- Smoking and Tobacco Use Basics
- Challenges to Smoking Cessation
- Assessing Smoking Status and Nicotine Dependence
- Client Educational Materials
- Treatment and Training
- Referring to VA
- Cool Tools
Smoking and Tobacco Use Basics
Smoking is the leading preventable cause of premature death and a leading cause of illness and mortality. Smoking is also one of the VA's biggest public health challenges. Many Veterans first began using tobacco while in the military and the culture of the military has historically been viewed as supporting tobacco use. While the rate of smoking among all Veterans currently enrolled for care in VA is roughly that of the U.S. population (19.7%), the rate of smoking among Veterans with mental health or substance use disorders is roughly 2-3 times that rate.
Approximately 70 percent of all smokers say they want to quit, but even the most motivated smoker may try to quit five or six times (or more) before they are able to quit. Over 3 million Americans successfully quit smoking every year. There is a strong evidence base for what works in smoking cessation treatment. The 2008 update of the U.S. Public Health Service Clinical Practice Guideline, Treating Tobacco Use and Dependence, outlines that a combination of behavioral counseling and the use of FDA-approved smoking cessation medications can greatly increase a smoker's likelihood of quitting.
Other tobacco use (e.g., smokeless tobacco, snuff, cigars, etc.) is not as prevalent and is less well studied, but it has harmful health consequences as well, such as increased cardiovascular disease and oral cancers.
What About Co-occurring Conditions?
Higher rates of smoking are seen in a variety of populations, including those with psychiatric disorders such as PTSD, depression, psychoses, and other substance use disorders. However, all these populations can successfully quit smoking with evidence-based treatment without any exacerbation of psychiatric symptoms or increased substance use. Research suggests that quitting smoking is frequently associated with improvements in psychological functioning, including decreased anxiety among smokers with PTSD and other disorders and increased abstinence in substance use disorder populations.
Visit the VISN 6 MIRECC website at http://www.mirecc.va.gov/visn6/quit/video/oefoifvid.html to learn more about how the challenges Veterans face when quitting smoking.
Challenges to Smoking Cessation
- Many smokers try to quit 'cold turkey' or without any support, decreasing their chances of success
- Smoking is a chronic, relapsing disease and smokers may require repeated measures/interventions
- Some mental health providers may feel uncomfortable about talking to their patients about their smoking as they may not have training in how to provide effective smoking cessation
- Nicotine withdrawal symptoms such as cravings, irritability, depressed mood, coughing, insomnia etc can be difficult for patients especially in the earlier portion of the quit attempt
- Cravings/triggers due to the habit of smoking can be difficult especially in the early stages of the quit attempt, but also during the maintenance phase as they can occur at any point
- Example: 56 year old Male Veteran quit for 9 months, but slipped due to socialization with one of his best friends that he has not seen in years, but smoked with him in the past.
- Stress remains a significant trigger to smoke, despite the fact that nicotine is a stimulant and there are other options for stress management
- Many patients cite concerns about weight gain concerns as a barrier to quitting. However, most patients gain an average of only 5-10lbs. Behavioral counseling on how to increase physical activity and healthy eating choices can help prevent weight gain
- Many patients with mental health or substance use disorders may be concerned that quitting smoking may make their psychological symptoms worse or may interfere with their recovery or treatment
Please see the Treatment and Training tab to learn more about addressing challenges in treatment.
Assessing Smoking Status and Nicotine Dependence
There are many tools for assessing Smoking status. As a first step, get a smoking or tobacco use history. Ask the patient how much they smoke and how long they have been smoking. You can calculate their 'pack years' by asking multiplying the number of years they smoke by the amount that they smoke each day (for example- 1 pack a day for 30 years = a 30 pack year history).
A quick and brief way to assess level of dependence is to use the Brief Fagerström Test for Nicotine Dependence*.
- How soon after waking do you smoke your first cigarette?
- Less than five minutes (3 points)
- 5-30 minutes (2 points)
- 31-60 minutes (1 point)
- How many cigarettes do you smoke each day? (See current status above)
- More than 30 cigarettes (3 points)
- 21-30 cigarettes (2 points)
- 11-20 cigarettes (1 point)
SCORE NICOTINE DEPENDENCE:
0 points: No dependence
1-2 points: Low dependence
3-4 points: Moderately dependent
5-6 points: Highly dependent
*Used with permission by Dr. Karl Fagerström.
Client Educational Materials
Check these websites for Patient Information on Smoking and Tobacco Use Cessation:
- The VA Office of Public Health Tobacco & Health website.
- This National Cancer Institute (NCI) website provides smoker with important tools and information.
- 'Quit Tobacco. Make Everyone Proud' is a website designed to provide military Service Members and Veterans with important information about quitting tobacco use.
- Be Tobacco Free is a website of the U.S. Department of Health and Human Services.
Treatment and Training
These web sites link to key resources that can support training in and treatment for smoking and tobacco use:
- 2008 Update of the United States Clinical Practice Guideline (CPG): Treating Tobacco Use and Dependence
- 2008 Update of the U.S. Public Health Service CPG - A Quick Reference for Clinicians
- Veterans Health Administration Tobacco Use Treatment Guidance:
- Part 1: Guidance on the 5 A's (Ask, Advise, Assess, Assist, Arrange) (PDF)
- Part 2: Assisting with Tobacco Cessation - Medication Options (PDF) - Provides guidance on what options to try first and what to do if there is a relapse.
- Part 3: Medications for Tobacco Use Cessation (PDF) - A table listing medication descriptions, pros/cons, limitations, and dosing recommendations.
Referring to VA
What Should I Consider When Referring?
If your client reports smoking or tobacco use and wants assistance with quitting, VA offers a variety of evidence-based treatment options, including brief counseling and FDA-approved mediations provided through outpatient primary care, mental health, and pharmacy settings.
Services offered by VA:
- Screening for tobacco use during primary care and mental health visits
- Individual or group counseling
- Prescriptions for nicotine replacement therapy, such as a nicotine patch or gum, or other medications
- Participation in evidence-based smoking cessation programs
- Online resources to provide additional information and support during a quit attempt
Veterans may work with a member of their primary care team or receive more intensive behavioral counseling and support through specialty program developed to provide smoking and tobacco use treatment. In addition, telehealth programs to support patients during a quit attempt are also available.
Veterans enrolled for care in VA may contact the nearest VA health care facility or contact their Patient Aligned Care Team (PACT) to learn more about treatment options or to schedule an appointment.
SmokefreeVET is a smoking cessation tool that provides up to eight weeks of supportive and encouraging texts to Veterans quitting smoking. SmokefreeVET, a collaboration between VA and the National Cancer Institute (NCI), is based on NCI's successful text program, which showed an 11% quit rate after six months among individuals who used the program.
- To sign-up for SmokefreeVET, Veterans can simply text VET to 47848 from their mobile phone or visit www.smokefree.gov/VET/.
- Veterans will receive between 1 and 5 messages each day beginning two weeks prior to their quit date. Veterans may also text the keywords URGE, STRESS, or SMOKED to 47848 at any time for extra support.
Consider encouraging your patients to use SmokefreeVET for extra support during their quit attempt. It's also important to provide your patients with smoking cessation medications to increase their chances of quitting smoking. Please continue to offer your patients behavioral counseling in addition to support services like SmokefreeVET. For more information visit www.smokefree.gov/VET/.
Stay Quit Coach:
Stay Quit Coach is a mobile phone app designed to help with quitting smoking. It is intended to serve as a source of readily available support and information for adults who are already in treatment to quit smoking - to help them stay quit even after treatment ends.
- The app guides users in creating a tailored plan that takes into account their personal reasons for quitting.
- It provides information about smoking and quitting, interactive tools to help users cope with urges to smoke, and motivational messages and support contacts to help users stay smoke-free.
- It is meant to be used in conjunction with Integrated Care for Smoking Cessation. However, it provides instruction and information for those using the app without their provider to get additional support during a quit attempt.
Download the Stay Quit Coach for free to any mobile Apple device (iPhone, iPod touch, iPad) on the Apple App Store. Stay Quit Coach will be available for Android devices in 2013.
This app represents a collaborative effort between the VA National Center for PTSD, VISN 21 & VISN6 MIRECCs, the DoD National Center for Telehealth & Technology, and VA Clinical Public Health Group.