WHOLE HEALTH: CHANGE THE CONVERSATION

Advancing Skills in the Delivery of Personalized, Proactive, Patient-Driven Care

This document has been written for clinicians. The content was developed by the Integrative Medicine

Program, Department of Family Medicine, University of Wisconsin-Madison School of Medicine and Public

Health in cooperation with Pacific Institute for Research and Evaluation, under contract to the Office of

Patient Centered Care and Cultural Transformation, Veterans Health Administration.

Information is organized according to the diagram above, the Components of Proactive Health and Well-Being.

While conventional treatments may be covered to some degree, the focus is on other areas of Whole Health

that are less likely to be covered elsewhere and may be less familiar to most readers. There is no intention to

dismiss what conventional care has to offer. Rather, you are encouraged to learn more about other

approaches and how they may be used to complement conventional care. The ultimate decision to use a

given approach should be based on many factors, including patient preferences, clinician comfort level,

efficacy data, safety, and accessibility. No one approach is right for everyone; personalizing care is of

fundamental importance.

Tobacco Use Disorders Clinical Tool

VHA Office of Patient Centered Care and Cultural Transformation Page 1 of 12

WHOLE HEALTH: CHANGE THE CONVERSATION Tobacco Use Disorders

Clinical Tool

Introduction

Negative health consequences of tobacco use disorders (TUDs) are one of the greatest public problems, with more than 20 million Americans having died as a result of TUDs in the past 50 years.1 Globally, tobacco use is the leading cause of preventable death2 and multiple serious health conditions, including smoking-related cancers, cardiovascular and pulmonary diseases, worsened pregnancy and birth outcomes, and residential fires; exposure to secondhand smoke can also lead to harm.2 It is estimated that TUDs have claimed over 10 times more Americans’ lives than the wars fought by the United States.1

Because TUDs are prevalent in the military personnel and Veterans, smoking can be viewed as a part of military culture. Tobacco use is not “compatible” with military life as it can have adverse effects on fitness level, deployment readiness and safety, and health care costs, and tobacco abstinence has been required in recruits during initial basic military training.3 The Veteran’s Health Administration has implemented a number of interventions to aid treatment of TUDs, including increased access to TUD-specific pharmacotherapy and the development of clinical practice guidelines.4,5

Empirically Supported Brief Interventions for Tobacco Use Disorders

There is strong evidence for Screening and Brief Intervention (SBI) as an effective tool to address tobacco use. Tobacco SBIs are recommended by the U.S. Preventive Services Task Force (USPSTF) and the U.S. Department of Veterans Affairs as a routine component of primary care for adults and pregnant women and for dental care. It also is relevant to other clinicians such as mental health providers and pharmacists.5,6 The National Institute on Drug Abuse provides a Resource Guide for the SBI services for tobacco, alcohol, and drug misuse.7 (See the Resources section below).

SBI approaches are often based on Motivational Interviewing, which has been shown to be effective for smoking cessation, especially when delivered by primary care physicians or counselors. Even a very brief, single SBI session can be beneficial. For best effects, clinicians should schedule follow-up visits and reassess the patient’s progress with smoking cessation efforts. The SBIs often include strategies such as the “5 A’s” (Ask, Assess, Advise, Assist, Arrange)8,9 and the FRAMES (Feedback, Responsibility, Advice, Menu of Strategies, Empathy, Self-Efficacy)10,11 methods. The “5 A’s” method is recommended as a counseling strategy.5,12 For those unwilling to quit, Motivational Interviewing strategies (e.g., express empathy, develop discrepancy, roll with resistance, and support self-efficacy) are recommended along with the “5 R’s” approach (Relevance, Risks, Rewards, Roadblocks, Repetition).5,13 Although smoking cessation is the recommended target, a reduction in the use of tobacco can also decrease harm (“harm reduction” approach). The Resources section outlines additional strategies for smoking cessation.

WHOLE HEALTH: CHANGE THE CONVERSATION Clinical Tool: Tobacco Use Disorders

VHA Office of Patient Centered Care and Cultural Transformation Page 2 of 12

For those interested in cessation, it is recommended that both counseling and pharmacotherapy are offered as it has been shown that the combination therapy is more effective than either intervention alone.14-16 Research supports individual, group, and telephone counseling for assisting individuals with smoking cessation, with evidence suggesting that more intensive individual and/or group interventions are more efficacious than less intense interventions or self-help.17-19 A study of Veterans found that, when combined with pharmacotherapy, intensive counseling (cognitive behavioral therapy) yielded better smoking cessation rates at 12 months than a minimal counseling intervention.20 Non-contact (distance) interventions delivered through the computer or other electronic or mobile devices can also be effective for smoking cessation,21,22 including in Veterans.23

TUDs are particularly prevalent among individuals with mental health disorders and alcohol and drug use disorders.1 Addressing co-occurring mental health conditions and other substance use disorders can increase the chance for a successful smoking cessation.24

Detailed reviews and recommendations about interventions for tobacco cessation are available in the U.S. Public Health Service Clinical Practice Guideline and from the Centers for Disease Control and Prevention’s Guide to Community Preventive Services.25,26 In addition to interventions aimed at tobacco cessation, the U.S. Preventive Services Task Force recommends (Grade B) annual screening for lung cancer with low-dose computed tomography in adults aged 55 to 80 years who have a 30 pack/year smoking history and currently smoke or have quit within the past 15 years.27 It also recommends (Grade B) a one-time screening for abdominal aortic aneurysm by ultrasonography in men aged 65 to 75 years who have ever smoked; current evidence is insufficient to extend such a recommendation to women.28

Pharmacotherapy for TUDs

Pharmacotherapy can aid in decreasing symptoms of nicotine withdrawal, reducing the rewarding aspect of smoking, and decreasing nicotine craving, thus, reducing relapse risk.29 Nicotine replacement, varenicline, and bupropion are evidence-based recommended pharmacological interventions for smoking cessation.29 Of note, electronic cigarettes (e-cigs), often marketed for smoking cessation, are not approved smoking cessation aids. E-cigarette use involves inhaling a vapor containing nicotine. Research on their efficacy for smoking cessation is very limited, and adverse effects related to e-cig use have been reported.30-32 It is not advisable for clinicians to endorse e-cig use for their patients at this time.

Nicotine-replacement therapy There are many nicotine-containing products that have been shown effective for smoking cessation.33 These products include gums, lozenges, inhalers, nasal sprays, and patches.29,34 It is often recommended to use a combined “long-acting” preparations (patches) with short-acting nicotine replacement products (for an as-needed use).29

WHOLE HEALTH: CHANGE THE CONVERSATION Clinical Tool: Tobacco Use Disorders

VHA Office of Patient Centered Care and Cultural Transformation Page 3 of 12

Non-nicotine pharmacotherapy Bupropion is an antidepressant that also reduces the symptoms of withdrawal.29 Varenicline is a partial agonist of nicotine receptors that reduces both symptoms of withdrawal and the rewarding aspect of smoking. These medications are usually prescribed a week before the chosen quit date so the medication is able to reach steady-state blood levels.29 They have been shown to increase the likelihood of smoking cessation two- to three-fold.29

Both bupropion and varenicline may have minor side effects that are often self-limited. However, they also have the potential for more severe negative effects. Bupropion can increase the risk of seizures, varenicline can exert cardiovascular adverse effects, and both medications can lead to worsened depressed mood and suicidality.29 This latter adverse effect is similar to those caused by antidepressant medications prescribed for depression.

Other Interventions

Biomedical risk assessment may sometimes be useful for motivating a patient to change and quitting smoking. Various biomedical assessments have been evaluated as interventions to aid smoking cessation (e.g., spirometry, ultrasonography of arteries, carotid plaque screening, carbon monoxide feedback). While they may provide a deeper understanding of the effects of smoking on a patient’s health, they are expensive and evidence is lacking on their efficacy for smoking cessation.35 There is also insufficient evidence on the efficacy of aversive smoking, which involves smoking in a concentrated or unpleasant way,36,37 and the use of incentives for smoking cessation. Incentives for smoking cessation appear beneficial during the period of time when they are available; only one study, which incentivized prolonged abstinence, documented increased quit rates beyond 6 months.38

Complementary and Alternative Medicine Modalities

Only preliminary research has focused on the evaluation of complementary and alternative medicine (CAM) modalities (e.g., black pepper extract,39 guided imagery,40 melatonin,41 massage,42 medicinal herb tea,43 and others44) for tobacco cessation. Limitations in methodological quality or sample size prevent drawing conclusions about their efficacy. Rigorous research is needed to assess the potential benefits of the CAM modalities. Resource Box 1 lists available evidence for the efficacy of CAM modalities that have been studied for tobacco cessation.

Note: Please see the module on Dietary Supplements for more information about how to determine whether or not a specific supplement is appropriate for a given individual. Supplements are not regulated with the same degree of oversight as medications, and it is important that clinicians keep this in mind. Products vary greatly in terms of accuracy of labeling, presence of adulterants, and the legitimacy of claims made by the manufacturer.

WHOLE HEALTH: CHANGE THE CONVERSATION Clinical Tool: Tobacco Use Disorders

VHA Office of Patient Centered Care and Cultural Transformation Page 4 of 12

Resource Box 1. Complementary and Alternative Interventions for Tobacco Use Disorders

Intervention Description Research Acupuncture Stimulation of

targeted points on the body using thin, solid metal needles that are manipulated by hand or using electrical stimulation.45

Acupuncture has been shown to be less effective than nicotine replacement therapy, and there is no evidence that acupuncture is better than wait list or psychological interventions for short- and long-term smoking cessation outcomes.46

Auriculotherapy Acupuncture localized to points on the ear, often with electrical stimulation.

There is little research on the use of auriculotherapy for TUDs. One randomized controlled trial did not find benefit of electrical auriculotherapy over the control condition for smoking cessation.47

Exercise Physical exertion can be helpful for improving general health.

The Cochrane-led systematic review found mixed results and indicated that more rigorous studies with adequate sample sizes need to be conducted.48 Two recent systematic reviews and meta-analyses found evidence that physical activity acutely reduces cigarette craving,49 regardless of the intensity of physical activity.50 A systematic review found that negative affect and tobacco withdrawal symptoms were reduced with light-to-moderate intensity exercise, but increased during high-intensity exercise.50

Hypnotherapy Hypnosis under the care of a trained clinician is used to help guide the mind to facilitate changes that may bring individuals toward their desired goals.

There is mixed preliminary evidence regarding the effectiveness of hypnotherapy for smoking cessation when compared to no treatment, advice, or psychological treatment.53 One randomized controlled trial of Veterans showed that hypnosis combined with nicotine patches compared favorably with behavioral therapy regarding long-term quit rates.54 It is recommended to use hypnotherapy cautiously in patients with psychosis/schizophrenia, delusional, bipolar, multiple personality, dissociative, and seizure disorders.44

WHOLE HEALTH: CHANGE THE CONVERSATION Clinical Tool: Tobacco Use Disorders

VHA Office of Patient Centered Care and Cultural Transformation Page 5 of 12

Mindfulness meditation

Trains the mind in nonjudgmental attention to present-moment experiences; involves becoming aware of one’s thoughts, emotions, and sensations in the present moment.

Research evidence shows that mindfulness meditation–based interventions may be beneficial in assisting with smoking cessation; however, more rigorous research is needed.56 In general, caution should be taken with any type of meditation practice (e.g., mindfulness meditation, transcendental meditation) in patients with underlying substantial mental health issues; these patients are recommended to consult with their mental health provider before beginning a meditation program.44

St. John’s wort An herb commonly used for the treatment of depression and related conditions.51

Preliminary research evidence does not support St. John’s wort efficacy for attenuating withdrawal symptoms or improving abstinence rates at a short-term follow-up.52

Transcendental meditation (TM)

Recitation of a mantra that is assigned by a certified TM teacher.

Evidence is limited for the use of TM for smoking cessation. One uncontrolled study with methodological flaws suggested potential benefit of TM as it noted that adherence to TM practice was predictive of the successful smoking cessation.55

Yoga (e.g., Hatha, Vinyasa, Ashtanga)

Engaging in various movements and postures to the rhythm of the breath; Hatha yoga is one of the most gentle yoga techniques.

Research evidence shows that yoga may be beneficial in assisting with smoking cessation; however, more rigorous research is needed.56

WHOLE HEALTH: CHANGE THE CONVERSATION Clinical Tool: Tobacco Use Disorders

VHA Office of Patient Centered Care and Cultural Transformation Page 6 of 12

Resources for More Information on Whole Health Approaches to Tobacco Use

Resource Box 2. Links and Other Resources for Clinicians

Tobacco Use Disorder Related Resources

VA-DoD guidelines

VA-DoD Clinical Practice Guidelines for the Management of Tobacco Use (2008): http://www.healthquality.va.gov/guidelines/CD/mtu/

Guides/ resources

Agency for Healthcare Research and Quality—Clinical Guidelines for Prescribing Pharmacotherapy for Smoking Cessation: http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/prescrib.html

Agency for Healthcare Research and Quality—Helping Smokers Quit: A Guide for Clinicians: http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/references/clinhlpsmkqt/clinhlpsmksqt.pdf

Agency for Healthcare Research and Quality—Patients Not Ready to Make a Quit Attempt Now (The “5 R’s”): http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/5rs.html

Agency for Healthcare Research and Quality—Treating Tobacco Use and Dependence—2008 Update: http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html

National Institute on Drug Abuse (NIDA). Resource Guide—Screening for Drug Use in General Medical Settings, Revised, March 2012: *Screening for alcohol, tobacco and substance abuse www.drugabuse.gov/publications/resource-guide

University of Pittsburgh, Smoking Cessation—Practical Skills for Healthcare Professionals Training Program, 2001, 2006—Smoking Cessation Educational Kit: http://www.nlm.nih.gov/medlineplus/smoking.html

U.S. Preventive Services Taskforce, Recommendations: http://www.uspreventiveservicestaskforce.org/uspstf/uspstbac2.htm

Education/ training

Brief Motivational Interviewing Training: http://vaww.chce.research.va.gov/apps/aft/Login.asp http://vaww.chce.research.va.gov/apps/bmiforsuv/default.htm

MIRECC Educational Products for Substance Use Disorders (including tobacco): http://www.mirecc.va.gov/apps/activities/products/keywordProductList.asp?id=20

Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment—Enhancing Motivation to Change in Substance Abuse Treatment, Treatment Improvement Protocol (TIP) Series, 35: *Chapter 2 provides information on the FRAMES approach http://store.samhsa.gov/shin/content//SMA13-4212/SMA13-4212.pdf

WHOLE HEALTH: CHANGE THE CONVERSATION Clinical Tool: Tobacco Use Disorders

VHA Office of Patient Centered Care and Cultural Transformation Page 7 of 12

Information and organizations

Centers for Disease Control and Prevention—Smoking and Tobacco Use: http://www.cdc.gov/tobacco/data_statistics/sgr/2010/consumer_booklet/index.htm

Department of Veterans Affairs Tobacco Dependence Website: https://vaww.portal.va.gov/sites/tobacco/Tobacco%20Cessation%20Clinical%20Updates%202009/Forms/AllItems.aspx

Medline Plus—Smoking: http://www.nlm.nih.gov/medlineplus/smoking.html National Center for Complementary and Alternative Medicine (NCCAM)—

Quitting Smoking: http://nccam.nih.gov/health/smoking National Clearinghouse for Alcohol and Drug Information—Tobacco:

http://store.samhsa.gov/facet/Substances/term/Tobacco National Institute on Drug Abuse (NIDA)—DrugFacts—Cigarettes and Other

Tobacco Products: http://www.drugabuse.gov/publications/drugfacts/cigarettes-other-tobacco-products

University of Wisconsin Center for Tobacco Research and Intervention: http://www.ctri.wisc.edu/Publications/Publications.Home.html

U.S. Preventive Services Task Force. Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women, 2009: http://www.uspreventiveservicestaskforce.org/uspstf/uspstbac2.htm

What to Tell Your Patients About Smoking—A Report of the Surgeon General—How Tobacco Smoke Causes Disease: http://www.cdc.gov/tobacco/data_statistics/sgr/2010/clinician_sheet/pdfs/clinician.pdf

Other Useful Resources

American Heart Association: http://www.heart.org/HEARTORG/ American Lung Association: http://www.lung.org/ National Cancer Institute: http://www.cancer.gov/ National Center for Complementary and Alternative Medicine (NCAAM)—Relaxation Techniques

for Health—An Introduction: http://nccam.nih.gov/health/stress/relaxation.htm National Emphysema Foundation: http://www.emphysemafoundation.org/ National Heart Lung and Blood Institute: http://www.nhlbi.nih.gov/ NIDA Clinical Toolbox: http://www.nidatoolbox.org/ Substance Abuse and Mental Health Services Administration: http://www.samhsa.gov/ See also the Substance Use Disorders clinical tool.

General Resources

Centers for Disease Control and Prevention: http://www.cdc.gov/ U.S. Department of Health and Human Services: http://www.surgeongeneral.gov/

WHOLE HEALTH: CHANGE THE CONVERSATION Clinical Tool: Tobacco Use Disorders

VHA Office of Patient Centered Care and Cultural Transformation Page 8 of 12

Resource Box 3. Patient Resources

After Deployment—Wellness Resources for the Military Community—Tobacco: http://afterdeployment.t2.health.mil/topics-tobacco

American Family Physician—Smoking: Do I Want to Quit: http://www.aafp.org.ezproxy.library.wisc.edu/afp/2002/1101/p1747.html

American Heart Association, (smoking cessation patient resource): http://www.heart.org/HEARTORG/GettingHealthy/QuitSmoking/Quit-Smoking_UCM_001085_SubHomePage.jsp

A Report of the Surgeon General—How Tobacco Smoke Causes Disease…What it Means to You: http://www.cdc.gov/tobacco/data_statistics/sgr/2010/consumer_booklet/index.htm

FamilyDoctor.org—Tobacco Addiction: http://familydoctor.org/familydoctor/en/diseases-conditions/tobacco-addiction/prevention.printerview.all.html

Nicotine Anonymous: https://www.nicotine-anonymous.org/

SMART Recovery: http://www.smartrecovery.org/

Smokefree.gov: http://smokefree.gov/

Smokefree (UK): http://www.nhs.uk/smokefree

This clinical tool was written by Cindy A. Burzinski, MS, LPCT, SACIT, Assistant Researcher,

and Aleksandra Zgierska, MD, PhD, Assistant Professor and integrative medicine family

physician in the Department of Family Medicine, University of Wisconsin-Madison School of

Medicine and Public Health.

References

1. U.S. Department of Health and Human Services. The Health Consequences of Smoking--50 Years of Progress, A Report of the Surgeon General, Executive Summary, 2014. http://www.surgeongeneral.gov/library/reports/50-years-of-progress/exec-summary.pdf. Accessed June 26, 2014.

2. Centers for Disease Control and Prevention (CDC). Smoking and Tobacco Use: Tobacco-Related Mortality. 2014.

Whole Health: Change the Conversation Website

Interested in learning more about Whole Health?

Browse our website for information on personal and professional care.

http://projects.hsl.wisc.edu/SERVICE/index.php

WHOLE HEALTH: CHANGE THE CONVERSATION Clinical Tool: Tobacco Use Disorders

VHA Office of Patient Centered Care and Cultural Transformation Page 9 of 12

http://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/tobacco_related_mortality/. Accessed on June 26, 2014.

3. Nelson JP, Pederson LL. Military tobacco use: A synthesis of the literature on prevalence, factors related to use, and cessation interventions. Nicotine Tob Res. May 2008;10(5):775-790.

4. Hamlett-Berry K, Davison J, Kivlahan DR, Matthews MH, Hendrickson JE, Almenoff PL. Evidence-Based National Initiatives to Address Tobacco Use as a Public Health Priority in the Veterans Health Administration. Military medicine. Jan 2009;174(1):29-34.

5. Department of Veterans Affairs, Department of Defense. VA/DoD clinical practice guideline for management of tobacco use (MTU), 2008. http://www.healthquality.va.gov/guidelines/CD/mtu/phs_2008_full.pdf. Accessed June 26, 2014.

6. US Preventive Services Task Force. Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women, 2009. http://www.uspreventiveservicestaskforce.org/uspstf/uspstbac2.htm. Accessed June 26, 2014.

7. National Institute on Drug Abuse (NIDA). Resource Guide: Screening for Drug Use in General Medical Settings. 2012. http://www.drugabuse.gov/publications/resource-guide/preface. Accessed on June 26, 2014.

8. Agency for Healthcare Research and Quality (AHRQ). Five Major Steps to Intevention (The "5 A's"), 2012. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/5steps.html. Accessed June 26, 2014.

9. Fiore MC. US public health service clinical practice guideline: treating tobacco use and dependence. Respiratory care. Oct 2000;45(10):1200-1262.

10. Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment. Enhancing Motivation to Change in Substance Abuse Treatment, Treatment Improvement Protocol (TIP) Series, 35. Chapter 2. 2013. http://store.samhsa.gov/shin/content//SMA13-4212/SMA13-4212.pdf. Accessed June 26, 2014.

11. Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. 3rd ed. New York, NY: Guilford Press; 2013.

12. US Preventive Services Task Force. Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women - Clinical summary of U.S. Preventive Services Task Force Recommendation, 2009. http://www.uspreventiveservicestaskforce.org/uspstf/uspstbac2.htm. Accessed June 26, 2014.

13. JA S. Smoking cessation counseling strategies in primary care. In: UptoDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013.

14. Tobacco use disorder. In: DynaMed. EBSCO Information Services. http://web.ebscohost.com/dynamed/. Updated August 14, 2013. Accessed September 4, 2013.

15. Berge JM MJ. Smoking cessation. In: Essential Evidence Plus. Hoboken (NJ): John Wiley & Sons, Inc., 2013. http://www.essentialevidenceplus.com/content/eee/837. Last Updated July 1, 2013. Accessed September 4, 2013.

16. Tonnesen P. Smoking cessation: How compelling is the evidence? A review. Health Policy. Jul 2009;91 Suppl 1:S15-25.

17. Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation. The Cochrane database of systematic reviews. 2005(2):CD001292.

WHOLE HEALTH: CHANGE THE CONVERSATION Clinical Tool: Tobacco Use Disorders

VHA Office of Patient Centered Care and Cultural Transformation Page 10 of 12

18. Mottillo S, Filion KB, Belisle P, et al. Behavioural interventions for smoking cessation: a meta-analysis of randomized controlled trials. European heart journal. Mar 2009;30(6):718-730.

19. Stead LF, Lancaster T. Group behaviour therapy programmes for smoking cessation. The Cochrane database of systematic reviews. 2005(2):CD001007.

20. Simon JA, Carmody TP, Hudes ES, Snyder E, Murray J. Intensive smoking cessation counseling versus minimal counseling among hospitalized smokers treated with transdermal nicotine replacement: a randomized trial. The American journal of medicine. May 2003;114(7):555-562.

21. Chen YF, Madan J, Welton N, et al. Effectiveness and cost-effectiveness of computer and other electronic aids for smoking cessation: a systematic review and network meta-analysis. Health Technol Assess. 2012;16(38):1-205, iii-v.

22. Whittaker R, McRobbie H, Bullen C, Borland R, Rodgers A, Gu Y. Mobile phone-based interventions for smoking cessation. The Cochrane database of systematic reviews. 2012;11:CD006611.

23. Severson HH, Peterson AL, Andrews JA, et al. Smokeless tobacco cessation in military personnel: a randomized controlled trial. Nicotine Tob Res. Jun 2009;11(6):730-738.

24. U.S. Department of Health and Human Services. Treating Tobacco Use and Dependence: 2008 Update. http://www.ncbi.nlm.nih.gov/books/NBK63952/. Accessed on June 27, 2014.

25. Centers for Disease Control and Prevention. Guide to community preventive services: Reducing Tobacco Use and Secondhand Smoke Exposure. 2014. http://www.thecommunityguide.org/tobacco/index.html. Accessed on March June 27, 2014.

26. Fiore MC, Jaen CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating tobacco use and dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service; 2008. Accessed at http://www.surgeongeneral.gov/tobacco/ on 24 September 2008.

27. U.S. Preventive Services Task Force. Screening for Lung Cancer: U.S. Preventive Services Task Force Recommendation Statement. AHRQ Publication No. 13-05196-EF-3. http://www.uspreventiveservicestaskforce.org/uspstf13/lungcan/lungcanfinalrs.htm. Accessed June 27, 2014.

28. U.S. Preventive Services Task Force. Screening for Abdominal Aortic Aneurysm: Final Recommendation Statement. AHRQ Publication No. 14-05202-EF-2. http://www.uspreventiveservicestaskforce.org/uspstf14/abdoman/abdomanfinalrs.htm. Accessed June 27, 2014.

29. Rennard SI RN, Daughton DM. Pharmacotherapy for smoking cessation in adults. In: UptoDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013.

30. University of Wisconsin Center for Tobacco Research and Intervention (UW-CTRI). E-cigarettes (e-cigs), 2014. http://www.ctri.wisc.edu/ecigs. Accessed June 26, 2014.

31. U.S. Food and Drug Administration (FDA). Electronic Cigarettes (e-Cigarettes), 2014. http://www.fda.gov/NewsEvents/PublicHealthFocus/ucm172906.htm. Accessed June 26, 2014.

32. Chatham-Stephens K, Law R, Taylor E, Melstrom P, Bunnell R, Wang B, Apelberg B, Schier JG. Morbidity and Mortality Weekly Report (MMWR), Notes from the Field: Calls to Poison Centers for Exposures to Electronic Cigarettes - United States, September 2010-February 2014. Centers for Disease Control and Prevention (CDC). 2014; http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6313a4.htm?s_cid=mm6313a4_w. Accessed June 27, 2014.

WHOLE HEALTH: CHANGE THE CONVERSATION Clinical Tool: Tobacco Use Disorders

VHA Office of Patient Centered Care and Cultural Transformation Page 11 of 12

33. Nicotine replacement therapy for smoking cessation. In: DynaMed. EBSCO Information Services. http://web.ebscohost.com/dynamed/. Updated June 21, 2013. Accessed September 4, 2013.

34. University of Wisconsin Center for Tobacco Research and Intervention (UW-CTRI). Quit Tobacco Series - Medications Chart, 2014. http://www.ctri.wisc.edu/News.Center/Fact%20Sheets/Updated%20ROS%20Resource Boxs/2.CME%20pharmacotherapy%20table.pdf. Accessed June 26, 2014.

35. Bize R, Burnand B, Mueller Y, Rege-Walther M, Camain JY, Cornuz J. Biomedical risk assessment as an aid for smoking cessation. The Cochrane database of systematic reviews. 2012;12:CD004705.

36. Tahiri M, Mottillo S, Joseph L, Pilote L, Eisenberg MJ. Alternative smoking cessation aids: a meta-analysis of randomized controlled trials. The American journal of medicine. Jun 2012;125(6):576-584.

37. Hajek P, Stead LF. Aversive smoking for smoking cessation. The Cochrane database of systematic reviews. 2004(3):CD000546.

38. Cahill K, Perera R. Competitions and incentives for smoking cessation. The Cochrane database of systematic reviews. 2011(4):CD004307.

39. Rose JE, Behm FM. Inhalation of vapor from black pepper extract reduces smoking withdrawal symptoms. Drug and alcohol dependence. Feb 1994;34(3):225-229.

40. Wynd CA. Guided health imagery for smoking cessation and long-term abstinence. Journal of nursing scholarship : an official publication of Sigma Theta Tau International Honor Society of Nursing / Sigma Theta Tau. 2005;37(3):245-250.

41. Zhdanova IV, Piotrovskaya VR. Melatonin treatment attenuates symptoms of acute nicotine withdrawal in humans. Pharmacology, biochemistry, and behavior. Sep 2000;67(1):131-135.

42. Hernandez-Reif M, Field T, Hart S. Smoking cravings are reduced by self-massage. Preventive medicine. Jan 1999;28(1):28-32.

43. Lee HJ, Lee JH. Effects of medicinal herb tea on the smoking cessation and reducing smoking withdrawal symptoms. The American journal of Chinese medicine. 2005;33(1):127-138.

44. Natural Standard Bottom Line Monograph: Smoking Cessation. Natural Standard. http://projects.hsl.wisc.edu/SERVICE/smoking/naturalstandard_2013_smoking.pdf. Accessed September 4, 2013.

45. National Center for Complementary and Alternative Medicine (NCCAM). Traditional Chinese Medicine: An Introduction, 2013. http://nccam.nih.gov/health/whatiscam/chinesemed.htm. Accessed May 27, 2014.

46. White AR, Rampes H, Liu JP, Stead LF, Campbell J. Acupuncture and related interventions for smoking cessation. The Cochrane database of systematic reviews. 2011(1):CD000009.

47. Fritz DJ, Carney RM, Steinmeyer B, Ditson G, Hill N, Zee-Cheng J. The efficacy of auriculotherapy for smoking cessation: a randomized, placebo-controlled trial. Journal of the American Board of Family Medicine : JABFM. Jan-Feb 2013;26(1):61-70.

48. Ussher MH, Taylor A, Faulkner G. Exercise interventions for smoking cessation. The Cochrane database of systematic reviews. 2012;1:CD002295.

49. Haasova M, Warren FC, Ussher M, et al. The acute effects of physical activity on cigarette cravings: systematic review and meta-analysis with individual participant data. Addiction. Jan 2013;108(1):26-37.

50. Roberts V, Maddison R, Simpson C, Bullen C, Prapavessis H. The acute effects of exercise on cigarette cravings, withdrawal symptoms, affect, and smoking behaviour: systematic review update and meta-analysis. Psychopharmacology. Jul 2012;222(1):1-15.

51. National Institutes of Health, U.S. Library of Medicine, Medline Plus. St. John's Wort, 2012. http://www.nlm.nih.gov/medlineplus/druginfo/natural/329.html. Accessed June 26, 2014.

WHOLE HEALTH: CHANGE THE CONVERSATION Clinical Tool: Tobacco Use Disorders

VHA Office of Patient Centered Care and Cultural Transformation Page 12 of 12

52. Sood A, Ebbert JO, Prasad K, Croghan IT, Bauer B, Schroeder DR. A randomized clinical trial of St. John's wort for smoking cessation. J Altern Complement Med. Jul 2010;16(7):761-767.

53. Barnes J, Dong CY, McRobbie H, Walker N, Mehta M, Stead LF. Hypnotherapy for smoking cessation. The Cochrane database of systematic reviews. 2010(10):CD001008.

54. Carmody TP, Duncan C, Simon JA, et al. Hypnosis for smoking cessation: a randomized trial. Nicotine Tob Res. May 2008;10(5):811-818.

55. A R. The role of the Transcendental Meditation technique in promoting smoking cessation: A longitudinal study. Alcoholism Treatment Quarterly. 1994;11(1-2):221-239.

56. Carim-Todd L, Mitchell SH, Oken BS. Mind-body practices: an alternative, drug-free treatment for smoking cessation? A systematic review of the literature. Drug and alcohol dependence. Oct 1 2013;132(3):399-410.