Tobacco was once a natural part of military life. United States service members received cigarettes in their rations, since tobacco was viewed as a comfort item, and the phrase “smoke ‘em if you got ‘em,” was used informally to signal a break for troops.
The practice ended in the mid-1970s, but its impact lingered for decades, with military personnel and veterans continuing to use tobacco and developing tobacco-related diseases, such as emphysema and lung cancer, at much higher rates than the general population.
Although rates of tobacco use among veterans and military personnel have declined significantly in recent years, the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DOD), referred to as the Department of War by some federal agencies and President Trump, still spend billions annually on tobacco-related expenses, from loss of productivity to hospitalizations.
Jessica Cook, PhD, a professor in the Department of Medicine at the University of Wisconsin School of Medicine and Public Health and director of veterans research at the school’s Center for Tobacco Research and Intervention (CTRI), studies ways to help veterans quit smoking. An expert in motivation-phase tobacco treatment, Cook was tapped by VA to join a national team in updating 20-year-old clinical practice guidelines across VA and DOD health systems. Cook’s innovative treatment, which she initially developed at UW-CTRI and then evaluated in veterans, addresses a long-overlooked group: people who aren’t ready to quit yet.
“It is really hard to quit smoking, because it’s an addiction,” said Cook. “Quitting is the most important thing you can do for your health, but if you are not quite ready to quit, we can still offer you treatment. Motivation-phase treatment offers a way for people to set goals such as reducing or avoiding smoking in certain situations, along with behavioral counseling and medication such as nicotine replacement therapy.”
The treatment essentially offers a stepping stone to help people gain confidence and learn skills that can prepare them to quit.
Through clinical trials, Cook and her team found that about 25% of participants who receive motivation-phase treatment decide to make a quit attempt and enter cessation treatment.
Cook’s recommendations for people who aren’t ready to quit, along with other current, evidence-based recommendations developed by the national workgroup, were included in VA’s 2026 guidelines, released in January and created in partnership with DOD to improve health outcomes for patients who use tobacco.
“VA and DOD are doing an incredible job addressing tobacco use,” Cook said. “VA’s National Tobacco Use Treatment Program office helps ensure that any veteran receiving VA care is asked about their tobacco use and connected with treatment.”
That treatment looks quite a bit different today compared to when the guidelines were last updated.
In addition to Cook’s contribution, new recommendations include treatment options for vapes and nicotine pouches, which didn’t exist when the original guidelines were created in the mid-2000s. Veterans and military personnel use these delivery systems at higher rates than traditional combustible tobacco products.
“Many of us in the workgroup are clinicians, and one question we asked was, ‘What would we like to see improve when it comes to treating tobacco use?’” Cook said.
With more data to support treatment approaches to vaping, the group was able to recommend either varenicline — a non-nicotine prescription medication that decreases craving and withdrawal symptoms — or nicotine replacement therapy, which involves controlled, low doses of nicotine through skin patches, gum or sprays to reduce exposure to harmful carcinogens in cigarette smoke. In addition, they added new recommendations that patients receiving treatment for alcohol and substance use disorders receive concurrent tobacco use treatment, since evidence shows this can improve patient outcomes on both fronts.
The national workgroup also incorporated UW researchers’ findings on relapse into their recommendations, with the new guidelines citing a CTRI paper that shows how encouraging patients, post-relapse, to immediately try to quit again (a process they call “recycling”), is more effective than other approaches.
Offering motivation phase treatment increases their likelihood of being successful when they do make a quit attempt.
- Jessica Cook
Cook called the inclusion of motivation-phase treatment in the updated guidelines a “paradigm shift.”
“When we offer cessation treatment, we know that 70% to 90% of patients will say, ‘I’m not ready to quit,’” she said. “Offering motivation-phase treatment connects many more patients with tobacco use treatment and increases their likelihood of being successful when they do make a quit attempt.”
Cook currently works with VA’s Tobacco Use Treatment Program office on a clinical pilot to connect veterans in outpatient mental health care with evidence-based tobacco use treatment. These veterans smoke at rates two to three times higher than those without mental health conditions and experience substantially greater smoking-related morbidity and mortality. Using VA’s electronic health records to identify veterans undergoing outpatient mental health care, the pilot enables VA staff, including Cook’s clinical research team, to proactively contact veterans by telephone to offer tobacco use treatment, without requiring an in-person health care visit. Veterans who agree to enter treatment have medication mailed to them and receive phone counseling.
“Proactive outreach is an evidence-based strategy that helps VA connect more veterans with tobacco use treatment, without waiting for them to come to us,” Cook explained. “We are removing treatment barriers and reminding veterans that VA is here to support them and inform them about their treatment options.”
The ongoing program has rolled out across seven VA facilities nationwide over the last year and a half, with Cook’s team overseeing efforts at Madison VA Hospital. According to a report the research team delivered at a 2026 meeting of the Society for Research on Nicotine & Tobacco, results of the pilot are encouraging. Out of participating veterans reached for follow-up, 45% reported having reduced daily tobacco use and 15.5% reported abstinence during a 7-day window leading up to the check-in.
“This clinical demonstration project, where we are collecting data as we implement a population-level strategy, is a great example of how VA efficiently adopts and disseminates new evidence-based approaches across its health care system, translating research into clinical practice,” Cook said.
In 2025, Cook and her team received $2.7 million from VA to launch the first clinical trial comparing the effects of using nicotine lozenges versus varenicline among veterans not ready to quit smoking. Cook, who co-leads the study with Dr. Neal Doran from Jennifer Moreno Department of Veterans Affairs Medical Center in San Diego, said she is excited to see if varenicline markedly reduces smoking enjoyment, withdrawal and craving among veterans who smoke but are not yet ready to try quitting. Participants who become ready to quit during the 12-week motivation-phase treatment span will transition into cessation treatment. Recruitment for the trial began in July.
Video produced with Media Solutions
