As part of a comprehensive tobacco-control program, DoD and VA
should:
• Place authority for developing tobacco-control policies and strategies
in a single high-level entity in DoD. In VA, the secretary and the
under secretary for health should actively promote tobacco cessation.
• Ensure that the surgeon general of each armed service and individual
installation commanders are accountable for DoD program
implementation and enforcement and that VISN directors are
accountable for VA program implementation and enforcement.
• Educate all DoD and VA health-care and health-promotion staff in
tobacco-control practices and train health-care providers in the 5
A’s.
• Provide all DoD and VA staff and patients with barrier-free access to
tobacco-cessation services if they use tobacco.
• Ensure that there are adequate resources, including infrastructure and
funding, at all facilities.
• Inventory tobacco-cessation programs at each military installation
and DoD and VA medical facility, and ensure that a trained tobaccocessation
counselor is available in each facility.
• All DoD and VA health-care providers, including counselors, should
be able to provide brief counseling and nicotine-replacement therapy
to patients.
• Report publicly and regularly on the performance of their tobaccocontrol
programs, adherence to clinical-practice guidelines, and
tobacco-cessation rates.

Generally, under the DSM-IV standards, a person must exhibit at least 5 of the following9 symptoms for at least two weeks in order to be diagnosed as having “major depressivedisorder” or MDD:

(1) feeling sad, blue, tearful;
(2) losing interest or pleasure in thingswe previously enjoyed;
(3) appetite much less or greater than usual, accompanied byweight loss or gain;
(4) a lot of trouble sleeping or sleeping too much;
(5) becoming soagitated, restless or slowed down that others begin noticing;
(6) being tired withoutenergy;
(7) feeling worthless or excessive guilt about things we did or didn’t do;
(8)trouble concentrating, thinking clearly or making decisions;
(9) feeling we’d be better offdead or having thoughts about killing ourselves.

But even if a person exhibits 5 of the above 9 symptoms, the symptoms cannot indicate amixed episode, must cause great distress or difficulty in functioning at home, work, orother important areas and may not be caused by substance use (e.g., alcohol, drugs,medication). But in regard to cold turkey nicotine cessation there may be an overridingconsideration, the “bereavement exclusion.”As reviewed in the prior chapter under “Symptoms,” it is the expert opinion of the editorof the DSM-IV standards that depression that is a normal and expected reaction to asignificant emotional loss is exempt under the DSM-IV "bereavement exclusion" frombeing classified as depression, so long as the symptoms are relatively mild and it doesn’tlast longer than two months

Yes, once all nicotine use ends, a single subsequent use is extremely accurate in predictingfull and complete relapse. Whether it happens immediately or even when we think we’vegotten away it, the brain’s “pay attention” circuitry records the relapse event in highdefinition memory. It will be etched along side survival instinct memories recording thebehaviors needed to keep us alive. The 1990 Brandon lapse/relapse study followed 129 smokers who successfully completed atwo-week stop smoking program for two additional years.121 Lapse was defined as anytobacco use regardless of how much.Among those who lapsed, the mean number of days between the end of the “quitting”program and lapse was two months (58 days), with nearly all lapsing within the first threemonths. While 14% took only one or two puffs, 42% smoked the entire cigarette, while theaverage smoked about two-thirds. A second cigarette was smoked by 93.5% who hadlapsed. Nearly half (47%) smoked that second cigarette within 24 hours, with one in fivesmoking it within an hour (21%). Still, a mean average of nine days passed betweensubjects sampling their first and second cigarette. Clearly, most of them likely thoughtthey’d gotten away with it, that they were controlling the uncontrollable.The Brandon study found that 60% who lapsed “asked for” the cigarette (bummed it), 23%purchased it, 9% found it, 6% stole it, and 2% were offered it. Also of note, 47% wholapsed drank alcohol prior to doing so.Overall, the study found that 88% who “tasted” a cigarette relapsed. In discussing thefinding Brandon wrote, “The high rate of return to regular smoking (88%) once a cigaretteis tasted suggests that the distinction between an initial lapse and full relapse may beunnecessary.” “In our study, high initial confidence levels may have reduced subjects'motivation to acquire skills and engage productively in treatment.”The Brandon study’s finding was echoed by the 1990 Boreland study, which followedcallers to an Australian telephone quit smoking line. There, among 339 quitters who lapsed(123 who didn’t make it an entire day and 172 who quit for at least 24 hours) 295 or 87%experienced relapse within 90 days.

Although the challenges of recovery have ended for hundreds of millions of nowcomfortable ex-users, each lives with nicotine dependency’s imprint permanently burnedinto their brain. Even after 10, 20 or 30 years, they remain wired for relapse.We’re not stronger than nicotine but then we don’t need to be. It is only a chemical. Likethe salt or pepper in our shakers, it has an I.Q. of zero.
Like the sugar in our sugar bowl, itcannot plot, plan, think or conspire. And it is not some big or little monster that dwellsinside us.Our blood serum becomes nicotine-free and withdrawal peaks in intensity within three daysof ending all nicotine use. But just one powerful jolt of nicotine and the deck gets stackedagainst us.
 The odds of us having the stamina to withstand and endure nicotine’s influenceupon the brain without relapsing are horrible. While Brandon and Boreland teach us thatrelapse isn’t 100% guaranteed, I encourage you to treat and see one hit of nicotine as though Our greatest weapon has always been our infinitely superior intelligence.
The mostimportant recovery lesson our intelligence can master is that being 99% successful at notusing nicotine equates to an 87% to 88% chance of defeat.As Joel Spitzer has now burned into my brain, there’s just one controlling principledetermining the outcome for all. Unlike quitting products, total adherence to a personalcommitment to not violate the law of addiction provides a 100% guarantee of success.Although obedience may not always be easy, the law is clear, concise and simple - nonicotine today, not one puff, dip or chew!