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Diabetes Standards of Care & Clinical Practice Resources

Tobacco and e-cigarette use

Tobacco use increases the risk of cancer, heart and lung diseases, and other illnesses. All forms of commercial tobacco–including cigarettes, chewing tobacco, and electronic nicotine delivery systems (commonly known as e-cigarettes or vapes)–contain nicotine and other harmful chemicals. People with diabetes should avoid using any commercial tobacco.

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Tobacco and e-cigarette use Sections

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Clinical Practice Recommendations

Tobacco Use Screening and Interventions

Tobacco use raises the already elevated risk of complications in people with diabetes. Tobacco dependence cessation treatment can significantly increase quit rates. Effective intervention strategies include counseling, behavioral support, and medications.

  • Screen people with diabetes at least once a year for non-ceremonial tobacco use (cigarettes, chewing tobacco) and exposure to secondhand smoke. Exit Disclaimer: You Are Leaving www.ihs.gov 
  • Advise tobacco users to quit and assess their willingness to quit, at every diabetes visit.
  • Use evidence-based models such as the Five Major Steps to Intervention Exit Disclaimer: You Are Leaving www.ihs.gov  (The “5 A’s”: Ask, Advise, Assess, Assist, and Arrange) for nicotine dependence cessation.
    • Ask about tobacco use - Identify and document tobacco use.
    • Advise to quit - Urge every tobacco user to quit.
    • Assess - Is there a willingness to quit?
    • Assist - For tobacco users willing to quit, offer cessation counseling and treatment including nicotine dependence medications or refer the patient to a tobacco cessation program (or outside referral services such as 1-800-QUIT-NOW or smokefree.gov). Exit Disclaimer: You Are Leaving www.ihs.gov 
    • Arrange - Schedule follow up, preferably within the first week after the quit date.

Tobacco cessation medications are available on the IHS National Core Formulary (for details see National Pharmacy and Therapeutics Committee Formulary Brief: Nicotine Dependence: [PDF]

  • Nicotine replacement therapy (long-acting patch and rapid-acting products such as gum, lozenges, inhaler and nasal spray)
  • Bupropion SR (Zyban)
  • Varenicline (Chantix)

Note: E-cigarettes are not FDA-approved for smoking cessation, and the U.S. Preventive Services Task Force has concluded that evidence supporting their use for smoking cessation is insufficient.

Electronic-cigarette Screening and Education

E-cigarettes or vapes may lead to addiction, affect brain development in youth and young adults, and cause respiratory illness. Individuals who “vape” may be at risk for E-cigarette or Vaping products Associated Lung Injury (EVALI).
(see Electronic Cigarettes) Exit Disclaimer: You Are Leaving www.ihs.gov 

  • Screen people with diabetes for Electronic Nicotine Delivery Systems (ENDS) use at least once a year.
  • Advise ENDS users to quit and assess their willingness to quit, at every diabetes visit.
  • Encourage people who use ENDS to participate in nicotine dependence cessation programs.

Patient Education Resources

Online Catalog: Free Tobacco Cessation Resources

IHS Division of Diabetes Treatment and Prevention


Tobacco Prevention

Indian Health Service


Smoking and Tobacco Use Exit Disclaimer: You Are Leaving www.ihs.gov 

Centers for Disease Control and Prevention


Smokefree.gov Exit Disclaimer: You Are Leaving www.ihs.gov 

Department of Health and Human Services