A Workbook
to Create Your
Personal Plan
to Overcome
Nicotine
and
Tobacco
Dependence
Breathe
easier.
Live
longer &
healthier.
Reduce your
risk of cancer
& heart disease.
Be free
from
tobacco,
vape & chew
.
© 1999-2023 Regents of University of California. All rights reserved.
Quitting smoking
is the single most
important thing
you’ll ever do for
your health.
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Table of Contents
About This Workbook 7
Chapter One 9
Clarence Brown. It’s Never Too Late 10
Lung Health 11
What’s in Cigarette Smoke? 12
What’s in E-cigarettes/Vape 13
Carbon Monoxide 14
Taking Care of Your Health 15
Denial 17
Two Types of Motivation: Fear vs. Desire 18
My “Want to” Motivation to Stop Smoking 19
Writing Your Mantra 21
Smoking Behavior: Awareness 23
Smoking Behavior: Environment 25
Setting Your Stop Date
26
A Break-up Letter 27
Write Your Break-up Letter 28
Practice and Exercises Week 1 29
Smoking, Vaping, and Chewing Awareness Journal 30
Chapter Two 33
Journey of Change 34
Seven Medications for Tobacco Cessation 36
Nicotine Patch 38
Nicotine Gum 40
Nicotine Lozenge 42
Nicotine Inhaler 44
Nicotine Nasal Spray 46
Varenicline 48
Bupropion SR 50
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Nicotine Levels in the Blood
52
Self Talk About Using Medication 53
Practice and Review Week 2 54
Smoking, Vaping, and Chewing Awareness Journal 55
Chapter Three 57
Nicotine Dependence 58
Habit Loop for Smoke, Vape, and Chew 59
Withdrawal Symptoms 61
Using Language 64
Entitlement: Another Language Trap 67
Commit to Quit
68
Self-talk to Support Your Decision 69
Strategies to Manage Triggers and Urges 70
Rewards and Celebrations 76
My Stop Plan 78
Practice and Exercises Week 3 83
Smoking, Vaping, and Chewing Awareness Journal 84
Chapter Four 85
Benets of Stopping 86
How Nicotine Changes the Brain 87
Preventing Relapse 89
The Road Back to Smoking 90
Steps to Take After a Relapse 91
Relapse During Intense Life Events 92
Quit Bonus Calculator
93
Practice and Exercises Week 4
94
Smoking, Vaping, and Chewing Awareness Journal 95
Appendix 97
Preparing for Your Journey 98
Clarence Brown 101
Barbara Vos 103
Joyce Lavey 105
Ernie Ring 108
Breathing, Smoking, and the Stress Response
112
Breathing Exercises 114
Stopping Smoking/Vaping/Chewing and Weight Gain 115
Why Heavy Drinking Seems to Boost Desire to Smoke More 118
Nicotine Withdrawal Symptoms: Time Course 120
In Gratitude 121
About the Fontana Tobacco
Treatment Center Workbook
The purpose of this workbook is to support
you as you gain freedom from your
dependence on nicotine and tobacco. For
the most part, we use the term ‘smoking’,
to apply to all forms of nicotine and tobacco
use. This would include cigarettes, chew,
vapes, pipes, cigars, hookahs, snus, and other
tobacco and nicotine products.
People often say, “I can’t stop smoking.
I have no will power.” For most people,
stopping smoking has more to do with
planning, strategizing, anticipating
challenges and making plans for how
to deal with them.
We are often asked “What about cold
turkey?” You may know people who have
quit cold turkey. That is, without medication
or planning. Cold turkey is throwing away
your cigarettes one day and saying, “I’m not
going to smoke again.” You might be
surprised to learn that the success rate for
cold turkey is 4%. If you had a serious health
issue and your provider said that the
treatment has a 4% success rate, your rst
question may be, “Don’t you have something
better?” We do have something better for
stopping smoking.
Research shows that people who follow a
2-pronged approach to overcoming nicotine
dependence have the best success. This
two-pronged approach is the foundation of the
Fontana program.
• Medication to treat nicotine withdrawal
for comfort
You might be asking why we recommend
nicotine replacement products if what
you are trying to do is stop using nicotine.
There is a big difference between nicotine
from the pharmacy and nicotine in
tobacco and vape products. Nicotine from
the pharmacy is pure, clean nicotine without
thousands of dangerous chemicals or the
addictive risks.
• Support and counseling to learn new ways
of living without cigarettes or vapes or chew.
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 7
Nicotine Dependence: A 2-Part Problem
Nicotine Dependence
PHYSIOLOGICAL
The addiction to nicotine
Treatment
Medications for cessation
BEHAVIORAL
The habit of using tobacco
Treatment
Behavior change pr
ogram
Treatment should address both the physiological and behavioral dependences
CONGRATULATIONS FOR MAKING THE IMPORTANT DECISION
TO START ON THIS JOURNEY.
By the end of this workbook, you will:
• Be aware of your use patterns.
• Learn how nicotine affects you.
• Understand addiction.
• Discover how to motivate yourself.
• Know how to use stop-smoking
medications.
• Identify triggers.
• Practice new habits.
• Learn to manage stress.
• Write a quit plan.
• Recognize risks for relapse.
• Develop skills to overcome a relapse,
if it occurs.
This workbook represents decades of experience helping people stop smoking, vaping, and chewing.
The workbook was created with the intention that it be used in conjunction with the Fontana Tobacco
Treatment Center program. If you are using this workbook as a tool to stop smoking, vaping, or chewing,
we encourage you to connect with us or with other tobacco treatment specialists. Professional counseling,
along with this workbook, can support you on your journey to freedom from nicotine and tobacco
dependence.
8 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
1
Chapter
One
Medical
• Lung health
• Tobacco-related disease
• What’s in cigarette smoke and vape?
Motivation
• Motivation defined
• Fear vs. Desire
• My “want to” motivation
• Power of denial
• Writing your mantra
Planning
• Smoking behavior awareness
• Your denial story
• Setting your stop date
• Writing a break-up letter
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 9
1
Clarence Brown. It’s Never Too Late.
In the photograph of Clarence Brown, the
medical records on the right side are from
the ve years before he stopped smoking;
the records on the left are from the ve years
after he stopped. Even for someone who has
smoked for years and has serious medical
problems, the improvements in their quality
of life and health that result from becoming
smokefree can be dramatic.
It is never too late to begin. When Clarence
became smokefree he was already disabled
with severe chronic obstructive pulmonary
disease (COPD). He needed to use a cane and
carried an oxygen tank. Had he not stopped
when he did, he could have likely died within
a year. Quitting smoking gave him many more
years of quality life.
Read Clarence’s story on page 101.
Medical records
5 years after
stopping smoking
Medical records
5 years before
stopping smoking
PHOTO: JOHN HARDING
10 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
1
Lung Health
Like the rest of the body, the lungs have a
natural process of aging. Smoking speeds up
that aging as well as creates disabling disease.
This graph shows the natural history of air-
ow blockage, a marker for decreased lung
function. The vertical axis shows the amount
of air that can be blown out during the rst
second of a forceful exhalation (FEV
1
). The
horizontal axis measures age in years.
• A person who never smokes begins a
natural, age-related, slow decline of lung
function starting at about age 60.
• Smoking speeds up that decline, often
leading to disability or early death.
• Even after 25 or more years of smoking,
stopping can slow the rate of decline back
to normal.
Beneficial Effects of Quitting on Lung Health: At any age, there are tremendous benefits
e 25)
Never smoked
100
value at ag
75
Smoked regularly
50
Stopped smoking at
45 (mild COPD)
FEV, (% of
Disability
25
Death
0
Stopped smoking at
65 (severe COPD)
25 50 75
Age (years)
COPD = Chronic Obstructive Pulmonary Disease
1 Fletcher & Peto. Br Med J 1977; 16077:1645-1648. Reproduced/amended with permission from the BMJ Publishing Group.
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 11
1
What’s in Cigarette Smoke?
More than 600 ingredients that when burned, produce 7,000 chemicals, including over 70 known
or suspected carcinogens. Every ingredient is carefully selected to contribute to the cigarette’s
addictiveness, signature taste and feel, and shelf-life.
Acetone
nail polish remover
Ammonia
household cleaner
Arsenic
rat poison
Benzene
used in rubber cement and gasoline
Butane
lighter uid
Cadmium
rechargeable batteries
Carbon monoxide car exhaust fumes
Formaldehyde embalming uid
DDT
insecticide
Hexamine
barbecue lighter uid
Lead
used in batteries
Naphthalene
mothballs
Methanol
rocket fuel
Nicotine
insecticide
Nitrous oxide phenols
disinfectant
Tar
material for paving roads
Toluene
solvent used in paint
Vinyl chloride
makes PVC pipes
12 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
1
What’s in E-cigarettes/Vape?
Not Just Nicotine and Water Vapor.
• 2000 chemicals have been found in E cigarettes/vape juice, many of which are known to
cause cancer.
• Higher and higher amounts of addictive nicotine.
• Propylene Glycol
• Glycerin
• Flavorings
• NNN
• NNK
• NAB
• NAT
• Ethylbenzene
• Benzene
• Xylene
• Toluene
• Acetaldehyde
• Formaldehyde
• Naphthalene
• Styrene
• Benzo(b)
fluoranthene
• Chlorobenzene
• Crotonaldehyde
• Propionaldehyde
• Benzaldehyde
• Valeric acid
• Hexanal
• Fluorine
• Pyrene
• Acenaphthylene
• Acenaphthene
• Fluoranthene
• Benz(a)anthracene
• Chrysene
• Retene
• Benzo(a)pyrene
• Ideno(1,2,3-cd)
pyr
ene
• Benzo(ghi)
perylene
• Acetone
• Acrolein
• Silver
• Nickel
• Tin
• Sodium
• Strontium
• Barium
• Aluminum
• Chromium
• Boron
• Copper
• Anthracene
• Selenium
• Arsenic
• Nitrosamines
• Polycyclic aromatic
hydr
ocarbons
• Cadmium
• Silicon
• Lithium
• Lead
• Magnesium
• Manganese
• Potassium
• Titanium
• Zinc
• Zirconium
• Calcium
• Iron
• Sulfur
• Vanadium
• Cobalt
• Rubidium
BOLD = FDA Harmful and
Potentially Harmful Substance
Established list.
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 13
1
Carbon Monoxide
What is carbon monoxide (CO)?
• Poisonous, tasteless, and odorless gas.
• Produced with any combustion or
burning.
• Cigarette smoke and vape contain CO.
• Affects the body’s ability to function
properly.
• Too much can cause death.
How is CO harmful?
CO decreases the body’s ability to deliver
oxygen to the body’s cells and organs.
• Normally, red blood cells pick up oxygen
from the lungs and deliver it to the cells
of the body. The cells need oxygen to
function and to stay alive.
• Carbon monoxide is dangerous because
it binds to the red blood cells 200 times
more tightly than oxygen, pushing the
oxygen aside.
• As a result, oxygen is not delivered to
the cells.
• Without oxygen the cells struggle to
function and eventually die.
What is your CO level?
• The more you smoke, the higher your
CO level will be.
• A normal CO level is less than 6 parts
per million (ppm).
• Within days of stopping smoking, your
CO level will return to normal.
• My CO level: ______________ ppm
Date: ____________ (baseline)
• My CO level: ______________ ppm
Date: ____________ (smokefree)
14 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
1
Taking Care of Your health
Stopping smoking is the single best action you can take to prevent certain cancers and chronic
diseases. Smoke affects the entire body.
Cancers
Mouth, Throat, Tongue
Voicebox
Esophagus
Wind Pipe, Bronchus
and Lung
Acute Myeloid
Leukemia
Stomach
Liver
Pancreas
Kidney
Cervix
Bladder
Colon, Rectum
Chronic Diseases
Stroke
Blindness, Cataracts, Age-Related
Macular Degeneration
Congenital Defects-Maternal
Smoking: Or
ofacial Clefts
Periodontitis
Aortic Aneurysm, Early Abdominal
Aortic Ather
osclerosis in Young
Adults
Coronary Heart Disease
Pneumonia
Atherosclerotic Peripheral
V
ascular Disease
Chronic Obstructive Pulmonary
Disease, T
uberculosis, Asthma,
and Other Respiratory Effects
Diabetes
Reproductive Effects in Women
(Including Reduced Fertility)
Hip Fractures
Ectopic Pregnancy
Male Sexual Function-Erectile
Dysfunction
Rheumatoid Arthritis
Decreased Immune Function
Overall Diminished Health
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 15
Manage a health condition by stopping smoking
Stroke
Prevent new strokes and TIA ( transient-ischemic attack).
Atrial Fibrillation
Get better control of irregular heart beats (palpitations, racing heart).
COPD
Improve breathing, reduce ares and hospitalization, preserve
lung function, allow treatment to work better. Avoid disability
and oxygen use.
Multiple Sclerosis
Improve symptoms by lowering exposure to toxins like cyanide
and carbon monoxide.
Macular Degeneration
Prevent blindness, allow treatment to work better.
Crohn’s Disease
Have fewer ares, less need for surgery, less disease recurrence
after surgery.
Prediabetes
Prevent type 2 diabetes.
Diabetes
Reduce insulin resistance, allow treatment to work better.
Rheumatoid Arthritis
Improve symptoms, prevent ares, improve disease course.
Cancer
Make chemotherapy and radiation therapy more effective, reduce
side effects of treatment, shorten recovery time after treatments.
Pain Control
Allow pain medication to work better.
Osteoporosis
Less risk of bone fractures.
Reux
Prevent symptoms or improve symptoms, prevent related cancers.
Infertility
Improve fertility in both men and women.
Periodontal Disease
Prevent tooth loss, improve gum health.
Fibromyalgia
Improve symptoms, reduce ares, allow treatment to work better.
Wound Healing
Better healing because of improved blood circulation and healthier
immune cells.
Insomnia
Improve sleep quality.
High Blood Pressure
Prevent or improve high blood pressure, allow medications to
work better.
Peripheral Arterial
Disease
Prevent limb loss.
Pregnancy
Prevent birth defects, stillbirth, spontaneous abortions, and Sudden
Infant Death Syndrome (SIDS). Improve birth weights.
16 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
1
Denial
Denial is the story we tell ourselves to make
it okay to keep smoking.
On the Journey of Change (page 34), the
rst section is the called
Denial and Decline.
Becoming aware of your own personal de-
nial stories is a rst step in making a plan to
escape to freedom from tobacco dependence.
Below are some familiar denial stories:
• I am going to die of something...why not
continue to enjoy smoking?
• I’ve tried to stop and I can’t.
• I had a chest X-ray a couple of years ago,
and my doctor said it looked great.
• My life is too stressful. I have to smoke.
• I only smoke two cigarettes a day…or on
the weekends…or “organic” cigarettes.
• It is no one’s business what I do.
• My sister got cancer and she never smoked,
so why not smoke?
• If I quit smoking, I’ll gain 50 pounds.
• I need to smoke to concentrate on my writing.
• I do not smoke as much as I used to.
• I’ve already had to give up everything else.
• I am going to quit when I’m 30…or 40…
or 50.
• It’s too late to stop.
What are your personal denial stories? Write them here:
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 17
1
Two Types of Motivation: Fear vs. Desire
FEAR
“The Stick”
• Restricts behavior
• Avoids something
“I have to do something
I don’t want to do!”
Fear leads to feeling…
• Resistant
• Weak
• Powerless
• Worthless
• Hopeless
• Stuck
Jolts you out of denial
But blocks progress with
continued use.
Cannot sustain
lasting change
VS.
DESIRE
“The Carrot”
• Encourages action
• Achieves something
“I want to do something!”
Desire leads to feeling…
• Condent
• Strong
• Empowered
• Self-assured
• Hopeful
• I have choices
Sustains
lasting
change
18 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
1
My “Want to” Motivation to Stop Smoking
To become and stay smokefree, it is helpful
to focus on your desire-based reasons for
stopping.
Focus on why you want to stop rather than
why you have to stop.
What good things will you get from being
smokefree?
1. Check the reasons below that speak to you.
2. Use the blank spaces to add your own
desires.
3. Stay inspired! Review these reasons daily to
remember why you are stopping smoking.
Health
I want to:
Lower my chance of having cancer, heart
attack, heart disease, stroke, COPD, and
other health issues.
Heal from surgery and have a lower risk
of infection after surgery.
Breathe easier and cough less.
Reduce the possible complications from
u and other infections.
Lower my blood pressure.
Walk without getting out of breath.
Have a healthy baby.
Live a healthier life.
Lessen the side effects from my cancer
treatment.
Improve the benets of my cancer treatment.
Loved ones
I want to:
Be a role model for my kids.
Protect my family or pet from secondhand
smoke.
See my children and grandchildren grow up.
Lessen my family’s worry about my health.
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 19
Appearance
I want to:
Have healthier skin.
Have clearer and brighter eyes.
Avoid getting more wrinkles.
Have healthy teeth and gums.
Keep my ngers and nails free of tobacco
stains.
Lifestyle
I want to:
Stop the stress from the nicotine
withdrawal cycle.
Be free from the anxiety about nding
time and a place to smoke.
Be free from worry about running out
of cigarettes.
Have more money to spend.
Have food taste better.
Be able to smell food, owers, and other
enjoyable things.
Have my hair and clothes smell clean.
Stop hiding.
Have my home and car smell clean.
Sleep better.
Be free of nicotine addiction.
Have more energy to do the things I love.
Be more in control of my life.
Feel the pride of being smokefree.
Be free of worrying about what smoking
is doing to my health.
20 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
1
Writing your Mantra
A mantra is a statement repeated frequently.
• A positive mantra can crowd out
negative thoughts.
• What we tell ourselves leads to what
we do.
• Choosing words that reect what we
want by becoming smokefree will
support moving in that direction.
• Saying and writing those words over and
over is a tool to support your choices.
One smoker’s mantra story
One person who smoked admitted to nagging
herself for years with thoughts like “I’m so
stupid to be smoking, I’m making myself sick,
I’m a bad mother, a bad nurse.” She believed
she could bully or scare herself into stopping
smoking.
She considered what could be different if she
were smokefree.
She realized that without cigarettes, she would
no longer be so mean to herself.
Without the fear and shame of smoking, she
would be fearless and proud.
She made a mantra that said “I am smokefree,
fearless and proud” to describe her new reality.
She started using her mantra immediately,
even though her stop date was days away.
When she stopped, it was a big support in
managing urges and keeping her focused.
“I am smokefree, fearless, and proud.”
If this mantra appeals to you, feel free to use
it, but we suggest you write your own.
Writing your own mantra:
1. Review your reasons for wanting to be
smokefree on page 19.
2. Select 2 or 3 reasons that feel especially
important to you.
Reason 1:
Reason 2:
Reason 3:
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 21
3. Use these reasons to make a short positive
statement expressing what is important to
you about becoming smokefree.
• Make it personal, about you.
• Make it positive. Make it about what
you want rather than what you
don’t want. You will move toward
whatever you are thinking about.
• Write your mantra in the present tense,
as if it is already achieved. You will
grow into it until it is true.
• Make it precise and easy to remember.
Choose words that are clear, not
general. For example, fantastic is more
powerful than good.
• We suggest starting with I am
smokefree…
• Use words that express emotion. Pick
feelings that are powerful for you.
• Have your mantra achievement
oriented, not ability oriented. Don’t
use words like can or will. Use words
like I am.
4. Write your mantra here:
I am smokefree
5. Use your mantra as much as possible.
• Take a blank piece of paper and write it
again and again.
• Use it as a screen saver on your computer
or as wallpaper on your phone.
• Write it on post-it notes that you can put up
on the bathroom mirror, on the refrigerator,
in the bedroom, in the car… everywhere.
• As you go to sleep, repeat your mantra over
and over.
• Do the same thing as you are getting up
in the morning.
Do your best to feel what living your mantra will
be like. For example, the person who chose I am
smokefree, fearless and proud knew very well what
it felt like to be afraid and ashamed. She began to
let herself experiment with feeling fearless and
proud. Doing this over and over rooted her goal
into her body, and once she actually became
smokefree, her mantra was a source of
immediate support whenever she needed it.
22 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
1
Smoking Behavior: Awareness
Many people who smoke report that they often smoke without even thinking about it. It is
just an automatic habit. An important step in the quitting process is to bring awareness to
your unique relationship to cigarettes.
Dependence
Four basic components work together to reinforce smoking behavior and create dependence.
On a scale of 0 to 10, rate how strong each component is for you to better understand what
strategies will be most important for your quit plan.
Hand-to-Mouth Stimulation 0 1 2 3 4 5 6 7 8 9 1 0
Problem
This includes all the behaviors that go
along with the act of smoking: holding
the cigarette, having it in your mouth,
lighting it, icking the ashes, etc.
Tools
Try avored toothpicks, straws, cinnamon
sticks, chewing gum, crunchy fruits and
vegetables, licorice root.
Nicotine 012345678910
Problem
Nicotine is among the most addictive
substances known. If you get strong
cravings to smoke and feel desperate for
it, you are probably experiencing nicotine
withdrawal.
Tools
You may benet from nicotine replacement
therapy or other stop-smoking medications.
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 23
Emotional & Psychological 0 1 2 34 5 6 78 91 0
Problem
People who smoke often use cigarettes to
push down difcult emotions or to deal
with unpleasant situations. Cigarettes can
become the main coping strategy for stress.
Deep Breathing
Problem
One reason people smoke is that it
allows them to take a deep breath. Deep
abdominal breathing itself is relaxing,
without the smoke!
Tools
Learn new coping skills such as stress
management, exercise, and deep breathing.
0 12 3 4 56 7 8 91 0
Tools
Practice deep breathing several times a day
so that when you have a craving taking deep
breaths will be a natural way to cope.
Deep breathing exercises can be found on page
114.
24 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
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Smoking Behavior: Environment
It is helpful to understand how your
environment is set up to support your
tobacco use. Without even realizing it,
you have developed certain ways of living
that allow you to continue using tobacco.
People who are addicted to nicotine protect
their supply in much the same way that
alcoholics keep close track of where they
will get their next drink. You might be
surprised at how much of your life is
arranged around your tobacco use. These
automatic, unconscious “arrangements”
are the behaviors that support your
addiction and make it possible for you
to continue using tobacco.
Think about the arrangements
you have made to make smoking
a convenient option:
• Where do you buy your cigarettes,
vapes, or chew?
• How much do you buy at once?
• Where do you keep your supply?
• How many lighters do you have?
• Where do you allow yourself to smoke,
vape, or chew?
• Who are all the people with whom you
smoke? Friends? Family? Coworkers?
• Do you seek out other smokers?
• How often are you in smokefree social
situations? Do you avoid them?
• What is your reaction when you are forced
into smokefree places? Malls? Restaurants?
Airplanes? Theaters?
To better understand your unique relationship
with tobacco, we encourage you to keep a daily
Smoking Awareness Journal, which is located
at the end of each section in your workbook.
Knowledge is power!
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 25
1
Setting Your Stop Date
There is no perfect day to stop. What’s important is setting a date and committing to it. We ask that
you select a stop date between weeks 3 and 4 of this program. Setting the date within this window
gives you enough time to prepare for success and get support from the group.
Think about your smoking pattern to help you decide your stop date:
Where do I smoke?
• I smoke mostly at work.
• I smoke mostly at home.
• I smoke in the car.
•
•
I should consider:
• A day I can stay at home
• A day at work.
• A day I don’t need to drive.
•
•
Where do I smoke?
• I smoke when I am alone.
• I am more likely to smoke with family
and friends.
• I smoke when I am drinking alcohol.
• I smoke when I am bored.
• I smoke before starting a task.
• I smoke to reward myself after
completing a task.
• I smoke in the morning with my coffee.
• I smoke after meals.
• I smoke when I am stressed.
•
•
I should consider:
• A day when I can spend time with family
and friends.
• A day when I can be alone.
• A busy day.
• Planning a fun activity like going to the
beach or working on a project.
• Planning a different morning routine.
• Getting a massage.
• Going for a bike ride or a hike.
•
•
My Stop Date:
26 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
1
A Break-up Letter
Stopping smoking, vaping, or chewing can feel like ending a relationship. Writing a letter to your
cigarettes, vapes, or chew can help clarify what you are leaving behind and what you are moving
towards.
Dear Cigarettes,
We have been together for many years. When I was a teenager, you helped me to feel grown up.
As I got older, you kept me company when I was lonely and lled the time when I was bored.
When I felt anxious or angry, you helped me manage these difcult emotions.
Now it is time for a change. I am afraid of what you are doing to me. I am scared of cancer. I get
winded walking up hills. I wake up in the morning with a cough. My ngers, hair, and clothing
stink. My gums are bleeding, and I may lose my teeth.
You are a drug dealer who got me addicted. You robbed me of my cash and my health. Part of
me is embarrassed at being duped by the marketing of the tobacco companies. I bought into
their advertising ploys. They knew all along you were not good for me. It was all about money.
I’ve tried to quit many times. I always thought I would have quit long before now. This time I
am getting help to beat this addiction.
It feels scary to go into my future without you, but I believe the future will be better and longer
if I leave you behind. I look forward to growing into my authentic, true self without you.
Good riddance. We are done!
No longer yours,
Smokefree, fearless, and proud
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 27
1
Write Your Break-up Letter
Write your break-up letter. Think about what role smoking, vaping, or chewing has played in
your life. Imagine what you would like about a life free from that dependency. Be kind to
yourself. Allow yourself to let go of an old friend. Embrace the excitement of building a new
relationship with yourself.
28 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
1
Practice and Exercises Week 1
Read
• Breathing, Smoking and the Stress
Response, page 112.
• Read Clarence Brown’s story on page 101.
• Read Preparing for Your Journey on
page 98.
Write
• Write in your Smoking Awareness
Journal each day, page 30.
• Review and check your “Want to”
Motivation, page 19.
• Set your stop date, page 26.
Do
• Build an awareness of why you are
smoking, pages 23-25.
• Listen to how you talk to yourself in your
mind. Note it in the Smoking Awareness
Journal. Is this how you would talk to your
friend about stopping smoking?
• Switch to a different brand of cigarettes
(this will bring you greater awareness of
when you are smoking and decreased
pleasure).
• Practice taking ve deep abdominal breaths
three or more times a day to delay or
eliminate cigarettes. This will also provide
you with a powerful stress management tool.
• Page 114 explains three easy breathing
exercises.
• Increase the amount of water you drink
each day. This may help with the elimination
of toxins and help to prevent constipation
from nicotine withdrawal.
• Bring your workbook to class every week.
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 29
1
Smoking, Vaping, and Chewing
Awareness Journal
Keeping track of your pattern can show you what is working and what might need troubleshooting.
Also, patterns you are not aware of may emerge. Write in the journal daily to track your progress.
Date # of cigarettes/
Amount of Vape/
Chew
How have you modied
your behavior?
What makes you want to
smoke/vape/chew? Describe
your feelings and thoughts.
Day 1
7/6/22
Thurs.
20 I tried to skip cigarettes
after meals. It was too
hard.
When I’m anxious, I want to
smoke.
When I think about quitting,
I want to smoke!
Day 2
7/7/22
Fri.
17
I didn’t smoke while
waiting for the bus –
this helped cut down
3 cigarettes today!
Doing something to take
care of myself makes the
anxiety easier to deal
with.
Be as specic as you can about how much vape or chew you are using:
Day 1
7/6/22
Thurs.
Started a new
pod. 60 puffs.
Taking more breaks
during the day at work
to stretch and practice
deep breathing.
Happy to finish a report.
Felt bored at home in the
evening.
Day 1
7/6/22
Thurs.
¼ can
10 times today
I didn’t do anything. Feeling discouraged.
30 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
Date
Day 1
Day 2
Day 4
Day 3
Day 5
Day 6
Day 7
# of cigarettes/
Amount of Vape/
Chew
How have you modied
your behavior?
What makes you want to
smoke/vape/chew? Describe
your feelings and thoughts.
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 31
2
Chapter
Two
Medical
• Stop-smoking medications
Motivation
• The Journey of Change
Planning
• Medication choices
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 33
2
Journey of Change
On a journey into the unknown, such as
learning how to stop smoking, it can be
comforting to have a map. On page 35 there
is a map to which you can refer over the
next months to reassure yourself that you
are moving in a positive direction.
As you move through learning how to stop
smoking, try to remember that being
uncomfortable doesn’t mean something is
wrong. In fact, some of the discomfort is a
sign that your body is healing.
• The Old Way – A Journey of Change
begins with the ending of an old way,
in this case the ending of smoking.
• Change Event – Sometimes something
happens to push you into making a
change. For example, a medical event
such as a new diagnosis or hospitalization.
• Denial and Decline – Starting out, you may
feel like you’re slipping off the edge; you
want something to grab. For example, you
may be thinking “I can just cut down.”
Much of your energy goes to resisting
change and trying to bargain your way back
to the Old Way (“I can smoke once in a while,”
“I can switch to organic cigarettes,” etc.). It
is helpful to identify your denial stories
(see page 17). Being in denial and decline can
keep you stuck for years.
• Letting Go – Eventually you stop bargaining
and commit to working toward the New Way
of smokefree living.
• Creative Confusion – You face many
challenges, don’t feel like yourself, things
are going up and down, and you problem-
solve as best you can. This is a time you
may nd it helpful to adjust your coping
methods and smoking cessation medications.
• Illumination – The light of awareness turns
on: “I’m doing this! I’m not there yet, but I can
see now how this works, one step at a time.”
• Rebuild – You are ready to reintroduce
things you temporarily let go to protect your
smokefree status. “I think I’m ready to
have a cup of coffee without a cigarette.”
“I can go out with my buddies without
smoking,” etc.
34 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
• The New Way – You arrive at the New
Way of being someone who does not smoke.
You probably are not even thinking about
smoking. Being without cigarettes feels as
natural as smoking used to feel. It takes most
people about a year to arrive here.
The New Way
Rebuild
Illumination
Creative
Confusion
Letting Go
Denial
and
Decline
Change Event
Old Way
Beginning Neutral Zone Ending
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 35
2
Seven Medications for Tobacco Cessation
Medications can improve success rates and
reduce physical nicotine withdrawal symptoms
allowing you to focus on changing habits and
routines linked to your smoking.
There are two types of medications for
smoking cessation that are approved by
the Food and Drug Administration:
1. Nicotine replacement therapy (NRT)
• Nicotine patch
• Nicotine gum
• Nicotine lozenge
• Nicotine inhaler
• Nicotine nasal spray
2. Non-nicotine replacement therapy (N-NRT)
• Varenicline (Chantix)
• Bupropion SR (formerly available as
Zyban)
The information on this sheet does not cover
all possible side effects; others may occur.
Please report any problems to your
provider.
Why do we recommend nicotine
replacement medications?
You might be wondering if it is safe to use
nicotine replacement products when trying to
stop your dependency on nicotine found in
cigarettes, vapes, and chew.
• Nicotine replacement products are safe to use
and do not have the strong addictive potential
of cigarettes, vapes, or chew.
• The harmful effects of smoking and vaping,
such as cancer, heart disease, and lung
disease are not caused by nicotine, but by
chemicals present in tobacco smoke and
possibly in vaping aerosols
• There is a big difference between NRT
and nicotine in tobacco and vape products.
NRT contains pure, clean nicotine without
the thousands of dangerous chemicals
present in tobacco smoke. While evidence
suggests that vape aerosols have lower
levels of harmful chemicals than tobacco
smoke, they are not considered safe.
• Another difference is that nicotine is
replaced at a low level, much lower than
36 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
what you get from smoking or vaping (see
page 52).
• Nicotine replacement makes you more
comfortable while you are quitting because
it reduces the cravings and withdrawal
that you feel when you stop smoking.
• Nicotine replacement products are tapered
to ease your process of withdrawal.
How long should you use medications?
• Stopping smoking is not a sprint. It is a
marathon. It may take months before your
brain chemistry and your skill set are
solidly in the no smoking zone.
• One mistake is to stop too early. You may
feel eager to stop taking medications, but
give yourself time to manage nicotine
withdrawal symptoms and rmly
establish new habits.
• If you taper down and feel at risk of
smoking, vaping, or chewing, go back up
on your dose of NRT.
• If you stop your bupropion SR or
varenicline, and feel at risk of smoking,
vaping, or chewing, restart your medication.
• Here are the general recommended
amounts of time for each of the medications.
You may need to take these medications for
longer than the times noted below.
Stop-smoking
Medications
Recommended
Duration of Therapy
Nicotine patch
8 to 10 weeks
Nicotine gum 12 weeks
Nicotine lozenge
12 weeks
Nicotine nasal spray 12 weeks
Nicotine inhaler
12 weeks
Varenicline (Chantix)
12 weeks
Bupropion SR
(formerly available
as Zyban)
7 to 12 weeks
The following pages describe medication
for smoking cessation. They are adapted
from the RX for Change patient handouts.
https://rxforchange.ucsf.edu/
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 37
Nicotine Patch
Also known as Habitrol
®
, NicoDerm CQ® (generics available)
Why choose the nicotine patch?
• The nicotine patch is used to help you
stop smoking, vaping, and chewing by
“replacing” the nicotine that you would
normally get from tobacco and vape
products, but without the harmful
chemicals, and at a lower amount.
• It makes you more comfortable while
you are quitting because it reduces the
cravings and withdrawal that you feel
when you stop smoking, vaping, or
chewing.
• It’s easy to use—you apply the patch
once a day. It can be used with other
nicotine medications (nicotine gum,
nicotine lozenge, nasal spray, or inhaler).
Studies have shown that this works better
than using only the patch when quitting.
• It is inexpensive compared to some of
the other medications for stopping
smoking/vaping/chewing.
• You do not need a prescription for this
medication. However, you will need a
prescription for your insurance to cover it.
How do I use the nicotine patch?
• Apply the patch to your skin, on an area
between your neck and waist or on your
upper arm. Try to apply to an area with as
little hair as possible to help it stay adhered
to your skin.
• Every 24 hours, remove the patch and
apply a new patch to a different area of
your body—don’t use the same skin site for
at least 1 week. This helps to reduce the
chances for skin irritation.
• The patch can take 2-4 hours to get to its
most effective level. It also takes about the
same time to completely stop working once it
is removed.
The patch strength depends on how much
you smoke:
If you smoke more than 10 cigarettes a day
21 mg patch
1 patch every day for
4 to 6 weeks, then
14 mg patch 1 patch every day
for 2 weeks, then
7 mg patch
1 patch every day
for 2 weeks.
If you smoke 10 or fewer cigarettes a day
14 mg patch
1 patch every day
for 6 weeks, then
7 mg patch
1 patch every day
for 2 weeks.
38 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
How long is the treatment?
• It is recommended that you use this
medication for at least 8 to 10 weeks but
many people need to use medications
longer than recommended.
• One mistake is to stop too early. You may
feel eager to stop taking medication but
give yourself time to rmly establish new
habits.
What are the side effects of the
nicotine patch?
• Skin irritation, such as redness, swelling,
and itching. This is likely caused by the
adhesive on the patch. You can apply
1% hydrocortisone cream to the area. If
it does not improve within a few days, call
your provider.
• Difculty sleeping or unusual dreams.
This is because you are getting nicotine
(which is stimulating) from the patch
while you sleep.
– Tobacco smoke causes caffeine to be
used up by your body more quickly. Be
sure to reduce your caffeine (e.g., coffee,
tea, soda) intake by half when you quit
smoking. Try to avoid beverages with
caffeine after lunchtime so you can
sleep well at night.
– If sleeping is still a problem, you can
remove the nicotine patch before bedtime
and put on a new one as soon as you wake
up. If you have strong morning cravings
for tobacco, you can use a piece of nicotine
gum or nicotine lozenge rst thing in the
morning to hold you over until the patch
takes full effect (about 2-4 hours).
What else do I need to know?
• Let your provider know if you are pregnant
or breastfeeding, had a heart attack within
the past 2 weeks, or have irregular heartbeats
or angina (e.g., chest pain).
• If you have eczema, sensitive skin (i.e., if
your skin reacts to adhesive bandages or
bandaids) or other skin conditions, the patch
might not be a good choice for you.
• Be sure to read all of the information on the
box of patches. Call your provider if you have
questions.
• If you plan to use the patch AND a short-
acting nicotine medication (nicotine gum,
nicotine lozenge, nasal spray, inhaler), you
can take the short- acting nicotine replacement
medication as needed (up to every 1-2 hours)
for breakthrough urges.
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 39
Nicotine Gum
Also known as Nicorette
®
(generics available)
Why choose the nicotine gum?
The nicotine gum is used to help you stop
smoking/vaping/chewing by “replacing” the
nicotine that you would normally get from
medication.
• It makes you more comfortable while
you are quitting because it reduces the
cravings and withdrawal that you feel
when you stop smoking, vaping, or
chewing.
• It can be used with the nicotine patch.
Studies have shown that this works
better than using only one nicotine
replacement medication.
• It is inexpensive compared to some of
the other medications for quitting
smoking.
• You do not need a prescription for this
medication. However, you will need a
prescription for your insurance to cover it.
How do I use the nicotine gum?
• Do not eat or drink for 15 minutes before
or while you have the nicotine gum in
your mouth (drinking water before using
the nicotine gum is OK).
• Chew 1 piece of nicotine gum slowly until
it feels tingly or peppery (after about 15 to
30 chews). This tingle is caused by the
nicotine being released from the nicotine
gum—then “park” it between your cheek
and gum.
• Keep the nicotine gum parked until the
tingle fades, then chew it again slowly until
you feel the tingling again. Park the nicotine
gum again in a different place in your
mouth.
• Repeat the “chew-and-park” process for
about 30 minutes, or until you no longer
feel the tingling when you chew the nicotine
gum—this means that there is no more
nicotine left and you can discard the nicotine
gum safely, away from children and pets.
• Do not chew too quickly or swallow the
nicotine gum because the medication might
be less effective, and it can upset your
stomach and cause hiccups.
• If the nicotine gum is the only medication
that you are using to stop smoking, vaping, or
chewing, be sure to use at least 9 pieces every
day for the rst 6 weeks.
If you plan to use the nicotine gum AND the
patch, you can take it as needed for break
through urges.
40 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
What strength you use depends on when
you smoke your first cigarette of the day:
If you smoke your rst
cigarette of the day Use the
Within 30 minutes
of waking
4 mg nicotine
gum
More than 30 minutes
after waking
2 mg nicotine 2 mg nicotine
gumgum
Dosing schedule*
(for use while you are awake):
Weeks 1 – 6
1 piece every 1 to 2 hours
Weeks 7 – 9
1 piece every 2 to 4 hours
Weeks 10 – 12
1 piece every 4 to 8 hours
* Do not use more than 24 pieces of nicotine gum a day.
How long is the treatment?
• It is recommended that you take this medication
for 12 weeks.
• Each medication has a recommended timeline,
but some people need to use medications longer
than recommended.
• One mistake is to stop too early. You may feel
eager to stop taking medication but give
yourself time to rmly establish new habits.
What are the side effects of the nicotine
gum?
• Hiccups or upset stomach (more common
when chewed too quickly).
• Sore jaw from chewing (nicotine gum is
harder to chew than regular chewing gum).
• Mouth or throat irritation (be sure to “park” the
nicotine gum in different areas of your mouth).
• May stick to dental work.
• Caffeine interacts with tobacco smoke. Be sure
to reduce your caffeine (e.g., coffee, tea, soda,
energy drinks) intake by half when you quit
smoking, and do not drink anything with
caffeine after lunchtime so you are able to
sleep well at night.
What else do I need to know?
• If you have TMJ (temporomandibular joint
disease; pain or general aching of the jaw) or
signicant dental work (e.g., crowns, dentures,
braces), the nicotine gum is not a good choice
for you.
• Let your provider know if you are pregnant,
or breastfeeding, had a heart attack within
the past 2 weeks, or have irregular heart
beats or angina.
• Be sure to read all the information on the
box of nicotine gum. Call your provider if
you have questions.
• Be sure to use nicotine gum according to a
regular schedule to prevent withdrawal.
• If you are using nicotine gum for break-
through cravings, do not wait until you
are craving a cigarette to take a dose. Nicotine
gum does not work as quickly as nicotine
from cigarettes or vapes. For example, if you
smoke in your car, plan to take a nicotine
gum 30 minutes before driving.
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 41
Nicotine Lozenge
Also known as Nicorette
®
Nicotine lozenge, Nicorette Mini
®
(generics available)
Why choose the nicotine lozenge?
• The nicotine lozenge is used to help you
stop smoking/vaping/chewing by
“replacing” the nicotine that you would
normally get from tobacco and vape
products, but without the harmful
chemicals, and at a lower amount.
• It makes you more comfortable while
you are quitting because it reduces the
cravings and withdrawal that you feel
when you stop smoking, vaping, or
chewing.
• It can be used with the nicotine patch.
Studies have shown that this works
better than using only one nicotine
replacement medication.
• It is inexpensive compared to some of
the other medications for stopping
smoking/vaping/chewing.
• You do not need a prescription for this
medication. However, you will need a
prescription for your insurance to cover it.
How do I use the nicotine lozenge?
• Do not eat or drink for 15 minutes
before or while you have the nicotine
lozenge in your mouth (drinking water
before using the nicotine lozenge is OK).
• Place it in your mouth, between your cheek
and gum, and let it dissolve slowly over 20 to
30 minutes.
• You will have a spicy, minty, or tingling
feeling in your mouth as the nicotine lozenge
dissolves (this is the nicotine working).
• Move the nicotine lozenge from one side of
your mouth to the other every few minutes.
• Do not chew or swallow the nicotine lozenge
because the medicine will not work, and it
will upset your stomach.
• If the nicotine lozenge is the only medication
that you are using to stop smoking, vaping, or
chewing, be sure to use at least 9 nicotine
lozenges every day for the rst 6 weeks. If you
are using it with the nicotine patch, you can
take it as needed for breakthrough urges.
What strength you use depends on when
you smoke your first cigarette of the day:
If you smoke your rst
cigarette of the day Use the
Within 30 minutes
of waking
4 mg nicotine
lozenge
More than 30 minutes
after waking
2 mg nicotine
lozenge
42 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
Dosing schedule* (for use while you are awake):
Weeks 1 – 6
1 nicotine lozenge every
1 to 2 hours
Weeks 7 – 9
1 nicotine lozenge every
2 to 4 hours
Weeks 10 – 12
1 nicotine lozenge every
4 to 8 hours
* Do not use more than 5 nicotine lozenges in 6 hours
or more than 20 nicotine lozenges a day.
How long is the treatment?
• It is recommended that you take this medication
for 12 weeks.
• Each medication has a recommended timeline,
but many people need to use medications longer
than recommended.
• One mistake is to stop too early. You may feel
eager to stop taking medication but give
yourself time to rmly establish new habits.
What are the side effects of the nicotine
lozenge?
• Mouth and throat irritation (be sure to move
the nicotine lozenge from side to side in your
mouth while it’s dissolving).
• Hiccups or upset stomach (be sure not to chew
or swallow the nicotine lozenge).
• Caffeine interacts with tobacco smoke. Be
sure to reduce your caffeine (e.g., coffee, tea,
soda, energy drinks) intake by half when
you quit smoking, and do not drink anything
with caffeine after lunchtime so you are able
to sleep well at night.
What else do I need to know?
• Let your provider know if you are pregnant
or breastfeeding, had a heart attack within
the past 2 weeks, or have irregular heartbeats
or angina (chest pain).
• Be sure to read all the information on the
box of nicotine lozenges. Call your provider
if you have questions.
• Be sure to take nicotine lozenges according
to a regular schedule to prevent withdrawal.
• If you are using nicotine lozenges for
breakthrough cravings, do not wait until
you are craving a cigarette to take a dose.
Nicotine lozenges do not work as quickly
as nicotine from cigarettes. For example,
if you smoke in your car, plan to take a
nicotine lozenge 30 minutes before driving.
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 43
Nicotine Inhaler
Also known as Nicotrol Inhaler
®
(no generic)
Why choose the nicotine inhaler?
• The nicotine inhaler is used to help you
stop smoking, vaping, or chewing by
“replacing” the nicotine that you would
normally get from tobacco and vape
products, but without the harmful
chemicals, and at a lower amount.
• It makes you more comfortable while
you are quitting because it reduces the
cravings and withdrawal that you feel
when you stop smoking, vaping, or
chewing.
• It can satisfy your urges to have something
in your hand that you bring to your
mouth.
• It can be used with the nicotine patch.
Studies have shown that this works
better than using only one nicotine
replacement medication.
• You must have a prescription for this
medication.
• It is covered by some insurance plans.
How do I use the nicotine inhaler?
• The nicotine inhaler mimics the hand-
to-mouth motion that many people miss
when they quit smoking.
• While the best results are often seen
with continuous pufng over 20 minutes,
many people use the inhaler for just a few
minutes, put it down and use it again later
for a total of 20 minutes of active pufng
per cartridge. Over time, you will nd what
works best for you.
• The cartridge is completely used when the
menthol avoring is gone.
• The nicotine is absorbed across the lining
of your mouth and back of your throat.
• Initially, use 1 cartridge every 1 to 2 hours
while awake.
• Do not eat or drink for 15 minutes before
or while you are using the inhaler (drinking
water before using the inhaler is OK).
• To use a cartridge, inhale gently into the
back of the throat or puff in short breaths—
do not inhale into your lungs (as you would
with a cigarette).
• Replace the cartridge after about 20 minutes
of pufng.
• When you open a cartridge, it will be good
for 24 hours; in hot weather, the nicotine
will evaporate more quickly.
44 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
• If the nicotine inhaler is the only medication
that you are using to stop smoking, vaping, or
chewing, be sure to use at least 6 cartridges
every day for the rst 3 to 6 weeks, then reduce
use after time. If you plan to use the inhaler
AND the patch, you can take it as needed for
breakthrough urges. Do not use more than 16
cartridges in 24 hours.
How long is the treatment?
• It is recommended that you use this medication
for at least 3 to 6 months.
What are the side effects of the nicotine
inhaler?
• Mouth and throat irritation
• Cough
• Hiccups
• Upset stomach or nausea
• Caffeine interacts with tobacco smoke.
Be sure to reduce your caffeine (e.g., coffee,
tea, soda) intake by half when you quit
smoking, and do not drink anything with
caffeine after lunchtime so you are able to
sleep well at night.
What else do I need to know?
• The nicotine inhaler might be less effective in
cold environments (temperatures under 60°F).
• Let your provider know if you are less than
18 years old, pregnant or breastfeeding, had a
heart attack within the past 2 weeks, or have
irregular heartbeats or angina (chest pain).
• Be sure to read all of the information that the
pharmacy provides to you when you ll your
prescription. Call your provider if you have
questions.
• Be sure to take this medication according to a
regular schedule to prevent withdrawal.
Do not wait until you are craving a cigarette
to take a dose, because it does not work as
quickly as nicotine from cigarettes.
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 45
Nicotine Nasal Spray
Also known as Nicotrol NS
®
(no generic)
Why choose the nicotine nasal spray?
• The nicotine nasal spray is used to help
you stop smoking,vaping, or chewing by
“replacing” the nicotine that you would
normally get from tobacco and vape
products, but without the harmful
chemicals, and at a lower amount.
• It makes you more comfortable while
you are quitting because it reduces the
cravings and withdrawal that you feel
when you stop smoking, vaping, or
chewing.
• It works more quickly than the nicotine
patch, nicotine gum, nicotine lozenge,
and inhaler.
• It can be used with the nicotine patch.
Studies have shown that this works
better than using only one nicotine
replacement medication.
• You must have a prescription for this
medication.
• It is covered by some insurance plans.
How do I use the nicotine nasal spray?
This medication is sprayed into your nose.
Follow these steps:
1. Blow your nose (if it is not clear).
2. Tilt your head back slightly.
3. Insert the tip of the bottle into the nostril
as far as it is comfortable.
4. Breathe through the mouth while you
push the bottom of the bottle upward
with your thumb to give yourself 1 spray
into each nostril.
5. In case of a runny nose, snifng gently
will keep the spray inside of your nose.
6. Do not inhale deeply or swallow the spray.
• Use 1 dose every 1 to 2 hours while you are
awake (1 dose = 2 sprays; 1 spray in each
nostril).
• If the nasal spray is the only medication that
you are using to stop smoking, vaping, or
chewing, be sure to use at least 8 doses every
day for the rst 6 to 8 weeks, then reduce
gradually during the next 4 to 6 weeks of
treatment. If you plan to use the nasal spray
AND the patch, you can take it as needed for
breakthrough urges.
46 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
• Do not use more than 5 doses in an hour
or 40 doses a day.
How long is the treatment?
• It is recommended that you use this medication
for 12 weeks.
• Each medication has a recommended timeline,
but some people need to use medications longer
than recommended.
• One mistake is to stop too early. You may feel
eager to stop taking medication but give yourself
time to rmly establish new habits.
What are the side effects of nicotine nasal
spray?
• Nose and throat irritation, such as runny nose
or stinging/burning (nicotine is irritating)
• Watery eyes
• Sneezing
• Coughing
• Caffeine interacts with tobacco smoke. Be
sure to reduce your caffeine (e.g., coffee,
tea, soda, energy drinks) intake by half when
you quit smoking, and do not drink anything
with caffeine after lunchtime so you are able
to sleep well at night.
What else do I need to know?
• If you have asthma, chronic allergies,
frequent sinus infections, or nasal polyps,
the nicotine nasal spray is not a good
choice for you.
• Let your provider know if you are pregnant
or breastfeeding, had a heart attack within
the past 2 weeks, or have irregular
heartbeats or angina (chest pain).
• Be sure to read all of the information that
the pharmacy provides to you when you
ll your prescription. Call your provider
if you have questions.
• Be sure to take this medication according to
a regular schedule to prevent withdrawal.
Do not wait until you are craving a
cigarette to take a dose, because it does not
work as quickly as nicotine from cigarettes.
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 47
Varenicline
Also known as Chantix
®
Why choose varenicline?
• Varenicline is a pill used to help you
stop smoking, vaping, or chewing.
• It makes you more comfortable while you
are quitting because it reduces the cravings
and withdrawal that you feel when you
stop smoking, vaping, or chewing.
• Research studies show that varenicline
is the most effective medication when you
stop smoking, vaping, or chewing.
• You must have a prescription for this
medication.
• It is covered by some insurance plans.
How do I use varenicline?
• Most people begin taking varenicline at
least one week before their stop date
because it takes some time for the
medication to take effect.
• You will start at a lower dose and then
increase to the full dosage.
• Take the pill with a full glass of water
after you eat a meal.
• If you miss a dose, take it as soon as you
remember. If it is less than eight hours
to your next dose, wait until your next
scheduled dose. Then return to your
normal schedule.
Usual dosing schedule:
Treatment Day Dose
Days 1 – 3
Take 1 white (0.5 mg)
pill each day.
Days 4 – 7
Take 1 white (0.5 mg)
pill in the morning and
1 in the evening each
day.
Days 8 –
end of treatment
Take 1 blue (1 mg) pill
in the morning and 1
in the evening each
day.
How long is the treatment?
It is recommended that you take this medication
for 12 weeks.
What are the side effects of varenicline?
Most common:
• Nausea (taking with food and water
will help to prevent this side effect)
• Problems with sleeping (insomnia, vivid
dreams)
Less common:
• Headache
• Constipation and atulence (gas)
• Changes in taste
• Changes in mood or behavior
48 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
What else do I need to know about
varenicline?
• This medication may cause changes in your
mood or behavior. If you or a family member
notice any changes that are not normal for
you, stop taking varenicline and contact your
provider right away.
• A large study compared varenicline, bupropion
SR, nicotine replacement therapy, and placebo.
The study did not show an increase in neuro
psychiatric problems from varenicline or
bupropion compared to the nicotine patch or
placebo.
• Let your provider know if you are pregnant,
or breastfeeding, or have kidney disease.
• Caffeine interacts with tobacco smoke. Be
sure to reduce your caffeine (e.g., coffee,
tea, soda, energy drinks) intake by half when
you quit smoking, and do not drink anything
with caffeine after lunchtime so you are able to
sleep well at night.
• Be sure to read all the information that the
pharmacy provides to you when you ll your
prescription. Call your provider if you have
questions.
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 49
Bupropion SR
Generic; formerly available as Zyban
®
, and Wellbutrin
Why choose bupropion SR?
• Bupropion SR is a pill used to help you
stop smoking, vaping, and chewing.
• It makes you more comfortable while
you are quitting because it reduces the
cravings and withdrawal that you feel
when you stop smoking, vaping, or
chewing.
• It can be used together with a nicotine
replacement medication, such as the
nicotine patch, to further reduce your
withdrawal symptoms.
• It is inexpensive compared to some of
the other medications for stopping
smoking, vaping, or chewing.
• You must have a prescription for this
medication.
• It is covered by some insurance plans.
How do I use bupropion SR?
• Start taking bupropion SR 1-2 weeks
before your stop date because it
takes some time for the medication to
take effect.
• The dose you will take is lower during
the rst 3 days of treatment, then it is
increased to the full dosage.
Dosing schedule:
Treatment Day Dose
Days 1 – 3
Take 1 (150 mg) pill
each day.
Day 4 –
end of treatment
Take 1 (150 mg) pill
in the morning and
1 in the evening.
Take the pills at least 8
hours apart.
Do not take more than
2 pills in one day.
How long is the treatment?
• It is recommended that you take this
medication for 7 to 12 weeks.
• If you feel that you need to be on the
medication longer, talk with your provider.
• Each medication has a recommended
timeline, but many people need to use
medications longer than recommended.
• One mistake is to stop too early. You may
feel eager to stop taking medication but give
yourself time to rmly establish new habits.
50 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
What are the side effects of bupropion SR?
More common:
• Difculty sleeping (insomnia)
• Dry mouth
Less common:
• Nausea
• Difculty concentrating
• Constipation
• Changes in mood and behavior
What else do I need to know?
• This medication may cause changes in your
mood or behavior. If you or a family member
notice any changes that are not normal for
you, stop taking bupropion SR and call your
provider right away. A large study compared
varenicline, bupropion, nicotine replacement
therapy, and placebo. The study did not show
an increase in neuropsychiatric problems from
varenicline or bupropion compared to the
nicotine patch or placebo.
• Let your provider know if you are pregnant
or breastfeeding, have liver disease, or are
taking any form of bupropion or Wellbutrin
®
or an MAO inhibitor (not common) for
depression.
• If you are already taking bupropion, you
do not take extra for the purpose of helping
you stop smoking.
• Do not use if you:
- are at risk for seizures, or if you have a
seizure disease (e.g., epilepsy), because
taking bupropion increases the risk of
having a seizure.
- have an eating disorder (e.g., bulimia
or anorexia).
- are abruptly stopping use of alcohol or
medications for anxiety (such as Ativan
®
,
Valium
®
, or Xanax
®
).
• Caffeine interacts with tobacco smoke.
Be sure to reduce your caffeine (e.g., coffee,
tea, soda, energy drinks) intake by half
when you quit smoking, and do not drink
anything with caffeine after lunchtime
so you are able to sleep well at night.
• Be sure to read all the information that
the pharmacy provides to you when you
ll your prescription. Call your provider
if you have questions.
The information on this sheet does not cover
all possible side effects; others may occur.
Please report any problems to your
provider.
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 51
2
Nicotine Levels in the Blood
Tobacco and nicotine products supply
different amounts of nicotine to the brain.
Once inhaled, high amounts of nicotine from
cigarettes and vape devices reach the brain
very quickly. The speed by which nicotine
reaches the brain promotes addiction.
Because nicotine replacement products, such
as the nicotine patch, deliver lower amounts of
nicotine slowly, they do not promote addiction
the same way as cigarettes, vapes, and chew.
How much nicotine are you getting?
BLOOD LEVELS OF NICOTINE ACHIEVED
with TOBACCO and NRT
0
5
10
15
20
25
1/0/00 1/10/00 1/20/00 1/30/00 2/9/00 2/19/00 2/29/00
Blood nicotine (mcg/l)
Cigarette
Moist snuff
Nasal spray
Inhaler
Lozenge
Gum
Patch
0 10 20 30 40 50 60
Time (minutes)
Cigarette
Moist snuff
Juul
Juul
52 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
0
5
10
15
20
25
1/0/00 1/10/00 1/20/00 1/30/00 2/9/00 2/19/00 2/29/00
Blood nicotine (mcg/l)
Cigarette
Moist snuff
Nasal spray
Inhaler
Lozenge
Gum
Patch
2
Self-Talk About Using Medications
Two qualities that will make your journey
of change continue smoothly are curiosity
and exibility. Not everyone uses medications,
but they might be right for you. It matters
less which medication you use, and more
that you be comfortable enough to really
give it a fair try.
Choose a medication and observe your
experience with curiosity:
• “I am taking this medication and will
discover how it works for me.”
• Depending on what you discover, be
exible.
• Perhaps you need a higher dose?
• Maybe you want to try a different
medication?
• Recognize that using medications is not a
“crutch” or a form of “cheating.” These
medications can make you physically more
comfortable, but you still have to put in
the effort to become free of smoke, vape,
and chew.
Find your path as you go and adapt to your
discoveries.
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 53
2
Practice and Review Week 2
Read
• Review workbook pages on nicotine
replacement and medications,
page 36-50.
• Read “Ernie Ring,” page 108.
Write
• Continue writing in your Smoking,
Vaping, Chewing Awareness Journal,
page 55.
Do
• Pick only one place in your home or work
to smoke, vape, or chew.
– Do not do anything else in this spot.
– For example, don’t combine smoking
with other activities such as talking on
the phone, enjoying a few minutes of
fresh air, drinking coffee, scrolling
through your phone, reading, etc.
– Do not get comfortable here –
no sitting!
– Smoke, vape, or chew, and then
immediately leave the area.
• Move all smoking, vaping, and chewing
paraphernalia to your designated spot.
• Continue deep breathing exercises to delay
or eliminate cigarettes you would otherwise
smoke. Take ve deep breaths, three or more
times a day.
• Continue to drink water and perhaps
increase the amount consumed each day.
• Set a stop date between week 3 and 4.
• Complete your Stop Plan on page 78.
• Get your stop-smoking medications either
by prescription or over the counter.
• For over the counter products, make sure
you purchase the correct strength of
medicine.
• If you need more information, call the
FTTC for information.
54 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
Smoking, Vaping, Chewing Awareness Journal
Date # of cigarettes/
Amount of Vape/
Chew
How have you modied
your behavior?
What makes you want to
smoke/vape/chew? Describe
your feelings and thoughts.
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 55
3
Chapter
Three
Medical
• Understanding nicotine effects,
dependence, and withdrawal
Motivation
• Using language
• Committing to quit
• The habit loop
Planning
• Stop date tips
• Dealing with urges
• Rewards and celebrations
• My stop plan
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 57
3
Nicotine Dependence
Nicotine has many effects on the body.
However, nicotine’s most important effects
are on the brain. The effect that nicotine
has on the brain is dramatic.
• Once inhaled into the lungs, nicotine
moves quickly into the bloodstream.
• The initial “hit” reaches the brain within
ten seconds or ve heartbeats, which is
much faster than other modes of delivery,
even faster than an injection with a needle.
• This massive and rapid upswing of nicotine
is part of the reason that it is so addictive.
Nicotine binds to millions of receptors and
causes a wide variety of effects:
• Pleasure
• Arousal
• Tension reduction
• Appetite suppression
• Cognitive enhancement
• Memory improvement
• Anxiety reduction
• Mood modulation
At the same time that nicotine creates these
effects, it is also making some serious changes to
the brain’s chemistry. In short, the brain devel-
ops a dependence upon nicotine. The absence
of nicotine leads to withdrawal symptoms. The
discomfort of these symptoms causes the person
to crave nicotine to feel comfortable again. The
ultimate result is that the person’s focus becomes
keeping a constant nicotine level during waking
hours. You need to smoke to get rid of the with-
drawal symptoms to feel normal. This is a classic
response to any addictive drug.
58 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
3
Habit Loop for Smoke, Vape, and Chew
Smoking is an addiction. It is also a habit.
Thinking about how habits get stronger
can help you interrupt the habit loop and
change your behavior. A habit loop has
four components:
1. Trigger – this could be anything –
a time of day, a place, an emotion, the
sight or smell of someone smoking/
vaping/chewing, or even boredom.
2. Urge –the desire to smoke, vape, or
chew. This can feel overwhelmingly
strong. Many people describe it as a
compulsion, like an “itch that has to be
scratched.”
3. Behavior –smoking, vaping, or chewing.
The thing you must do. It can be automatic.
Sometimes people say, “before I knew it,
I was lighting up.”
4. Reward –the “pay off.” Smoking, vaping,
chewing causes a dopamine surge. The
reward reinforces the behavior and keeps
you stuck in the loop.
Break your habit loop
Habit loops can be strong after years of
repetition.
• On average, if you have smoked a pack
a day (20 cigarettes) every day for 20 years,
you have smoked about 146,000 cigarettes.
You have reinforced that habit loop many,
many times over the years.
• This habit loop can change but it requires
your commitment and patience.
Rewiring your brain to break the cycle of a habit
loop requires attention to triggers and how you
react to the triggers.
• Preparing for triggers and urges can help
you have options other than smoking,
vaping or chewing.
• When you have an urge to smoke, take
a breath and acknowledge that a trigger
and urge are present, and a better behavior
is available.
• Using short acting nicotine gum or nicotine
lozenge can satisfy the nicotine receptors.
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 59
• Be aware of the other rewards you get from
smoking. For example, it keeps you from
eating, gives you something to do with your
hands, gives you an easy escape from
uncomfortable situations.
• You are building a new habit loop. The
new loop will be reinforced each time you
use it. It will feel natural after a period of time.
• When you see this loop happening and use
a new behavior for your reward, pat yourself
on the back literally or in your mind.
The Old Habit keeps you smoking, vaping, and chewing:
1. Trigger:
Anger
2. Urge to smoke,
vape, chew
THE OLD
LOOP
4. Rewards:
Dopamine release
Anger is suppressed
3. Behavior: Step away to
smoke, vape, chew
Learning new ways to cope frees you from the cycle:
1. Trigger:
Anger
2. Urge to smoke,
vape, chew
THE NEW
LOOP
4. Rewards:
Dopamine release
Anger is processed
3. Behavior: Step away
Take deep breaths
Use nicotine gum/lozenge
60 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
3
Withdrawal Symptoms
Quitting smoking, vaping, or chewing brings
about a variety of physical and psychological
withdrawal symptoms. For some people,
coping with withdrawal symptoms is like
riding a roller coaster. There can be sharp
turns, slow climbs, and unexpected plunges.
Most symptoms begin within the rst 1 to 2
days, peak within the rst week, and subside
within 2 to 4 weeks. Report new symptoms to
your health-care provider, especially if severe.
Remember, symptoms are temporary and will
improve with time.
• Circle the symptoms you have experienced or
are concerned about.
• Select the tools that you think may relieve
your symptoms.
• Write in other tools that may help you cope
better.
Symptom Cause and Duration Tools for Relief
Chest tightness Your lungs are undergoing
changes, and your body is tense
because it is craving nicotine.
It also might be caused by sore
muscles from coughing.
Can last several weeks.
• Use relaxation techniques.
• Try deep breathing.
• Use one or more of the
stop-smoking medications.
•
•
Constipation,
stomach pain, gas
Intestinal movement decreases.
Can last several weeks.
• Drink plenty of uids.
• Eat more fruits, vegetables,
and whole-grain cereals.
• Exercise more.
•
•
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 61
Symptom Cause and Duration Tools for Relief
Cough, sore throat
62 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
The body is getting rid of
accumulated mucus in the
airways.
Duration varies.
• Drink plenty of uids.
•
•
Craving a cigarette
Nicotine is a strongly addictive
drug, and withdrawal causes
cravings.
Frequent for the rst 2-3 days;
can occur for months.
• Wait out the urge, which lasts
only a few minutes.
• Exercise (take walks).
• Use one or more of the
stop-smoking medications.
•
•
Depressed mood It is common to feel sad for a
period of time after you rst
quit smoking. It takes time for
the brain to adjust to being
without nicotine. Many people
have a strong urge to smoke
when they feel depressed.
Duration varies; could last
months.
• Increase pleasurable
activities.
• Talk with your clinician about
changes in your mood when
quitting.
• Get extra support from
friends and family.
• See a therapist.
• Use one or more of the
stop-smoking medications.
•
•
Difculty
concentrating
The body needs time to adjust
to the lack of stimulation from
nicotine.
Can last several weeks.
• Plan workload accordingly.
• Take frequent breaks.
• Use one or more of the
stop-smoking medications.
•
•
Symptom Cause and Duration Tools for Relief
Dizziness
The body is getting extra
oxygen.
Typically improves within a
couple of weeks.
• Use extra caution.
• Change positions slowly.
• Stay hydrated.
•
•
Hand and mouth
cravings
Missing the experience of
handling or tasting cigarettes/
vapes/chew can result in wanting
something to put in your hands
and mouth.
Can last weeks to months.
• Drink sips of water.
• Prepare low-calorie snacks.
• Play with dget toys.
• Use straws, chewing gum,
mints, and avored
toothpicks.
•
•
Insomnia Nicotine affects brain wave
function and inuences sleep
patterns. Coughing and dreams
about smoking are common.
Can last weeks to months.
• Reduce caffeine intake by
about half (and none after
lunchtime) because you will
be more sensitive to caffeine
while stopping smoking.
• Use relaxation techniques.
• Stick to a bedtime routine.
•
•
Irritability
The body’s craving for nicotine
can produce irritability.
Can last several weeks but
usually ends within 4 weeks.
• Take walks.
• Decrease caffeine use.
• Use relaxation techniques.
• Use one or more of the
stop-smoking medications.
• Be kind to yourself.
•
•
Adapted from materials from the National Cancer Institute and Rx for Change
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 63
3
Using Language
Language is a powerful tool that when used
correctly can help you successfully change
behavior. What you tell yourself will directly
impact what you do.
Our beliefs about ourselves and the situation
at hand lead to the thoughts we have, which in
turn lead to the language we use. The words
we choose set our options for action. Only by
taking the right actions can we ever realize the
results we want. The good news is…
By using clear, goal-focused language we can
override unhelpful beliefs and thoughts that do
not line up with results we desire.
Here, two different perspectives create very
different results.
PERSPECTIVE 1:
“I hate this.”
Leads back to smoking/vaping/chewing.
Deprivation:
• I am being denied something I love.
• I am being forced to do something.
• Something I want/need is being taken
away from me.
Weakness:
• This is too hard.
• It’s harder for me than most people.
PERSPECTIVE 2:
“I can do this.”
Leads to a positive vision of being
smoke/vape/chew free.
Opportunity:
• This is my chance to change a habit
I no longer want.
• I am in charge of my choices.
• I am learning to deal with life without
harming myself.
Strength:
• This is an important challenge.
• I am more powerful than cigarettes/
vapes/chew.
64 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
PERSPECTIVE 1:
“I hate this.”
Leads back to smoking/vaping/chewing.
PERSPECTIVE 2:
“I can do this.”
Leads to a positive vision of being
smoke/vape/chew free.
Entitlement:
• Why can’t I just smoke/vape/chew once
in a while?
• I deserve at least one vice.
Lack of commitment:
• It’s not a good time.
• I’m waiting to want to stop.
Empowerment:
• I can beat this habit.
• I deserve to take care of myself.
Strength:
• I am -free.
• I am no longer looking for the chance
to smoke/vape/chew.
Start using positive language that declares “I am smoke/vape/chew free” even if it sounds odd, fake,
or like a lie at rst. Without a doubt, the most powerful words you can say to yourself (even if it isn’t
quite true yet) are “I am smoke/vape/chew free.”
What message could you give yourself that would lead to the results you want? Write it here.
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 65
WARNING
SMOKE
FREE
TRY
TRY TRY
TRY
Using the word
TRY
is an easy
way to divert
yourself from your
DESTINATION
(You are allowing yourself lots of options for failure
while remaining a “good” person for the effort)
66 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
3
Entitlement: Another Language Trap
Entitlement is the belief that one deserves
something, that they have earned the right
to something. Do you feel entitled to smoke?
Here are some examples that may help you
recognize if feelings of entitlement are playing
a part in keeping you from stopping smoking,
vaping, or chewing.
• If it is in my house (or my purse, or my
car), I am entitled to it; The decision is
already made. I get to have it.
• No more cigarettes after midnight…but
right now I can smoke.
• I will nish the pack and then quit.
• I paid a lot for my vape pen; I can’t waste
so much money.
• I don’t have any other vices; I deserve to
keep smoking.
• I’ve already had to give up so much;
I shouldn’t have to give up using chew.
• I should be given this surgery even if I
am smoking.
• I only smoke occasionally; I should be
allowed to continue.
How do you feel entitled to smoke?
Write your response here:
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 67
3
Commit to Quit
Many people report that a weight is lifted once
they truly decide to stop smoking.
Their mindset becomes:
• Smoking/vaping/chewing is not an option.
• Life no longer revolves around little
moments of sneaking in a cigarette/vape/chew.
• I am relieved of the constant struggle to
resist smoking/vaping/chewing.
• I am a non-smoker/vaper/chewer and ready
to “move on.”
• I live with fewer daily “regrets.”
Commit to Quit Agreement
On , I will stop using
(Cigarettes, vapes, chew, etc.)
I choose to see this as a serious and important shift in my life. With this commitment,
I am demonstrating:
• A sincere desire to stop
• The motivation to make the necessary changes, and
• The willingness to experience discomfort as I heal from nicotine dependence.
I understand there will be challenging times, and I agree to do my best to meet them.
I will work to be kind to myself during this process and seek support when I need it.
By choosing to quit, I am taking a stand for my health, for the health of those around me,
for the people who care for me, and most importantly, for myself.
Signature Date
68 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
3
Self-talk to Support Your Decision
Positive self-talk can reinforce the decision to
quit. Replacing thoughts such as “I can’t do
this,” or “this is too hard,” with more realistic
thoughts can calm overwhelming emotions.
Here are some practical suggestions for
self-talk:
• “This is temporary.”
• “Take it one moment/day at a time.”
• “This will get easier as time goes by.”
• “This cigarette is not going to x my
problem.”
• “I don’t need it.”
• “I’m glad I don’t have to do that anymore.”
• “The craving will go away whether or not
I smoke.”
• “Smoking won’t make me feel better.”
• “Withdrawal symptoms are my body
healing from nicotine.”
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 69
3
Strategies to Manage Triggers and Urges
Becoming successful at learning how to stop
smoking, vaping, and chewing requires
planning and learning new skills. Don’t tell
yourself that you can’t stop because you
don’t have willpower. It is not about willpower
alone. The pages below will show you the steps
to success.
Urges and cravings are normal. By smoking,
your brain and your body have been trained
to expect the regular doses of smoke and
nicotine. Your body and brain feel like
something is wrong. It is going to take time to
adjust to your new lifestyle.
Many people who have stopped smoking,
vaping, or chewing report that quitting was
not nearly as hard as they had feared. Hold
on to that thought. This might be your story,
too!
Planning for urges and cravings is key
Triggers can cause strong urges. Be ready
with a response. It is important to remember
that urges may last 5 to 10 minutes and then
fade. They don’t last forever!
Common triggers
Below are some common triggers. Mark the ones
that are strong for you. Add your own triggers
that are not listed here.
I want to smoke, vape, or chew when:
I wake up.
I have my morning coffee.
I have had a stressful conversation.
I see someone smoking.
I smell a cigarette.
I’m celebrating.
I’m watching TV.
I’m taking a break.
I’ve nished a task.
I’ve worked out at the gym.
I’ve nished a meal.
I need to concentrate.
I need more energy.
I’m bored.
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I get home from work.
I’m driving.
I’m waiting for the bus.
I want a snack, but I don’t want to
gain weight.
I have pain.
I’m sad.
I’m lonely.
I’ve had sex.
I want to be by myself and think.
I’m afraid.
Vulnerable situations
The four conditions below (HALT) can make
you very vulnerable to smoking. Do what you
can to avoid feeling:
• Hungry – Eat regular meals.
• Angry/Anxious – Find outlets like exercise
for difcult emotions. Consider counseling
or anger management classes.
• Lonely – Take a walk in the park where
there are people. Ask someone if you can
pet their dog. Make someone smile. Attend
the weekly Fontana support group.
• Tired – Get regular sleep and rest.
High-risk situations
• Drinking alcohol. Alcohol can derail
your efforts. Consider not drinking
alcohol at least during the rst weeks of
your quit journey. Rehearse what you will
say if you are offered alcohol.
• Being around people who are smoking. In
the beginning of your quit journey, avoid
family and friends who will smoke around
you. Rehearse what you will say if offered
something to smoke.
Tools to deal with urges
There are many activities you can use to address
strong urges. Plan ahead and be ready to respond
to an urge. Don’t wait for an urge to happen and
then try to gure out what to do.
The Five Ds
• Drink water.
• Delay the craving.
• Do something else.
• Deep breathe.
• Discuss with a friend.
Nicotine Replacement Therapy
For known stressful events, use nicotine gum
or lozenge starting 30 minutes before or nicotine
inhaler or nasal spray 5-10 minutes before.
For example, if you always smoke when you
are talking on the phone with your sister after
work, plan to use your nicotine gum or
nicotine lozenge 30 minutes ahead of your
daily call.
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Make sure your short acting nicotine
replacement is with you. If you are out
and about and have a strong urge and your
nicotine gum is at home, it will not do you
any good. Have these medications close to
you. Keep them in your backpack, desk,
vehicle, purse, kitchen, and bedside table.
Urge Surng
There are many strategies for meeting and
dealing with urges. One powerful option is
known as urge surng, a mindfulness
technique.
• You start by imagining a wave.
• You ride out an urge like a surfer
riding a wave.
• Like a wave, an urge slowly builds to a
peak, and then fades away.
• While the urge is growing, it can feel
like it will never go away. Use deeper
breaths to help carry you up and over
the peak of the urge.
• As you surf the urge, notice and name
what is happening, including what
thoughts, feelings, and body sensations
you are having.
• Remind yourself, these are feelings, and
like the urge, they are temporary. They
will peak and disappear even if all you
are doing is paying attention to what is
happening.
• Urge surng is a practice to accept whatever
you are experiencing rather
than trying to get rid of it or push it
away. Surng the urge mindfully and
with your breath allows it to unfold
naturally and as quickly as possible.
The Emergency Exit
When building your quit plan, always look
ahead to possible challenges and plan how
to overcome them.
If your original plan is not working you
always have an emergency exit. For example,
if you have been tobacco free for some time,
you may feel ready to go to a party where
there may be smoking. What will you do if
your coping plan is not working?
Plan ahead to just leave. No need to explain
a reason to anyone. This is an emergency exit
to save your health and keep you on the path
of your smokefree living.
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Check the strategies you could use
when an urge occurs. Add your own
ideas to the list.
Repeat your mantra again and again.
Remind yourself of your reasons to quit.
Deep breathe. (page 114).
Look at pictures of loved ones.
Use short-acting NRT.
Use a toothpick, straw, cinnamon gum
or strong mints.
Look at funny videos on your phone.
Go outside and see the delights in nature.
Listen to music or a podcast.
Read a book or magazine.
Blow bubbles.
Call a friend or family member.
Clean you house or car.
Go for a walk or jog.
Drink a glass of water with a bit of
orange, lemon, or lime.
Have a small snack. (Fresh fruit, raw
carrots, celery, frozen grapes, sunower
seeds.)
Brush your teeth.
Play a game or puzzle.
Work on an art project.
Hold something in your hand.
(Pen, coin, dget spinner, or paper clip.)
Keep your hands busy. (e.g., knitting,
needlework, woodworking, drawing,
coloring, doodling, sketching.)
Do the dishes or laundry.
Take a warm shower or bath.
Garden.
Pet your dog or cat.
Take your dog for a walk.
Set a timer for 10 minutes and complete
a task.
Pray.
Meditate.
Dance.
Sing.
March in place.
Stretch.
Keep a gratitude journal.
Leave.
Surf the urge.
Jump rope.
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Sample Trigger
Sample Strategy
Waking up in the morning
• Keep nicotine lozenges on my bedside table to
use before getting out of bed
Drinking coffee
• Change up my routine
• Switch to tea
• Have my coffee in a different room or on
the porch
Talking on the phone
• Have a doodle pad with colored pens available
• Sip ice water with a bit of orange
Driving by the gas station where I usually
buy cigarettes
• Get gas at another station
• Don’t drive by until I’m condent that I won’t
turn in to the usual station
Not knowing what to do with my
hands
• Hold a paper clip, coin, pen, dget spinner,
stress ball, knit
Needing to chew or have something in
my mouth
• Chew on carrots, gum, strong mints, or
cinnamon sticks
• Drink water from a straw or keep a straw in
my mouth
• Eat sunower seeds one at a time
Being at a party where people are
smoking
• Leave
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Explore strategies for your triggers
Finding your best strategies will take some experimenting. If one strategy doesn’t work for you, try an-
other, or try combining a couple. This experimenting takes patience and curiosity.
Think about your most frequent triggers and list them below. Add some strategies to tackle each one.
My Trigger My Strategy
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Rewards and Celebrations
3
Fact 1
Learning to stop smoking or vaping is one of
the most difcult challenges a human being
can ever undertake.
Fact 2
Nonsmokers do not understand Fact 1.
Fact 3
Ex-smokers often forget Fact 1.
• An important part of staying smokefree
is being able to remember and acknowledge
all of the work it has taken to get this far.
• If you are unwilling to give deep
appreciation to your accomplishment
or if you begin to think it was “no big
deal,” you are cheating yourself of the
power of this extraordinary experience.
• Each cigarette not smoked is a victory
to be celebrated. You nished a meal
without a cigarette. Pat yourself on
the back physically and mentally. Rewarding
each victory supports new habits and
strengthens your commitment.
• Being smokefree deserves and needs to be a
signicant and ongoing source of pride,
strength, and condence.
• For many people, feeling proud and
condent is an odd and uncomfortable
experience. Celebrating and rewarding both
large and small victories will lead to greater
comfort with feeling proud and condent.
• Choosing rewards that are good for you
helps to move you away from using
cigarettes as rewards. You get to reclaim the
reward experience in honor of your good
health!
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When you You could
Delay a craving
Buy fresh owers
Choose not to smoke after an argument
Chat with a friend
Decide not to bum a cigarette from a coworker
Buy new shoes
Avoid a situation where you know you would
want to smoke
Have a one-minute parade in your own honor
with confetti and noisemakers
Say, “No, thank you” when offered a cigarette
Eat chocolate
Recommit after a lapse
Plant a tree
Wait for an urge to subside on its own
Get a massage
Have a glass of wine without smoking
Listen to your favorite song
Buy a box of toothpicks instead of cigarettes
Take a candlelit bath
See a cigarette somewhere and do not pick it up
Declare your quit date a monthly holiday
Visit your in-laws without taking a smoke break
Put a gold star on your bathroom mirror
Leave a party early because you might smoke
Play with a puppy
Really want one…but don’t do it
Visit a museum
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3
My Stop Plan
These three planning sections will help you organize your efforts for success:
1. Getting Ready
2. My Stop Day
3. Staying the Course
Plan what steps you will take to respond to urges and challenging situations. Rehearsing what you
will do gives you condence that you can follow your plan.
Getting Ready to Stop: Steps to Take
My Notes
Make the commitment to be free from smoke,
vape, and chew. Sign My Commitment Letter
on page 68.
Get my medications. If using varenicline or
bupropion, begin taking at least a week before
my quit day. It’s also okay to start nicotine
replacement therapy before my quit day.
Nicotine patch
Nicotine gum
Nicotine lozenge
Nicotine nasal spray
Nicotine inhaler
Varenicline
Bupropion
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Getting Ready to Stop: Steps to Take (continued) My Notes
Have my short acting nicotine replacement in
numerous places such as my car, pockets, purse,
backpack, night table, and desk.
Address my plan for alcohol use and depression,
etc. such as therapy or joining an AA meeting.
Taper caffeine drinks or mix decaf with caffeinated
coffee to ward off caffeine jitters.
Have my “Want to” motivation list (page 19) in
several locations to review frequently, such as on
my phone, on post-it notes on the fridge, in my
car, on my computer screen, in my wallet.
Review my triggers & strategies on page 75.
Review how to address withdrawal symptoms on
page 61.
Get a water bottle.
Stock up on strong mints, toothpicks, straws,
cinnamon sticks or gum, carrot sticks, celery.
Decide on something to hold in my hand such
as a pen, dget spinner, stress ball, or straws.
Plan what to do instead of smoking, vaping, or
chewing, such as walking, puzzling, reading,
exercising, cooking.
Get bubble mix for blowing bubbles.
Clean my living space and get rid of all smoking
items (ashtrays, cigarettes, vape pens, chew,
lighters).
Remove cigarettes and lighters from my car.
Wash my car/have it detailed.
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Getting Ready to Stop: Steps to Take (continued) My Notes
Practice my mantra.
Practice deep breathing.
Choose celebrations for each victory, large and
small.
Build a support system. Tell supportive family
and friends.
Take a vacation from alcohol.
Plan to avoid places and people who may trigger
me to smoke.
Rehearse what I will say if offered a cigarette.
“Play out” the story: I am with a friend. She
offers me a cigarette. I accept. What happens
immediately, in 5 minutes, in a few hours,
tomorrow…
Speak to myself as I would a friend who is
stopping smoking. Positive self-talk helps me
support myself on the journey. “I’m smoke free!
I’ve got this! I can do it!”
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My Stop Day: Steps to Take
Review my “Want to” list on page 19.
Take my medications.
Don’t wait for an urge to overwhelm me. Use my
short acting nicotine before I have urges.
Change up my routine.
Drink less caffeine.
Drink more water.
Have my morning coffee or tea in a different chair
with a different mug.
Plan my response to urges.
Remind myself that the urges will pass in less than
5-10 minutes.
Practice my deep breathing.
Use strong mints, toothpicks, straws, cinnamon
sticks or gum, carrot sticks, and celery.
Keep my hands busy by holding a pen, dget
spinner, stress ball, straw, rubber band.
Keep busy.
Meditate. Pray. Dance. Sing. Blow bubbles.
Take a walk. Paint. Read. Journal.
Congratulate and celebrate.
My Notes
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Staying the Course: Steps to Take
Check if my strategies need adjusting.
Attend the UCSF FTTC support group for new
ideas, support, and to help others.
Use my support systems to stay on course.
Remind myself of the “emergency exit” strategy.
If I am in danger of smoking: Leave!
Continue to be vigilant of triggers.
Be wary of overcondence. Take my medication
for at least the recommended time.
Remember, Not One Puff Ever (NOPE).
Remember, HALT (page 71).
Remember, the 5 D’s (page 71).
Tally how much money I am saving by not smoking
(page 93).
Celebrate every victory, big and small!
Practice deep breathing frequently.
If I have a lapse or relapse:
Don’t use my lapse as permission to keep smoking.
Use my lapse as a learning experience. Note and
address obstacles I uncover.
Think about what worked in the past to help me
stop. For example, if I took varenicline and was
able to quit, I could start taking varenicline again.
Review this Stop Smoking Workbook. Use the
tips to get back on track.
Use my mantra frequently.
Attend the UCSF FTTC Support Group for
help getting back on track.
Review the Relapse section on page 89 for
more suggestions.
My Notes
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3
Practice and Exercises Week 3
Read
• Barbara Vos’s story, page 103.
Write
• Sign the Commit to Quit Agreement,
page 68.
• Create your Stop Plan, page 78.
• Track your progress and success in
your Smoking Awareness Journal,
page 84.
Do
• Stop smoking this week, if you haven’t
already.
• Add exercise to your daily routine.
• Use your Stop Plan to help with urge
responses.
• Keep deep breathing and drinking water.
• Remember to celebrate and reward
yourself.
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Smoking, Vaping, Chewing Awareness Journal
Date # of cigarettes/
Amount of Vape/
Chew
How have you modied
your behavior?
What makes you want to
smoke/vape/chew? Describe
your feelings and thoughts.
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
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4
Chapter
Four
Medical
• Benefits of stopping smoking, vaping,
and chewing
Motivation
• Preventing relapse
• Quit bonus calculator
Planning
• Attend FTTC Freedom from Smoking/
Vaping/Chewing Support Group
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4
Benets of Stopping
Stopping smoking will improve your health
including better blood pressure and blood sugar
control. You may be pleasantly surprised that you
need a lower dose of some medications.
Let your doctor know that you are stopping
smoking.
Within the first day of stopping smoking:
• You stop polluting the air with dangerous
second-hand smoke.
• Blood pressure and pulse rate improve.
• Temperature of hands and feet returns to
normal.
24 hours:
• Chance of heart attack decreases.
48 hours:
• Carbon monoxide level in blood back
to normal.
• Oxygen level in blood increases to normal.
• Ability to smell and taste things is
enhanced.
72 hours:
• Bronchial tubes relax, making breathing
easier.
2 weeks to 3 months:
• Circulation improves.
• Walking becomes easier.
• Lung function increases up to 30%
1 to 9 months:
• Coughing, sinus congestion, fatigue, and
shortness of breath all decrease.
• Cilia regrow in lungs, increasing ability to
clean the lungs and reduce infection.
• Body’s overall energy level increases.
1 year:
• Heart disease death rate is halfway back to
that of a nonsmoker.
5 years:
• Heart disease death rate drops to the rate for
nonsmokers.
• Lung cancer death rate decreases halfway
back to that of nonsmokers.
10 years:
• Lung cancer death rate drops almost to
the rate for nonsmokers.
• Incidence of other cancers decreases—
mouth, voicebox, esophagus, bladder,
kidney, pancreas, etc.
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4
How Nicotine Changes the Brain
Neurotransmitters are chemical messengers that carry information from neuron to neuron or
neurons to muscles. Receptors are structures in the brain that receive specic neurotransmitters.
One neurotransmitter, acetylcholine, is shaped similar to nicotine. This allows nicotine to connect
to the receptors where acetylcholine usually connects. When you smoke, these nicotinic-acetylcholine
receptors increase in number to receive more and more nicotine. The images below are explained in
detail on page 88.
1. 2.
3. 4.
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1. A brain with no history of exposure to nicotine
has normal number of nicotinic-acetylcholine
receptors.
2. Exposure to nicotine stimulates the brain to
produce more nicotinic-acetylcholine receptors.
3. When these receptors are not lled with nicotine,
there is a strong urge to smoke. Similarly, a person in
the early stages of stopping smoking has many unlled
receptors, leading to symptoms of withdrawal.
4. After months of not smoking or vaping, the receptors
return to normal levels. The brain has grown accustomed
to normal function without needing nicotine. However,
important to note that once exposed to nicotine, the
receptors retain a memory of the pleasure experienced
so that even a puff can set you up for regular smoking
once again. Also, any addiction generates new neural
circuits in the brain similar to other types of learning.
For example, once you learn to ride a bicycle, those
circuits persist for many years, so that even after not
riding for decades one still remembers how to ride.
Addiction is similar. Addiction-related brain circuits
persist for many years and in some people for a lifetime.
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4
Preventing Relapse
On the road to becoming truly smokefree, you
might encounter bumps, roadblocks, and de-
tours. If this happens, your job is to get back on
the right road as soon as you can. Not all detours
are the same, and it can be helpful to know the
differences.
A Lapse: “Oops!”
You decide to smoke one or maybe a few
cigarettes, but within a very short period of
time, you return to being smokefree. A lapse
can last as little as a few minutes or up to a
day or two.
A Relapse: “Return to square one.”
You decide to smoke, and within a short period
of time you are back to smoking at the same
level as before you started the quitting process.
There is a sense that you need to recommit and
start over.
A Collapse: “I can’t do this!”
In addition to deciding to smoke and quickly
returning to your pre-quit level, you lose faith
in yourself and your ability to quit. You see the
bump in the road as proof that you can’t and
might not ever be able to become smokefree.
You are worse off than before you attempted
to quit.
Remember, a relapse is not
a failure.
You have learned a lot that
you can now apply to your next
quit attempt.
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4
The Road Back to Smoking
Your mind is setting you up. It starts with a whisper, which if not disrupted, grows louder.
Be listening and be aware. Monitor your thoughts. “Maybe” means “yes.”
1.
The ex-smoker
entertains the idea
that there exists a
vage possibility
of smoking again
in the future.
2.
The ex-smoker
accepts the notion
that such a possibility
exists and searches for
those certain conditions that
would provide the
permission
to smoke
3.
The vague
possibility results in the
ex-smoker anticipating,
perhaps even fantasizing
about the smoking
experience.
4.
The anticipation
transforms into craving
which continues
to build until intolerable
levels ar
e reached.
5.
The ex-smoker
now reevaluates how
vague the possibility
to smoke really is. The criteria
for smoking again become
less vague and now
include more
possibilities.
6.
The ex-smoker has
successfully set the stage
for clear permission to
smoke. At this point,
smoking cannot be
avoided...it is just a
matter of time.
In conclusion...
the vague possibility
leads to craving
which leads to
clear permission
which leads to
smoking.
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4
Steps to Take After a Relapse
Get Support
• Attend the UCSF FTTC Freedom
from Smoking/Vaping/Chewing
Support Group to get ideas and
support.
• Use my support system to get
back on course.
Be curious, not critical
Use my lapse as a learning experience.
• What triggers led me o track?
What could I have done dierently?
• What did I get out of smoking?
• What worked well?
• Did I stop taking my stop-
smoking medications
too early? Did I use the
right dosage?
• Did I use my tools and
strategies frequently and
consistently?
• Was I overcondent or did
I take my new smokefree
status for granted?
Recommit immediately
• Do not use my lapse as permission
to keep smoking.
• New Stop Date:
• Estimate how many cigarettes I didn’t
smoke while I was smokefree. Each one
counts as an improvement in my health.
• Tally how much money I saved while not
smoking (pg. 93).
• Review key sections of the workbook:
My “Want to” motivation list (pg. 19)
My Triggers, Urges and Strategies
(pg. 70)
My Stop Plan (pg. 78)
Stay vigilant
•
N.O.P.E: Not One Pu Ever.
• Use my emergency exit when at risk for smoking
or vaping: Leave.
• Monitor my thoughts. Be wary of overcondence.
• Celebrate victories and reward myself.
• Use my mantra frequently.
• Practice my deep breathing exercises several
times a day.
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4
Relapse During Intense Life Events
Stay Vigilant when Life gets Really Bad
or Really Good
Life brings intense experiences, both joyful
and sad. Even if you have been smoke/vape/
chew-free for years, these kinds of experiences
can catch you unaware. It’s not unusual to hear
of relapses related to the period of grief that
comes with the death of a loved one, a divorce,
or an ending of a signicant relationship. Deep
loss can temporarily bring feelings of hopeless-
ness and an inability to care about one’s personal
goals. Do not add to your suffering by allowing
smoking/vaping/chewing to creep back into your
life. Reach out for support and give yourself
extra care and compassion.
Likewise, getting caught up in celebrations such
as a wedding or graduation, you can become
vulnerable to relapse. When in the “bubble” of
what may be “once in a lifetime” events, you may
be tempted to indulge in smoking/vaping/chew-
ing. You may be thinking that this is an isolated
event, but the reality is that for most, this leads
back to addiction.
Protect yourself from a lapse or relapse during
periods of intensity.
• Be aware of your feelings and thoughts,
especially thoughts that give you “permission”
to smoke/vape/chew.
• Explore possible strategies for managing
feelings and thoughts.
• Join a support group if you are grieving the
loss of a loved one or relationship.
• Consider limiting alcohol, or even going
alcohol free while celebrating.
• End the celebration on a high note.
• Attend the UCSF FTTC Freedom from
Smoking/Vaping/Chewing Support Group.
• Review your mantra or update it to reect
the valuable investment you’ve made in
your health.
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4
Quit Bonus Calculator
Stopping smoking puts more money in your pocket. Consider it your quit bonus! How much will
you get?
This link to the Smokefree.gov website will calculate how much money you save by not smoking:
https://smokefree.gov/quit-smoking/why-you-should-quit/how-much-will-you-save
1. Enter how many cigarettes you smoke a day.
2. Enter how much you pay per pack.
If the link doesn’t work, google “smokefree.gov + save money.”
Example from the Smokefree.gov website:
Quit Bonus Amount: $
I plan to use my quit bonus for…
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4
Practice and Exercises Week 4
Read
• Review the workbook and your notes
from time to time.
• “Joyce Lavey” on page 105.
Write
• Set goals to support staying smokefree.
• Continue to document your progress and
feelings.
Do
• Practice deep breathing.
• Remember: be kind to yourself!
• Check in with yourself about preparing
for challenges today.
• What are you going to do this week to
stay smoke/vape/chew free?
• Keep exercising and drinking water.
• Use your Stop Plan to help with urge control.
• Celebrate and reward yourself.
• Join the FTTC Freedom from Smoking/
Vaping/Chewing Support Group:
1. Be part of a community.
2. Prevent relapse.
3. Learn or practice coping skills.
4. Share success.
5. Get support and support others.
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Smoking, Vaping, Chewing Awareness Journal
Date # of cigarettes/
Amount of Vape/
Chew
How have you modied
your behavior?
What makes you want to
smoke/vape/chew? Describe
your feelings and thoughts.
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
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Appendix
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 97
Preparing for Your Journey
Getting ready to quit smoking sets the
foundation for your success. Having an
open and curious mind can help you gure
out what has tripped you up in the past and
how you can address issues now. For example,
trying different ways to address triggers can
help you identify which strategies work best
for you. Experiment!
Unhelpful thinking styles
Your mind is powerful. The way you talk to
yourself can have a big impact on how you feel
and what you do. We would never talk to other
people the way that we talk to ourselves.
Below are some examples of unhelpful ways to
talk to yourself. Circle the ones that you have
experienced.
Keep in mind that thoughts are just thoughts.
They are not necessarily true. When you have
an unhelpful thought:
• Look at the evidence. Is this a helpful
thought?
• What evidence is there that it is not
completely true?
• What is the most realistic outcome?
• How would you talk to a friend or close
family member who was in this situation
and had this thought?
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Unhelpful Thought How It Works Example
All or nothing thinking
You view a situation only in
two categories instead of on a
continuum.
“If I’m not a total success,
I’m a failure.”
Catastrophizing
You predict the future negatively
without considering other, more
likely outcomes.
“I’ll be so upset; I won’t be
able to function at all.”
Disqualifying the
positive
You unreasonably tell yourself that
positive experiences, deeds, or
qualities do not count.
“I did that project well,
but that doesn’t mean I’m
competent, I just got lucky.”
Emotional
reasoning
You think something must be
true because you “feel” (actually
believe) it so strongly, ignoring or
discounting evidence to the
contrary.
“I know I do a lot of things
okay at work, but I still feel
like I’m a failure.”
Labeling You put a xed, global label on
yourself or others without
considering that the evidence
might more reasonably lead to
a less disastrous conclusion.
“He’s a loser. He’s no good.”
Magnication/
minimization
When you evaluate yourself,
another person or a situation, you
unreasonably magnify the negative
and/or minimize the positive.
“Getting a mediocre evaluation
proves how inadequate I am.”
“Getting high marks doesn’t
mean I’m smart.”
Mental lter
You pay attention to one negative
detail instead of seeing the whole
picture.
“Because I got one low rating
on my evaluation (which also
contained several high ratings),
it means I’m doing a lousy job.”
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Unhelpful Thought How It Works Example
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Mind reading
You believe you know what others
are thinking, failing to consider
other more likely possibilities.
“He’s thinking that I don’t
know the rst thing about
this project.”
Overgeneralization
You make a sweeping negative
conclusion that goes far beyond
the current situation.
“Because I felt uncomfortable
at the meeting, I don’t have
what it takes to make friends.”
Personalization
You believe others are behaving
negatively because of you, without
considering one plausible
explanations for their behavior.
“The repairman was curt to
me because I did something
wrong.”
“Should” and “must”
statements
You have a precise, xed idea of how
you or others should behave, and you
overestimate how bad it is that these
expectations are not met.
“It’s terrible that I made a
mistake. I should always do
my best.”
Tunnel vision
You only see the negative aspects
of a situation.
“My son’s teacher can’t do
anything right. He’s critical
and insensitive and lousy at
teaching.”
Clarence Brown
Hello, my name is Clarence. I was a smoker for
33 years. I had my rst cigarette when I was 11
years old. It made me sick and I thought I was
going to die. I smoked again when I was 18 years
old. When I started smoking it was the cool thing
to do and I smoked to be part of the group. As
I became older, smoking became a way of life. I
had a cigarette when I was thinking things over,
when I needed to relax, with coffee, and with
meals. I felt that smoking made me smarter.
When the bad news about cigarettes and health
started coming out, I thought that it wouldn’t affect
me; I kept smoking. When my nurse warned me
about cigarettes’ hazards on my health, I thought
that it wouldn’t happen to me; I kept smoking.
When I was 46 years old, I was intubated for the
rst time. Since I was unable to breathe for myself,
“I had abused
cocaine, heroin,
and marijuana.
I quit them all,
but nothing
was as hard as
cigarettes.”
©JOHN HARDING
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a tube was put down my throat and into my
lungs. Oxygen was pushed through this tube by
a machine. I couldn’t talk because a tube was
down my throat; it was terrible.
I remember being trapped in this hospital bed
with all kinds of tubes going in and out of me.
My only thoughts were about when I could get
out of bed and push my IV to the patio and have
a cigarette. This same story gets repeated seven
times. I’d be in the hospital, intubated, and turn
around and continue the same habits that got
me there in the rst place.
Three years later, I tried to quit for the rst
time. I went to one group, then dropped the
program. It took three more tries, but ve years
later, I quit smoking for good. It wasn’t easy.
I had abused cocaine, heroin, and marijuana.
I quit them all, but nothing was as hard as ciga-
rettes.
As I attended the groups and began to view
myself as a nonsmoker, I began to notice some
changes in my physical health. I was able to
walk farther without having to stop and catch
my breath. I’d recuperate faster at home without
having to come to the hospital. Two years after I
“I went to one group, then dropped
the program. It took three more
tries, but ve years later, I quit
smoking for good.”
stopped smoking, for the rst time in years, I went
a whole year without being hospitalized once!
Believe me, I know it is hard to quit, but you CAN.
It’s your life. I know how the mind can run things.
Always making excuses for smoking, not taking
care of your health or the health of the people
around you. The biggest barrier you have to face is
your mental attitude. That you have to change.
I know my life is much better as a nonsmoker.
My health is better. Even my friends and family
tell me that they see that things are going better
for me.
I used to think, ‘Why should I quit? I enjoy
cigarettes.’ Now as I look back on my smoking,
I didn’t enjoy them. I say to people, “Sure, you
tell me you want to quit, but what are you going
to DO to quit smoking?”
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Barbara Vos
I was born in Long Island, New York, but I
grew up in Brooklyn. I’ve lived in San Francisco
since 1976, the year after my mother died. I went
back to take care of her when she found out that
she had a rare form of cancer. It killed her in six
months. She was a smoker and she never quit.
A pack and a half, two packs a day, that was how
she smoked; she was in a cloud all the time. I was
breathing second-hand smoke my whole life.
Of course, I thought I’d never smoke, because
I hated my mother’s smoking.
When I was in art school, I started rolling ciga-
rettes for this friend of mine. I’m very dexterous
and I like doing things with my hands. I smoked
just one cigarette that was rolled and I felt tough,
tomboyish. On my own, 17, in college, I was
scared. Smoking denitely has a lot to do with
maintaining a stance to stave off fear. You leave
for college and two months later you’re smoking,
the rst time you’re away from the person that
smokes a lot.
I hold a lot of anxieties in my upper respiratory
system and my shoulders. Whenever I focused
on my breath, I would have anxiety because of all
the years of smoking, but also because I had asthma.
I remember having an asthma attack and my
mother smoking at the same time. I remember
walking in the country in some pristine beautiful
place, and the fog, the mist in the morning,
something so frail and beautiful, so fragrant,
beautiful, and ne, and having that smell of smoke.
I remember it being so depressing to have her
trailing behind everybody to hide that she was
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smoking. My mother had a lot of shame and she
just added smoking into that big lot of shame
that she had. If you already have shame in you
then smoking is a pretty handy way to feel it, but
it isn’t a way of dealing with it; it’s just a way of
letting that pain be there and suffering with it.
She always wanted to quit. She never could and
in that pattern of wanting to quit and not being
able to, I felt like I was doing the same thing
that she was doing. I was keeping her alive by
smoking. What made it so hard for me to quit
was letting go of her and doing something that
she hadn’t done.
What really shifted it for me was having a
steady stable place, with all kinds of people with
different stories; everybody’s trying to be truthful
and open, and trying to get help to do something
that they need to do and want to do. It is what
got me to quit: going through all of the practice,
doing all the exercises and really letting it be the
focus. You have to really focus on not smoking,
and do good things for yourself that help you
not smoke. When you’re troubled, it’s hard to do
those good things for yourself instead of smoke.
It could never be a negative, it has to be like
lifting up out of something, and it means taking
care of yourself, which was hard for me to do.
Before, I used to go, “Oh well, I think I’ll
exercise,” and then I’d go have a cigarette. You
can’t exercise right after you have a cigarette.
I never did aerobic exercise before about three
months ago. I never knew what it was really like
to sweat. Deep abdominal breathing if you’re
smoking is too scary. You just couldn’t, because
when you’re taking abdominal breaths, you’re
really thinking about your body. I have another
chance now to have another body, to have a healthy
body. My breathing has changed a lot. I can relax.
My diaphragm used to hurt all the time; now I can
relax it. I feel a spaciousness in my lungs. That is just
one of the best things about quitting smoking. Only
now am I even just beginning to know what it
really feels like to be relaxed. Smoking is the fool’s
relaxation; it’s like fool’s gold.
There’s so much pain in smoking, it reminds you
of your pain. If you have had a terrible thing
happen, a crisis, and you start smoking, then it
just keeps reminding you of that crisis. I used to
think there was something wrong about being in
a bad mood and that I should have a cigarette.
Now I get in bad moods and I don’t like it, but
I’m more willing to not be perfect and not think
that I better smoke a cigarette because I should be
perfect. I feel so much freer from that repetition
of anxiety and pain.
As a nonsmoker, you can focus and be in something
longer, so it pushes your limits a little bit more.
Your anxiety might come and then it goes down,
but you’re still staying with it. It does let you
develop more feelings, like feeling lonely. Things
that would be controlled by having a cigarette can
be explored more and then solved in some way. To
realize that you’re mad at somebody and to let it be
uid, not keep it at a certain point, not decide
“okay, well I’m mad,” and just puff away at a
cigarette, but to say “I’m mad” and then let it be,
ee what’s gonna happen next.
That’s such an amazing thing: to let the natural
course of an emotion go free, without trying to
control it with cigarettes.
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Joyce Lavey
One day when my parents were gone and my
sister and I were taking care of their grocery
store, I took a pack of cigarettes and said, “I’m
gonna smoke.” It was sort of a fuck-you thing
to my parents. My mother’s reaction was,
“Nyaa nyaa nyaa, well you think you’re so smart
smoking,” so I lit up another one.
I was going away to college and I couldn’t afford
to eat three meals [a day], so I smoked and ate
just one meal. It helped me to manage not
knowing if I was going to make it nancially or
otherwise. I used smoking to manage feelings
of anger, fear, and sadness.
When I was angry at somebody I would sit and
think about how I was going to express my anger
to them. I would always think with my ciga-
rettes, and after one, I might have another to
think even more. For 25 years, I was really
angry with myself that I ever started. I was very
anti-smoking before I ever smoked, and I never
ever imagined I would get hooked. I didn’t like
being addicted.
I mentally worked at quitting, but I didn’t make
many real attempts to quit, for 29 years. Before I
quit, I went to Nicotine Anonymous (NA) for
“Before I quit, I went to Nicotine
Anonymous (NA) for two and a
half years. There, I didn’t attempt
to quit smoking. I just wanted to
keep it at the same level.”
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two and a half years. There, I didn’t attempt to
quit smoking. I just wanted to keep it at the same
level. I was nally pushed over the edge because
my oldest sister was diagnosed with terminal
lung cancer and that scared the shit out of me.
I had been diagnosed with breast cancer myself
a few years earlier and I was still smoking.
There is a gene factor in my family for breast
cancer. For the four years I smoked after my
diagnosis, I would say to myself, “I wish I had
quit. Maybe I could have prevented this.”
When I was diagnosed, I thought I’d be gone
before my siblings. I never would’ve thought
that seven years later two sisters would have
died, one of lung cancer, the other of a
pulmonary embolism; another sister would be
diagnosed with lung cancer and have a lung
removed; and still another one would have lung
cancer and be getting chemo. My brother still
smokes. I thought, “The best I can do is to put
myself in groups and talk about it.”
People I knew in Nicotine Anonymous and
Group were supportive of me, for two and a half
years. They never made fun of me for coming
even though I was smoking. They kept nagging
me about a quit date, so, to satisfy them, I picked
a date, but I never intended to follow through.
The day came, and I didn’t have a whole lot
riding on it. I didn’t say “If you quit, you’re good.
If you don’t, you’re bad.” I put the patch on and
that was it. It worked, and I never expected it to.
I never, ever thought I would quit smoking.
I spent so many years whipping myself about not
being able to quit that I got to the point where
“Now, I’m the one who’s sitting
inside myself. I am more real and
more vulnerable and less interested
in maintaining an image. I value
myself and my life over smoking. ”
I gave up punishing myself. When I gave up,
it allowed space for some kind of strength that
I didn’t even know existed.
Not being so hard on yourself is a good start.
When I was always at myself, I was putting
myself in a weakened position.
The nicotine patch really helped. I had temper
tantrums, but it wasn’t like I had imagined it
would be. The thing that kept me from quitting
smoking all those years was that I didn’t want to
experience the extreme discomfort of going
through withdrawal, and I didn’t want to gain
weight. I only gained a few pounds. I started
running, and I went to the movies practically
every night for the rst two to three weeks. I
bought a pacier, so when I got really uptight,
I would chew on the pacier. I had a lot of
trouble carrying on conversations with people,
especially if they bored me or they were long-
winded. I just wanted to shut ’em up. After
stopping smoking, I got in touch with lots of
anger. I found that I could track it more easily
because I didn’t have a distraction. I also got
in touch with how sad I was. I always knew
that, but I didn’t know it went that deep. The
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turning point was nding out that one of my
favorite sisters was dying. That brought it right
home, bang! Even breast cancer didn’t bring it
home to me; her death brought it home to me.
I’m angry at all the death and illness. I have
begun feeling the pain, and when it hits, it’s like
a ton of bricks, like my heart is just breaking.
What surprised me in quitting smoking was
that I was able to experience the death of my
sister and my father’s death and then another
sister’s death, all of this really heavy stuff,
without returning to smoking. I wonder if
I could have done that if I hadn’t been
chewing Nicorette gum.
One sister had tried a number of times to quit
and had not been successful, but she was very
supportive of me. When I relapsed, she said,
“Just because you smoked three or ve cigarettes
doesn’t mean you can’t put the patch back on and
start all over again.” She really helped me quit.
Cigarettes helped me isolate. Now, there isn’t
that barrier, so I relate to people. When I smoked,
I could distance myself with cigarettes. I could
stay home with cigarettes rather than seek
company. Now I turn to people for support more
than in the past. I’m more genuine, more honest
with people, and honest with myself about what
my needs are and what I want. I’m a kinder
person, more considerate, and more generous
than I was before. I’m more even tempered,
I are up less, and I’m more tolerant. I don’t
have all that shame I had about smoking. I
don’t have that mental agony, that torture. I
feel so much better.
My self-esteem is higher, and I feel more
attractive. I feel able to handle most things in
my life because I’m doing it without cigarettes.
I thought I was strong before. But now I realize
I have an amazing amount of strength that I didn’t
even know I had. When I was a smoker, I felt very
weak. I felt all my strength was false because I was
dependent. Now, I’m the one who’s sitting inside
myself. I am more real and more vulnerable and
less interested in maintaining an image. I value
myself and my life over smoking.
I now see how people sacrice their health and
well-being to cigarettes. The tobacco companies
disgust me. I believe in people’s right to smoke.
But having one sister die at 61, another sister lose
a lung at 52, and still another sister with stage
three lung cancer at 52, I see it’s a human
sacrice, and it’s very sad. I don’t condemn
people for smoking, I just feel sad because of
my own experience.
I was so grateful to quit smoking after 29 years.
I never thought I would be able to do it. I thought
I was married to cigarettes—that I was in a prison
serving a sentence. Why would I want to go back
to all that self-hatred that comes with smoking?
Life is rough enough without that torture. Here I
was with breast cancer and I was smoking. I hated
myself every time I lit a cigarette and always said to
myself, “Who is this person? She must want to die.”
That self-torture is what I didn’t want to return to.
I felt like a hard-core, I’ll-die-with-a-cigarette-in-
my-hand person. No matter how hopeless people
feel, they should never give up. I am a testament
to hopelessness turned hopeful.
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Ernie Ring
I am currently chief medical ofcer for UCSF.
1
It is a key position and an opportunity to play
a role in how hospitals work and potentially
to have a role in improving the overall care
provided at UCSF to the thousands of patients
we serve each year.
I graduated from medical school in 1969
and have been a practicing physician for
37 years. I received training in radiology at
the Massachusetts General Hospital in
Boston. I stayed on an extra year, as chief
resident and a fellow in what was then called
angiography, to get special training in the
catheterization procedures that were done in
the 1970s. I joined the faculty at the University
of Pennsylvania in 1976 to head up the
angiography section. As part of that experience
I was put in a position to help innovate what
became a new eld of medicine, interventional
radiology. We had a remarkable relationship
with the surgery department, who saw the
kinds of procedures that we were able to do
under uoroscopic guidance with catheters
as an opportunity to be very innovative in
©JOHN HARDING
practicing surgery. We worked together closely
to expand this methodology into a major new
approach to the treatment of surgical patients.
I eventually became president of a society that
promotes interventional radiology. The creation
of the society’s journal took place in my ofce;
the establishment of a foundation to support the
research side took place over conference calls
in my ofce. Then I became a member of the
board of chancellors of the American College of
Radiology, where I helped move interventional
radiology from a group of procedures done by
1 Ernie Ring, MD served as Chief Medical Ofce of UCSF Medical Center from 2004-2008.
108 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
fearless and creative people to a eld that is now
practiced throughout the world. It has given me
an opportunity to lecture on new procedures
around the globe and to see them developed
and become part of treatment in nearly every
country on earth.
In 1997, I had my rst heart attack. At the time,
I was working eighty to one hundred hours a
week at a job with enormous responsibility.
I was not only engaged in complex procedures
but also expected not to have failures or
complications, and that meant I had to oversee
every procedure done by my colleagues. It
was a very gratifying time, a very difcult time,
and, eventually, it overwhelmed me physically.
I started smoking when I was fteen, primarily
because that’s what everybody did. It was in
the 1950s, and smoking was the norm. I
quickly became addicted. There was nothing
wrong with it. It was accepted. Throughout
the 1960s and 1970s, smoking in the hospital
was standard practice. In those days, there was
no digital imaging,
There were no digital imaging, so to see what
you were doing with these procedures, you took
frequent breaks to interpret lms and evaluate
your progress. Everyone would light up outside
“I really enjoyed smoking. I truly
believed that it helped me to think.
It was widely known among the
people who trained with me that
when a case was difcult or going
badly, I would go into my ofce
and come out with a solution
to the problem.”
the processor while waiting for the lm. I
would smoke two packs on those eighteen-hour
days.
In the 1980s, as society gained a better
understanding of the dangers of smoking,
more and more restrictions on smoking were
imposed and social unacceptability grew.
Between 1980 and 1990, smoking went from
being pretty normal and socially acceptable to
being something that could not be done around
others, and totally unacceptable. By 1990, I was
smoking surreptitiously in my ofce.
When I had the heart attack in 1997, it was a
reafrmation of what I already knew. The
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 109
“I nally got somebody at Stanford
to say, “Just keep putting patches
on until you feel comfortable.”
primary disease that I treat is peripheral vascu-
lar disease, but everybody I treat is a smoker.
I would tell my patients that I smoke, and I
would tell them that they had the disease and
I didn’t. Then I would tell them to quit
smoking because the disease was only going
to get worse; the people who had never smoked
who told them to quit didn’t understand what
I was asking them to do. But I did understand.
I recognized how hard it was to quit, and when I
nally got the disease, I would have to quit too.
I really enjoyed smoking. I truly believed that
it helped me to think. It was widely known
among the people who trained with me that
when a case was difcult or going badly, I
would go into my ofce and come out with a
solution to the problem. I was concerned that
smoking was something I could rely on as a
benet when I needed it: clarity of thought for
re-energizing at two or three in the morning.
I saw it as a great benet—a great risk, yes,
but also a great benet. I enjoyed it to the
extent that it became relatively easy to deny
the risk to continue to achieve the benet. I
continued to feel that way after my rst heart
attack right up until my second one in 2003.
At that point, I decided to quit. But it was
extremely difcult: the physical addiction, the
mental dependence, the overall feeling of clarity
I believed it gave me when I needed it, the absence
of friends to turn to. I was the expert, and smoking
was both a crutch and a friend that were very real
to me. Giving that up in the complicated world in
which I lived was tough. The mechanism ultimately
involved lots of nicotine.
The mornings were the hardest, and moments
of decisiveness were difcult.
I liked everything about smoking. In the early
years, I liked the camaraderie associated with it.
I liked the time-out nature of it. I liked the taste
of it. It was part of my persona. Take me or leave
me. I am really good at being who I am. I am
really good at what I do. It is my business, not
yours. After my second heart attack, my wife
insisted that I quit smoking, and her reasoning
was solid: only a fool would continue to smoke
after two cardiac events. Up to that point, it
had been almost part of a caricature of me: most
people knew me as a smoker and recognized
me from afar even if all they could see clearly
was a cigarette. But once the second heart attack
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demonstrated the damage smoking was causing
me, it would have only been a demonstration of
some pretty dumb behavior to continue. That
fact was highly motivating.
I nally got somebody at Stanford to say,
“Just keep putting patches on until you feel
comfortable,” which took the process from
impossible to just very difcult. That lasted
probably nine months. I augmented the patches
with nicotine gum as needed, despite wearing
three patches at once at one point. Eventually,
I got off the patches. I was in no rush. It took
more than two years before I didn’t think about
smoking all the time.
Once I made the decision to quit, I saw it as
an enormous challenge. I was willing to give
up everything that I had been for the past
40 years to become whatever I would be as a
smoke-free person. The challenge was more
than just giving up a profound addiction. It
was also the willingness to accept everything
that came with that.
Everything discourages smoking now. There is
no reason to start. In most of society, it is totally
unacceptable. Of course, there may be some
sense of leadership or uniqueness associated
with smoking, just as there is with tongue
piercing or tattooing, all practices that t into a
“I augmented the patches with
nicotine gum as needed, despite
wearing three patches at once
at one point.”
similar “outside-the-norm” category. But that’s not
the way it was 45 years ago, and I think that is an
important change.
The key message now is to stay away from
smoking in the rst place. There is no reason to
start, and it is so hard to undo once it is done.
The cost, the stigma, and the labeling associated
with smoking will have devastating implications
for your entire life. I didn’t have that when I
started. It was okay to have the ambition I had
to be an important, leading physician and to
be a smoker. That is no longer true. If you
choose to smoke today, your future will be
subject to constraints. It is not the health side
that is going to keep you from smoking; you
have to wait too many years to feel the effects of
that. The thing that makes you feel badly is the
stigma. When you think highly of yourself and
success is measured in a lot of different ways,
smoking in an overachieving world is a symbol
of underachievement.
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Breathing, Smoking, and the
Stress Response
The quality of our breath affects the quality of
our lives. When smoking and/or vaping lead to
breathing problems, the effects are felt in dai-
ly life. Many people nd they become winded
walking up a ight of stairs or feel chest tight-
ness several times a week or even daily.
Over time, lung health can worsen and lead to
chronic obstructive pulmonary disease (COPD).
In addition to shortness of breath and increased
phlegm production, COPD causes muscle wast-
ing of the limbs. As we age, we all experience
some loss of muscle mass, but this is worse in
people with COPD.
If left unchecked, COPD leads to needing to
carry an oxygen tank. This will limit how far
or quickly a person can move. It is a burden to
carry or drag a bulky tank, and some may feel
self-conscious about being dependent on oxygen.
People who smoke may avoid exercise because
it can worsen shortness of breath and muscle
cramping. Sometimes people avoid doing the
things that will draw their attention to the
decline in their ability to exercise. Lack of
exercise leads to problems with muscle tone,
joint and exibility problems, constipation, etc.
Many people can experience depression as they
become less able to do simple daily activities.
Becoming aware of disturbing symptoms can
be an important step in breaking out of denial.
Once that has been done, you can address the
problem. Pay attention to how you feel when
you are inhaling the cigarette or vape. Notice
what you feel in your chest and throat. Be aware
of any breathing problems and consider the
improvements that will occur with stopping
smoking or vaping.
People who smoke often use cigarettes to man-
age stress. They may not be aware that smoking
itself causes stress for several reasons.
112 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
Check the ways that smoking creates
stress for you and add your own to
the list below:
Planning where and when to smoke
Recurring nicotine withdrawal
Paying for cigarettes or vapes
Friction with family and friends
Anxieties about health
The Stress Response
The stress response is a complex series of
changes that happen in the body to manage a
threat. Whether real or imagined, the body goes
into survival mode to either ght or ee from
danger. When the stress response is triggered,
here are a few things that happen:
• The heart beats faster.
• Blood pressure rises.
• Breathing becomes rapid and shallow.
• Muscles tense.
• Adrenaline and cortisone are released into
the circulation.
The Relaxation Response
The relaxation response is the opposite of the
stress response.
• Breathing becomes deep and slow.
• Blood pressure drops to normal.
• Heart rate decreases.
• Muscles relax.
• Excess cortisol and adrenalin are eliminated.
Deep Breathing
Research shows the easiest and most powerful
tool for reversing the stress response is deep
breathing. Slowing down and deepening the
breath into the belly creates a bridge from the
stress to the relaxation response.
• The heart slows and blood pressure normalizes.
• Sleep deepens.
• Energy, concentration, focus, and memory
increase.
Our natural state of breathing is to take the breath
deep into the abdomen. When breathing becomes
shallow, stale air lls the lower portion of the
lungs. The upper part of the chest rises and the
abdomen never completely relaxes. Breathing
takes more effort and is faster.
Abdominal breathing helps to lower the breathing
rate and fully expand the lower lungs. Since the
most efcient part of the lungs is being used for
richer and easier oxygenation of blood, the lungs
don’t have to work as hard.
For many people, deep breathing is a skill that
needs to be relearned. For people who smoke,
it can also be an effective technique to delay
smoking and ultimately stop.
Here are some exercises to get you started.
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 113
Breathing Exercises
Practice these exercises several times a day.
Making them familiar will let you use them
when you need them. They will help to
postpone or eliminate cigarettes and
manage stress.
4-7-8 Breathing Technique
(from Andrew Weil, MD)
1. Sit comfortably.
2. Empty the lungs of air.
3. Breathe in quietly through the nose for
4 seconds.
4. Hold the breath for a count of 7 seconds.
5. Exhale forcefully through the mouth,
pursing the lips and making a “whoosh”
sound, for 8 seconds.
6. Repeat up to 4 times.
Deep abdominal breathing:
1. Sit comfortably tall in a chair with your feet
at on the oor, about shoulder width apart.
2. Take in an easy normal breath through
your nose.
3. Purse your lips and exhale through your
mouth as though you were blowing out a
candle.
4. Keep blowing until you can no longer
exhale and then allow the breath to come
back in naturally and effortlessly. The
inhalation will be deep and go to the
abdomen.
5. Practice this exercise several times a day with
5-10 deep breaths each time.
Relaxing sigh:
1. Sit or stand comfortably.
2. Breathe in through your nose and, at the
same time, raise your shoulders up to
your ears.
3. Hold the breath and the position of your
shoulders for a few seconds.
4. Let your shoulders drop as you exhale the
breath with a loud sigh.
5. Repeat 8–10 times.
114 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
Stopping Smoking/Vaping/Chewing
and Weight Gain
Nicotine is an appetite suppressant. It makes you
want to eat less. When you stop smoking, vaping,
or chewing, you may nd that you want to eat
more or eat more frequently.
On average, some people gain about 5 to 10
pounds of weight when they stop smoking. A
small amount of people gain more weight. Using
nicotine gum or Bupropion can delay weight
gain. They do not completely prevent it.
The health benets of stopping smoking, vaping,
and chewing are greater than the health risks of
gaining weight.
Ways to stay at a healthy weight
1. Get moving.
• Exercise reduces the urge to smoke/vape/
chew and helps to manage withdrawal
symptoms.
• CDC guidelines recommend most adults
exercise for 150 minutes a week. You
don’t have to do it all at once. It could be
30 minutes a day, 5 days a week.
• Moderate aerobic exercise gets you
breathing harder and your heart beating
faster. During the activity you can talk,
but not sing.
• Examples of moderate aerobic exercise:
- Walking briskly
- Riding a bike on level ground or with
a few hills
- Water aerobics
- Playing doubles tennis
- Pushing a lawn mower
- Taking a dance class
- Leisurely swimming
2. Drink plenty of water.
Staying hydrated prevents overeating, ushes
toxins, and prevents constipation.
3. Use calorie-free substitutes.
To manage a hand-to-mouth compulsion,
try avored toothpicks, straws, and
cinnamon sticks.
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 115
4. Diet carefully.
Restrict calories cautiously; feeling hungry
can increase the urge to smoke.
5. Choose healthy foods.
• Eat more whole foods like fruits and
vegetables. Whole foods can be found
fresh, frozen, canned, or dried.
• Choose good fats and lean proteins such
as sh, eggs, skinless poultry, nuts,
vegetable oils, plain Greek yogurt, beans,
peas, and lentils.
• Limit processed foods. They contain
added preservatives, avors, or additives
like salt, sugars, and fats. Examples of
processed foods are simple bread, cheese,
and canned tuna, and canned beans.
• Avoid ultra-processed foods. These foods
contain all the additives of the processed
foods and have also gone through
processing that changes the food’s
stability, texture, and taste, and shortens
the cooking time. Examples of ultra-
processed foods are sugary drinks,
cookies, some crackers, chips, breakfast
cereals, candy, ice cream, hot dogs,
luncheon meats, and frozen foods like
pizza, fast food, microwave dinners,
pre-made frozen foods.
6. Plan and prep meals.
• Eat at regular times. Getting too hungry
can lead to poor food choices and
over
-eating.
• Be ready with low-calorie snacks like
carrot sticks and jicama sticks prepared
ahead of time.
7. Limit alcohol.
Alcohol provides calories, but not nutrients.
For more information, see appendix page 118.
8. Get enough high-quality sleep.
• Sleep at least 7 hours a night. Fewer hours
of sleep affect hormones that can make you
feel hungry, eat more, and store more fat.
• Poor sleep because of sleep apnea has been
linked to weight gain.
• Feeling tired can make you seek out more
sugar and “comfort” foods.
9. Remain aware of your mood and motivation.
• Eat only at mealtimes or when you are
hungry.
• Consider if you are eating because of
some other reason, such as feeling bored
or anxious.
10. Get help.
Depending on your goals, it may be worthwhile
to talk to a nutritionist.
116 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
Suggestions for low calorie foods and avorings
Low-calorie foods that can be eaten without limitation
• Cucumbers
• Daikon
• Radishes
• Jicama
• Tomatoes
• Zucchini
• Lettuce
• Kale
• Spinach
• Celery
• Popcorn
• Watermelon
• Asparagus
• Cauliower
Very low-calorie foods
• Carrots
• Oranges
• Beets
• Mushrooms
• Grapefruit
• Brussel
sprouts
• Apples
• Strawberries
• Blueberries
• Broccoli
Low-calorie avorings
• Lemons
• Kimchi
• Horseradish
• Vinegar
• Salsa
• Sauerkraut
• Sharp
cheddar
• Parmesan
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 117
Why Heavy Drinking Seems to
Boost Desire to Smoke More
WEDNESDAY, May 18, 2016 (HealthDay
News) -- The reason alcoholics struggle to stop
smoking may be because their heavy drinking
speeds up how quickly their body breaks down
nicotine, a new study suggests.
“Our study showed that chronic heavy alcohol
consumption may lead to an increase in the rate
of nicotine metabolism, which could be one
contributing factor to the poor smoking
cessation rates in smokers addicted to alcohol,”
said senior study author Maciej Goniewicz.
Nicotine metabolism is the term used to describe
how quickly a body breaks down this addictive
substance. People who break down nicotine
more slowly may have an easier time quitting
because the nicotine stays in their body longer.
But, the investigators found, alcohol appears to
speed up the breakdown of nicotine.
For the study, the researchers measured markers
(such as cotinine) that indicated nicotine levels
among male smokers in Poland who were being
treated for alcoholism. The measurements
were taken immediately after they’d stopped
drinking, and four and seven weeks later.
The results indicated that nicotine metabolism
returned to normal by the fourth week after the
men stopped drinking, according to Goniewicz,
an assistant professor of oncology at Roswell
Park Cancer Institute in New York, and
colleagues.
The study didn’t prove that heavy drinking
makes it harder to quit smoking. But,
Goniewicz said, “it is an important nding
since a faster rate of nicotine metabolism was
previously found to be associated with
smoking more cigarettes per day, greater
nicotine withdrawal symptoms and decreased
efcacy of nicotine replacement therapy for
smoking cessation.
“Importantly, we also found that when smokers
stopped drinking, their nicotine metabolism
slowed down,” he added in an institute news
SOURCE: Roswell Park Cancer Institute, news release
118 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
release. Once that happened, nicotine stayed
longer in their bodies so their withdrawal
symptoms were not as intense.
Study co-author Dr. Neal Benowitz, a professor
of medicine at the University of California,
San Francisco, said the ndings “could have
important implications for understanding
smoking behavior and improving smoking
cessation interventions for current and former
heavy alcohol drinkers.”
In addition, Benowitz said, “This could have
implications for the timing or choice of smoking
cessation treatments in recovering alcoholics.”
The study was published recently in the journal
Drug and Alcohol Dependence.
Goniewicz received a research grant from
Pzer Inc., and Benowitz serves as a paid
consultant to pharmaceutical companies that
market or are developing smoking cessation
medications and has been a paid expert witness
in litigation against tobacco companies.
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 119
Nicotine Withdrawal Symptoms:
Time Course*
Irritability/Frustration/Anger
Anxiety
Difculty Concentrating
Restlessness/Impatience
Depressed Mood/Depression
Insomnia
Impaired Task Performance
Increased Appetite
Weight Gain
Cravings
Most symptoms manifest
within the rst 1–2 days,
peak within the rst week,
and subside within 2–4 weeks.
Quit
date
1 week 4 weeks 12 weeks
6 months
Can persist for months to
years after quitting
Recent quitter
Former tobacco
user
*Timeline aspect of the figure is not according to scale. Data from Hughes. (2007). Nicotine Tob Res 9:315—327
120 | Fontana Tobacco Treatment Center | Stop Smoking/Vaping/Chewing Workbook
In Gratitude
Jeanne Fontana contacted the UCSF Tobacco Education Center (TEC) in 2007. She had attempted
to quit smoking many times before and had little hope that this program would work for her any
more than anything else she had tried. She suffered from a number of smoking-related diseases,
which forced her to carry an oxygen tank.
When Jeanne showed up at my ofce, she was irritable and defensive. “I’m tired of snooty people
who treat me like some kind of dumbbell, like I don’t know smoking is bad for me!” She went on
to say that she knew to expect a lot of nger-wagging over how she made herself sick. She was not
about to put up with it.
My reply took her off-guard. “I have been waiting for you for such a long time! All those things you
are saying are exactly what we do not want to do in our program. Please come and see what we do
and, if you catch us being judgmental or pushy, let us know right away.”
Initially, Jeanne, like all TEC participants, attended the Center on a weekly basis for one month.
In the class that I was teaching, she watched me like a hawk, ready to pounce at any perceived insult.
I persisted with reassurance, acceptance, and support.
Jeanne kept to her half of our bargain and came to each class. She practiced all the exercises.
She learned information that turned out to be critical to her ultimate success. In the pharmacy
class, for example, she found out about combining medications and used both the nicotine patch
and the Nicotrol inhaler. She was also profoundly inspired by the story of Clarence Brown, a
long-time smoker and former patient of mine. He had advanced pulmonary disease and, after
much effort, became smokefree. “Clarence became my role model. His story moved me to tears.”
When it came time to quit between the third and fourth weeks of the program, I called to check in
Stop Smoking/Vaping/Chewing Workbook | Fontana Tobacco Treatment Center | 121
with Jeanne. “I so appreciated your calling me. I was struggling. Am I going to do this or not? I had
prepared to quit. I felt like I didn’t have any excuses.”
By the end of the four-week program, Jeanne was smokefree. “Holy cow, I quit smoking!”
I encouraged her to reward herself. She went for that in a big way and was very excited.
For the next two years, Jeanne became a regular participant in our weekly relapse prevention
group. Although she relapsed briey, when she died in 2009, Jeanne had been smokefree for a
year. Grateful for the help she received to overcome her addiction, she made TEC a beneciary
of her estate.
Jeanne knew as well as any person who has experienced tobacco dependence what an incredibly
powerful addiction this is. She also knew the feelings of shame and hopelessness that can persist
as we keep smoking, even with debilitating smoking-related disease. At TEC, she discovered that
nding the right treatment and learning how to support herself were key to her success. She was
passionate about doing whatever she could to ensure that other smokers would have the same
opportunity for freedom that she had found.
With deep gratitude, the Fontana Tobacco Treatment Center, now named in Jeanne’s honor,
continues to impact the lives of hundreds people working to become free of tobacco and nicotine
dependence annually. .
Suzanne Harris, RN, NCTTP
CO-DIRECTOR AND NURSE ADMINISTRATOR
FONTANA TOBACCO TREATMENT CENTER
Fontana Tobacco Treatment Center 122 | | Stop Smoking/Vaping/Chewing Workbook
