Patient Name: ___________________________
Date: ___________________________
Nurse/Provider: ___________________________
1. Why Quitting Smoking Matters
Smoking harms almost every organ in your body. Quitting lowers your risk of:
Heart attack and stroke
Lung cancer and other cancers
COPD and breathing problems
High blood pressure
Poor wound healing
Early death
Good news: Your body starts healing within minutes to days after your last cigarette.
2. What to Expect After You Quit
You may experience:
Cravings
Irritability or mood changes
Headache or difficulty concentrating
Trouble sleeping
Increased appetite
Coughing as your lungs clear
These are normal and temporary. They usually improve after 2–4 weeks.
3. Tips to Help You Stay Smoke-Free
Avoid triggers: alcohol, stress, certain friends, long drives, or break times where you used to smoke.
Change routines: drink water, chew sugar-free gum, take a walk.
Stay active: exercise reduces cravings.
Keep hands busy: stress ball, pen, or healthy snacks.
Tell your family/friends: ask them to support you by not smoking around you.
Remove all tobacco: cigarettes, lighters, ashtrays.
4. Medications and Nicotine Replacement Options
Your provider may recommend one of the following:
Nicotine Replacement Therapy (NRT)
Nicotine patch — provides steady nicotine all day
Nicotine gum/lozenges — for cravings
Nicotine inhaler or nasal spray (less common)
Prescription Medications
Varenicline (Chantix) — reduces cravings and pleasure from smoking
Bupropion SR (Zyban) — helps with cravings and mood
Medications Prescribed Today:
☐ None
☐ Nicotine patch
☐ Nicotine gum
☐ Nicotine lozenge
☐ Varenicline
☐ Bupropion SR
Instructions: _________________________________________________________
5. Warning Signs — When to Seek Medical Help
Call your provider or go to the ER if you experience:
Chest pain or shortness of breath
Severe depression or suicidal thoughts (if using bupropion or varenicline)
Allergic reaction: swelling, rash, difficulty breathing
Severe or persistent vomiting
Irregular heartbeat
6. Follow-Up
Please schedule follow-up to support your quit plan.
Next Appointment: ___________________________________
Phone Number: _______________________________________
7. Helpful Resources
Quitline (24/7): 1-800-QUIT-NOW (1-800-784-8669)
Text Support: Text “QUIT” to 47848
Apps: QuitGuide, QuitNow!, SmokeFree
Website: smokefree.gov
8. Your Quit Plan
Quit Date: __________________________________________
Signature (Patient): ___________________ Date: __________
Signature (Provider): __________________ Date: __________
Date: ___________________________
Nurse/Provider: ___________________________
1. Why Quitting Smoking Matters
Smoking harms almost every organ in your body. Quitting lowers your risk of:
Heart attack and stroke
Lung cancer and other cancers
COPD and breathing problems
High blood pressure
Poor wound healing
Early death
Good news: Your body starts healing within minutes to days after your last cigarette.
2. What to Expect After You Quit
You may experience:
Cravings
Irritability or mood changes
Headache or difficulty concentrating
Trouble sleeping
Increased appetite
Coughing as your lungs clear
These are normal and temporary. They usually improve after 2–4 weeks.
3. Tips to Help You Stay Smoke-Free
Avoid triggers: alcohol, stress, certain friends, long drives, or break times where you used to smoke.
Change routines: drink water, chew sugar-free gum, take a walk.
Stay active: exercise reduces cravings.
Keep hands busy: stress ball, pen, or healthy snacks.
Tell your family/friends: ask them to support you by not smoking around you.
Remove all tobacco: cigarettes, lighters, ashtrays.
4. Medications and Nicotine Replacement Options
Your provider may recommend one of the following:
Nicotine Replacement Therapy (NRT)
Nicotine patch — provides steady nicotine all day
Nicotine gum/lozenges — for cravings
Nicotine inhaler or nasal spray (less common)
Prescription Medications
Varenicline (Chantix) — reduces cravings and pleasure from smoking
Bupropion SR (Zyban) — helps with cravings and mood
Medications Prescribed Today:
☐ None
☐ Nicotine patch
☐ Nicotine gum
☐ Nicotine lozenge
☐ Varenicline
☐ Bupropion SR
Instructions: _________________________________________________________
5. Warning Signs — When to Seek Medical Help
Call your provider or go to the ER if you experience:
Chest pain or shortness of breath
Severe depression or suicidal thoughts (if using bupropion or varenicline)
Allergic reaction: swelling, rash, difficulty breathing
Severe or persistent vomiting
Irregular heartbeat
6. Follow-Up
Please schedule follow-up to support your quit plan.
Next Appointment: ___________________________________
Phone Number: _______________________________________
7. Helpful Resources
Quitline (24/7): 1-800-QUIT-NOW (1-800-784-8669)
Text Support: Text “QUIT” to 47848
Apps: QuitGuide, QuitNow!, SmokeFree
Website: smokefree.gov
8. Your Quit Plan
Quit Date: __________________________________________
Signature (Patient): ___________________ Date: __________
Signature (Provider): __________________ Date: __________
