smoking cessation


Cigarette smoking is the leading preventable cause of mortality. Smokers who stop smoking reduce their risk of developing and dying from tobacco-related diseases. To increase smoking cessation rates, patient’s smoking status should as assessed and documented in every visit

Behavioral counseling and pharmacotherapy produces the best results when combined together.  

Smoking status assessment:

Practioners should first assess the patient's tobacco use; including the duration of smoking history, the number of cigarettes smoked daily, and how soon after waking up the smoker has his first morning cigarette. More dependent smokers have smoked for many years, smoke more cigarettes daily, and smoke within the first 30 minutes of awakening.

The desire to stop smoking, and the history of previous quit attempts, the smoker's degree of nicotine dependence predicts the difficulty in quitting and the intensity of treatment needed.


Quitting barriers:

Smokers face several difficulties when they try to quit. The addictiveness of nicotine is the primary barrier.

Nicotine withdrawal syndrome:

In the absence of nicotine, a smoker develops cravings for cigarettes and symptoms of the nicotine withdrawal syndrome. These symptoms include:

  • depressed mood
  • Insomnia
  • Irritability, frustration, or anger
  • Anxiety
  • Difficulty concentrating
  • Restlessness
  • Increased appetite or weight gain

These symptoms should be will known by practioners and patients so patients can know what to expect and how to deal with these symptoms.

Other barriers include daily activities associated with smoking like morning coffee, an alcoholic drink, or the end of a meal. These triggers contribute to the difficulty smokers have in smoking cessation.

Smoking cessation treatments:  

Behavioral counseling  

Behavioral counseling includes direct patient-clinician encounters, via telephone, computer programs, text messaging, or group-based therapy. The most intensive behavioral intervention acceptable to the patient should be offered. A simple five-step algorithm called the 5 A's (Ask, Advise, Assess, Assist, Arrange) helps you in remember counseling elements:




Smoking status should be assessed for every patient and documented in his medical files


Strongly advice all smokers to quit in a clear, strong, personalized manner.



assess the patient’s willingness to quit in the next 30 days.

If the patient is willing to quit smoking provide assistance, while if the patient is not willing to quit smoking a motivational intervention is needed



Provide assistance to patients trying to quit smoking by behavioral counseling and pharmacotherapy


Arrange for a follow up appointment, preferably in a week


Most former smokers had to try to quit several times before they finally achieved success so the clinician should assess the smoker's previous experiences with attempts to quit. Assessing the methods that have been tried and the smoker's degree of success with each in order to guide recommendations for the next attempt.

The first step in Setting a quit plan is setting a quit date preferably within the next two weeks. Patients should be directed to stop smoking completely on their quit day and should be familiar with nicotine withdrawal symptoms and how to deal with it.

Some patients begin to reduce smoking in the days and weeks prior to the quit date. Also removing tobacco products from the environment and asking family and friends for support will increase smoking cessation rates.

Follow-up  — A follow-up visit should be scheduled within three to seven days of the patient's quit day to monitor response to smoking cessation therapy. Then patients should then be followed monthly for at least three months.  

Difficulty quitting and relapse 

When patients fail to stop smoking after the quit date, practioners should identify the cause of failure. Different reasons could contribute to this including high nicotine dependent, low self-confidence or little social support for quitting, not using medications optimally (eg, chewing nicotine gum too rapidly, failure of the medication to reduce nicotine withdrawal, or intolerance of medication side effects).

In this case you should remind your patients that they might need multiple attempts before they quit smoking permanently.

Always remember to ensure patient adherence and to intensify behavioral counseling.

Relapse prevention  

 Long-term follow-up is very important because even successful quitters can remain at high risk of relapse for several years after smoking cessation.

The clinician should encourage and congratulate the patient on quitting; simply asking how their lives have changed since they stopped smoking can highlight the benefits of smoking cessation. Also, it is important to know if the patient is facing any problems due to smoking cessation (eg, weight gain, depression, alcohol use) and to help him accordingly.

Management of relapse:

Lack of support for cessation


Schedule follow up visits, refer the patient to an appropriate cessation counseling organization

Negative mood or depression


Provide counseling, prescribe appropriate medications, or refer the patient to a specialist


Strong withdrawal symptoms

Consider adding/ combing pharmacotherapy

Weight gain

Ensure the importance of a healthy diet and physical exercise

Reassure the patient that some weight gain after quitting is common and appears to be self-limiting


Flagging motivation

Reassure the patient that these feelings are common

Recommend rewarding activities



Smoker who are not ready to quit yet!

 For smokers who are not ready to quit, you have to assess the patient's motivation, benefits and risks in order to help the smoker to begin to think about quitting. A personalized message concerning a smoking-related health problem of the smoker himself or a family member may motivate some patients to quit smoking


Pharmacologic treatments:

First-line drug therapy for smokers includes

1.     Nicotine replacement therapy incuding nicotine gum, lozenges, spray and patches

2.     Buprobion

3.     Varenicline (champix)


Behavioral counseling in addition to pharmacological treatment when combined is better than either alone in increasing smoking cessation rates. The choice of pharmacological agent depends on patient preference, previous experience with the drugs, cost and medical conditions.

Light smokers: 

Behavioral counseling is the first line treatment for those who smoke 10 cigarettes per day or less.

Pharmacotherapy can also be used in light smokers who do not respond to behavioral counseling. The doses of nicotine replacement therapy, bupropion , and varenicline should be reduced for use in this population.


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