Smoking and Tobacco Use
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.
The rate of smoking among all Veterans currently enrolled for care in VA is roughly that of the U.S. population (16.8%). However, the rate of smoking among Veterans with mental health or substance use disorders is roughly 2-3 times that rate.
Tobacco users with mental illness have a greater risk of dying from CVD, respiratory illnesses, and cancer than people without mental illness. In addition, tobacco-related disease accounts for approximately half of the mortality for individuals with schizophrenia, bipolar disorder, and depression.
Over 3 million Americans successfully quit smoking every year. 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. The best evidence-based approach to tobacco cessation is the combination of behavioral counseling and medications.
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.
The Benefits of Tobacco Cessation
Research suggests that quitting smoking is frequently associated with improvements in psychological functioning, including decreased anxiety and depression among smokers with PTSD and other disorders and increased abstinence in substance use disorder populations.
Callaghan R.C., Veldhuizen S., Jeysingh T., Orlan C., Graham C., Kakouris G., Remington G., & Gatley J. Patterns of tobacco-related mortality among individuals diagnosed with schizophrenia, bipolar disorder, or depression. J Psychiatr Res., 48(1), 102-10.
Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff. (2008). A clinical practice guideline for treating tobacco use and dependence: 2008 update. A U.S. Public Health Service report. Am J Prev Med, 35(2):158-76.
Dalton, S.O., Mellemkjaer, L., Olsen, J.H., Mortensen, P.B., & Johansen, C. (2002). Depression and cancer risk: a register-based study of patients hospitalized with affective disorders, Denmark, 1969-1993. Am J Epidemiol. 155(12), 1088-95.
Himelhoch S., Lehman A., Kreyenbuhl J., Daumit G., Brown C., & Dixon L. (2004). Prevalence of chronic obstructive pulmonary disease among those with serious mental illness. Am J Psychiatry, 161(12), 2317-9.
Lichtermann D., Ekelund J., Pukkala E., Tanskanen A., & Lönnqvist J. Incidence of cancer among persons with schizophrenia and their relatives. Arch Gen Psychiatry, 58(6), 573-8.
Olfson M., Gerhard T., Huang C., Crystal S., & Stroup T.S. Premature Mortality Among Adults With Schizophrenia in the United States. JAMA Psychiatry, 72(12), 1172-81.
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 Clinical Psychology, 72(6), 1144-1156.
Taylor, G., McNeill, A., Girling, A., Farley, A., Lindson-Hawley, N., & Aveyard, P. (2014). Change in mental health after smoking cessation: Systematic review and meta-analysis. BMJ, 348, g1151. Retrieved from https://www.bmj.com/content/348/bmj.g1151.full
How to Quit
Quitting tobacco is not easy, and many Veterans make multiple quit attempts before quitting for good. VA health care providers are ready to help all Veterans who are ready to quit smoking or using smokeless tobacco products.
Video source: VA Mental Health
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.
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, and insomnia can be difficult for patients especially in days and weeks immediately after quitting.
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: A 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 for many smokers.
Many patients cite concerns about weight gain concerns as a barrier to quitting. However, most patients gain an average of only 5-10 lbs. 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. In fact, the opposite is true as quitting smoking is associated with better mental health and substance abuse treatment outcomes and improvement in psychological functioning.
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 and 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*.
Nicotine Dependence Test
1) 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)
2) 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 Tobacco & Health website provides facts about tobacco and effective treatment options. This site also provides information about VA’s national quitline, 1-855-QUIT-VET and mobile texting program SmokefreeVET.
The SmokefreeVET website provides interactive tools on how to build a quit plan, information on why smokers smoke, and helpful tips and information on how to quit.
VHA also has developed workbooks for patients to assist them with quitting tobacco use as well as information sheets on how to use FDA-approved smoking cessation medications.
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
Clinical Training Resources: A 2-part Presentation on Evidence-Based Tobacco Use Treatment
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
Evidence-based smoking cessation programs
Online resources to provide additional information and support during a quit attempt
1-855-QUIT-VET- a national quitline for Veterans enrolled for care in VA. Hours of operation are Monday-Friday 8 am- 10 pm (not open on Federal Holidays)
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.
Intervention and Technology:
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 https://smokefree.gov/tools-tips-vet/smokefreevet.
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.
2) 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) in the Apple App Store. Stay Quit Coach is also available on Android and can be downloaded from the Google Play Store.
This app represents a collaborative effort between the VA National Center for PTSD, VISN 21 & VISN 6 MIRECCs, the DoD National Center for Telehealth & Technology, and the VA Clinical Public Health Group.