Overview of smoking cessation management in adults

INTRODUCTION — Clinician involvement increases the likelihood that the patient will successfully quit smoking. The goal is to routinely identify individuals who smoke tobacco products and offer them evidence-based help to quit [1,2].

This topic provides an overview of smoking cessation management in adults.

Pharmacologic treatments and behavioral counseling to support smoking cessation, benefits of smoking cessation, smoking cessation during pregnancy, and smoking cessation in adolescents are each discussed in detail elsewhere:

●(See "Pharmacotherapy for smoking cessation in adults".)

●(See "Behavioral approaches to smoking cessation".)

●(See "Benefits and consequences of smoking cessation".)

●(See "Tobacco and nicotine use in pregnancy: Cessation strategies and treatment options".)

●(See "Management of smoking and vaping cessation in adolescents".)

THE ROLE OF THE CLINICIAN — Clinician involvement increases the likelihood that the patient will successfully quit smoking. The goal is to routinely identify individuals who smoke tobacco products and offer them evidence-based help to quit.

The 5A's approach — The clinician’s role is to document the smoking status of all patients and to provide individuals who use tobacco with clear advice to quit, offer and connect them to pharmacologic and behavioral treatment options, and provide follow-up at future visits. For those individuals who are not ready to make a quit attempt, the clinician can use motivational interviewing to move these individuals towards quitting and use harm-reduction strategies such as initiating pharmacotherapy even before the patient is ready to stop tobacco use. A five-step treatment framework, the 5A’s (table 1 and table 2), serves as a guide to the components of this strategy. In the United States, this method has been recommended in national guidelines since 2008 and is recommended by US Preventive Services Task Force guidelines [3-8]. (See 'Implementing 5A's in practice' below.)

The 5A’s steps are as follows:

●Ask about tobacco use (see 'Ask about tobacco use and exposure' below)

●Advise quitting (see 'Advise smoking cessation' below)

●Assess readiness to quit (see 'Assess readiness to quit' below)

●Assist smokers ready to quit (see 'Assist smokers ready to quit' below)

●Arrange follow-up (see 'Arrange follow-up' below)

Variations of the 5A's approach — Since 2008, a number of professional organizations have abbreviated the 5A’s framework to three steps that aim to be more feasible to deliver in a busy outpatient practice and to incorporate more members of the care team. The abbreviated versions vary slightly but share a common strategy.

A typical framework is AAR:

●Ask about tobacco use

●Assist – Offer advice to quit and assistance to make a plan, including prescribing cessation medication

●Refer to behavioral support resources to continue treatment after the visit

In the AAR, asking the patient about tobacco use can be done and documented in the health record by office staff while they prepare the patient for the visit and obtain vital signs. The clinician’s unique role is to then offer advice, assistance, and cessation medication. Referral to behavioral support resources (usually located outside the office setting, elsewhere in the health system or community) can be facilitated by office staff after the process is initiated by the clinician.

Another alteration to the 5A’s approach is to replace the step of assessing readiness to quit with a proactive offer of treatment. With this method, the clinician approaches tobacco use like other chronic diseases; instead of first asking if the patient is ready to quit, the clinician proactively offers treatment. This approach resembles the approach to treatment of a chronic disease (eg, diabetes or hypertension), where embarking on a treatment plan is generally presented as an expectation, rather than as an option. Another similarity between chronic conditions and management of tobacco dependence is that they all require long-term follow-up [9].

A suggested “proactive offer of treatment” approach is for the clinician to begin by briefly presenting treatment-related facts, including the availability of treatment, and then ask whether the patient would like to quit smoking:

●“Stopping smoking can be difficult.”

●“Effective treatment for tobacco dependence is available.”

●“I am prepared to help you, using available treatments.”

●“Can I tell you more about these options?”

A proactive approach still includes several components of the 5A’s approach, including asking about use, assisting those ready to quit and/or willing to engage with tobacco treatment, and arranging follow-up. (See 'Ask about tobacco use and exposure' below and 'Assist smokers ready to quit' below and 'Arrange follow-up' below.)

Offering treatment to individuals who smoke in a positive way (rather than presenting it as optional) is hypothesized to increase the likelihood that they will use the treatment. Randomized trials of proactive outreach programs that offer smoking cessation interventions to individuals, regardless of readiness to set a quit date, have been shown to increase smoking cessation rates (compared with usual care) in veterans and patients of low socioeconomic status [10-12].

IMPLEMENTING 5A'S IN PRACTICE — The 5A’s are a simple algorithm (table 1 and table 2) for treating tobacco use. Because implementing smoking cessation programs can be challenging in a busy practice, team-based versions have been proposed that involve the office staff as a team rather than having only the clinician involved [13,14]. In this model, office staff members take on the responsibility for assessing each patient's smoking status and reminding the clinician to address smoking when identified. Documenting smoking status in an electronic medical record can improve identification of patients who use tobacco, which may increase the use of smoking cessation interventions [15,16].

Once a smoker is identified, the clinician's primary role is to advise the individual to quit, consider prescribing smoking cessation pharmacotherapy, and refer the smoker to other services that can provide additional behavioral support for tobacco cessation.

Ask about tobacco use and exposure — Step 1 of the 5A’s is asking all patients about tobacco use and exposure. The US Preventive Service Task Force recommends that smoking status should be evaluated and recorded as every health encounter [7]. This practice of routinely asking about tobacco use has been shown to increase smoking-related discussions and smoking cessation rates [3-6].

It is important to ask a patient if they ever smoke cigarettes; otherwise, non-daily or intermittent smokers may not identify themselves as smokers. It also important to assess the full extent of tobacco use by asking specifically about the use of other tobacco and nicotine products (eg, cigars, pipes, smokeless tobacco, water pipes/hookahs, bidis, and electronic cigarettes). Many tobacco users consume more than one type of tobacco product, including both cigarettes and e-cigarettes. Often, patients incorrectly perceive that using tobacco products other than cigarettes poses less health risk to the user. (See "Patterns of tobacco use" and "Vaping and e-cigarettes".)

For patients who use tobacco, a full assessment includes determining frequency of use, products used, degree of nicotine dependence, history of quit attempts (including methods used and their effectiveness), and readiness to stop using tobacco at this time [17].

The degree of nicotine dependence can be estimated from the age of smoking initiation, the number of cigarettes/tobacco materials used daily, and how soon after awakening the individual has their first morning cigarette/tobacco product. An individual’s degree of nicotine dependence predicts the difficulty that they will have in quitting and the intensity of treatment likely to be required. More dependent patients started smoking early in life, smoke more cigarettes daily (the average number in the United States is 15 per day), and smoke within the first 30 minutes of awakening [17,18].

Those who do not use tobacco products should be asked about secondhand exposure to smoke (eg, in the home, car, or workplace). Such exposure is associated with increased health risks (eg, coronary heart disease and lung cancer) in nonsmokers. (See "Secondhand smoke exposure: Effects in adults" and "Secondhand smoke exposure: Effects in children".)

Advise smoking cessation — Step 2 of the 5A’s is advising smoking cessation. The main impact of clinician advice is prompting smokers to attempt to quit.

We offer brief advice and assistance to quit smoking. There is clear evidence that brief (<5 minutes) clinician advice to quit at each encounter can increase smoking abstinence rates, even though not every patient counseled about smoking cessation will be prepared to consider quitting immediately [6,19]. For some patients, such as those with smoking-related disease, more intensive clinician counseling may be associated with increased cessation rates [7].

Even if they are not ready to quit, patients who are asked about their tobacco use or are advised to quit smoking report being more satisfied with their care than patients who do not receive such advice [20].

Providing physiologic measurements to a smoker to demonstrate the negative effects of smoking on their health has variable efficacy depending on the study; more evidence is needed to determine whether any such measurements should be routinely recommended. Some studies show improved smoking cessation rates after providing patients with certain physiologic measurements. For example, a randomized trial showed that providing results of salivary nicotine metabolite levels was associated with increased short-term quit rates compared with counselling alone [21]. In another randomized trial, smokers who were told their “lung age” (the age of the average person with a forced expiratory volume in one second [FEV1] equal to the smoker’s measured FEV1) were more likely to quit smoking (verified quit rate at 12 months of 13.6 percent compared with 6.4 percent among those not told) [22]. The lung age was calculated as follows: (for men) lung age = 2.87 x height (inches) – (31.25 x observed FEV1 [liters] - 39.375), and (for women) lung age = 3.56 x height (inches) – (40 x observed FEV1 [liters] – 77.28) [23].

However, other studies have not found efficacy for biomedical risk assessment (eg, carbon monoxide level measurement) in smoking cessation [9,24-26].

Although complete smoking cessation is always preferable, reducing the number of cigarettes smoked daily has been advocated as a possible alternative to complete cessation by patients who are unable to quit smoking. However, few data are available that support a goal of smoking reduction rather than complete cessation. (See "Benefits and consequences of smoking cessation", section on 'Questionable utility of smoking reduction'.)

Assess readiness to quit — Step 3 of the 5A’s is assessing readiness to quit. The clinician should assess the patient's willingness to make a quit attempt. Smokers differ in their readiness to change their tobacco use. Understanding the smoker’s perspective is essential to providing useful assistance.

The concept that change is gradual is a useful construct when discussing smoking cessation. One model, called the “Stages of Change,” describes a process by which behavior change occurs. It identifies five stages through which smokers may progress as they move from smoking to abstinence [27]:

●Pre-contemplation (not ready to quit)

●Contemplation (considering a quit attempt)

●Preparation (actively planning a quit attempt)

●Action (actively involved in a quit attempt)

●Maintenance (achieved smoking cessation)

After determining the patient's readiness to quit, the clinician can differentiate between those ready to quit (eg, contemplative stage or beyond), described below, for whom assistance with behavioral support and pharmacotherapy is indicated, and those not yet ready to quit (eg, precontemplative stage) for whom motivation to quit is needed. For those not yet ready to quit, it can be useful for the clinician to gain an understanding of the patient’s perspectives about quitting, consider using motivational interviewing techniques and components of the proactive approach (eg, offering treatment such as pharmacotherapy), and describe methods to limit exposure of others to secondhand smoke. (See 'Assist smokers not ready to quit' below and 'Variations of the 5A's approach' above.)

Some critics noted that individuals do not move through predictable stages of behavior change. A 2010 systematic review of 41 trials concluded that stage-based help-interventions were equivalent to their non-stage-based equivalents [28,29].

Another alternative to assessing readiness to quit is to use the proactive approach, advise quitting, and offer treatment. (See 'Variations of the 5A's approach' above.)

Assist smokers ready to quit — Step 4 of the 5A’s is assisting smokers ready to quit. When a smoker is motivated to quit (eg, contemplative stage or beyond), the clinician should follow several practical steps to assist with smoking cessation (table 2), including helping the smoker access appropriate resources and assessing the smoker's previous experiences with quit attempts. Understanding the methods that the smoker has tried and the degree of success with each method is important to guide the recommendations for the next attempt.

We recommend that smokers be managed with a combination of behavioral support and pharmacologic therapy. (See "Pharmacotherapy for smoking cessation in adults" and "Behavioral approaches to smoking cessation".)

Set a quit date — The process of quitting generally begins by setting a "quit date" within the following two to four weeks. We advise patients to quit abruptly on the quit date, but gradual reduction prior to the quit date is an acceptable alternative.

In a systematic review including 22 randomized trials and over 9000 participants, there was no difference in abstinence rates between those who reduced smoking before the quit date and those who quit abruptly (risk ratio [RR] 1.01, 95% CI 0.87-1.17) [30].

Address barriers to quit — Clinicians should help the patient anticipate and address barriers to quitting. Several factors (eg, nicotine withdrawal symptoms, triggers to smoke) contribute to the difficulty that smokers encounter when they try to quit. (See "Behavioral approaches to smoking cessation", section on 'Content of therapy'.)

Nicotine withdrawal — Nicotine withdrawal symptoms should be discussed so that smokers will know what to expect and how to respond if these symptoms occur. The addictiveness of nicotine is the primary barrier for smokers to quit.

Nicotine withdrawal symptoms peak in the first three days of smoking cessation and subside over the next three to four weeks. Symptoms include increased appetite and weight gain, changes in mood (dysphoria or depression), insomnia, irritability, anxiety, difficulty concentrating, and restlessness. (See "Benefits and consequences of smoking cessation", section on 'Nicotine withdrawal syndrome'.)

These symptoms can be alleviated by any of the first-line smoking cessation medications (nicotine replacement, varenicline, or bupropion). Behavioral approaches can also be used, though most often smokers use pharmacotherapy to relieve nicotine withdrawal symptoms. (See "Behavioral approaches to smoking cessation", section on 'Content of therapy' and "Pharmacotherapy for smoking cessation in adults", section on 'Initial therapy selection'.)

Other barriers — Approximately two-thirds of patients who smoke say that they want to quit, and over half of those who smoke report that they tried to quit in the past year [31,32]. However, less than one-third of adults who try to quit seek help, and even fewer use the most effective treatments [31-33].

Many patients who have failed to quit state that they have "tried everything"; however, often they are not actually aware of the full set of available smoking cessation tools and in fact may not have engaged in any formal smoking cessation counseling program and may not have used effective medications adequately. All smokers should be told that effective treatments are available and that the clinician is willing to help them work through any obstacles.

Practical counseling can help patients deal with these situations (table 2). Common trigger events are a frequent obstacle to quitting smoking. People who use tobacco become conditioned to associate the pleasurable effects of tobacco and tobacco use with environmental triggers such as their morning coffee, an alcoholic drink, or the end of a meal. These triggers contribute to the difficulty individuals have in remaining abstinent from nicotine [31]. (See "Behavioral approaches to smoking cessation", section on 'Identification of triggers' and "Behavioral approaches to smoking cessation", section on 'Content of therapy'.)

Some patients are concerned about costs of treatments; for patients in the United States, insurance plans are required to cover tobacco-cessation interventions, including behavioral counseling and medications approved by the US Food and Drug Administration (FDA) [34].

Other barriers to quitting include the possibilities of weight gain. Behavioral counseling and choice of pharmacologic treatment can help mitigate these risks. (See "Benefits and consequences of smoking cessation", section on 'Possible consequences of smoking cessation' and "Behavioral approaches to smoking cessation" and "Pharmacotherapy for smoking cessation in adults", section on 'Initial therapy selection'.)

Treatments

Combination behavioral and pharmacotherapy most effective — We recommend that patients who wish to quit smoking be managed with a combination of behavioral and pharmacologic treatments. Depending on the medication chosen, pharmacotherapy is started either before or on the quit date.

Meta-analyses of clinical trials have found that the combination of behavioral counseling and pharmacotherapy both have greater efficacy for smoking cessation when used in combination than when either is used alone [35-37]. In a meta-analysis including 52 trials and almost 20,000 patients, smoking abstinence at six months or more was greater with combined behavioral and pharmacotherapy compared with usual care or minimal support (RR 1.83, 95% CI 1.68 to 1.98) [36]. With optimal treatment, 25 to 35 percent of smokers who try to quit can succeed for six months or more [38]. By contrast, only 3 to 6 percent of smokers who make an unaided quit attempt are still abstinent one year later [31,32].

Specific options for behavioral counseling and specific drug therapies for smoking cessation are discussed in detail separately. (See "Behavioral approaches to smoking cessation" and "Pharmacotherapy for smoking cessation in adults".)

Behavioral counseling — Most studies demonstrate that quit rates increase with increasing behavioral support [33,39]. The approaches to behavioral counseling and benefits of individual counseling strategies are discussed in detail separately. (See "Behavioral approaches to smoking cessation".)

The most intensive behavioral intervention available, such as a specialty clinic or smoking cessation program, should be offered to the patient. For many patients, the only face-to-face option is brief clinician counseling in the office. This can be supplemented by external resources, such as telephonic quitline support and counseling. A useful resource for a patient or clinician to access is their state’s free telephone quitline support in the United States: 1-800-QUIT-NOW. Information about resources offered by each state in the United States and every province in Canada can be found at map.naquitline.org. In many US states, the clinician's office can also directly refer a patient to a quitline by sending a referral via fax or electronically. The state quitline then proactively contacts the patient to offer smoking cessation support and links them to local available resources. Most states also offer free samples of medication, usually nicotine patches, gum, and/or lozenges.

Other behavioral counseling options include text messaging, web-based interventions, and phone apps. A list of other options for behavioral counseling and web resources is available separately. (See "Behavioral approaches to smoking cessation", section on 'Selection of behavioral therapy'.)

Pharmacotherapies — First-line pharmacotherapies for smokers are varenicline, combination nicotine replacement therapy (NRT) consisting of a long-acting NRT and a short-acting NRT, and bupropion (table 3). Each medication has proven efficacy for smoking cessation (table 4). With a few exceptions, choice of medication is generally based upon patient preference after discussion with a clinician. For most patients, we suggest either varenicline or a combination of two NRT products (a patch plus a short-acting form such as the gum or lozenge) [40]. There are specific considerations for certain populations. They are described in detail separately. (See "Pharmacotherapy for smoking cessation in adults", section on 'Considerations for special populations' and "Pharmacotherapy for smoking cessation in adults", section on 'Initial therapy selection'.)

Other interventions — Several other types of interventions have been tried for smoking cessation with variable efficacy, including financial incentives, acupuncture, and hypnotherapy. Clinicians can help patients understand which types of interventions have proven efficacy.

●Financial incentives for quitting smoking seem to improve smoking cessation rates while they are in place [41,42]. Randomized trials have shown that financial rewards (receiving up to USD $800 for smoking cessation) can increase smoking cessation rates compared with usual care [43,44], sometimes coupled with support from a patient navigator [45]. Some of the studies were conducted in populations with lower socioeconomic status. One trial also found that different incentives vary in attractiveness to smokers and incentive effects differ based on the amount of money at risk for failing to quit.

●Acupuncture is included in some commercially available smoking cessation programs. A meta-analysis of randomized trials of acupuncture treatment suggested potential benefits for smoking cessation [46], whereas a prior meta-analysis had found a short-term benefit but not a long-term difference in abstinence rates for acupuncture compared with sham acupuncture or placebo [47]. Acupuncture was found to be less effective than NRT [47]. (See "Overview of the clinical uses of acupuncture".)

●A meta-analysis of randomized trials of hypnotherapy for smoking cessation suggested potential benefits [46], whereas a prior systematic review of 11 randomized trials had found insufficient data to support the use of hypnotherapy for smoking cessation [48].

Arrange follow-up — Step 5 of the 5A’s is arranging follow-up. Follow-up should be scheduled within one to two weeks of the patient's quit date to provide reinforcement, monitor response to smoking cessation therapy, optimize treatment with first-line therapies if necessary, and monitor for adverse or side effects of pharmacotherapy. The follow-up visit may be a face-to-face appointment or a contact by telephone. (See "Pharmacotherapy for smoking cessation in adults", section on 'Follow-up' and "Behavioral approaches to smoking cessation", section on 'Patients who recently quit'.)

Regardless of whether or not the patient has successfully quit smoking, clinicians should address any problems that develop associated with smoking cessation efforts, such as weight gain, depression, or a change in relationships with friends or relatives who smoke. These issues may lead to treatment failure or relapse any time after a successful quit attempt.

Successful smoking cessation — Relapse prevention should be part of every encounter with a patient who has recently quit, especially in the first three months when most relapses occur (table 5). The following should be covered at follow-up [33]:

●Congratulating the patient and encouraging continued abstinence (a single puff may lead to relapse)

●Identifying problems encountered and anticipating upcoming challenges

●Assessing medication use, problems, and efficacy

●Reminding the patient of additional available support resources

Follow-up to assess for new side effects, smoking status, and relapse should be scheduled at three months and at one year, and more frequently if necessary. At each visit within the first year after quitting, smoking status should be discussed. Follow-up should continue annually for several years, because successful quitters remain at high risk of relapse for several years after smoking cessation. It is important at these visits to continue to ask the patient about type and amount of tobacco or any other nicotine product use (See 'Ask about tobacco use and exposure' above.)

Ideally, we continue pharmacotherapy for at least three months and until patients feel confident that they will not relapse. Individuals who have successfully quit at 12 weeks may benefit from continuing on treatment for an additional 12 weeks, or even longer, to prevent relapse. Mixed evidence from a 2019 meta-analysis indicates that continued pharmacotherapy (for up to 18 months) might help prevent relapse [49]. In the United States, most insurance companies do not cover smoking cessation medications after three months of pharmacotherapy, although increasingly they are extending coverage to six months. There is little evidence of harm from a longer duration of treatment with these pharmacotherapies, although the optimal duration has not been established. (See "Pharmacotherapy for smoking cessation in adults", section on 'Duration of pharmacotherapy' and "Pharmacotherapy for smoking cessation in adults", section on 'Management of relapse'.)

It is reasonable to use simple interventions that promote abstinence (table 5). The benefits of smoking cessation can be highlighted by simply asking how the patient’s life has changed since stopping smoking. An equally important step is to address any problems encountered as a result of abstinence (eg, weight gain, depression, alcohol use). However, there is relatively little evidence that long-term use of specific behavioral interventions prevents relapse after smoking cessation [49]. A 2019 systematic review of 81 studies evaluating interventions for relapse prevention found that there was insufficient evidence to support the use of any specific behavioral intervention to help smokers avoid relapse [49].

Difficulty quitting — If the patient does not succeed in quitting on the quit date, the clinician can help the patient work through any problems that are identified and explore solutions for the next quit attempt, as well as adjusting pharmacotherapy and intensifying behavioral interventions. Individuals who fail to quit on an adequate trial of first-line pharmacotherapy may benefit from second-line pharmacotherapy. (See "Behavioral approaches to smoking cessation" and "Pharmacotherapy for smoking cessation in adults", section on 'Assess and respond to adherence issues and side effects'.)

Briefly, the clinician should carefully review the patient's experience during the attempt to quit, especially the circumstances surrounding the first cigarette smoked after the quit date. The clinician should also determine the patient's own insight into the possible reasons why the attempt failed, most importantly how the patient is able to cope with withdrawal symptoms. Patients may be highly dependent on nicotine, have low self-confidence or little social support for quitting, or have comorbid psychiatric illness; patients may also not have used medications correctly, including nicotine gum or inhaler, or may erroneously think that nicotine causes cancer. These matters should be addressed with the patient before setting another quit date. Specifics as to how patients may effectively use the various types of short-acting NRT are described separately. (See "Pharmacotherapy for smoking cessation in adults", section on 'Short-acting nicotine replacement therapy'.)

Patients who do not adhere to a quit date usually feel discouraged and the clinician can help the patient to interpret what is perceived as failure into a partial success by calling attention to small positive steps such as the number of hours that the smoker was able to refrain from smoking and framing that as a first step toward success.

Relapse — Following relapse, patients should be encouraged to make another attempt to stop smoking, with enhanced behavioral counseling, pharmacotherapy, or both. Patients who relapse often have had inadequate behavioral support as part of their cessation plan, have strong withdrawal symptoms, or experience weight gain or mood symptoms (table 5).

Patients should be reminded that most smokers require multiple attempts at smoking cessation before permanently quitting. One study estimated that 72 percent of smokers were not abstinent at three months [50]. Thirty-five to 40 percent of patients relapse between years 1 and 5 after quitting [49,51-53]. Nearly two-thirds of smokers who relapse report wanting to quit again within 30 days [54].

For patients who relapse, we attempt to provide or intensify behavioral counseling with referral to a quitline or to in-person counseling. A quitline typically provides proactive smoking cessation counseling over several calls. This service is free in the United States at 1-800-QUIT-NOW. Formal in-person smoking cessation behavioral counseling support is advised for a smoker who is heavily dependent on nicotine or has had multiple unsuccessful attempts. Involving different types of providers (eg, clinicians, nurses, psychologists, dentists) through a multidisciplinary program can improve smoking cessation rates.

If a previous pharmacotherapy for smoking cessation was helpful temporarily, we typically recommend the same therapy that worked previously. This strategy may be enhanced by combining the previously useful medication with another medication. If the initial pharmacotherapy was unhelpful, we select a different pharmacotherapy. We couple this with encouragement to use behavioral support. (See "Pharmacotherapy for smoking cessation in adults" and "Pharmacotherapy for smoking cessation in adults", section on 'Assess and respond to adherence issues and side effects'.)

ASSIST SMOKERS NOT READY TO QUIT — For patients who are not yet ready to quit, the clinician's role is to understand the patient's perspective of the risks and benefits of continuing to smoke in order to help the smoker contemplate quitting. Most people who smoke have a general desire to stop smoking, but for a variety of reasons they may not be ready to take specific actions to quit. Asking a patient what they like and do not like about smoking is a way to explore those reasons. Additionally, a personalized message about a smoking-related health problem the patient is experiencing may motivate some patients to act.

Motivational interviewing techniques are useful to explore a patient’s feelings, beliefs, ideas, and values regarding tobacco use. An example is the "5 R’s" (Relevance, Risks, Rewards, Roadblocks, Repetition) model, a set of questions that can help motivate smokers who are not ready to quit (table 6). Motivational interviewing techniques are described separately. (See "Behavioral approaches to smoking cessation", section on 'Patients not ready to quit'.)

Patients who are considering quitting but are not yet ready to discontinue tobacco use should be offered the option of initiating pharmacotherapy, rather than waiting until they are ready to stop tobacco use [55]. This may help reduce cigarettes smoked in preparation for quitting in the future. We prefer varenicline rather than nicotine replacement therapy (NRT), although either may be used; evidence from randomized trials indicates that both are effective in achieving smoking abstinence when used in patients not ready to abruptly quit [56,57]. This is discussed in detail elsewhere. (See "Pharmacotherapy for smoking cessation in adults", section on 'Individuals less committed to quitting'.)

Those who continue to smoke should be advised to protect other people (eg, household members and apartment dwellers, especially children, and coworkers) from exposure to secondhand smoke and urged to adopt a strict smoke-free policy for their homes, workplaces, and cars, especially if children are present. (See "Secondhand smoke exposure: Effects in children" and "Secondhand smoke exposure: Effects in adults".)

TREATMENT CONSIDERATIONS FOR SPECIFIC POPULATIONS — All smokers should be offered both behavioral counseling and pharmacotherapy. For certain patient populations, there are specific considerations when selecting smoking cessation pharmacotherapy. These are discussed in detail separately. (See "Pharmacotherapy for smoking cessation in adults", section on 'Considerations for special populations'.)

Individuals with cancer — Patients diagnosed with cancer can benefit substantially from smoking cessation; continued smoking after a cancer diagnosis is associated with an increased risk for a subsequent primary cancer and increased mortality [58-60]. Providing tobacco treatment at the time of a cancer diagnosis may be the ideal opportunity for intervention in such patients [61,62]. In the United States, multiple organizations recommend tobacco treatment as a fundamental part of cancer care [60,63-65]. Longer-duration behavioral interventions may be particularly effective in this population [62].

Psychiatric illness — Smoking is highly prevalent among patients with mental illness, but they are less likely to be treated for smoking use compared with patients without mental illness [66]. Despite concerns that smoking cessation could exacerbate psychiatric illness, evidence indicates that this does not happen; an observational study suggested that smoking cessation was associated with a reduced risk for a mood or anxiety disorder, even among patients with a preexisting disorder [67].

Behavioral and pharmacologic therapies can increase abstinence rates in smokers with psychiatric illness. The choice among pharmacologic and behavioral therapies may vary with the underlying psychiatric illness. Evidence indicates that the same medications are effective for smokers with and without psychiatric comorbidity, although among severely mentally ill patients with psychotic disorders, the efficacy of nicotine replacement therapy (NRT) for smoking cessation is unclear. Thus, for most patients with comorbid psychiatric disease, we suggest treatment with varenicline rather than NRT. Specific considerations in pharmacotherapy for patients with psychiatric illness are discussed separately. (See "Approach to managing increased risk for cardiovascular disease in patients with severe mental illness", section on 'Tobacco smoking' and "Pharmacotherapy for smoking cessation in adults", section on 'Psychiatric illness'.)

Substance use disorder — Among smokers with substance use disorders, reviews show that participating in a smoking cessation program is not associated with an increased use of other substances [68]. In addition, smoking cessation sometimes or often had a positive effect on substance use outcomes. A systematic review of smoking cessation methods among substance users found that use of NRT, behavioral supports, or combinations of both along with use of bupropion was associated with smoking cessation [69,70].

Cardiovascular disease — The management of smoking cessation in patients with stable cardiovascular disease (CVD) is similar to the management of patients without CVD and is outlined in a consensus document from the American College of Cardiology [40]. However, for patients with acute coronary syndrome (ACS), there may be specific pharmacotherapy considerations. Pharmacotherapy for smoking cessation for CVD and ACS, including risks of adverse events, and behavioral approaches to smoking cessation for patients with CVD are discussed separately. (See "Pharmacotherapy for smoking cessation in adults", section on 'Cardiovascular disease' and "Behavioral approaches to smoking cessation", section on 'Patients ready to quit'.)

Hospitalized patients — Because of smoke-free policies, hospitalization typically provides a setting that is free of usual cues to smoke. The illness or procedure precipitating the admission may also reinforce the patient’s perceived vulnerability to the harms of tobacco use and motivate a quit attempt [71,72], even if the reason for hospitalization is not directly related to smoking-induced disease. For example, patients who have undergone surgery during the hospitalization are more likely to quit smoking than those who have not had surgery. Quit rates are also higher after major surgery than after outpatient procedures [73]. Specific considerations about the choice of pharmacotherapy in hospitalized patients are discussed in detail separately. (See "Pharmacotherapy for smoking cessation in adults", section on 'Hospitalized patients'.)

At hospital discharge, it is important to offer continued treatment for tobacco dependence. Studies show that interventions in the hospital without continued cessation treatment (beyond advice not to smoke and a prescription) were not effective, whereas those with follow-up were effective compared with standard treatment [74,75]. A meta-analysis of 50 randomized trials in hospitalized smokers found that intensive counseling (≥1 contact during the hospital stay with continued support for ≥1 month after discharge) was associated with increased the likelihood of smoking cessation (relative risk 1.37, 95% CI 1.27-1.48). Another randomized trial found that a series of postdischarge computerized telephone calls, each offering a way to reach a live counselor for help along with provision of free medication, increased smoking cessation rates by 71 percent at six months after hospital discharge compared with a discharge recommendation to use counseling and provision of a prescription [75].

Preoperative management — Patients should be assessed for smoking during the preoperative evaluation so effective therapies can be initiated. Current smokers are at risk for postoperative pulmonary and other complications, and smoking cessation prior to surgery may improve outcomes. NRT and varenicline are suggested choices in this population; if surgery will occur within a few days, NRT is favored due to its rapid onset of action. Pharmacotherapy in preoperative smokers is discussed separately. (See "Pharmacotherapy for smoking cessation in adults", section on 'Preoperative management' and "Strategies to reduce postoperative pulmonary complications in adults", section on 'Smoking cessation' and "Smoking or vaping: Perioperative management".)

Preoperative intensive behavioral therapy, typically with concomitant NRT, can reduce smoking and complications of surgery. A meta-analysis found that intensive preoperative behavioral interventions (typically with NRT) led to a greater rate of smoking cessation at the time of surgery (risk ratio [RR] 10.76, 95% CI 4.55-25.46) and to reduced postoperative complications (RR 0.42, 95% CI 0.27-0.65) compared with standard of care [76]. However, brief interventions (eg, 15 to 90 minutes of counselling) were associated with a smaller reduction in smoking cessation by the time of surgery and were not associated with a significant reduction in complications. (See "Behavioral approaches to smoking cessation", section on 'Patients ready to quit'.)

Additionally, a preoperative smoking cessation intervention may be maintained after surgery. A randomized trial found that smoking cessation rates were higher one year after surgery for patients who had received a perioperative smoking cessation intervention compared with usual care (25 versus 8 percent) [77].

Light or intermittent tobacco use — Those with light tobacco use (<10 cigarettes per day [33]) and intermittent use (who do not smoke daily) benefit from smoking cessation. Although the adverse effects associated with smoking are dose-dependent, even light smoking is associated with increased mortality and several smoking-related diseases [78].

Behavioral counseling is the first-line treatment for those with light tobacco use (see "Behavioral approaches to smoking cessation"). Although the role of pharmacotherapy is less clear because few trials of smoking cessation medications enrolled light or intermittent smokers, medications effective for those with heavier tobacco use may also be effective for those with lighter use. However, the dose of NRT products typically needs to be reduced in those with light tobacco use. (See "Pharmacotherapy for smoking cessation in adults", section on 'Light smoking'.)

Pregnancy — Behavioral interventions tailored specifically to pregnant women are effective in increasing smoking cessation rates. Management of smoking cessation in pregnant women is discussed in detail separately. (See "Tobacco and nicotine use in pregnancy: Cessation strategies and treatment options".)

Adolescents — Strategies to support adolescents in smoking cessation should be adapted to the special concerns of this age group. Management of smoking cessation in adolescents is discussed in detail separately. (See "Management of smoking and vaping cessation in adolescents".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Smoking cessation, e-cigarettes, and tobacco control".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Quitting smoking (The Basics)" and "Patient education: Cough in adults (The Basics)" and "Patient education: Secondhand smoke and children (The Basics)")

●Beyond the Basics topic (see "Patient education: Quitting smoking (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Smoking cessation should be addressed with all patients who smoke. One approach to encouraging smoking cessation is the 5A’s five-step algorithm (Ask, Advise, Assess, Assist, Arrange) (table 1 and table 2). A team-based 5A’s approach is a strategy a busy clinician can use to offer smoking cessation to patients. An alternative approach is to proactively offer treatment using the three-step AAR (Ask, Assist, Refer) approach. (See 'The 5A's approach' above and 'Variations of the 5A's approach' above.)

●Assessing tobacco use during each patient visit by asking about use of cigarettes and any of the other available forms of tobacco or nicotine increases the likelihood of smoking-related discussions between patients and clinicians and increases smoking cessation rates. (See 'Ask about tobacco use and exposure' above.)

●All individuals who smoke cigarettes should be advised to quit smoking. Even brief advice to quit has been shown to increase quit rates. (See 'Advise smoking cessation' above.)

●For individuals who are willing to quit, we recommend a combination of behavioral support and pharmacologic therapy (Grade 1B). Combination therapy is superior to either behavioral intervention or pharmacologic therapy alone (see 'Combination behavioral and pharmacotherapy most effective' above and "Behavioral approaches to smoking cessation").

•We encourage patients to use the maximal behavioral intervention acceptable to them. Behavioral intervention can consist of brief clinician counseling in the office, but smokers should also be referred to a free telephone quitline for continued counseling support. In the United States, this can be accessed through a national toll-free number (1-800-QUIT-NOW). (See 'Treatments' above.)

•With a few exceptions, choice of medication is generally based on patient preference after discussion with a clinician. For most patients, we suggest either varenicline or a combination of two nicotine replacement therapy (NRT) products (a patch plus a short-acting form such as the gum or lozenge) (Grade 2B). (See "Pharmacotherapy for smoking cessation in adults", section on 'Initial therapy selection'.)

●Patients who relapse or who are unsuccessful in quitting may benefit from pharmacotherapy adjustments as well as behavioral therapy intensification. These are described in detail separately. (See 'Relapse' above and "Pharmacotherapy for smoking cessation in adults", section on 'Management of relapse' and "Behavioral approaches to smoking cessation", section on 'Patients who recently quit' and "Pharmacotherapy for smoking cessation in adults", section on 'Assess and respond to adherence issues and side effects' and "Behavioral approaches to smoking cessation", section on 'Difficulty quitting'.)

●For patients who are not ready to quit, the clinician's role is to assess the patient's perspective about the risks and benefits of continuing to smoke in order to help the individual begin to think about quitting. Those who are considering quitting but are not yet ready to discontinue tobacco use should be offered the option of initiating pharmacotherapy, rather than waiting until they are ready to stop tobacco use. This may help reduce cigarettes smoked in preparation for quitting in the future. Patients should also be advised about the health risks of secondhand smoke exposure to their household members and urged to commit to keeping their home and car smoke-free, especially if children are present. Clinicians can use motivational interviewing techniques for those not ready to quit. (See "Behavioral approaches to smoking cessation", section on 'Patients not ready to quit'.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Stephen Rennard, MD, and David Daughton, MS, who contributed to an earlier version of this topic review.