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Smoking Cessation: How to Make It Work

Smoking Cessation: How to Make It Work

The health benefits of smoking cessation are impressive--even in those who have smoked for many years (Dr Thomas Petty reports on this topic on page 1385). The risk of lung cancer is reduced by 50% to 70% after 10 years of abstinence, and it continues to decline thereafter.1

Recently, the National Guideline Clearinghouse2 compared smoking cessation recommendations from the Public Health Service,3 the University of Michigan Health System,1 the Singapore Ministry of Health,4 the New Zealand Guidelines Group,5 and the US Preventive Services Task Force.6 Highlights of guidelines from the US groups are presented here.

The American groups concur on nearly all aspects of screening and counseling for tobacco use. All the guidelines follow the "5-A" behavioral counseling framework (Box).


Ask all patients whether they use tobacco, and document their smoking status at every visit. If the patient is a smoker, ascertain his or her readiness to quit. Studies have shown that advice from a physician to quit smoking increases abstinence rates.1


If the patient is ready to stop using tobacco, set a "quit date"; provide personalized advice; offer pharmacologic therapy if appropriate and information on community programs; and arrange follow-up. If the patient is not ready to quit, try to motivate him using the "4 R's."

Counseling patients about quitting for as brief a period as 3 minutes is effective in smoking cessation. Intensive intervention (frequently defined as a minimum of 1 weekly meeting for the first 4 to 7 weeks of cessation) and pharmacotherapy are more effective than less intensive interventions and should be used whenever possible. If feasible, try to meet 4 or more times with patients who are attempting to quit. Phone calls and letters may be more cost-effective than follow-up visits at the office.

Cessation strategies. Help the patient create a plan to quit using tobacco:

  • Set a quit date and record this on the patient's chart. Ask the patient to mark the date on a calendar.
  • Recommend that the patient inform family, friends, and coworkers of his plan to quit and request their support.
  • Have the patient remove cigarettes from home, car, and workplace environments.
  • Caution the patient to anticipate challenges (ie, nicotine withdrawal symptoms), particularly during the critical first few weeks.

When to refer. Consider referral to intensive counseling (multisession, group, or individual). Referral considerations include:

  • Multiple unsuccessful quit attempts initiated by brief intervention.
  • Increased need for skill building (coping strategies/problem solving), social support, and relapse prevention.
  • Psychiatric cofactors, such as depression, eating disorder, anxiety disorder, attention deficit disorder, or alcohol abuse.


Encourage patients who are attempting to quit to use pharmacologic therapies for smoking cessation. Both nicotine replacement therapy and bupropion significantly improve cessation rates.

Consider the following first-line medications:

  • Bupropion SR (sustained release).
  • Nicotine gum.
  • Nicotine inhaler.
  • Nicotine nasal spray.
  • Transdermal nicotine (patch).

The following medications are second-line options:

  • Clonidine.
  • Nortriptyline.
  • Combination nicotine replacement therapy.

Combining the nicotine patch with a self-administered form of nicotine replacement therapy (either nicotine gum or nasal spray) is more effective than a single form of nicotine replacement. Encourage patients to use combination therapy if they are unable to quit using a single type of first-line pharmacotherapy.


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