be initiated at intermediate doses
with careful monitoring. Large randomized trials have found no signicant
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
43
IV. Medications for Tobacco Cessation
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 (specically, nicotine gum),
hyperthyroidism, peptic ulcer disease, and severe renal impairment. Although the
FDA has developed a uniform warning for all NRTs because of the risks of nicotine
in pregnancy, they believe that NRT is safer than smoking during pregnancy.
The safety of NRT in the elderly has not been systematically evaluated. However,
one small pharmacokinetic study concluded that though there were statistically
signicant differences, the disposition of nicotine does not seem to be changed
to a clinically important extent in the elderly compared to younger subjects.
BUPROPION
6,19‑23
Bupropion (Zyban
®
, Wellbutrin
®
) is a weak dopamine-norepinephrine reuptake
inhibitor with some nicotine receptor blocking activity.
19,20
The mechanism by
which bupropion enables patients to abstain from smoking is unknown. However,
it is presumed that bupropion acts by enhancing central nervous noradrenergic
and dopaminergic release and antagonizes nicotinic acetylcholine receptor
function. The antismoking effect of bupropion does not seem to be related
to the antidepressant effect, as bupropion is equally effective as a smoking
cessation therapy in smokers with or without depression.
21
Steady-state levels of bupropion and metabolites are reached within
5-8 days, respectively. It is best to start bupropion one week before
one’s target quit date.
In patients with severe hepatic cirrhosis, extreme caution is advised
since peak bupropion levels are substantially increased. For patients
with mild-to-moderate hepatic cirrhosis, a reduced frequency or
dose should be considered.
Bupropion should be used with caution in patients with renal
impairment and a reduced frequency of dosing should be
considered. Patients should also be closely monitored for possible
adverse effects that could indicate high drug or metabolite effects.
Bupropion has the potential to interact with other drugs that are
metabolized by or which inhibit/induce the CYP2B6 isoenzyme. It
can also interact with drugs metabolized by the CYP2D6 isoenzyme.
44
IV. Medications for Tobacco Cessation
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,
uoxetine, sertraline, haloperidol, risperidone, thioridazine,
metoprolol, propafenone, ecainide) to a patient already receiving
bupropion, consider initiating the coadministered drug at the
lower end of the dose range. Conversely, if bupropion is added
to a regimen containing a drug metabolized by CYP2D6, consider
decreasing the dose of the original medication; especially for those
concomitant medications with a narrow therapeutic index.
MAO (monoamine oxidase) inhibitors: Wait 14 days after
discontinuing before starting therapy with bupropion.
Although the recommended duration of treatment is 7-12 weeks,
bupropion is approved for use up to six months to prevent relapse
to smoking.
22
Bupropion may be associated with less weight gain.
Bupropion may be used in combination with the nicotine patch.
6,23
Bupropion Safety
24-26
Bupropion is associated with a dose-dependent risk of seizures; maximum bupropion
SR dose for treating smoking is 300 mg/day. Although higher doses of bupropion SR
have been used for treating depression, they have not been tested for smoking
cessation. Also, there is no evidence that higher doses improve quit rates.
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.
Rare incidences of neuropsychiatric symptoms have been reported in patients
taking bupropion for smoking cessation. These symptoms include, but are not
limited to depression, suicidal ideation and suicide attempt. The Food and
Drug Administration (FDA) has provided the following recommendations for
monitoring bupropion when used for tobacco cessation:
45
IV. Medications for Tobacco Cessation
It is important to discuss the possibility of serious
neuropsychiatric symptoms in the context of the benets of
quitting smoking with patients before prescribing bupropion.
Bupropion is an effective smoking cessation aid and the health
benets of smoking cessation are immediate and substantial.
Healthcare professionals should monitor all patients taking
bupropion for serious neuropsychiatric symptoms. These
symptoms include changes in behavior, hostility, agitation,
depressed mood, suicidal ideation, suicidal behavior, and attempted
suicide. These symptoms have occurred in patients without
pre-existing psychiatric illness and have worsened in some patients
with pre-existing psychiatric illness. In most cases, neuropsychiatric
symptoms developed during treatment with bupropion but in others,
symptoms developed after stopping drug treatment.
Patients should be informed that it is not unusual to have
symptoms such as irritability, feeling anxious, depressed mood
and trouble sleeping when they are withdrawing from nicotine,
independent of whether they are taking bupropion.
Patients with serious psychiatric illness such as schizophrenia, bipolar
disorder, and major depressive disorder, may experience worsening of
their pre-existing psychiatric illness while taking bupropion.
Patients who discontinue treatment because of neuropsychiatric
events should continue to be monitored until symptoms resolve.
Although in many cases symptoms resolved after treatment was
stopped, there were some cases where the symptoms persisted.
VARENICLINE
27‑30
Varenicline tartrate (Chantix
®
/Champix
®
) is a partial agonist that binds
selectively to the α4β2 subunit of the nicotinic acetylcholine receptor thereby
reducing the symptoms of nicotine withdrawal during abstinence.
27‑28
Because
of the signicantly higher afnity 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.
46
IV. Medications for Tobacco Cessation
Primarily eliminated via glomerular ltration 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 efciently removed by hemodialysis.
Dosage adjustment is necessary for patients with estimated
creatinine clearance <30 ml/min.
No clinically signicant 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 benecial in maintaining and increasing the
likelihood of long-term abstinence and preventing relapse.
30
To date, the safety and efcacy of varenicline in conjunction with
NRT or bupropion for smoking cessation has not been studied
extensively and is not recommended.
Varenicline Safety
26,32-35
Varenicline is a very effective tobacco cessation medication and VA would like
to ensure that all Veterans who are interested in quitting and are appropriate
candidates for use of varenicline are able to have access to and be prescribed
a full course of varenicline to help them stop smoking. In December 2016, the
FDA removed black box warnings on Chantix (varenicline) regarding serious
mental health side effects.
Following multiple systematic reviews, there do not appear to be any
statistically signicant increases in either adverse cardiovascular events or
adverse neuropsychiatric events (including depression, suicidal ideation, or
suicide attempt) associated with varenicline use.
47
IV. Medications for Tobacco Cessation
TABLE 6: VHA TOBACCO USE CESSATION TREATMENT GUIDANCE – MEDICATIONS FOR TOBACCO CESSATION
DESCRIPTION AND EXAMPLE
CLINICAL CONSIDERATIONS DOSING RECOMMENDATIONS HOW TO USE
Nicotine Patch
21mg, 14mg, 7mg
(Generic available, over-the-
counter
(OTC))
Delivers nicotine directly
through the skin
VA Formulary 1st line
Pros
• Provides constant levels of nicotine
replacement
• Easy to use
• Only needs to be applied once a day
Cons
• Less-flexible dosing — cannot titrate
dose to acutely manage withdrawal
symptoms
• Slower onset of delivery
• Mild skin rashes and irritation
• > 10 cigarettes/day = 21 mg per/day for
4-6 wks
‑ then 14mg/day for 2-3 wks
‑ then 7mg/day for 2-3 wks
• < 10 cigarettes/day = 14 mg/day for 6
wks
‑ then 7mg/day for 2 wks
Adjust based on withdrawal symptoms,
urges, and comfort. After 4-6 weeks of
abstinence, taper every 2-4 weeks in
7-14 mg steps as tolerated.
Duration – 8-12 weeks
Recommend using in combination with
a short acting Nicotine Replacement
Therapy (NRT) such as nicotine gum or
nicotine lozenge. (See combination dosing
strategy section)
• Patches may be placed anywhere on the
upper body, including arms, chest and
back. Avoid hairy areas.
• Use for 24 hours. If vivid dreams remove
patch before bedtime
• Rotate sites to avoid minor skin irritation
(avoid an area for a week if possible)
• Avoid smoking while on the patch but
if have slips, don’t remove patch to use
tobacco, continue using the patch as
prescribed (stop only if still smoking a
consistent amount)
48
IV. Medications for Tobacco Cessation
TABLE 6: VHA TOBACCO USE CESSATION TREATMENT GUIDANCE – MEDICATIONS FOR TOBACCO CESSATION
DESCRIPTION AND EXAMPLE
CLINICAL CONSIDERATIONS DOSING RECOMMENDATIONS HOW TO USE
Nicotine Lozenge
2mg, 4mg
(Generic available (OTC))
Delivers nicotine through the
lining of the mouth while the
lozenge dissolves.
VA Formulary, 1st line
Pros
• Easy to use
• Can titrate and taper to manage
withdrawal symptoms
• May satisfy oral cravings
• Best when used with nicotine patch
for breakthrough cravings
• Delivers doses of nicotine 25% higher
than nicotine gum
Cons
• Requires proper technique or
increased risk of side effects. Most
common side effect is nausea (12-15%)
or stomach upset
• Frequent use during the day required
to maintain adequate nicotine
levels (may compromise compliance
especially if using monotherapy)
• Dosage is based on time to first
cigarette of the day (TTFC) or
cigarettes/day
If using as monotherapy-
• Based on TTFC:
‑ if TTFC is > 30 minutes, start with 2
mg
‑ if TTFC is < 30 minutes, start with 4
mg
‑ Use at least 8 lozenges per day
‑ Maximum 20 lozenges per day
• Based on # cigarettes/day:
‑ if < 20 cigarettes/day, start with 2 mg
‑ if >20 cigarettes/day, start with 4 mg
Taper as tolerated each week. Average
tapering is 3-6 months but can be longer
if needed.
Recommend using in combination with
nicotine patch or bupropion
If using in combination with patch or
bupropion:
• can use 2mg for most patients and 4mg
in more dependent patients),
• use as needed up to 10-12 pieces per day
and reduce each week.
• if used with nicotine patch, may
increase when stepping down to a lower
dose patch (See combination dosing
strategy section)
• Instruct patients to allow lozenges
to dissolve slowly over 20-30 minutes
(faster if mini lozenges). Do not chew or
swallow.
• Rotate to different sites of the mouth
• Avoid eating or drinking anything acidic
15 minutes before or during use (reduces
nicotine absorption
• Review package directions carefully to
maximize benefit of product
49
IV. Medications for Tobacco Cessation
TABLE 6: VHA TOBACCO USE CESSATION TREATMENT GUIDANCE – MEDICATIONS FOR TOBACCO CESSATION
DESCRIPTION AND EXAMPLE
CLINICAL CONSIDERATIONS DOSING RECOMMENDATIONS HOW TO USE
Nicotine Gum
2mg, 4mg
(Generic available (OTC))
Delivers nicotine through the
lining of the mouth while gum is
parked between the cheek and
gum.
VA Formulary, 1st line
Pros
•
Convenient/flexible dosing that allows
for titration and tapering to manage
withdrawal symptoms
• Faster delivery of nicotine than patch
• May satisfy oral cravings
• Best when used in combination with
nicotine patch for breakthrough
cravings
Cons
• Requires proper chewing technique
for maximum benefit and to minimize
adverse effects (patient should be
advised to ‘bite down and not chew’)
• Most common side effect is nausea
(12-15%) or stomach upset
• Avoid in patients with dental
problems, dentures, or
temporomandibular jaw disorder
(TMJ)
• Frequent use during the day required
to maintain adequate nicotine
levels (may compromise compliance
especially if using as monotherapy)
• Dosage is based on time to first
cigarette of the day (TTFC) or
cigarettes/day
If using monotherapy-
• Based on TTFC:
‑ if TTFC is ≥ 30 minutes, start with
2mg gum
‑ if TTFC is < 30 minutes, start with
4mg gum
‑ use at least 9 pieces per day, up to
maximum of 24
Based on cigarettes/day:
• if < 20 cigarettes/day, start with 2 mg
gum
• if ≥ 20 cigarettes/day, start with 4 mg
gum
Taper as tolerated each week. Average
tapering is 3-6 months, but can be longer
if needed
Recommend using in combination with
Nicotine patch or Bupropion. (See
combination dosing strategy section)
If using in combination-
• can use 2mg for most patients and 4mg
in more dependent patients
•
use as needed up to 10-12 pieces per day
and reduce each week.
• if using with nicotine patch, may
increase when stepping down to a lower
dose patch (See combination dosing
strategy section)
• Advise the patient not to ‘chew’ like
regular gum.
• The patient should be instructed to
slowly bite down on the gum until they
sense a peppery flavor or slight tingling
in their mouth and then ‘park’ the gum
between their cheek and gum
• Patient should then park the gum
between their cheek and gum for about
one (1) minute to absorb until taste or
tingle is gone. Repeat step of ‘bite down
and park’ until taste or tingle does not
return (about 30 minutes).
• Each piece should last about 20-30
minutes
• Avoid eating or drinking anything acidic
15 minutes before or during use (reduces
nicotine absorption
• Review package directions carefully to
maximize benefit of product
50
IV. Medications for Tobacco Cessation
TABLE 6: VHA TOBACCO USE CESSATION TREATMENT GUIDANCE – MEDICATIONS FOR TOBACCO CESSATION
DESCRIPTION AND EXAMPLE
CLINICAL CONSIDERATIONS DOSING RECOMMENDATIONS HOW TO USE
Combination Nicotine
Replacement Therapy (NRT)
Most commonly used
combinations:
Nicotine patch + Nicotine
gum PRN
Nicotine Patch + Nicotine
lozenge PRN
Pros
• Permits sustained levels of nicotine
(patch) with rapid adjustment for
acute cravings and urges (PRN gum or
lozenge)
• More efficacious than NRT
monotherapy
Cons
• Added cost of two NRT products vs.
one
• May increase potential risk of nicotine
toxicity (rare)
• Dose patch as described above
• Prescribing 2 mg or 4 mg gum or lozenge
(according to dose-dependence level
described above) on an as-needed basis
when acute withdrawal symptoms and
urges to use tobacco occur. (Initially
most patient require about 6-8 pieces of
gum or lozenges/day).
• Nicotine patch dose many be increased
if patient is requiring more frequent use
of PRN gum or lozenge after patch taper.
Duration
• Patch: 8-10 weeks (with lozenge) or 8-24
weeks (with gum)
• Gum: 26-52 weeks
• Lozenge: 12 weeks
• Providing two types of delivery systems,
one passive and one active, appears to
be more efficacious
• Should be considered for those who have
failed single therapy in the past or those
considered highly nicotine dependent
• Considered a first-line treatment in the
USPHS Clinical Practice Guidelines
Nicotine Oral Inhaler
Nicotine is delivered and
absorbed to mouth or throat
VA Formulary, 1st line
Pros
• Can titrate and taper to manage
withdrawal symptoms
• May help with the hand to mouth
ritual
Cons
• May increase respiratory symptoms in
patients with allergies or uncontrolled
reactive airway disease
• Frequent use during the day required
to maintain adequate nicotine
levels (may compromise compliance
especially if using monotherapy)
• Start with 6 cartridges per day
• Increase up to 16 cartridges (usual
maximum dose) per day.
• Taper as tolerated each week. Average
tapering is 3-6 months but can be longer
if needed.
• Use by inhaling deeply into back of
throat or puff in short breaths (preferred
method)
• Each cartridge lasts about 20 minutes
with active use (~400 puffs)
• Avoid eating or drinking anything acidic
15 minutes before or during use (reduces
nicotine absorption
• Rinse mouthpiece regularly with warm
soapy water
• Review package directions carefully
to maximize benefit of product and
complete direction of use
51
IV. Medications for Tobacco Cessation
TABLE 6: VHA TOBACCO USE CESSATION TREATMENT GUIDANCE – MEDICATIONS FOR TOBACCO CESSATION
DESCRIPTION AND EXAMPLE
CLINICAL CONSIDERATIONS DOSING RECOMMENDATIONS HOW TO USE
Nicotine Nasal Spray
VA Formulary, 1st Line
Pros
• Can titrate and taper to manage
withdrawal symptoms
• May be better for highly dependent
patients.
Cons
• The quickest onset and peak for
nicotine absorption out of all the
NRTs so also has highest dependence
potential
• Frequent use during the day required
to obtain adequate nicotine levels
(may compromise compliance
especially if using as monotherapy)
• May increase symptoms in patients
with allergies or uncontrolled reactive
airway disease (avoid in patients with
chronic nasal conditions)
• Can irritate nasal cavity so most
common side effects are hot, peppery
feeling in back of throat or nose,
sneezing, coughing, watery eyes, or
runny nose
• Start with 8 doses per day
• Increase up to 40 doses (usual max dose)
per day
• A dose is equal to 1 spray in each nostril
(2 total sprays).
• Slowly decrease each week as directed.
Max dosing is 5 doses per hour and 40
doses per day.
Taper as tolerated each week. Average
tapering is 3-6 months but can be longer
if needed.
• Instruct the patient to ‘prime’ the nasal
spray before use until a fine spray (likely
6-8 times of pressing the spray)
• Instruct the patient to blow nose if it is
not clear before use
• Insert the nasal spray as far back as
comfortable and consider spraying away
from the septum to avoid irritation.
• Use 1 spray in each nostril (1 dose)
• Due to irritability and potential for
tearing, do not operate heavy machinery
for 10 minutes after use
• Review package directions carefully
to maximize benefit of product and
complete direction of use
52
IV. Medications for Tobacco Cessation
TABLE 6: VHA TOBACCO USE CESSATION TREATMENT GUIDANCE – MEDICATIONS FOR TOBACCO CESSATION
DESCRIPTION AND EXAMPLE
CLINICAL CONSIDERATIONS DOSING RECOMMENDATIONS HOW TO USE
Bupropion
Sustained Release (SR)
(150mg)
Other Formulations such as
Immediate Release (IR) and
Extended Release (ER) can be
considered.
(Generic available)
VA Formulary, 1st line
Pros
• Easy to use
• Pill form and may be associated with
better compliance
• Can be combined with NRT
• May be beneficial in patients with
depression
Cons
• Contraindicated in patients with
seizures (seizure risk 1/1000)
• Assess seizure risk in patients with
active Substance Use Disorder (e.g.
alcohol), anorexia, bulimia, head
trauma, brain injury
Start 1 week before target quit date
(TQD):
• 150 mg daily for at Bupropion SR 150mg
daily for 3 days
• then 150mg twice a day (8 hrs apart) for
4 days, then,
• on target quit date, STOP SMOKING,
• continue at 150 mg twice a day for 8 to
12 weeks.
• If patient has been successful at
quitting, an additional 12 weeks may be
considered.
• May stop abruptly
• No need to taper
Patients with cirrhosis, consider adjusting
dose to 150mg every other day
Recommend in combination with
nicotine lozenges or nicotine gum (See
combination dosing strategy section)
• Medication should be initiated 1 week
prior to quit date and titrated
• Avoid bedtime dose to minimize
insomnia, but allow 8 hours between
doses
• Use with caution in patients with liver
disease (dose adjustment necessary)
• A slight risk of seizure (1:1000) is
associated with use of this medicine.
• Assess seizure risk and avoid if:
‑ History of seizures
‑ Significant head trauma/brain injury
‑ Anorexia nervosa or bulimia
‑ Abrupt discontinuation of alcohol or
sedatives
‑ Concurrent use of meds that lower
seizure threshold
• If patients experience any suicidal
ideation/mood changes (rare adverse
event), advise the patient to stop
medication and contact you and call
the Veterans Crisis Line at 988 or at
1-800-273-8255 and press 1.
53
IV. Medications for Tobacco Cessation
TABLE 6: VHA TOBACCO USE CESSATION TREATMENT GUIDANCE – MEDICATIONS FOR TOBACCO CESSATION
DESCRIPTION AND EXAMPLE
CLINICAL CONSIDERATIONS DOSING RECOMMENDATIONS HOW TO USE
Bupropion SR + Nicotine Patch Pros
• Easy-to-use combination (FDA
approved)
• Uses agents with two different
mechanisms
• More efficacious then monotherapy
Cons
• Does not allow for adjustment of
acute cravings or urges
• Many be associated with more side
effects than monotherapy
• Use standard doses and duration
• Bupropion: See bupropion dosing
above; continue for 8-12 weeks
• If patient had been successful at
quitting, as additional 12 weeks may be
considered.
• Nicotine patch: Dose patch as
described above for total duration of
8-12 weeks
• Providing two types of mechanisms of
actions appears to be more efficacious
• Should be considered for those who
have failed single therapy in the past of
those considered to be highly nicotine
dependent
• Considered a first-line treatment in the
USPHS Clinical Practice Guidelines
Bupropion SR + Nicotine
Lozenge or Gum
Pros
• Uses agents with two different
mechanisms
• Allows for rapid adjustment for acute
cravings and urges (PRN use of gum
or lozenge)
• More efficacious than monotherapy
Cons
• May be associated with more side
effects than monotherapy.
• Use standard doses and duration
• Bupropion: See bupropion dosing
above; continue for 8-12 weeks
• If patient had been successful at
quitting, as additional 12 weeks may be
considered
• Prescribing 2 mg or 4 mg gum or
lozenge (according to dose-dependence
level described above) on an as-needed
basis when acute withdrawal symptoms
and urges to use tobacco occur.
(Initially, most patients require about
6-8 pieces of gum or lozenges/day.)
• Providing two types of mechanisms of
action, including an active delivery
system, appears to be more efficacious.
• Should be considered for those who
have failed single therapy in the past of
those considered to be highly nicotine
dependent
54
IV. Medications for Tobacco Cessation
TABLE 6: VHA TOBACCO USE CESSATION TREATMENT GUIDANCE – MEDICATIONS FOR TOBACCO CESSATION
DESCRIPTION AND EXAMPLE
CLINICAL CONSIDERATIONS DOSING RECOMMENDATIONS HOW TO USE
Varenicline
(0.5 mg)
VA Formulary, 1st line
Pros
• Easy to use
• In pill form and may be associated
with better compliance
• Only medication that blocks nicotinic
receptors and also stimulates the
receptors to reduce cravings
• No known drug interactions
Cons
• Nausea common in up to 1/3rd of
patients
• Vivid dreams also noted as a common
side effect
• Start medication one week prior to the
quit date:
‑ 0.5 mg once a day for 3 days, then,
‑ 0.5 mg twice a day for 4 days, then,
‑ On the quit dates STOP SMOKING and
‑ Take 1.0 mg twice a day for 11 weeks
• If not smoking at the end of twelve
weeks, may continue for an additional
12 weeks
• May stop abruptly
• No need to taper
• Treatment should be initiated 1 week
prior to quit date and titrated
• Taking the medication with food and
titrating the dose as directed may
help with nausea
• Take with a full glass of water
• Dose must be adjusted if kidney
function is impaired (0.5 mg/day)
• Allow up to 12 weeks to become
tobacco free. Then 28 days and 2
refills can be sent to patient for a
maximum of 6 months treatment.
• If patients experience any suicidal
ideation/mood changes (rare adverse
event), advise the patient to stop
medication and contact you nd call
the Veterans Crisis Line at 988 or at
1-800-273-8255 and press 1.
55
IV. Medications for Tobacco Cessation
56
IV. Medications for Tobacco 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 ndings on smoking of abused substances [NIDA Research
Monograph 99]. Rockville, MD: U.S. Department of Health and Human Services.
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 efcacy 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. Accessed at https://www.ncbi.nlm.nih.gov/
books/NBK63952
7. U.S. Department of Health and Human Services, Public Health Service. (2000).
Treating tobacco use and dependence. Clinical practice guideline. Accessed at
http://www.treatobacco.net/en/uploads/documents/Treatment%20Guidelines/
USA%20treatment%20guidelines%20in%20English%202000.pdf
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.
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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. Accessed at http://www.ncbi.nlm.nih.gov/pmc/articles/
PMC2933113/?tool=pubmed
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. Accessed at http://www.ncbi.nlm.nih.gov/pmc/articles/
PMC2891174/?tool=pubmed
14. Rigotti, N. A. (2012). Strategies to help a smoker who is struggling to quit.
Journal of the American Medical Association, 308(15), 1573-1580. doi: 10.1001/
jama.2012.13043
15. Fiore, M. C., & Baker, T. B. (2011). Clinical practice. Treating smokers in the
health care setting. New England Journal of Medicine, 365(13), 1222-1231. doi:
10.1056/NEJMcp1101512
16. 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
17. 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. New England Journal of Medicine,
335(24), 1792–1798. Accessed at http://www.nejm.org/doi/full/10.1056/
NEJM199612123352402
18. 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
19. GlaxoSmithKline. (2010, September). Zyban
®
(bupropion hydrochloride)
sustained-release tables [Package insert]. Greenville, NC: GlaxoSmithKline
Research Triangle Park.
20. 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. Accessed http://jpet.aspetjournals.org/content/295/1/321.long
21. 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. New England Journal of Medicine, 337(17), 1195-
1202. Accessed at http://www.nejm.org/doi/full/10.1056/NEJM199710233371703
22. 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,
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23. 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. New England Journal of
Medicine, 340(9), 685-691. Accessed at http://www.nejm.org/doi/full/10.1056/
NEJM199903043400903
24. 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/
jamjmed.2006.04.024 55
25. 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. Accessed at
http://eurheartj.oxfordjournals.org/content/24/10/946.long
26. U.S. Food and Drug Administration. (2016). FDA Drug Safety Communication:
FDA revises description of mental health side effects of the stop-smoking
medicines Chantix (varenicline) and Zyban (bupropion) to reect clinical trial
ndings. Retrieved March 2, 2017 from https://www.fda.gov/Drugs/DrugSafety/
ucm532221.htm
27. 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: 0.1021/jm050069n
28. Pzer Labs. (2010). CHANTIX
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(varenicline). New York (NY): Pzer Labs.
Accessed at http://www.chantix.com
29. Cahill, K., Stead, L., & Lancaster, T. (2011). Nicotine receptor partial agonists
for smoking cessation. Cochrane Database of Systematic Review, (2), CD006103.
10.1002/14651858.CD006103.pub5
30. 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. Journal
of the American Medical Association, 296(1), 64-71. doi: 10.1001/jama.296.1.64
31. U.S. Department of Veterans Affairs, VHA Pharmacy Benets Management
Services, Medical Advisory Panel, and VISN Pharmacist Executives. (2015).
National PBM Varenicline Criteria for Use Updated December 2015. Accessed at
https://www.pbm.va.gov/apps/VANationalFormulary/
32. Hays, J. T., & Ebbert, J. O. (2008). Varenicline for tobacco dependence. New
England Journal of Medicine, 359(19), 2018-2024. Accessed at http://www.ncbi.
nlm.nih.gov/pmc/articles/PMC2959114/?tool=pubmed
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33. 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
34. 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.
35. Anthenelli, R. M., Benowitz, N. L., West, R., St Aubin, L., McRae, T., Lawrence,
D., Ascher, J., Russ, C., Krishen, A., & Evins, A. E. (2016). Neuropsychiatric
safety and efcacy of varenicline, bupropion, and nicotine patch in smokers
with and without psychiatric disorders (EAGLES): a double-blind, randomised,
placebo-controlled clinical trial. Lancet, 18(387), 2507-2520. Retrieved from
https://www.ncbi.nlm.nih.gov/pubmed/27116918
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V. Relapse Prevention
and Tobacco Cessation
Maintenance
63
V. Relapse Prevention and Tobacco Cessation Maintenance
CHAPTER SUMMARY
Tobacco use is a chronic, relapsing disorder
Multiple quit attempts and interventions may be necessary
Relapse is NOT uncommon
Continue to address tobacco use status at every visit and provide
ongoing support
Offer retreatment with medication and counseling
Provide patients with options for the management of
withdrawal symptoms
TOBACCO USE: A CHRONIC, RELAPSING DISORDER
Patients who have recently quit using tobacco are at very high risk for relapse.
Relapse is more likely to occur early in the process of quitting, but it can
also occur months or years later. While there have been numerous studies
attempting to identify strategies or interventions that are effective to prevent
relapse, these studies have failed to identify specic interventions that are
effective.
1
The most effective strategy to prevent relapse appears to be use
of an evidence-based tobacco cessation treatment from the start, including a
combination of tobacco cessation medications and behavioral counseling, as
described in previous chapters.
For patients who have recently quit using tobacco, continue to provide support
at each visit, especially if they express concerns about relapse. Patients should
receive reinforcement for their decision to quit, be congratulated on their
success at quitting, and encouraged to remain abstinent. Ask open-ended
questions about noticeable benets they have experienced since quitting.
It may be helpful to talk with patients about previous quit attempts and
encourage them to plan for how they will cope with challenges to quitting.
Encourage patients to identify their sources of support and if needed, refer
them to a counselor or tobacco cessation program for additional support.
Additional support available from VA is summarized on the VA Tobacco &
Health webpage (www.mentalhealth.va.gov/quit-tobacco). Other resources
include the VA telephone quitline, which can be reached at 1-855-QUIT VET
(1-855-784-8838) Monday-Friday, 9AM-9PM EST (counseling is also available in
Spanish); and the SmokefreeVET text support program (text the word VET to
47848 or sign up at smokefree.gov/VET).
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V. Relapse Prevention and Tobacco Cessation Maintenance
MANAGEMENT OF WITHDRAWAL SYMPTOMS
For patients who relapse, encourage them to describe the challenges they
encountered during their quit attempt and recommit to another quit attempt.
If needed, also consider referring them to a more intensive smoking cessation
treatment program. If the previous quit attempt included medication, review
whether the patient used it in an effective manner and determine whether
the medication was helpful. Based on this assessment, retreatment can be
recommended with either the same medication or with combination NRT.
2
Those who relapse often report problems that have been worsened by smoking
withdrawal. These may include depression, weight gain, or withdrawal
symptoms. If a patient reports prolonged cravings or other withdrawal
symptoms, consider using combination therapy or extending the use of a short-
acting 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
specic withdrawal symptoms commonly associated with quitting tobacco.
TABLE 7. TOBACCO WITHDRAWAL SYMPTOMS* AND
RECOMMENDATIONS
Withdrawal Symptom Recommendation
Chest tightness
(tension created
by the body’s
need for nicotine)
Practice relaxation techniques
Nicotine replacement therapy might
be helpful
Stomach pain
Constipation
Gas
Drink uids
Avoid stress
Increase ber in diet
Cravings/
urges (nicotine
withdrawal/
behavioral
patterns)
DEADS Strategy
(Delay, Escape, Avoid, Distract, Substitute)
Delay: The most important thing to remember is
that an urge will go away if you just give it time.
Waiting out an urge, especially if you begin to do
something else, is easier than you may expect.
*Most withdrawal symptoms go away after a few days to 1-2 months at the
most. Cravings and urges are the only symptoms that can return even after
one year of tobacco cessation.
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V. Relapse Prevention and Tobacco Cessation Maintenance
TABLE 7. TOBACCO WITHDRAWAL SYMPTOMS* AND RECOMMENDATIONS cont.
Withdrawal Symptom Recommendation
Cravings/
urges (nicotine
withdrawal/
behavioral
patterns)
(cont.)
Believe it or not, the urge will fade after 5 to 10
minutes, even if you do not smoke. It also helps
if you have a positive attitude about the urge
disappearing. Think "this won't last, the urge will
go away," or "I would like a cigarette, but I'm not
going to have one, because I don't need one."
Escape: Another technique for dealing with an
urge is to remove yourself from the situation or
event which led to the urge. If you're in a room
where others are smoking, and an urge hits, get
up and take a short walk. You can walk around
the building, or outside, until you feel ready to
re-enter the situation--without smoking.
Avoid: Avoiding situations where you’ll be
tempted to smoke will be particularly important
in the rst days and weeks after you quit. For
example, if you regularly go to places where
there’s a lot of smoking, like coffee shops or
clubs, it’s best to avoid them for a little while to
allow you to get used to not smoking.
Distract: Another way to control urges is to get
busy, get back to what you were doing before the
urge hit. Also, there may be other things you enjoy
doing that are incompatible with smoking such as
working in the yard, reading a magazine, walking,
taking a shower, or working a crossword puzzle.
Substitute: When you feel that you want a
cigarette, substitute something else for a
cigarette. We suggest sugar-free candy or sugar-
free gum, especially if you are watching your
weight. You could eat a piece of fruit or drink
a juice or tea. 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.
*Most withdrawal symptoms go away after a few days to 1-2 months at the
most. Cravings and urges are the only symptoms that can return even after
one year of tobacco cessation.
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V. Relapse Prevention and Tobacco Cessation Maintenance
TABLE 7. TOBACCO WITHDRAWAL SYMPTOMS* AND RECOMMENDATIONS cont.
Withdrawal Symptom Recommendation
Depressed
mood (normal
process for a
short period)
Increase pleasurable activities
Get support from family/friends
Discuss with provider
Difculty
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 rst few days
Fatigue
(lack of
stimulation
of nicotine)
Take naps
Do not push yourself
Nicotine replacement therapy may
be helpful
Hunger
(cravings for a
cigarette can
be mistaken
for hunger)
Drink lots of water
Eat low-calorie snacks
Insomnia
(nicotine
affects
brain wave
function and
sleep patterns)
Limit caffeine (reduce by 50%)
Practice relaxation techniques
*Most withdrawal symptoms go away after a few days to 1-2 months at the
most. Cravings and urges are the only symptoms that can return even after
one year of tobacco cessation.
67
V. Relapse Prevention and Tobacco Cessation Maintenance
TABLE 7. TOBACCO WITHDRAWAL SYMPTOMS* AND RECOMMENDATIONS cont.
Withdrawal Symptom Recommendation
Irritability
(body’s craving
for nicotine)
Exercise
Practice relaxation techniques
Take a hot bath
Stress
Exercise
Practice relaxation techniques
Avoid known stressful situations
Plan workload accordingly
*Most withdrawal symptoms go away after a few days to 1-2 months at the
most. Cravings and urges are the only symptoms that can return even after
one year of tobacco cessation.
68
V. Relapse Prevention and Tobacco Cessation Maintenance
References:
1. Fiore, M. C., Jaén, C. R., Baker, T. B., Bailey, W. C., Benowitz, N. L.,
Curry, S. J., Dorfman, S. F., Froelicher, E. S., Goldstein, M. G., Healton, C. G.,
Henderson, P. Nez, Heyman, R. B., Koh, H. K., Kottke, T. E., Lando, H. A.,
Mecklenburg, R. E., Mermelstein, R. J., Mullen, P. D., Orleans, C. Tracy,
Robinson, L., Stitzer, M. L., Tommasello, A. C., Villejo, L., & Wewers, M. E.
(2008, May). Treating tobacco use and dependence: 2008 update. Clinical
practice guideline. Rockville, MD: U.S. Department of Health and Human
Services, Public Health Service. Accessed at https://www.ncbi.nlm.nih.gov/
books/NBK63952/
2. U.S. Department of Veterans Affairs, Ofce of Public Health and Environmental
Hazards. (2010, July). VHA tobacco use cessation treatment guidance part 2:
Assisting with tobacco cessation — medication options. Accessed at
https://dvagov.sharepoint.com/sites/VHAtobacco/SitePages/Medication.
aspx#guidance-and-resources
(NOTE: This is an internal VA website that is not available to the public)
69
VI. Establishing A
Tobacco Cessation
Program In Primary
Care Clinics
71
VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
CHAPTER SUMMARY
Group counseling program
Session 1: Introduction
Session 2: Why do I use tobacco and nicotine addiction
Session 3: Medications to help you quit tobacco and getting ready for
quit day
Session 4: Quit day
Session 5-7: Follow-up sessions
GROUP COUNSELING PROGRAM
This chapter offers suggestions on how to moderate a tobacco cessation
group counseling program using the guidance below and My Tobacco Cessation
Workbook: A Resource for Veterans. The participant manual is designed to
be used in a group format for patients in primary care clinics. The program
is exible when choosing which chapters to use in each group session. To
encourage an environment that supports motivational interviewing, topics for
discussion can be introduced at the beginning of each session. The group can
then have input on the topics they would like emphasized. Sessions should be
instructed in a format that encourages discussion among the group members.
Participants have the opportunity to choose the topics they would like to focus
on for the session. Group moderators should feel free to incorporate these
suggestions or make changes that they nd appropriate. However, providers
should ensure that changes to the program follow the guidelines provided in
the 2008 U.S. Public Health Service Clinical Practice Guideline Treating Tobacco
Use and Dependence.
It is recommended that the group program consist of 5-7 group sessions, each
lasting 60 minutes in duration. The program could be extended to 8-10 sessions
to allow coverage of all topics in adequate detail and to have a longer follow-
up period.
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
Sessions At A Glance
Session Corresponding Chapter In
Par
ticipant's Manual
Topic
1 Chapter 1
Introduction
2 Chapters 2 & 3
Why do I use tobacco?
Nicotine addiction
3 Chapters 4 & 5
Medications to help you
quit tobacco
Getting ready for
quit day!
4 Chapter 6
Quit day
5-7 Chapters 7-9
The rst two weeks after
quit day
How do I stay
off tobacco?
Living as a nonsmoker
Additional sessions can be added to allow group support for the rst few months
after quit day. The duration of follow-up sessions can be extended for a longer
period of time if the instructor feels this is necessary. Another consideration
for follow up could be to do telephone follow up at one month and two months
after quit day and potentially adding follow up at six and 12 months to evaluate
long-term cessation.
A more detailed look at the sessions is reviewed below.
Session 1
Covers Chapter 1: Introduction
Room Set Up
This group program would be best delivered in a room with chairs arranged in
a circle. A dry erase board is useful when having a group discussion to write
down ideas from the group.
At the beginning of the session, take time to do introductions and give some
background into what participants can expect from the program. Introduce
yourself to the group and include your experience in providing tobacco
73
VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
cessation counseling. Discuss if you have smoked in the past and if so, how
you quit tobacco. If you have never smoked cigarettes, you are still able to
moderate this program. Just be honest with the group and let them know
that you will be providing information and counseling that is based on strong
evidence to help people quit tobacco. If you are currently a tobacco user, it is
advised that you not be an instructor for this group.
Background For Providing Tobacco Cessation Counseling
Review with participants that research has shown that providing tobacco
cessation counseling in addition to medications for tobacco cessation is the
most effective way to help people quit smoking. While the research is not as
strong for the use of tobacco cessation counseling and medication for people
who use chewing tobacco, cigars or pipes, it is felt that these interventions
may still help people quit. The program can be used by all types of tobacco
users. Discuss that on average, it takes 6-8 tries for people to quit tobacco. It
is important to highlight that participants should not be frustrated if they have
tried to quit in the past and have not been successful. Each time a person tries
to quit tobacco they learn a little more about how to quit. These lessons can
be applied in future quit attempts. Review that tobacco use can be thought of
as a chronic disease like hypertension or diabetes and that tobacco users can
rotate between using tobacco and not using tobacco many times before they
quit for good.
Next, have the group introduce themselves and state what type of tobacco they
use, how much daily, and when they started using tobacco. This information is
good to enter into your progress notes for the group. Note if participants are
using chewing tobacco. If participants are using chewing tobacco, try to say
“tobacco” rather than “cigarettes” when instructing the program so everyone
feels included.
It is a good idea to set up “rules” for the program. Examples include respecting
other group participants, keeping information that is said in the group condential,
no tobacco breaks during group and limiting topics of discussion to tobacco
cessation. It is benecial to keep political talk out of the group sessions. Also ask
the group for rules they would like to include. Participants can sign condentiality
agreements at the rst session to be scanned into their charts.
Give A Brief Summary Of The Program, Reviewing The Topics For Discussion For
Each Of The Sessions
A discussion about the regional tobacco use for the state where you live is a
good way to start participants talking in the group. You can nd your state-
specic prevalence of cigarette and smokeless tobacco use on the Centers
74
VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
for Disease Control and Prevention (CDC) website at: www.cdc.gov/tobacco/
stateandcommunity/state-fact-sheets/index.htm. The prevalence of tobacco
use among VA patients is very similar to the state-specic data, but in some
cases might be slightly higher.
The next topic of discussion is the participants’ reasons to quit tobacco.
Explain that it is important to start thinking about why they want to quit and to
keep these reasons at the forefront of their minds as they embark on this quit
attempt. Ask the participants to give one reason they have for quitting tobacco
to facilitate a discussion. If participants offer “my health” as a reason, ask
them to be specic about what part of their health they are concerned about
and list each health reason separately. Being specic about health reasons will
make it more personalized for the group members.
Ask participants to review why they use tobacco. Again have them go around
the room and give one reason they use tobacco. Reassure participants that it is
ok to admit that they like to smoke or chew (or both) and this does not impact
whether they will be successful in stopping tobacco. Once they have reviewed
their reasons to use tobacco, have them look at the participant manual pages
(p. 3-4) listing their reasons to quit and their reasons to use tobacco. Ask: Do
your reasons to quit outweigh your reasons to continue to use tobacco? If the
answer is yes, then they are ready to quit tobacco.
Next, ask the participants if they have tried to quit tobacco in the past.
Then have them think about what caused them to go back to using tobacco.
Introduce this as a barrier to quitting. Barriers can be thought of as “speed
bumps” that can get in the way of quitting successfully. The barriers can also
become a “back door” that is left open to justify going back to smoking or
chewing. It is helpful to close these “back doors” so there is no reason to
return to tobacco. Have the group give one barrier they feel might hinder their
chances of quitting tobacco. Participants can mark off their barriers to quitting
on page 5 of the participant manual. Discuss each barrier and have the group
think of ways to manage each barrier without using tobacco.
75
VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
Session 2
Covers Chapter 2: Why Do I Use Tobacco? & Chapter 3: Nicotine Addiction
Why Do I Use Tobacco?
Review the types of behaviors related to tobacco use:
1. Learned behavior: Ask the participants where they learned to use
tobacco. The list could include family, friends, TV/movies, magazines,
and military life. Then go over the calculation of how often they puff
on a cigarette a day and mention how many puffs this would equal in
a year.
If you look at smoking one pack a day for 40 years you would have
taken approximately three million puffs from cigarettes.
Example My Experience
If you smoke 1 pack per day
I smoke ____ packs/
cigarettes per day
Estimate 10 puffs on
each cigarette
Estimate 10 puffs on
each cigarette
10 puffs/cigarette x 20 cigarettes/
day = 200 puffs each day
200 puffs/day x 365 days/year =
73,000 puffs/year
10 puffs/cigarette x ___
cigarettes/day = ____ puffs
each day
2. Triggered behavior: Have the participants discuss their triggers
and have them mark these off in the participant manual (p. 8-9).
Then pose a challenge: Ask each participant to pick one trigger they
have each day. An example of a trigger could be after breakfast.
The challenge is to avoid smoking or chewing tobacco for 10 minutes
after that trigger for the rst day. If they are successful in waiting
10 minutes, then they are encouraged to add 10 minutes a day until
they have reached not smoking for 60 minutes after the trigger.
They should only attempt one trigger once in a day to start. If they
are successful with the rst trigger, then the next week they can try
a new trigger. Have participants think of things they can do instead
of smoking. Examples could be taking a walk, deep breathing, using
sugar-free candy or gum, chewing on a straw or toothpick, reading a
book, doing yard work, or brushing their teeth. This can help them
be more successful at avoiding using tobacco use around the trigger.
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
3. Automatic behavior: Review that tobacco use can develop over
time into an automatic behavior where they use tobacco without
even thinking about it. To help reduce the automatic behavior,
suggest they move their tobacco to a different location. This could
mean putting the pack of cigarettes on the kitchen counter instead
of in their pocket. They could also bring only one cigarette with
them when going outside to smoke instead of the entire pack. This
way they have to go back inside to get more if they want more than
one cigarette. This may help them reduce the amount of daily use.
The other tip is to try using Table 2. Tobacco Tracker (p. 13) of the
participant manual. For this exercise, participants mark off each
cigarette they smoke or each time they chew, noting their mood
before using tobacco and their need for the tobacco. They can mark
off ½ cigarettes, if they are smoking only ½ of the cigarette at a
time. By writing down each time they use tobacco, it can help them
see patterns in their use and whether they smoke due to emotional
changes or from boredom. They may also nd that they can put
off having a cigarette for a while and this may help reduce their
daily consumption.
Nicotine Addiction
N i c o t i n e i s a s u b s t a n c e f o u n d n a t u r a l l y i n t o b a c c o t h a t c a u s e s f e e l i n g s o f p l e a s u r e ,
relaxation or stimulation, and stress reduction. Many people mistakenly think
that nicotine is the substance that causes cancer, lung disease and the other
toxicities related to tobacco use. Explain that the body is harmed by the many
other substances found in tobacco and those compounds are formed when they
are burned. Advise that tobacco, even when grown organically and harvested
and dried without chemicals, is harmful to the body and still contains cancer-
causing substances. There are more than 7,000 chemicals in tobacco smoke
that cause cell damage, cell death, and cancer. Some of the compounds that
are harmful to humans include:
Carbon monoxide
Hydrogen cyanide
Ammonia
Lead
Cadmium
Polonium‑210
Arsenic
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
Benzene
Formaldehyde
Nicotine is one of the most addictive substances available on earth; this is why
it is so hard to stop smoking. Explain that you feel a need for a cigarette when
the level of nicotine in your body starts to drop. If you go for long periods of
time between cigarettes or after sleeping during the night without cigarettes,
you will have a strong craving to smoke. This is because the amount of nicotine
in your body has dropped and since your body is used to having nicotine, it will
want more.
Now ask participants if they have tried to quit tobacco in the past and what
withdrawal symptoms they have experienced. Some common withdrawal
symptoms include:
Irritability/frustration/anger
Anxiety
Difculty concentrating
Restlessness
Depressed mood
Difculty sleeping
Increased appetite
Cravings
Coughing
Runny nose
Explain that most of these symptoms start on the rst or second day after
stopping tobacco. They are at the worst in the rst week and get better with
time. Most symptoms will disappear after 2-4 weeks. Irritability and difculty
sleeping will usually be gone after 2-4 weeks, but the urge to smoke can stay
for a long time. The urge will be stronger at rst and seem to last for minutes.
However, after the rst 2-4 weeks, the urges become shorter. For most people
the urge lasts only seconds after they have been off tobacco for a month or
longer. Nicotine withdrawal symptoms can be managed by some medicines and
with behavioral coping strategies. Medications to help with tobacco cessation
will be discussed during Session 3.
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
Here are some suggestions to deal with the withdrawal symptoms:
Withdrawal Symptom Recommendation
Irritability
Avoid stress
Practice relaxation techniques
Exercise
Depressed
mood
Do something fun
Get support from family and friends
Discuss with your medical provider
Difculty
concentrating
Avoid stress
Plan your workload accordingly
Dizziness
Get up slowly from sitting position
Chest tightness
Practice relaxation techniques
Fatigue
Get more sleep
Take naps
Don't push yourself
Hunger
Drink lots of water
Eat low-calorie snacks
Stomach pain,
constipation, gas
Drink uids
Eat fruits and vegetables
Cough, dry
throat, runny
nose
Drink uids
Eat sugar-free candy
Use cough drops
Difculty
sleeping
Reduce caffeine consumption (e.g., reduce
daily intake by 50%)
Stress
Practice relaxation techniques
Avoid stress
Exercise
Plan your workload accordingly
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
Withdrawal Symptom Recommendation
Craving/urge
for tobacco
Practice DEADS Strategy (see p. 47 of
participant manual)
Use nicotine replacement therapy
Administer the Fagerström Test for Nicotine Dependence, go over the questions
with the group, and have them discuss some of their answers.
Fagerström Test for
Nicotine Dependence
Points* Your
Points
1. How soon after you wake up
do you smoke/use your rst
cigarette/chew?
Less than 5
min.
3
6-30 min. 2
31-60 min. 1
After 1 hr. 0
2. Do you smoke/chew more
frequently in the hours after
waking than during the rest
of the day?
Yes 1
No 0
3. Do you nd it difcult not to
smoke/chew?
Yes 1
No 0
4. Which cigarette/chew would
be the hardest to give up?
First one in
the morning
1
Any other 0
5. How many cigarettes do you
smoke in a day?
10 or less 0
11-20 1
21-30 2
31 or more 3
6. Do you smoke when you're so
sick that you're home in bed?
Yes 1
No 0
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
Fagerström Test for
Nicotine Dependence
Points* Your
Points
NICOTINE DEPENDENCE SCORE (Points): Your Score:
(0-2 pts.) Very low dependence
(3-4 pts.) Low dependence
(5 pts.) Medium dependence
(6-7 pts.) High dependence
(8-10 pts.) Very high dependence
_______
Note. Adapted with permission from “The Fagerström Test for Nicotine
Dependence: a revision of the Fagerström Tolerance Questionnaire,” by T. F.
Heatherton, L. T. Kozlowski, R. C. Frecker & K. O. Fagerström, 1991, British
Journal of Addiction, 86(9), 1119-1127. Copyrighted.
Explain what their scores mean. The higher the number (up to 10) suggests a
higher level of nicotine addiction. In the end, whether the score is high or low,
quitting tobacco will still require hard work.
How Tobacco Affects Your Body
Review with participants how tobacco affects the body, starting from the head
and going to the toes. To encourage group participation, write each body part
(e.g., head) on a board and ask the group the effect of tobacco on each of
the parts.
Head
Stroke (blockage or breaking of a blood vessel in the brain)
Alzheimer's disease and other dementia
Increased rate of long-term cognitive decline
Impaired brain function (it is harder for people who smoke to focus
on tasks and process information)
Mouth and throat cancers
Cavities and loss of teeth
Bad breath
Decreased night vision
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
Yellow staining of skin and teeth
Nose congestion and infections
Wrinkles
Lungs
Cancer (up to 85% of all lung cancers are from smoking)
Emphysema and chronic bronchitis
Worsening of asthma
Lung infections
Heart
Congestive heart failure
Heart attacks
Increased blood pressure and heart rate
Stomach/intestines
Cancers
Ulcers
Heartburn
Pancreas
Cancer
Circulation in arms, legs and feet
Reduced circulation in arms, legs and feet that sometimes leads
to amputations in severe cases - particularly among people with
diabetes.
Bones
Increased bone thinning leading to a higher risk of broken bones
Genitals/urinary system
Cancers in kidneys, bladder and reproductive organs
Erectile dysfunction in men
Sexual dysfunction in women
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
Fertility problems and early menopause in women
Secondhand Smoke
Review the effects of secondhand smoke on adults, children, and pets.
Adults exposed to secondhand smoke may:
Have more breathing problems
Get colds or u more easily
Have higher chances of heart disease and cancer
Die younger than people not exposed to secondhand smoke
Children exposed to secondhand smoke may have:
More breathing problems like asthma
More ear infections
More lung infections like pneumonia
More dental problems like cavities
Pregnant women and infants exposed to secondhand smoke may have:
A higher risk of giving birth to a low birth-weight baby
A higher risk of sudden infant death syndrome (SIDS)
Pets exposed to secondhand smoke may have:
Higher risk of oral cancer, lung cancer and lymphomas (cats)
Higher risk of lung and nasal cancers (dogs)
Higher risk of lung cancer (birds)
A fatal nicotine overdose if your pet eats a cigarette
After reviewing the harmful effects of tobacco, it is time to review how the
body heals after stopping tobacco. Review the section Recovery Of Your Body
After Stopping Tobacco (p. 26-27) in the participant’s manual. Start with 20
minutes after stopping and end at 20 years. It can be mentioned that the
benets of lowered blood pressure and heart rate occurring 20 minutes after
quitting can be experienced by participants as they sit in the group.
20 minutes after you quit
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
Reduction in your heart rate and blood pressure; the temperature of your
hands and feet will start returning to normal.
12 hours after you quit
Carbon monoxide level in your blood drops.
24 hours after you quit
Anxiety and irritability may start due to withdrawal from nicotine. These
symptoms get better the longer you are off tobacco.
2—3 days after you quit
Nerve endings in your body start to regenerate and you may notice a
return in your taste and smell. Anger, anxiety and irritability from nicotine
withdrawal may be at the worst level during this time. Nicotine replacement
with nicotine gum or lozenges may help this. Breathing may be easier now.
1 week after you quit
Tobacco cravings and urges may be less frequent and shorter in duration.
2 weeks after you quit
Blood circulation in your gums and teeth are similar to a nonsmoker.
You should no longer have anger, anxiety and irritability from nicotine
withdrawal. Cravings and urges should be shorter and less frequent.
1—3 months after you quit
Your heart attack risk has started to drop and your lung function is improving.
The blood circulation in your body has improved and walking might be easier.
Give walking a try and see if you can go farther than when you were smoking.
If you had a cough when you smoked, the cough should be gone now.
1—9 months after you quit
Smoking-related nasal congestion, fatigue, and shortness of breath should
be improving. Cilia (little hairs in the lungs, throat and nose) have re-grown
in your lungs and can clean your lungs to remove irritants and mucous, and
reduce infections.
1 year after you quit
The risk of cardiovascular disease, heart attack, and stroke has dropped to
less than half that of a smoker.
10—15 years after you quit
Your risk of having a stroke or heart attack has dropped to a similar rate as
a nonsmoker.
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
Your risk of lung cancer is 30-50% less than a continuing smoker’s risk. Your
risk of death from lung cancer is one-half of the risk if you were an average
smoker (one pack per day). Your risk of pancreatic cancer is similar to a person
who has not smoked and your risk of mouth, throat, and esophageal cancer has
reduced signicantly.
Your risk of tooth loss has decreased to a rate similar to someone who has
never smoked.
Your risk of Alzheimer's disease is the same as someone who has never smoked.
20 years after you quit (women)
Your risk of death from smoking-related causes, including cancer and lung
disease, is the same as a person who never smoked.
Session 3
Covers Chapter 4: Medications To Help You Quit Tobacco & Chapter 5: Getting
Ready For Quit Day!
(Please refer to Chapter IV of this manual for detailed information on
medications used for tobacco cessation.)
Medications To Help You Quit Tobacco
When presenting information about medications for tobacco cessation,
emphasize to the participants that the medications can help them quit tobacco,
but they are not a “magic bullet.” Research shows that using medication, in
addition to behavioral counseling is the best method to quit tobacco. It is
important to present the medications in an unbiased manner, understanding
that each group participant might need to use a different regimen due to their
medical history or current medications. If one regimen is highlighted to be
signicantly more effective than another regimen, then participants will want
to use that regimen even if it might not be advisable with their medical history
or current medications.
There are many ways to present the medication section to the group. One way
to present the information would be to rst present NRTs, highlighting the
nicotine patch, nicotine gum and nicotine lozenge. The nasal spray and oral
inhaler could be introduced to an individual patient if they have had problems
tolerating the other NRTs. Refer to Table 6. VHA Tobacco Use Cessation
Treatment Guidance on p. 47 that covers medications.
The nicotine patch, nicotine gum and nicotine lozenge can be presented to
include the following information:
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
Directions for use
Duration of therapy
Potential adverse effects
Options for combination therapy and instructions on use of
combination therapy
Bupropion can be presented next with the following information highlighted:
Relative contraindications
General dosing instructions
Potential adverse effects
Directions for use
Duration of therapy
Options for combination therapy and instructions on use of
combination therapy
Varenicline can be presented next with the following information highlighted:
Relative contraindications
General dosing instructions
Potential adverse effects
Directions for use
Duration of therapy
Inform participants that varenicline is not generally used in
combination therapy
Smoking And Drug Interactions
When a person smokes, they inhale polyaromatic hydrocarbons, which can
increase the metabolism of certain medications. Specically the polyaromatic
hydrocarbons cause an induction of the CYP1A2 liver enzymes. This effect is
only seen with smoking tobacco and is not seen when using chewing tobacco
or when using NRT.
Medications that can be affected by this include:
Atypical antipsychotics
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
Theophylline
Warfarin
Anxiolytics
Antihypertensives
Caffeine
When an individual stops smoking, their liver enzymes will return to normal
functioning in 2-3 days. If they are taking the medications listed above,
they might have increased adverse effects. If this occurs, a reduction in the
medication dose may be needed.
If patients drink coffee or consume other caffeinated beverages, they might
have side effects of too much caffeine if they continue their same level
of consumption. It is recommended that a person reduce their caffeine
consumption by 50% when they stop smoking.
Getting Ready For Quit Day!
With the group, review the following steps to get ready for quit day.
1. Plan out your tobacco usage so you will run out by your quit day.
Make sure you remove all tobacco from your home. Look in jacket
pockets, kitchen drawers, the freezer, your garage, or other
frequent tobacco storage sites. Also check inside your car for any
stashes of tobacco. Considering that the average craving for tobacco
lasts 2-3 minutes, removing nearby tobacco products will keep you
from being tempted. For most folks, the urge may pass before you
can get in the car and go to a store to buy tobacco.
2. Remove all ashtrays and lighters. These can be triggers for tobacco
once you get to quit day. Since your plan is to quit, do you really
still need them? Remove ashtrays and lighters in the car as well.
3. Clean up your smoking area. If you smoke in one room (e.g., porch,
garage) or in the car, clean up these locations, as they can be
triggers for you to smoke. Remove cigarette butts, wash down
furniture, and spray upholstery with an odor neutralizer to help
remove the smoke smell. Getting your car cleaned or detailed may
help. You may nd you have trouble spending time in these areas for
a while. That is ok, just take a break and come back when you have
a few weeks being tobacco free.
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
4. Go to the store and stock up on tobacco substitutes. Sugar-free
gum, sugar-free mints or candies, carrot and celery sticks or other
vegetables, toothpicks, straws, and cinnamon sticks. These items
can be helpful to use when you are having a craving.
5. Think about hobbies or other interests you have to ll up your
day. Some hobbies/interests to consider would be puzzles, games,
reading, exercise, shing, woodworking, painting, drawing, and
cooking. Make sure it is a hobby not associated with tobacco use.
Encourage participants to consider packing an emergency kit for their rst long
car trip or a pending adventure. Such a kit would contain:
Sugar-free candy
Sugar-free gum
Toothpicks
Straws
Vegetables and fruit
Water
Cinnamon sticks
Throat lozenges
Planning For Quit Day
Group Activity
Page 45 of the participant manual has participants list the top situations where
they use tobacco and what they will do instead of using tobacco. They can
also use the information from Table 2. Tobacco Tracker (p. 13) to review their
pattern of using tobacco. Then pick three times that they use tobacco and
write these into the spaces on page 45. Ask the group to write down an activity
they can do or a substitute they can use instead of using tobacco. Have the
group share one of their times that they smoke/chew and something they will
do at that time instead of using tobacco.
Stress And Tobacco Use
Most Veterans who use tobacco say that stress is their biggest trigger. When
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
under stress, many smokers will inhale deeper and hold the smoke in longer.
Most people feel that using tobacco helps them relax when they are feeling
stress. It is important to explain that the feeling of relaxation is usually from
the nicotine treating the withdrawal symptoms between cigarettes or chewing
tobacco. Nicotine is actually a stimulant and can increase heart rate and blood
pressure very quickly. This can result in physical stress.
Ask the group to think about situations that cause them to have more stress.
They can write down these situations in their manual.
Discuss with the group the stress reduction tips listed in the participant manual
including:
Talking to a friend
Deep breathing
Going for a walk or a jog
Doing chair exercises
Reading a book
Listening to relaxing music
Working a crossword puzzle
Playing computer games
Cravings For Tobacco
Review that it is common to have cravings for tobacco after quit day. Almost
all people have tobacco cravings when they quit. Explain that having a craving
for tobacco should never be thought of as a relapse.
Introduce the DEADS Strategy (see p. 64‑65):
Delay
Escape
Avoid
Distract
Substitute
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
Get Help From Family And Friends
Finding a support person can be helpful. It could be a family member, a friend,
a neighbor, or someone from work. It is best to choose someone who does not
smoke. How can your support person help you?
Listen when you want to talk
Call to see how you are doing
Offer to help you with chores, errands, childcare, shopping, etc.
Talk about problems and how to solve them
Cheer you on
You can help your support person in the following ways:
Let them know what will help you
Let them know when you will be quitting tobacco
Plan on when you want to talk to them after quit day
Plan fun activities that can keep you from thinking about tobacco
Teach your support person about quitting tobacco, especially if they
have not used tobacco themselves
If you are keeping your quit attempt a secret, then let your support
person know this
Thank your support person for helping you quit tobacco
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
Session 4
Covers Chapter 6: Quit Day
Quit Day
Celebrate the quit day! Congratulate everyone in the group for making it to
this day. Take time to go around the group and ask everyone when they last
smoked or chewed tobacco. Congratulate those who have quit so far and give
encouragement to those who have not quit. Provide assistance to those who
have not yet quit. Review briey getting ready for quit day again and suggest
they try quitting tomorrow if they are ready.
Review The Following:
It Is Time To Make Some Changes:
Change your routine
Switch the order of your morning
Be active — take a walk
Have your morning coffee in a new mug
Drink less caffeine
Drive to work on a new route
Take your work break inside
Get up from the table as soon as you nish eating
Sit in a different chair to watch TV or read the newspaper
Keep Busy:
Do something fun like see a movie
Exercise for 20-30 minutes a day
Wash your clothes and sheets
Use substitutes to keep your mouth busy
Meet with friends who don’t smoke
Go to nonsmoking places like the library
Drink more water
Stay away from places where you smoked
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
Don’t:
Feel like smoking has been taken away from you, remember you are
better off without it.
Test yourself by trying a cigarette. This can lead to a full relapse.
Forget there will be difcult times when you stop smoking: be proud
of how well you are doing!
Drink alcohol and go to bars for a while; this can be too tempting
and you may want to smoke.
Forget to bring nicotine lozenges or nicotine gum with you when you
need to go places or do things where you used to smoke.
Handling Nicotine Cravings
Review that nicotine cravings at rst seem like they last minutes and happen
frequently. The cravings will reduce in intensity and frequency with more time
off tobacco. Review the DEADS Strategy (p. 64-65). Also remind participants
that have been using nicotine gum or lozenges in combination therapy that
these are used to help reduce nicotine cravings. Encourage them to contact
their VA provider if they experience strong cravings or withdrawal symptoms
to see if they may need to change their medication dosage.
Spend a few minutes reviewing deep breathing exercises and suggest using
these to help with nicotine cravings.
Discuss how exercise can be used to help reduce nicotine cravings. For
participants who do not currently exercise, emphasize that they start very
slowly at about ve minutes and slowly increase as tolerated. Review activities
they can try:
Walking or jogging
Tennis
Dancing
Golng without a cart
Aerobic exercise classes
Cycling
Gardening and pushing a lawn mower
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
Yoga
Swimming
Water walking
Weight machines
Aqua aerobics
Healthy Eating
This can be particularly helpful if participants are concerned about weight gain
after quitting tobacco.
Suggestions to review:
The health benets of stopping tobacco use generally outweigh any
health concerns about weight gain after stopping.
Weight gain is typically small from quitting tobacco, about 5-10
pounds on average.
Eating more healthy foods and staying active can minimize weight
gain after stopping tobacco.
Eat more fresh fruits and vegetables. If you cannot afford fresh
fruit/vegetables, then try buying them frozen.
Drink more water, which will help you feel full and reduce
weight gain.
Eat carrot and celery sticks to help with the hand-to-mouth behavior
from smoking.
Eat crunchy foods like pretzels, rice cakes, or air popped popcorn,
so your mouth has to work.
If craving a sweet, eat a small square of dark chocolate or a low-fat
frozen yogurt.
Eat smaller meals, but more often. If you eat snacks in between
meals, you are less likely to overeat. This can help prevent weight
gain as well.
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
Congratulate the group one more time to nish the session and wish them luck
for the next week.
Sessions 5-7: Follow-up sessions
Covers Chapter 7: The rst two weeks after quit day, Chapter 8: How do I stay
off tobacco? & Chapter 9: Living as a nonsmoker
The ideal time for the rst follow-up session is in the rst week after quit day.
Subsequent follow-up sessions can be done weekly or could be extended to
every two weeks.
The First Two Weeks After Quit Day
The rst portion of each follow-up session can be used to ask each participant
to share how they have done since quit day. Ask the group to comment on the
following:
Have you had any slips since quit day?
• If you had a slip, what caused it?
• Did you continue to smoke or did you stop after the slip?
• What could you do in the future to prevent having a slip?
What benets have you noticed since quit day?
• Examples of some benets they may have noticed so far:
Improved breathing
More energy
Improved sense of taste and smell
Yellow staining almost gone from ngers and sides of mouth
Feeling in control instead of the cigarette being in control
MORE MONEY!
Reward Yourself
Discuss that rewarding yourself along the way when you quit tobacco can help
you stay motivated. Review examples of rewards:
Buy yourself something special to celebrate quitting
Splurge on a massage or dinner at a new restaurant
See a movie or sporting event
Start a new hobby
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
Begin exercising
Use your savings to pay off your bills
Go on a nice trip after being a nonsmoker for six months
Ask the group if they have some rewards they plan to do after quit day. Review
page 61 of the participant manual and the cost savings from quitting tobacco.
Have the group calculate their savings.
If participants have problems with triggers and urges for tobacco, review
the section:
How Do I Stay Off Tobacco?
Watch Out For Triggers
Go back to your list of triggers on pages 8-9.
What triggers are the most common now that you have quit?
How have you kept from using tobacco when you have a trigger?
Resist The Urges
Remember, the urge to use tobacco will go away whether you smoke/chew
or not. Try to avoid using tobacco and the urges will slowly lose their power
over you.
Go back to page 45 when you were planning for quit day. On that page you
wrote down what you could do instead of smoking when you had a craving for
tobacco. Have these strategies worked?
Make a new list if your strategies are not working.
Instead of using tobacco I could:
• Go for a walk
• Chew gum
• Eat a sugar-free mint or candy
• Talk to a friend
• Listen to music
• Play with your dog/cat
• Try deep breathing
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
No matter what, don’t think “Just one won’t hurt”…yes it can hurt and
cause you to go back to smoking daily. You have worked so hard!
Keep things simple. Work through this one day at a time.
Planning For The Future
It is time to start looking at your calendar and see if there are any big events
coming up that might be a trigger for you to use tobacco. Examples of some
events that could cause triggers:
Weddings
Holidays
Anniversaries
Birthdays
Family or group events
Sporting events
Hunting season
Fishing season
List some upcoming events where you might be triggered to use tobacco.
What could you do instead of smoking at these events?
Slip Prevention
This is an important section to review with participants. Include an explanation
o
f what a slip is and how to prevent slips. Use the information below to assist
with the discussion.
What is a slip? This is when you smoke a couple cigarettes and then go back
to not smoking. This is not a full relapse but can lead to a relapse if not
corrected quickly.
To prevent slips:
Be aware of triggers—during these times you will crave tobacco
more often
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
Do not get overcondent—you may think that you can smoke just
one and go back to being a nonsmoker. Many people relapse and go
back to full-time smoking after just one cigarette.
Think about the benets you have experienced and feel good about
your progress
To continue your success, try to:
Be aware of your triggers
Not get discouraged if you slip and stay the course of becoming
tobacco free
Stay positive and praise your achievements
Focus on the benets of quitting and beginning a healthier lifestyle
What if I have slipped?
Don’t get discouraged! One cigarette is better than smoking the whole pack.
Get back on track quickly.
Slips can quickly lead to a relapse
If you bought a pack, throw it away and destroy it so you will not be
tempted to dig it out of the garbage
Continue to use medications as prescribed
Figure out what caused the slip:
If you can identify what caused the slip, you can try to prevent this
from happening in the future
If stress is the cause, review your stress reduction strategies
such as:
• Deep breathing
• Going for a walk
• Removing yourself from the stressful situation
• Using nicotine lozenges or nicotine gum if you were prescribed
these medications. If you were not prescribed these, ask your
provider if these would be appropriate for you.
Don’t let one slip take you back to smoking again!
What if I am back to daily smoking?
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
If you go back to daily smoking then this is called a relapse. If you relapse, get
back on track as soon as you can.
Stop your medications until you are ready to quit again
Set a new quit day in the next two weeks
Review what led you to start smoking again
Plan out your cigarettes so you will not have any left once you get to
your new quit day
Throw out ashtrays and lighters on quit day
Talk to your provider about the medication you used for
stopping tobacco
• You might want to consider a change in medication if the
medication did not seem to help you or if you had adverse effects
from the medication.
• If the medication did help you, then you can retry the
same medication.
Don’t tell yourself negative messages like:
“It’s no use, I can’t quit. I may as well give up because I smoked!”
• In reality, it takes people on average 6-8 tries to quit for good.
“I smoked because I’m weak and don’t have the willpower.”
• This is not about willpower. It’s more about learning from the
relapse to make sure you don’t fall back again. You learn more
about your addiction and the best way for you to quit the more
times you try.
“I’m too old to quit smoking; it is too late for me anyway.”
• Everyone can benet from stopping smoking no matter their age
or current health status.
• Even people with very severe lung disease can see improvements
by stopping smoking.
Living As A Nonsmoker
For each follow-up session, go around the room and have each participant
comment on the progress of their quit attempt. Have each participant
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
comment on the following:
Have you had any slips since quit day?
• If you had a slip, what caused it?
• Did you continue to smoke or did you stop after the slip?
• What could you do in the future to prevent having a slip?
What benets have you noticed since quit day?
• Examples of some benets they could have noticed so far:
Improved breathing
More energy
Improved sense of taste and smell
Yellow staining almost gone from ngers and sides of mouth
Feeling in control instead of the cigarette being in control
MORE MONEY!
Review with the group tips to maintain cessation from tobacco products. Use
the information to assist with the discussion. Congratulate everyone in the
group on their progress in quitting tobacco. For those who are still smoking,
provide continued encouragement to help them quit completely. One strategy
is to set another quit day and try again. For those who have quit completely,
encourage continued cessation by reviewing the following:
Avoid smoking and chewing
• Smoking or chewing even one time can lead to relapse.
Sometimes you might think that “it is only one” but many people
have relapsed from “just one.”
• Avoid cigars and e-cigarettes as well. These can lead you back to
smoking or chewing and cause a relapse.
Try to be around people who do not smoke
• It can be challenging to stay off tobacco when you are around
people who still smoke. Try to be around nonsmokers if you can
do this. If you must be around people who smoke, let them know
you have quit smoking and ask them not to offer you any tobacco.
You can also be around them in places where they can’t smoke.
• Bring your emergency kit and other items to help distract you
from wanting to use tobacco.
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
Continue to use substitutions and distractions
• Use your emergency kit or some sugar-free candy or gum
• Have a book, the newspaper, or a puzzle book to do when you
have extra time on your hands
Don’t be afraid to ask for help
• If you have been working with your primary care provider or
tobacco cessation counselor to quit, contact them if you are
struggling to remain off tobacco
• Ask for help from friends and family
• Call the VA tobacco quitline at 1-855-QUIT VET (1-855-784-8838),
Monday through Friday, 9AM-9PM EST. English- and Spanish-
speaking counselors are available
• Get supportive text messages from SmokefreeVET, text the
word VET to 47848 (manda VETesp para espanol). If you need an
immediate tip, text keywords URGE, STRESS, SMOKED, or DIPPED
to 47848 (smokefree.gov/VET)
If you have been using medication to help you quit, take it for the
entire course of treatment
• You may feel ready to stop the medication early, but try not
to do this. The medication may work better if you nish the
entire course.
• If you need the medication for a longer period of time, talk to
your primary care provider or tobacco cessation counselor.
Congratulate yourself every day
• You have done an amazing job and you deserve it!
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
Remind Participants: If you feel like using tobacco again, remember why
you quit.
Go back to page 3 and look at your reasons for quitting tobacco. Check off the
things you are enjoying now that you have quit tobacco:
I have more energy
I can breathe better
I am not wheezing
I sleep better
I can walk farther
I have saved money
I don’t have to stand outside
to smoke
I can say I am a nonsmoker
I am setting a good
example for my children/
grandchildren
I smell better
I can taste my food
I have lowered my risk
of cancer
I have lowered my risk of
heart disease
I have less stress since I
quit tobacco
I am in control now
I am proud of myself
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
Dealing With Stress
Here are more tips on how to deal with stress. We all have stress, so remember
that there are ways to deal with stress other than using tobacco.
Do what is best for you
Give yourself extra time to get to work or appointments
Make time to do things you want to do
Learn to say “no” to things you don’t want or don’t have time to do
Eat healthy foods
Get enough sleep
Reward yourself
Have fun
Enjoy your hobbies
Go for a walk, go swimming, or get on your bike
Go to a movie
Play with your favorite pet
Go outside
Spend time with others
Visit or call a friend
Go out to eat
Spend time with family members
Cook a special meal for your spouse or friend
Go to a fun event
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VI. Establishing A Tobacco Cessation Program In Primary Care Clinics
Keep busy
Go dancing
Work on your yard
Fix or build something
Clean your home
Listen to music
Find time to relax and have quiet time
Read a book or magazine
Listen to music
Take a bath
Practice deep breathing
Meditate
Daydream
Take a yoga class
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Appendices
Appendix A. Evaluating Tobacco
Cessation Programs
Appendix B. Tobacco Cessation
Resources
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Appendices
Appendix A. Evaluating Tobacco
Cessation Programs
To assess the effectiveness of your program, track the outcome measures
related to its objectives. The use of these outcome measures as performance
measures will elicit more participation support among your fellow clinicians.
Below is a list of tobacco cessation program performance measures you may
want to track yearly, quarterly, monthly, weekly, and/or daily.
Number of patients seen in your clinic
Number of patients identied as a tobacco user in CPRS or in the
Social History section of the Cerner electronic health record, as
appropriate.
Number of patients identied as a tobacco user when prompted by
a provider
Number of patients in each dependence level, as dened 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, CO
2
— 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 tobacco 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
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Appendices
regimens and their outcomes (abstinence)
• Combination NRTs such as the patch + lozenges
• Combination bupropion + NRT (e.g., nicotine patch)
• NRT monotherapy
• Varenicline
Number and details of counseling sessions
• Face‑to‑face
• Telephone
• Duration and frequency
• Provider who delivered the intervention
To track the effectiveness of your facility in providing tobacco cessation
assistance, below is a checklist of performance measures you may want to
track yearly, quarterly, monthly, weekly, and/or daily.
Number of tobacco users screened for their interest in a tobacco
cessation program
Number of tobacco users ready for a screening visit with a tobacco
cessation counselor following this visit
Number of tobacco cessation medication prescriptions ordered
by providers
Number of patients prescribed specic 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
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Appendices
Appendix B. Tobacco Cessation Resources
Web And Telephone Resources
VHA Tobacco & Health
www.mentalhealth.va.gov/quit-tobacco
SmokefreeVET website
veterans.smokefree.gov/
Go to “Build Your Quit Plan” to create a personalized, printable quit plan
Go to "Nicotine Replacement Therapy" to learn how to quit for good
with NRT
1-855-QUIT-VET, Veterans Tobacco Quitline
1-855-784-8838, Monday-Friday, 9AM-9PM EST
Available in English and Spanish
SmokefreeVET Text Message Program
Text the word VET to 47848 or sign up online:
smokefree.gov/VET
SmokefreeVET en Español
Envie la palabra VETesp al 47848
smokefree.gov/VETesp
Stay Quit Coach smartphone app
Download from the App Store or Google Play
mobile.va.gov/app/stay-quit-coach
Women.smokefree.gov
www.women.smokefree.gov
My HealtheVet
www.myhealth.va.gov/mhv-portal-web/home
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/topics/tobacco-use.html
Ofce of the Surgeon General
www.surgeongeneral.gov
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Appendices
Smokeless Tobacco Resources
SmokefreeVET smokeless tobacco website
veterans.smokefree.gov/smokeless-tobacco
U.S. Food and Drug Administration
www.fda.gov/TobaccoProducts/Labeling/
ProductsIngredientsComponents/ucm482582.htm
Center for Disease Control and Prevention
www.cdc.gov/tobacco/data_statistics/fact_sheets/smokeless/
health_effects/index.htm
Web Resources and Online Trainings for Health Care Providers
VHA Tobacco & Health SharePoint site
dvagov.sharepoint.com/sites/VHAtobacco/ (NOTE: This is an internal VA
website that is not available to the public)
National Institutes of Health — National Institute of Drug Abuse —
Smoking Cessation
nida.nih.gov/drug-topics/tobacconicotine-vaping
Centers for Disease Control and Prevention — Smoking and
Tobacco Use
www.cdc.gov/tobacco
The Health Consequences of Smoking—50 Years of Progress
A Report of the Surgeon General (2014)
www.ncbi.nlm.nih.gov/books/NBK179276/
Smoking Cessation
A Report of the Surgeon General (2020)
https://www.ncbi.nlm.nih.gov/books/NBK555591/
U.S. Department of Health and Human Services,
Public Health Service
Treating Tobacco Use and Dependence: 2008 Update
(Clinical Practice Guideline)
ncbi.nlm.nih.gov/books/NBK63952
U.S. Preventive Services Task Force
Tobacco Smoking Cessation in Adults, Including Pregnant Persons:
Interventions
www.uspreventiveservicestaskforce.org
U.S. Department of Veterans Affairs
Veterans Health Administration
Washington, DC 20420
Primary Care & Tobacco Cessation Handbook:
A Resource for Providers
Revised September 2022
IB 10-565; P96622
Sponsored by
U.S. Department of Veterans Affairs
Veterans Health Administration
