Tobacco use has detrimental effects on all aspects of women’s health and is one of the leading causes of early death for adults. The use of tobacco can lead to various forms of cancer, lung disease, reproductive health issues, and many other problems. Additionally, maternal smoking is a modifiable risk factor that can directly impact birth outcomes. Tobacco use during pregnancy can lead to restricted fetal growth, preterm birth, birth defects, and Sudden Infant Death Syndrome (SIDS). As such, it is important for healthcare providers and programmatic personnel to identify tobacco use among their clients and offer comprehensive interventions to address cessation efforts.

Ohio Smoke Free Families has developed several resources, including provider toolkits and set of resources to be used with the consumer, to educate providers on tobacco use and cessation to help tobacco users in all stages of the quit process. These are accessible through the links below or the hovering bubbles on the right of your screen.

Provider Toolkit Includes:

  • 5 A’s Algorithm
  • Stages of Change Model
  • Motivational Interviewing Steps
  • Client Intake Form
  • Intervention Record
  • 5 R’s Detailed Description
  • Referral Resources

Please use the tabs below to access additional resources on Pharmacology, E-cigarettes, Mental Health, and Other Substance Use.


When a tobacco user does not successfully complete a quit attempt with psychosocial interventions alone, treatment specialists may suggest pharmacology. Pharmacotherapies for smoking cessation prove to be effective in reducing withdrawal symptoms and blocking the effects of nicotine without negative effects. Pharmacological aids, or Nicotine Replacement Therapies (NRT), can include a NRT trans-dermal patch, gum, nasal spray, inhaler, and lozenges. Additional options include oral medications like Bupropion (Zyban) and Varenicline (Zyrtec). Some forms of replacement therapies provide the tobacco user with a small amount of nicotine to help curb the symptoms of withdrawal and help to manage cravings.

Pharmacotherapies can also cause potential side effects in the user, depending on the treatment used, and their use should be monitored by a licensed healthcare professional. Additionally, the effects of nicotine replacement therapies have not been widely studied with women who are trying to become pregnant, currently pregnant, or breastfeeding. The best candidates for this type of therapy are tobacco users who are not currently pregnant, motivated to quit, and heavy smokers (i.e. greater than 10 cigarettes per day). Providers should ensure all clients have thoroughly exhausted behavioral intervention therapies independent of NRT prior to encouraging the use of pharmacology.

For more information on consumer education, download the consumer resources or visit the Help to Quit section of our website.

Citation: The American College of Obstetrics and Gynecologists (2015). Smoking Cessation During Pregnancy. Retrieved September 28, 2016 from


Electronic Cigarettes, or e-cigarettes, contain a nicotine-based liquid called e-juice. The e-cigarette cartridge heats the juice to a point where it turns to vapor and is able to be inhaled by the user. There are versions of e-cigarettes that look similar to traditional cigarettes and simulate a traditional smoking experience. Other less traditional versions of e-cigarettes include MODS and cigalites that may include the option for refillable cartridges. The amount of nicotine delivered by an e-cigarette varies based on the device, juice used, and user.

Are E-Cigarettes Safe?

There is limited information on the safety of e-cigarettes, though data shows that less nicotine is typically inhaled when using an e-cigarette compared to a traditional cigarette. However, e-cigarettes contain other chemicals like Nitrosamine, Diethylene glycol, Diecetyl which are shown to be associated with certain types of cancer.

It is important for both the healthcare provider and user to know that e-cigarettes have not been regulated in the United States and as such there is little oversight on which contents are included in an e-cigarette. This may be subject to change, pending a ruling by the Federal Drug Administration (FDA) in August of 2016, in which all tobacco products would be subject to the Federal Food, Drug and Cosmetic Act.

Despite the risks, e-cigarettes have continued to rise in popularity over the past few years with adolescents and young adults.  According to the National Youth Tobacco Survey, the use of e-cigarettes has increased from about 4% in 2011 to almost 16% in 2015. Among adults, the use is highest among ages 18-242. With little information on the long term health impacts of these types of products, health care providers should caution their users on the using these to supplement or replace traditional tobacco projects and instead focus on the quit process.

Citation: Centers for Disease Control and Prevention. Tobacco Use Among Middle and High School Students - United States, 2011–2015. Morbidity and Mortality Weekly Report, 2016;65(14):361–7. Schoenborn and Gindi (2015). Centers for Disease Control and Prevention. Electronic Cigarette Use Among Adults: United States, 2014. NCHS Data Brief No. 217, October 2015.

Dangers to Children

The liquid used in e-cigarettes comes in hundreds of flavors including chocolate, bubblegum, and cherry. These flavors can appeal to young children, so all users should ensure they are kept high and out of reach from children.

Due to the high concentration of nicotine and chemicals, drinking e-juice can result in illness or even prove fatal to children.

E-cigarette vapor also leaves a deposit which can accumulate on surfaces like the tables and floors. Children who touch these surfaces can get the deposits on their skin and ingest them through their skin or orally. Even small amounts of exposure to either nicotine or the other chemicals found in e-juice can be unsafe for children.

Learn more!

E-cigarettes are commonly viewed as the safer option than traditional cigarettes, but nicotine is not safe regardless of the form in which it is used. For more information on e-cigarettes, see our fact sheet or visit our Help to Quit page to learn more about available educational resources for consumers.

Mental Health

According to the CDC, “Nicotine has mood-altering effects that put people with mental illness at higher risk for cigarette use and nicotine addiction.” In fact, individuals with a mental illness are more likely to smoke tobacco products. One in three adults (36%) with a mental illness use cigarettes, compared to about one in five adults (21%) with no mental illness . There are a variety of possibilities that come into play when considering why this population is more vulnerable to tobacco use.


People with mental illness are more likely to report:

  • Having a stressful living situation
  • Obtaining less education
  • Being low income
  • Being Medicaid or Medicaid eligible vs. private insurance
  • Lacking access to health care

Did you know?

Smoking during pregnancy can lead those babies to develop mood and behavioral disorders later in life.

All of these factors put the individual with a mental illness at higher risk for stress as well, which in and of itself is a trigger for tobacco use. Tobacco is often accepted by the user as a way to self-medicate or reduce symptoms of their mental health diagnosis. While the nicotine in cigarettes may give the user a brief high, it is a short-lived side effect and only increases long term damage to the user’s health. All of these scenarios compounded demonstrate that individuals who live with mental health challenges face a unique risk for long term tobacco use, and traditional interventions to quit should be closely monitored.

If a tobacco user with mental illness indicates a willingness to quit, mental health professionals should be included in the quit process to monitor potential behavioral changes that can occur when withdrawing from nicotine. If the client’s mental health diagnosis has warranted medication to manage the symptoms, health care providers should also be aware that these medications must be monitored closely and may need to be adjusted. Medications are often less effective when nicotine is present, so upon quitting, the client may experience increased side effects from certain medications. For more information on assisting clients with mental illness in the quit process, please visit the Provider Toolkit.

Citation: Centers for Disease Control and Prevention (2013). Adult Smoking. Focusing on People with Mental Illness. Retrieved October 28, 2016 from

Other Substance Use

Adults with substance use disorders smoke cigarettes more than people who do not have a substance use disorder. Prevalence of smoking is 3 to 4 times higher among people who are being treated for substance abuse than that of the general population. The combination of smoking and substance abuse poses an even higher risk for users to die prematurely than just substance use alone. In fact, substance users who smoke are four times more likely to die prematurely than users who do not smoke.

Although there is strong evidence linking tobacco use and substance abuse to negative health outcomes and premature death, smoking cessation has not regularly been incorporated into substance abuse treatment programs. In the US, only 42% of substance abuse treatment centers offered tobacco cessation services and only 34% offered counseling in 2011. Resistance to treating co-morbid addictions has often been based on the concern that treatment to both conditions would decrease referrals and increased dropout rates in substance use treatment programs.

Studies have shown, however, that treating both addictions does not impact recovery from substance use or referrals to treatment programs. One study found tobacco cessation combined with substance use treatment may even help users quit drug use. Participants who received tobacco cessation services in another study were nearly twice as likely to have stayed substance free than participants who had not received tobacco cessation services. Surveys have also shown clients to be interested, ready, and willing to participate in treatment programs that concurrently address substance and tobacco use.

Substance and tobacco users should always be offered treatment if they are willing to quit, and a trained professional should be included in the quit process. Several forms of treatment have been shown to be effective in increasing the quit rate for substance users who smoke. The 5 A’s method has been recommended by the U.S. Public Health Service for treatment with any patient with a nicotine addiction. Along with the 5 A’s (Ask, Advise, Assess, Assist, Arrange), a sixth A of Affirm has been recommended when working with substance abusers. With this recommendation, providers are encourage to Affirm past successes and acknowledge the client’s strengths. Pharmacotherapy, phone support, and other forms of psychotherapy, including Motivational Interviewing, have shown success as treatment options in residential, methadone maintenance, outpatient, inpatient, and detoxification settings for substance and tobacco users.

For more information on the 5 A’s method, Motivational Interviewing, and assisting substance and tobacco users in the quit process, please visit the Provider Toolkit.


6. 20Rprt 20Tobacco 20Cessation 20Services/The 20N-SSATS 20Report 20 20Tobacco 20Cessation 20Services/The 20N-SSATS 20Report 20 20Tobacco 20Cessation 20Services.htm