TOOLKIT: Integrating Tobacco Dependence Treatment in Behavioral Health Settings

Therapist and client

This toolkit is designed to support behavioral health facilities develop and integrate tobacco use disorder (TUD) treatment into substance abuse and mental health care treatment. These materials are intended for agency clinicians, providers, and administrators.

Navigate the toolkit by clicking on a commonly asked question below. Explore links, videos, examples, and additional resources within each question.

Download and print TOOLS located throughout the toolkit to use at your organization.

Tip

Providing a tobacco-free environment reinforces tobacco treatment efforts and supports clients in recovery. This toolkit complements the Implementing Tobacco-Free Environments in Behavioral Health Settings Toolkit. The toolkits are designed to be used in tandem but can be used independently.

Getting Started

There are six primary components to integrating tobacco treatment into the standard of care. These six components will enable an organization to successfully assess and treat tobacco dependence. It is important to note, implementing tobacco treatment at your facility is often not a linear process. Facilities may need to revisit components and/or discuss how to sustain elements of each component throughout the implementation process.

Steps to treat tobacco addiction

You can start with this Checklist TOOL to distinguish specific tasks within your organization for each tobacco dependence treatment component:

Understanding Tobacco Use

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What is tobacco use disorder (TUD)?

Tobacco use is the most common substance use disorder in the United States. As with other substance use disorders, TUD is classified by the inability to control the use of tobacco, despite the harm it causes. It is classified by tolerance, difficulty stopping, strong cravings, and withdrawal symptoms in the absence of nicotine.

Why treat tobacco use dependence in substance use treatment settings?

People with behavioral health conditions use tobacco at very high rates

Despite the progress that has been made to reduce tobacco use in the general population, individuals suffering from a mental health condition and/or substance use disorder remain at higher risk for tobacco use. People living with behavioral health conditions are 2-4 times more likely to use tobacco than the general population.1

On average, people with mental illnesses and addictions can die between 5 and 25 years earlier than the general population with tobacco use being a major contributor.2,3 Individuals in substance use disorder treatment are more likely to die from tobacco use than all other substance use disorders combined.4  Smoking-related illnesses cause half of all deaths among people with behavioral health disorders.

Tobacco recovery enhances recovery from all substances

Individuals who stop using tobacco at the same time as other substances are 25% more likely to remain abstinent from all substances.5

Tobacco recovery is a powerful mental health intervention

Recovery from tobacco addiction leads to decreased stress, anxiety, depression, and improved quality of life.6,7

Behavioral health providers have the skills and knowledge to treat tobacco use disorders

Tobacco dependence is recognized both as a chronic, relapsing disease and as an addiction. Its treatment requires the same skills, knowledge, and experience that addiction counselors already have and apply to other addictions. These include a combination of Food and Drug Administration (FDA)-approved medication and behavioral strategies, such as cognitive behavioral therapy and skills-based counseling. Further, individuals not ready to quit tobacco will benefit from motivational interventions.

Tobacco dependence treatment can be easily integrated into existing SUD treatment services.

Can people with behavioral health conditions successfully stop using tobacco?

Yes. People living with behavioral health conditions do achieve long-term recovery from TUD at rates that approach those within the general population.1 The majority of people with another addiction who use tobacco report wanting to stop or reduce their tobacco use.8

If clients want to quit using tobacco, why do so many still use tobacco?

Despite the desire to quit and demonstrated success with evidence-based interventions1, high tobacco use prevalence remains among behavioral health populations due to limited access to treatment and resources.

Among SUD treatment facilities in the United States in 20219:

SUD treatment facilities

How does tobacco dependence impact a person’s recovery?

When someone is in recovery for alcohol and other substances, the brain starts to heal and balance itself. Continued use of tobacco impacts the brain’s ability to fully heal as nicotine continues to activate the dopamine reward system. The co-use of nicotine with other substances demonstrates a strong neurobiochemical link via the dopaminergic pathways in the brain. Nicotine can enhance the rewarding effects of other substances (e.g. marijuana and opioids), balance out the negative effects (e.g. alcohol), or lessen the withdrawal symptoms of other substances (e.g. opioids). There is also a conditioned behavioral component to co-use; nicotine and other substance are often used at the same time, in the same situations, or around the same people. Given the biological and behavioral underpinnings of tobacco use with alcohol and other drugs, continued tobacco use may be a trigger for other substance use and increase risk of alcohol- and drug-use relapse.10

How does tobacco dependence impact a person’s mental health?

While many people report smoking to ease feelings of stress, anxiety, or depression, research has shown that smoking exacerbates mental health symptoms. People who smoke have greater depressive symptoms, greater likelihood of psychiatric hospitalization, and increased suicidal behavior.11  Many continue to use tobacco only to manage the withdrawal symptoms (anxiety, depression, agitation, sleep disturbance) that develop when nicotine levels in the brain fall.

Additionally, smoke from tobacco products interacts with many psychotropic medications, reducing their effectiveness, and often requiring clients to be on higher doses.12 As a result, clients may have higher treatment-related side effects, which can affect treatment adherence and overall quality of life.

How does quitting tobacco impact a person’s recovery?

Tobacco cessation enhances treatment and recovery goals. Co-treatment of nicotine with other SUD is associated with a 25% greater likelihood of long-term abstinence from all substances.5 Research has also shown that individuals with a history of SUD who continue to or start to smoke while in recovery were more likely to relapse than those who did not smoke.13

How does quitting tobacco impact a person’s mental health?

During recovery from tobacco, people experience lower levels of anxiety, depression, and stress.11,14

Changes in symptoms from tobacco recovery one-year out:6

Changes In Symptoms

Estimated effect of tobacco recovery one-year out:14

Outcome Effect Estimate (95%CI)
Anxiety -0.37 (-0.70 to -0.03)
Depression -0.29 (-0.42 to -0.15)
Mixed anxiety and depression -0.36 (-0.58 to -0.14)
Psychological quality of life 0.17 (-0.02 to 0.35)
Positive affect 0.68 (0.24 to 1.12)
Stress -0.23 (-0.39 to -0.07)

 

How does treating tobacco dependence impact our agency?

Developing TUD treatment requires commitment and effort to gain leadership support, get buy-in from staff, develop new procedures, and train the behavioral health team. This initial investment is justified by the many positive outcomes that result from treating TUD. They include:

  • Addiction treatment outcomes improve
  • Risk for client relapse is reduced5
  • Client’s physical and mental health improve5,15
  • Clinician skills to address all addictions improve by treating tobacco dependence
  • Client satisfaction improves
  • Agencies will achieve satisfaction from effectively treating the deadliest of addictions
  • Agencies will become community sources for comprehensive addiction treatment

Build a Foundation to Treat Tobacco Use Disorder

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Who should be involved in the process of integrating tobacco dependence treatment?

Involve clinical, non-clinical, and leadership stakeholders to ensure a successful tobacco treatment integration process. Engaging with and securing support from administrative and clinical leadership will enable the necessary integration steps to be prioritized.

Establish a tobacco dependence treatment integration team that includes clinicians/providers, peer support specialists, clinical leadership, as well as non-clinical staff such as information technology, billing, marketing and promotion, and quality improvement. This team should have the expertise to: build additional support; establish tobacco dependence treatment integration goals; review current and develop new tobacco dependence treatment protocols and policies; and evaluate progress. The diverse perspectives and feedback from these stakeholders will help guide the development of and buy-in for a tobacco dependence treatment policy and practice, and decisions about staff roles and workflow.

Identify a clinician champion who is passionate about helping staff and clients treat their tobacco use. The champion will serve on your tobacco dependence treatment integration team and provide leadership for recommending and implementing system changes to integrate tobacco dependence treatment. If necessary, provide this champion with additional training about how to address TUD.

How do we assess our current efforts and resources on treating tobacco dependence?

Before developing a tobacco dependence treatment integration plan, it is important to recognize strengths, potential barriers, and areas to increase capacity. Complete the Tobacco Treatment Integration Agency Assessment TOOL to identify opportunities for tobacco treatment integration at your agency.

Do you have sample tobacco dependence treatment policies?

  • SAMPLE: TOBACCO TREATMENT POLICY
  • SAMPLE: TOBACCO TREATMENT AGREEMENT

How do we create a supportive environment for successful tobacco dependence treatment?

Implementing and strengthening a hospital or clinic-wide tobacco-free policy is an important step in creating an environment that supports the health and recovery of clients, staff, and visitors. Tobacco acts as a cue for other substance use and maintains drug-related coping mechanisms. A tobacco-free policy expands the long-standing established SUD treatment standard of “alcohol and drug-free” treatment environments. It also sends a message that you prioritize TUD treatment and recognize the impact tobacco use has on physical and mental health and recovery from other substances.

Train Staff

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How do we train staff to treat tobacco dependence?

Behavioral health clinicians already have many of the skills, competencies, and knowledge required to treat tobacco. Specifically, clinicians who treat SUD have core competency standards in their certification process that are equally applicable for evidence-based TUD treatment, such as the use of pharmacotherapy, motivational interventions, and tailored stage-appropriate interventions. Additional training focused on TUD will increase clinician buy-in, confidence, and comfort. Provide sufficient staff training on evidence-based best practices as well as the benefits of tobacco recovery to health and wellness. Trainings can increase knowledge, shift beliefs on tobacco use, and have been shown to increase confidence and rates of interventions with clients.15

Training Opportunities:

Training Description Format
Bucket Approach Training Skills and competency training to provide evidence-based tobacco treatment tailored to people who use tobacco who are also coping with mental illness and/or other addictions Online
Contact your Regional Outreach Specialist

 

Free, tailored training and technical assistance based on agency needs and experience In-person or virtual
An Updated Review of Tobacco Treatments Understand tobacco dependence as a chronic disease and learn how to initiate evidence-based clinical interventions using a brief intervention model Online
Training for Systems Change: Addressing Tobacco in Behavioral Health

 

Learn how to successfully address tobacco in your clinical setting; and to develop a plan and policy to integrate evidence-based tobacco treatment Online
Certified Tobacco Treatment Specialist Training Learn effective evidence-based clinical interventions for the treatment of tobacco dependence and become certified in the treatment of tobacco dependence (CTTS Certification) Virtual, in-person, blended

 

What is the most effective way to treat tobacco dependence?

Tobacco cessation and recovery is difficult, and most people benefit from assistance. The United States Clinical Practice Guideline: Treating Tobacco Use and Dependence18 shows that the most effective way to treat tobacco use is to combine skills-based counseling with an FDA-approved tobacco cessation medication. The combination of counseling and medication is more effective than either alone and can increase odds of abstinence by 40% compared to medication alone.18 This is because, like other substance use disorder treatment, it targets both the physical and psychological aspects of nicotine addiction. If a client declines or it is not feasible to do both, provide counseling or medication as a stand-alone intervention.18

Effectiveness of Tobacco Dependence Treatments:17

Treatment Estimated Abstinence Rate
No treatment 4-7%
Self-help 11-14%
Individual Counseling 15-19%
Group Counseling 12-16%
Quitline counseling 11-14%
Medication Alone 23%
Medication and Quitline Counseling 25-32%

How do we talk to clients about quitting tobacco?

A brief intervention can be used to promote and enhance motivation for changing tobacco use. It is recommended that clinicians provide motivational interviewing (MI) counseling strategies to explore a client’s feelings, beliefs, ideas, and values regarding tobacco use. Doing so helps to understand factors that might help motivate change. MI strategies also promote change talk, which can increase motivation to make a quit attempt.15

Principles of Motivational Interventions17

Principle Description Example Language
Express empathy
  • Use open-ended questions
  • Use reflective listening
  • Normalize feelings and concerns
  • “What might happen if you no longer used tobacco?”
  • “So you think smoking helps you maintain your recovery from alcohol.”
  • “Many people worry about managing without cigarettes.”
Develop discrepancy
  • Highlight discrepancy between behaviors and expressed goals and priorities
  • Reinforce “change talk”
  • Build and deepen commitment to change
  • “It sounds like you are very committed to your alcohol recovery. How do you think your tobacco use is linked to your recovery?”
  • “It’s great that you have been looking into changing your tobacco use with the new tobacco-free environment policy.”
  • “There are effective treatments that will ease the uncomfortable feelings that come with recovery, including counseling and medications.”
Roll with resistance
  • Back off and use reflection when client demonstrates resistance
  • Ask permission to provide information
  • “It sounds like you are feeling pressured about your smoking.”
  • “Would you like to hear about some strategies that can help you address your concern of __?”
Support self-efficacy
  • Identify and build on past successes
  • Offer options for achievable steps towards change
  • “Last time you went three days without smoking. How did you do it then?”
  • “Would you be interested in learning about options to cut back on the number of cigarettes? This could be a good way to start gaining some control over smoking.”

How do we motivate clients to quit?

Like all the addictions, clients may be ambivalent towards changing their tobacco use. Often clients need increased motivation to change. Fortunately, the same approaches clinicians take to motivate clients with other addictions apply to motivating clients on their tobacco use. It is often important to build client buy-in on the importance of tobacco recovery. This can be done by linking tobacco use to their other addictions.

Motivational interventions can effectively prepare clients to move towards changing their tobacco use. Determining a client’s readiness for change can guide you to provide appropriate motivational interventions and treatment. Research shows most people who use tobacco are interested in reducing or stopping completely and can be engaged in discussion.

Some clients are ready for change but need motivation to sustain their progress. Congratulate small successes and encourage clients to quit completely because of the health risks that remain even at reduced levels of smoking.

Some clients will be interested in making a change but feel unprepared to do so. The clinician’s responsibility here is reduce their ambivalence and strengthen their motivation. Clients may feel prepared to make small changes to practice problem-solving and coping skills and learn to gain control over their tobacco use. To build skills and confidence clients could:

  • Reduce the number of cigarettes smoked per week
  • Delay time to the first cigarette of the day
  • Make a practice quit attempt for a set amount of time
  • Limit smoking in certain places (e.g. car)
  • Replace cigarettes with NRT throughout the day as part of a reduction plan and become comfortable with using a medication

Other clients will be open to discussing their smoking. Help clients explore their beliefs about smoking and quitting, build change talk, and resolve ambivalence. Through open-ended questions, you can help your client recognize the discrepancy between their smoking and things that are important to them, as well as addressing their concerns about quitting. The Clinical Practice Guideline: Treating Tobacco Use and Dependence17 recommends use of the 5R Model to motivate people who use tobacco.

The 5 R Model for Motivating Clients to Quit Using Tobacco

The 5Rs Pie Chart

Due to the chronic and relapsing nature of TUD and the fluctuations of motivations, repeated interventions are recommended. Engage clients in regular conversation about their tobacco use to strengthen skills and motivation over time.

What are the 7 Food and Drug Administration (FDA)-approved medications to treat tobacco?

Tobacco cessation medications effectively reduce the withdrawal symptoms (e.g. irritability, anger, anxiety) that many people experience when they stop using tobacco products. Using a medication can lessen the strength and frequency of urges and cravings. Notably, while these medications reduce cravings and urges, they rarely eliminate them. Tobacco users also benefit from learning coping skills and receiving support.

There are 7-FDA approved medications that significantly increase rates of recovery from tobacco dependence. All medications have been shown to be safe and effective at treating tobacco use in individuals with behavioral health conditions.

FDA-approved Tobacco Cessation Medications
Nicotine Replacement Therapy Non-Nicotine Medications

There is a lack of research on the effectiveness and safety of the tobacco dependence medications for the following populations – pregnant persons, adolescents, smokeless tobacco users, and light smokers (fewer than 10 cigarettes/day).18 Review the medication chart linked below for dosing instructions, side effects, precautions, and contraindications for each medication.

My client says tobacco cessation medications don’t work. Are there ways to enhance effectiveness of medications?

When used as directed, tobacco cessation medications can reduce most or all significant cravings. However, some clients, particularly those with a high level of nicotine dependence, may need additional support. There are various strategies that can increase medication effectiveness to review with a client.

Concurrent Skills-Based Counseling – Tobacco dependence treatment needs to address the physiological and behavioral aspects of dependence to improve clients’ chances of being successful. Behavioral therapies help clients develop and strengthen problem-solving and coping skills, increase confidence, and enhance relapse prevention techniques. Medication lessens withdrawal symptoms, so clients can better focus on behavior change. Research shows the combination of counseling and medication is more effective than either alone.

Medication Adherence – Tobacco cessation medications, particularly NRT, are often under-dosed. Confirm client adherence to medication; make sure clients are taking the proper dose, as directed, and for the full duration. Medication side effects, such as nausea or insomnia, can also make adherence difficult. There are ways to lessen some side effects, such as removing the nicotine patch at night or taking medication with a full meal.

Combining Medications – Clients with a high level of nicotine dependence can benefit from combination pharmacotherapy treatment, using two tobacco cessation medications concurrently to provide a higher dose of medication. Studies have shown that combination treatments may provide an increase in long-term recovery.

There are several options for combination treatments. Typically, the nicotine patch is used to provide a steady dose of nicotine throughout the day is paired with an oral product (nicotine gum or nicotine lozenge), which can more effectively relieve breakthrough cravings. Other options shown to be safe and effective include:

  • Patch + patch
  • Patch + oral product
  • Oral product + oral product
  • NRT and bupropion/varenicline

Pre-cessation Use – Starting medications before cessation can increase chances of a successful quit attempt. Studies show the use of the nicotine patch 2-3 weeks before quitting increases the odds of quitting by about 25%. Research supports the use of NRT pre-quit when paired with a smoking reduction plan for clients willing to reduce their smoking. The aim is to reduce the number of cigarettes smoked per day by replacing some cigarettes with NRT. It is recommended that NRT be initiated while a client is still smoking to help them cut back on their level of smoking and increase their self-efficacy. Importantly, the FDA has determined NRT is safe to use while smoking.

Extended Use of Medications – Clients with a high level of nicotine dependence can benefit from a longer duration of treatment, beyond the typical 12 weeks, to prevent relapse and maintain abstinence.19,20

Are tobacco cessation medications safe for people with a behavioral health condition?

The 7 FDA-approved tobacco cessation medications for treating tobacco dependence are safe and effective for people with behavioral health conditions. In the largest smoking cessation study to date, researchers compared the effectiveness and safety of all 7 FDA-approved medications and found no significant increase in neuropsychiatric adverse events attributed to varenicline or bupropion compared to the nicotine patch or placebo.21 All medications were found to reliably increase the likelihood of quitting at 6 months, however, clients receiving varenicline had the greatest likelihood of abstaining from tobacco.22

As with any new medication, clients should report any changes in mood, behavior, or thinking, but these neuropsychiatric side effects were rare. The most common side effects across all treatment groups in the study were nausea, insomnia, and abnormal dreams.

How does tobacco interact with other medications clients may be using?

Chemicals in tobacco products interact with many psychotropic medications by influencing the absorption, distribution, metabolism, and potentially causing an altered pharmacologic response.12 Because of these interactions, people who use tobacco may require higher doses of certain medications and may experience more treatment-related side effects. Therefore, when quitting tobacco products, clients should be carefully monitored and medications should be adjusted as appropriate.

Tip

Medication and counseling do not need to be provided by the same clinician. For example, a health educator could provide counseling while a psychiatrist prescribes a medication. A team-based approach is both time-efficient and clinically effective.

Develop Tobacco Treatment Program

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How do we develop a tobacco dependence treatment program?

There are a variety of tobacco dependence treatment strategies that agencies can integrate into their existing services. The appropriate strategy will depend on the setting, services provided, capacity, and current culture and practices. It is recommended that agencies use as many strategies as are practical. Below are several such strategies, many of which can be combined.

Comprehensive Training and TreatmentAll clinicians address tobacco use with their own client. Clinicians can briefly address tobacco during regular visits. This option is ideal as each clinician has a relationship with their own clients and understands their skills and motivations. Addressing tobacco need not consume a large amount of any one treatment visit. Rather, interventions can be brief but spread over multiple visits thus being integrated with other clinical interventions.

Centralized Tobacco Interventionist – Utilize a certified tobacco treatment specialist (TTS), an existing employee, who receives additional intensive training on tobacco treatment. In this strategy, the responsibility need not fall solely on a tobacco treatment specialist. The referring provider, such as the primary clinician, is responsible for screening for tobacco use, assessing motivational readiness, and prescribing medication, while the tobacco treatment specialist can provide more intensive counseling and/or medication management and follow-up.

Group Program – Many substance use treatment settings use a group format as part of treatment and there may be an inclination to continue this format for tobacco.  There can be a free-standing tobacco group or addressing tobacco can be integrated into existing groups such as wellness groups. Groups can be stratified by motivational level (making a quit attempt vs. getting ready to make a quit attempt or a single group can include all motivational levels. Groups can be closed or open ended.

Refer to a treatment extender –The Wisconsin Tobacco Quit Line (WTQL) (800-QUIT-NOW) offers free 24/7 telephone- and text-based counseling and medication to Wisconsin residents. The WTQL complements services clients are already receiving in a clinical setting. While Quitlines can effectively assist individuals with tobacco recovery, they should not be relied upon exclusively to treat tobacco dependence. Instead, clinicians should approach the Quitline or other programs as treatment extenders. Following a referral, the clinician can review what was discussed during the Quitline call with the client at a subsequent session and further support the treatment plan. If necessary, incorporate updates into the clinic treatment plan for that client. Consider setting up direct fax or eReferral process at your facility for proactive Quitline calls to further increase utilization and recovery.

Refer pregnant, postpartum, and caregiving individuals to First Breath, a free, statewide program that provides a range of evidence-based tobacco treatment services. Agencies that provide direct services to pregnant and postpartum people should consider becoming a First Breath Referral Site. After completing a short, online training, the site will have the information and tools needed effectively address tobacco dependence among perinatal populations and can refer patients to First Breath. More information can be found at www.providefirstbreath.org. Pregnant and postpartum people can also refer themselves to the First Breath program at www.joinfirstbreath.org.

Utilize peer specialists – “Peer supports specialists and recovery coaches can be valuable contributors to the behavioral health system. Research has documented the benefits of including those with lived experience as support/mentors to clients with behavioral health conditions. Additionally, the literature has documented several roles for peers and coaches in tobacco dependence treatment efforts. Most serve as co-facilitators of tobacco groups, either tobacco education/awareness group or smoking cessation groups. Some served as peer mentors who met with clients by phone or in-person to reinforce group content, establish rapport, provide encouragement, help participants implement their goals, and problem solving toward reduction and cessation.”23

How do we address and treat tobacco dependence at the clinic level?

The 5As provides a foundation for systematically addressing tobacco use in all clients. It provides the framework to treat all clients who use tobacco products, with the understanding that tobacco use is both a chronic, relapsing condition and an addiction.

  • EXAMPLE: 5A’s Framework in Behavioral Health Settings (need PDF)

The components of the 5As tobacco treatment model are reflective of the Core Counseling Functions of SUD treatment providers.

Matching the 5 A’s to SUD Core Counseling Functions

Five A’s Core Counseling Function
Ask Screening/Intake/Assessment
Advise Orientation/Client Education
Assess Treatment Planning
Assist Treatment Planning/Counseling/Case Management/Referral/Consultation with Other Professionals (for prescribing medication and med management)
Arrange Referral
  • EXAMPLE: Outpatient workflow chart (need pdf)
  • EXAMPLE: Inpatient workflow chart (need pdf)

How do we develop a group program for tobacco dependence?

There are two types of tobacco dependence treatment groups: tobacco awareness groups and tobacco recovery groups,24 that address needs based on motivational readiness.

  1. Tobacco Awareness Groups provide education to increase knowledge, skills, attitudes, and motivations about tobacco. Focus on motivational interventions to understand beliefs and reduce ambivalence.
  1. Tobacco Recovery Groups provide support for people in recovery for tobacco use. These groups focus on making behavioral changes and practicing problem-solving and coping skills.

Are other behavioral health facilities in Wisconsin treating tobacco dependence?

Many substance use treatment agencies in Wisconsin address concurrent tobacco use and have integrated tobacco treatment as standard practice. According to SAMHSA NSSATS Survey in 2020, 71.9% of substance use treatment facilities in Wisconsin screened for tobacco use and 54.9% provided smoking or tobacco cessation counseling, compared to national average of 75.9% and 61.8%, respectively.25 Some form of Nicotine Replacement Therapy (NRT) was offered by 32.5% of facilities in Wisconsin and 33.9% offered non-nicotine tobacco cessation medications (i.e. varenicline or bupropion).25

Hear from other agencies in Wisconsin who have implemented tobacco treatment:

Tip

Caffeine metabolism and clearance increases in the presence of hydrocarbons from tobacco smoke.12,40 Caffeine can also worsen withdrawal symptoms. Advise clients to decrease caffeine intake when reducing tobacco use.

Implement Tobacco Dependence Treatment Interventions

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How do we assess tobacco use?

The primary goal of assessment and screening is to identify clients who use tobacco and guide clinicians in developing a treatment plan tailored to the client’s patterns of use and motivational readiness. Screen for tobacco use status upon intake and at each clinical visit thereafter as you would other chemical dependencies. Integrating tobacco use screening questions directly into the EHR or paper intake assessment is the easiest way to ensure all clients are screened consistently.

Brief tobacco dependence treatment interventions, including an assessment, can be completed in as little as three minutes. As motivational readiness can change over time, it is important to regularly assess for changes. For most visits, a tobacco assessment may consist of the following questions:

  1. Do you currently use any tobacco products?
  2. Have you ever used a tobacco products?
  3. Which of the following statements best describes your interest in quitting tobacco use at this time?
    1. I am willing to try to quit smoking/using tobacco in the near future.
    2. I am willing to cut down or reduce my smoking/tobacco use or learn how to quit someday.
    3. I am willing to talk about my smoking/tobacco use with my treatment team.
    4. I prefer not to talk about my smoking/tobacco use.

In certain cases, a more thorough assessment may be required.

What should be included in a tobacco dependence treatment plan?

The components of a comprehensive treatment plan include problem statements, goal statements, objectives, and interventions. The treatment plan is individualized to each client, developed in collaboration with clients, and should be updated to reflect changes in the client’s readiness, progress towards goals, or changes in treatment.26

Problem Statements are specific problems associated with an individual’s tobacco use. For example, “The client smokes cigarettes at home, and the secondhand smoke is negatively affecting his daughter’s health.”

Goal Statements are broad outcomes made by reframing the problem statements. For example, “The client will ensure that his daughter is not exposed to secondhand smoke at home by making his house and yard smoke-free.”

Objectives are specific and measurable actions that can be taken to reach each goal. For example, “The client will sign an agreement with his case worker to keep his home smoke-free. The case worker will follow-up about this at each visit.”

Integrated Program of Therapies and Activities (IPTA) is a list of actions the provider or agency will take to help the client complete their objectives and achieve their goals. For example, “The client will receive individual counseling once per week for 12 weeks” and “The client is prescribed Bupropion: 150mg once daily for three days, then 150mg twice a day for 12 weeks.”

 

How do we integrate tobacco dependence treatment into our electronic health record (EHR) or record-keeping system?16

Integrating the 5A tobacco dependence treatment protocol (Ask, Advise, Assess, Assist, Arrange) into the electronic health record (EHR) or client record is a systems-level change that can increase tobacco use screening and provision of treatment to clients who use tobacco. Tobacco use screening as part of the vital signs or intake assessment ensures that all patients who use tobacco are consistently identified.

How do we integrate tobacco dependence treatment into our electronic health record (EHR) or record-keeping system?

Integrating the 5A tobacco dependence treatment protocol (Ask, Advise, Assess, Assist, Arrange) into the electronic health record (EHR) or client record is a systems-level change that can increase tobacco use screening and provision of treatment to clients who use tobacco.25 Tobacco use screening as part of the vital signs or intake assessment ensures that all patients who use tobacco are consistently identified.

Build Organizational Capacity

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What resources are available for our clients to seek additional support for tobacco use disorder?

There are resources available to extend tobacco dependence treatment beyond the clinical setting that provide additional support for clients.

Resource Target Population Description and Services
Wisconsin Tobacco Quitline

 

Wisconsin residents over the age of 13 Free counseling and medication for help to quit smoking, vaping, or other tobacco use
First Breath Pregnant, postpartum, and caregiving individuals in Wisconsin A free program that provides a range of services to help people make positive changes to their tobacco, alcohol, and other substance use during pregnancy and beyond.
Live Vape Free Teens age 13 – 17; Parents, caregivers, health educators, health care providers Teen Program – An interactive, multi-media texting program for teens that provides tools and interventions to stop vaping

 

Adult Program – A self-paced, online learning program that empowers concerned adults to have meaningful, no-pressure dialogue with teens about vaping

 

 

How do we bill for tobacco use disorder treatment?

Billing for tobacco dependence treatment is an important element of tobacco treatment integration. Treatment for Tobacco Use Disorder is considered a billable service by Medicaid, Medicare, and many commercial insurance plans.

Resource Description
American Lung Associations Billing Guide Addendum for Behavioral Health

 

Reviews eligible providers, diagnosis codes and service codes

 

In Brief: What Substance Use Providers Should Know Information on Wisconsin Medicaid for Substance Use and Mental Health Providers

 

How do we sustain tobacco dependence treatment efforts long-term?

  • Create and maintain a workgroup within your agency to review the tobacco dependence treatment integration work and process regularly. Include representatives from various roles on the treatment team as part of the workgroup such as leadership, administration, clinicians, and non-clinical staff. Client representation is also highly beneficial.
  • Integrate screening process and treatment options into client charts using prompts, dot phrases, etc. to streamline workflow and documentation for staff.
  • Include a team-based approach. Train all care team members to offer a consistent message and support within their role.
  • Offer training for new staff and regular refreshers for existing staff; add policies and protocols to onboarding and orientation for new staff (training/education plans).
  • Ensure that interventions, treatment, enforcement policies, and consequences are consistent with policies that govern the use of other substances and misuse of medications.
  • Track performance measures (on clinician, clinic, program, system level) and provide feedback.

How do we support staff who use tobacco products?

  • Ensure staff have knowledge of and access to treatment services
  • Cover/offer discounted tobacco cessation benefits found to be most effective: counseling and medications, multiple counseling sessions, counseling services (including telephone, individual, and group), all 7 FDA medications
  • Consider how employee assistance programs and employee wellness programs can support staff with TUD
  • Consider the chronic nature of TUD: offer and cover the cost of a variety of treatment options and at least two courses of treatment per year (consistent with the standard of practice for other SUD’s)
  • Offer a supportive smoke-free/tobacco-free environment: alternatives while on campus property like walking trails, distractions during break time (books/magazines, puzzles, games in breakroom)

Evaluate Your Tobacco Dependence Treatment Program

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How can we ensure the tobacco dependence treatment program is implemented as it was designed?

Consider including TUD treatment measures in your quality assessment efforts. Examples include chart audits, EMR extracts, clinician interviews or client surveys. Key TUD treatment indicators include:

  • Was smoking status noted for every client?
  • Did the treatment plan list tobacco cessation as a goal for every current tobacco user?
  • Was motivation to quit assessed and documented for every current tobacco user?
  • Did the treatment plan include a tobacco cessation plan consistent with the motivational status of the tobacco user (quit plan, counseling based on client motivation, cessation medications)?
  • Was every client who quit tobacco assessed for risk for relapse and was appropriate interventions (relapse prevention) provided?

Consider asking clients themselves about their satisfaction about how their tobacco use was addressed.

How do we know the tobacco dependence treatment we provide is effective?

The desired outcomes from tobacco dependence treatment are either expressed as the number of clients who quit in a given period of time or a falling rate of tobacco use among all clients. But there are many intermediary outcomes that can be used to track progress. These include:

  • What percent of your tobacco users have made a quit attempt?
  • Are clients smoking less? How much less?
  • Not all quit attempts succeed. How many smoke-free days occurred even within failed attempts?
  • What percent of tobacco users who were not willing to even talk about their tobacco use are now willing to do so?
  • What percent of tobacco users who were willing to only talk about tobacco are beginning to prepare to quit or have agreed to learn about how to quit? (Reduce, cessation medications, have a practice quit attempt, etc.)
  • What percent of tobacco users who were willing to prepare to quit but not ready to try have now made a quit plan and are trying to quit?

Client satisfaction with treatment is always a key outcome. Consider asking clients about their satisfaction with how their tobacco use was addressed.

A widely used, very brief instrument (three questions) to measure the therapeutic bond between client and therapist (Working Alliance Inventory)27–29 has now been validated to measure clients’ perceptions of their therapists efforts to address tobacco use.30

  • LINK: Working Alliance Inventory (confirming link with Bruce)

Treat E-cigarette Use

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What should we know about e-cigarettes/vaping?

What are e-cigarettes?

E-cigarettes come in a variety of shapes and sizes, can be rechargeable or disposable, and have many different names (e-cigs, mods, vapes, vape pens, and electronic nicotine delivery systems (ENDS)). They heat a liquid to produce an aerosol that the user inhales into their lungs. Most e-cigarettes contain nicotine and are thus considered to be tobacco products. E-cigarettes can also be used to vape cannabis derived compounds, such as tetrahydrocannabinol (THC) or cannabidiol (CBD), and other drugs.31

Vape samples
Image source: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/about-e-cigarettes.html#what-are-e-cigarettes

Prevalence of e-cigarette use among adults with behavioral health conditions

Studies show the prevalence of ever using an e-cigarette among individuals in substance use disorder treatment is between 50-75%.32–34 Individuals with mental health conditions are twice as likely to be currently using an e-cigarette compared to those without mental health conditions.35 The primary reasons individuals in substance use disorder treatment are trying e-cigarettes is to quit or reduce their smoking, and because they perceive vaping to be less harmful and less addictive than smoking.32–34,36

Do e-cigarettes help people to quit smoking?

E-cigarettes are still a relatively new tobacco product, and the landscape of products continues to change, making it difficult to generalize the efficacy of an e-cigarette to help people quit smoking. The FDA has not approved e-cigarettes as a smoking cessation aid.15

Are e-cigarettes safer than cigarettes?

E-cigarettes are widely believed to be safer than use of combustible tobacco (smoking cigarettes).

But safer does not mean safe or risk free. The long-term health effects of vaping exclusively are not well understood. While e-cigarette aerosol contains fewer harmful chemicals than combustible cigarettes, there are still cancer-causing chemicals and ultrafine particles in the aerosol that cause risks to health.15 Most e-cigarette products contain nicotine, which may perpetuate dependence on nicotine and enhance the reinforcing effects of substance of abuse.32,33

A concerning trend is the dual use of e-cigarettes and combustible cigarettes. For example, using, e-cigarettes only when smoking is prohibited.36 Current research on the risks to health of dual use show the higher exposure to chemicals from both products increases risks to lung and heart health.37

What advice can be given to people who want to use e-cigarettes to quit smoking?

Given the high lethality of cigarettes, the unknown long-term health effects of e-cigarettes, and the danger that nicotine dependence poses to alcohol and other drug relapse, the goal for all clients should be to completely stop using all nicotine-containing products. Clients should be encouraged to use the seven-FDA approved medications and counseling strategies that have proven effectiveness and safety. If clients insist on trying e-cigarettes to quit smoking, inform clients that e-cigarette use can only help improve their health if it helps them reduce and eventually stop smoking entirely. Dual use should be discouraged. The goal remains the eventual cessation all forms of nicotine, including e-cigarettes.

Are there special considerations for treating tobacco use in pregnant clients?

Using tobacco during pregnancy is a major risk factor for preterm birth and low birth weight, increasing the risk for serious health problems and infant death. As recommended by the American College of Obstetricians and Gynecologists, pregnant women who use tobacco products should be offered individualized care that may include psychosocial, behavioral, and pharmacotherapy interventions.38,39 Use of nicotine replacement therapy should be considered only after a detailed discussion with the client of the known risks of continued tobacco use, the possible risks of nicotine replacement therapy, and the need for close monitoring. If nicotine replacement therapy is used, it should be with the clear goal of quitting smoking.

Additional Resources

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Additional Training on Treating Tobacco Use and Dependence

Training Description Format Continuing Education Credits
Bucket Approach Training Skills and competency training to provide evidence-based tobacco treatment tailored to individuals who use tobacco and are coping with mental illness and/or other addictions Online 8.25 free CE/CME credits
Contact your Regional Outreach Specialist Free, tailored training and technical assistance based on agency needs and experience In-person or virtual N/A
An Updated Review of Tobacco Treatments Understand tobacco dependence as a chronic disease and learn how to initiate evidence-based clinical interventions using a brief intervention model Online 1 CE/CME credit
Training for Systems Change: Addressing Tobacco in Behavioral Health

 

Learn how to successfully address tobacco in your clinical setting; and to develop a plan and policy to integrate evidence-based tobacco treatment Online 3.50 free CE/CME credits

 

Certified Tobacco Treatment Specialist Training Learn effective evidence-based clinical interventions for the treatment of tobacco dependence and become certified in the treatment of tobacco dependence (CTTS Certification) Virtual, in-person, blended Varies

Additional Clinician Resources

Resource Description
Toolkits
ASAM – Integrating Tobacco Use Disorder Interventions in Addiction Treatment American Society of Addiction Medicine’s guide for addiction treatment clinicians and programs to integrate tobacco use disorder interventions
Million Hearts Tobacco Cessation Change Package

 

Suite of evidence-based process improvements and resources to effectively implement tobacco cessation interventions
Smoking Cessation Leadership Center: Tobacco Free Toolkit for Behavioral Health Agencies

 

 

SAMHSA: Implementing Tobacco Cessation Programs in Substance Use Disorder Treatment Settings: A quick guide overviewing challenges and benefits of tobacco cessation and implementing smokefree policy, as well as tips substance use disorder treatment facilities can use to implement tobacco cessation programs
American Lung Association: Toolkit to Address Tobacco in Behavioral Health

 

Toolkit and materials for mental health and substance use treatment professionals, including direct providers, administrators, and behavioral health organizations
American Lung Association: Integrating Tobacco Use Dependency Treatment in Behavioral Health Settings | American Lung Association

 

Collection of tools and resources for State Tobacco Control Program staff and other health professionals, including a quick reference guide and webcast recordings.
USPSTF: Tobacco Smoking Cessation in Adults, Interventions

 

Implementing Tobacco Cessation Programs in Substance Use Disorder Treatment Settings

 

Treating Tobacco in Behavioral Health Resources
Smoking Cessation Leadership Center
National Council for Mental Wellbeing

 

Membership organization that drives policy and social change for mental health treatment organizations and clients, offering consulting, programs, and resources
National Behavioral Health Network Resource hub for organizations, health care providers, and public health professionals seeking to address tobacco use disparities among individuals with mental illnesses and addictions
UW-Center for Tobacco Research and Intervention Source for tobacco treatment training for Wisconsin clinicians, based on the latest peer-reviewed research. Online CME-CE training, materials, factsheets, webinars, videos, and research.
General Tobacco Treatment Resources
Wisconsin DHS Tobacco Prevention and Control Program Resources to help people quit and information about Wisconsin programs to help tobacco users across the state
Smoking Cessation: A Report of the Surgeon General – Chapter 6: Interventions for Smoking Cessation and Treatments for Nicotine Dependence

 

Additional Client Resources

Resource Description
Wisconsin Tobacco Quit Line Free counseling and medication for help to quit smoking, vaping, or other tobacco use.
First Breath A free program that provides a range of services to help people make positive changes to their tobacco, alcohol, and other substance use during pregnancy and beyond.
American Indian Program American Indian program offers free medications and culturally tailored support to quit commercial tobacco. Connect with a dedicated quit coach to get back to a healthy, sacred relationship with tobacco.
Smokefree.gov Free resources, tools and tips for various populations: 60+, teens, women, veterans, support people, etc.
BecomeAnEx.org Free online community for quitters. Run by Mayo Clinic Nicotine Dependence Center. Offers expert guidance and interactive tools.  Tips, advice, texts and emails.
UW-CTRI patient resources List of self-help resources on UW-CTRI website

References

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Click here to see references

  1. Lasser K, Boyd JW, Woolhandler S, Himmelstein DU, McCormick D, Bor DH. Smoking and mental illness: A population-based prevalence study. JAMA. 2000;284(20):2606-2610. doi:10.1001/JAMA.284.20.2606
  2. National Council for Mental Wellbeing. Tobacco. Accessed April 30, 2022. https://www.thenationalcouncil.org/our-work/focus-areas/public-health/tobacco/
  3. Tam J, Warner KE, Meza R. Smoking and the Reduced Life Expectancy of Individuals With Serious Mental Illness. American Journal of Preventive Medicine. 2016;51(6):958-966. doi:10.1016/J.AMEPRE.2016.06.007
  4. Xu J, Murphy SL, Kochanek KD, Bastian B, Arias E. National Vital Statistics Reports Volume 67, Number 5 July 26, 2018, Deaths: Final Data for 2016. National Vital Statistics Reports. 2018;67. Accessed April 30, 2022. https://www.cdc.gov/
  5. Prochaska JJ, Delucchi K, Hall SM. A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery. Journal of Consulting and Clinical Psychology. 2004;72(6):1144-1156. doi:10.1037/0022-006X.72.6.1144
  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. BMJ. 2014;348:g1151-g1151. doi:10.1136/bmj.g1151
  7. Cavazos-Rehg PA, Breslau N, Hatsukami D, et al. Smoking cessation is associated with lower rates of mood/anxiety and alcohol use disorders. Psychological Medicine. 2014;44(12):2523-2535. doi:10.1017/S0033291713003206
  8. Babb S, Malarcher A, Schauer G, Asman K, Jamal A. Quitting Smoking Among Adults — United States, 2000–2015. MMWR Morbidity and Mortality Weekly Report. 2019;65(52):1457-1464. doi:10.15585/MMWR.MM6552A1
  9. Substance Abuse and Mental Health Services Administration. National Survey of Substance Abuse Treatment Services (N-SSATS): 2020 Data on Substance Abuse Treatment Facilities.; 2021. Accessed April 30, 2022. https://www.samhsa.gov/data/sites/default/files/reports/rpt35313/2020_NSSATS_FINAL.pdf
  10. Compton W. The need to incorporate smoking cessation into behavioral health treatment. The American Journal on Addictions. 2018;27(1):42-43. doi:10.1111/AJAD.12670
  11. Prochaska JJ, Das S, Young-Wolff KC. Smoking, Mental Illness, and Public Health. https://doi.org/101146/annurev-publhealth-031816-044618. 2017;38:165-185. doi:10.1146/ANNUREV-PUBLHEALTH-031816-044618
  12. Zevin S, Benowitz NL. Drug Interactions with Tobacco Smoking. Clinical Pharmacokinetics. 1999;36(6):425-438. doi:10.2165/00003088-199936060-00004
  13. Weinberger AH, Platt J, Esan H, Galea S, Erlich D, Goodwin RD. Cigarette Smoking Is Associated With Increased Risk of Substance Use Disorder Relapse: A Nationally Representative, Prospective Longitudinal Investigation. The Journal of Clinical Psychiatry. 2017;78(2):19746. doi:10.4088/JCP.15M10062
  14. U.S. Department of Health and Human Services. Smoking Cessation: A Report of the Surgeon General.; 2020. Accessed March 17, 2022. https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdf
  15. Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. U.S. Department of Health and Human Services. Public Health Service; 2008. Accessed March 31, 2022. https://www.ncbi.nlm.nih.gov/books/NBK63952/
  16. Treating Tobacco Use and Dependence: 2008 Update – NCBI Bookshelf. Accessed March 12, 2022. https://www.ncbi.nlm.nih.gov/books/NBK63952/
  17. Baker TB, Piper ME, Smith SS, Bolt DM, Stein JH, Fiore MC. Effects of Combined Varenicline With Nicotine Patch and of Extended Treatment Duration on Smoking Cessation. JAMA. 2021;326(15):1485. doi:10.1001/jama.2021.15333
  18. Schnoll RA, Goelz PM, Veluz-Wilkins A, et al. Long-term Nicotine Replacement Therapy. JAMA Internal Medicine. 2015;175(4):504. doi:10.1001/jamainternmed.2014.8313
  19. Anthenelli RM, Benowitz NL, West R, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. The Lancet. 2016;387(10037):2507-2520. doi:10.1016/S0140-6736(16)30272-0
  20. Anthenelli RM, Benowitz NL, West R, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. The Lancet. 2016;387(10037):2507-2520. doi:10.1016/S0140-6736(16)30272-0
  21. Christiansen B, Mason M, Wolfe G. Roles for Certified Peer Specialists to Support Peers as they Address their Smoking. Published online 2020.
  22. The Tobacco Interventions Project – New York State Department of Health Tobacco Control Program. Clinician Tools. Tobacco Recovery Resource Exchange.
  23. SAMHSA, CBHSQ. National Survey of Substance Abuse Treatment Services (N-SSATS): 2020 Data on Substance Abuse Treatment Facilities ii. Accessed March 14, 2022. https://www.samhsa.gov/data/.
  24. Tobacco Recovery Resource Exchange. Developing Tobacco Treatment Plans.; 2009.
  25. Brenna VanFrank M, Kaitlin Graff M, Gillian Schauer P, et al. Million Hearts Tobacco Cessation Change Package. Accessed April 30, 2022. https://millionhearts.hhs.gov/files/tobacco_cessation_change_pkg.pdf
  26. Hatcher RL, Gillaspy JA. Development and validation of a revised short version of the working alliance inventory. Psychotherapy Research. 2006;16(1):12-25. doi:10.1080/10503300500352500
  27. Horvath AO, del Re AC, Flückiger C, Symonds D. Alliance in individual psychotherapy. Psychotherapy. 2011;48(1):9-16. doi:10.1037/a0022186
  28. Horvath AO, Greenberg LS. Development and validation of the Working Alliance Inventory. Journal of Counseling Psychology. 1989;36(2):223-233. doi:10.1037/0022-0167.36.2.223
  29. Christiansen B, Smith SS, Fiore MC. Measuring Therapeutic Alliance for Tobacco Cessation Counseling for Behavioral Health Clinicians. Journal of Smoking Cessation. Published online 2021. doi:10.1155/2021/6671899
  30. US Department of Health and Human Services. E-Cigarette Use among Youth and Young Adults: A Report of the Surgeon General.; 2016. Accessed May 5, 2022. https://e-cigarettes.surgeongeneral.gov/documents/2016_SGR_Full_Report_non-508.pdf
  31. Peters EN, Harrell PT, Hendricks PS, O’grady KE, Pickworth WB, Vocci FJ. Electronic cigarettes in adults in outpatient substance use treatment: Awareness, perceptions, use, and reasons for use. The American Journal on Addictions. 2015;24(3):233-239. doi:10.1111/AJAD.12206
  32. Stein MD, Caviness CM, Grimone K, Audet D, Borges A, Anderson BJ. E-cigarette knowledge, attitudes, and use in opioid dependent smokers. Journal of Substance Abuse Treatment. Published online May 2015:73-77. doi:10.1016/j.jsat.2014.11.002
  33. Gubner NR, Blakely Andrews K, Mohammad-Zadeh A, Lisha NE, Guydish J. Electronic-cigarette use by individuals in treatment for substance abuse: A survey of 24 treatment centers in the United States. Addict Behav. 2016;63:45-50. doi:10.1016/j.addbeh.2016.06.025
  34. Cummins SE, Zhu SH, Tedeschi GJ, Gamst AC, Myers MG, Cummins S. Use of e-cigarettes by individuals with mental health conditions. Tob Control. Published online 2014:48-53. doi:10.1136/tobaccocontrol-2013-051511
  35. El-Shahawy O, Schatz D, Sherman S, Shelley D, Lee JD, Tofighi B. E-cigarette use and beliefs among adult smokers with substance use disorders. Addictive Behaviors Reports. 2021;13:100329. doi:10.1016/j.abrep.2020.100329
  36. Wang JB, Olgin JE, Nah G, et al. Cigarette and e-cigarette dual use and risk of cardiopulmonary symptoms in the Health eHeart Study. PLoS ONE. 2018;13(7). doi:10.1371/journal.pone.0198681
  37. Tobacco and Nicotine Cessation During Pregnancy. Obstetrics & Gynecology. 2020;135(5):e221-e229. doi:10.1097/AOG.0000000000003822
  38. Patnode CD, Henderson JT, Coppola EL, Melnikow J, Durbin S, Thomas RG. Interventions for Tobacco Cessation in Adults, Including Pregnant Persons. JAMA. 2021;325(3):280. doi:10.1001/jama.2020.23541
  39. Vistisen K, Loft S, Poulsen HE. Cytochrome P450 IA2 Activity in Man Measured by Caffeine Metabolism: Effect of Smoking, Broccoli and Exercise. In: ; 1991:407-411. doi:10.1007/978-1-4684-5877-0_55

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