Applied Evidence

Smoking cessation: What should you recommend?

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Fifty years after a landmark report on its perils, smoking remains a major public health problem. Here’s the latest on how best to help patients quit.




› Prescribe varenicline, bupropion, or nicotine replacement as first-line single pharmacotherapy for smoking cessation. A
› Provide counseling along with medication, as the combination has proven to be more effective than either option alone. A
› Refer patients to their state Quit Line—a toll-free tobacco cessation coaching service that has been shown to be an effective form of counseling. A

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

In its 2014 report, “The Health Consequences of Smoking—50 Years of Progress,”1 the US Surgeon General concluded that, while significant improvements have been made since the publication of its landmark 1964 report, cigarette smoking remains a major public health problem. It is the leading cause of preventable death, increasing the risks of such common causes of mortality as cardiovascular disease, pulmonary disease, and malignancy. Cigarette smoking is responsible for an estimated 443,000 deaths annually.2

Overall, 42 million US adults and about 3 million middle and high school students smoke, despite the availability of an array of pharmacologic interventions to help them quit.1 Half of those who continue to smoke will die from a tobacco-related cause. Stopping before the age of 50 years cuts the risk in half, and quitting before age 30 almost completely negates it.3

The number of cigarettes smoked per day and how long a patient is awake before smoking that first cigarette are important factors in determining which medication to select for smoking cessation.

The most recent comprehensive smoking cessation guideline, sponsored by the US Public Health Service, was published in 2008.4 The US Preventive Services Task Force (USPSTF) recommendation that “clinicians ask all adults about tobacco use and provide tobacco cessation interventions” for those who smoke was issued one year later.5 Since then, multiple studies have assessed the merits of the various medications, forms of nicotine replacement therapy (NRT), and counseling aimed at helping smokers maintain abstinence from tobacco.

This article reviews the guideline and provides family physicians with an evidence-based update.

The guideline: Treating tobacco use and dependence

Prescribing a first-line medication (bupropion SR, varenicline, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, or nicotine patch) for every patient who seeks to quit smoking is a key component of the 2008 guideline (See TABLE W1).4 The only exceptions: patients for whom such agents are medically contraindicated and groups for which there is insufficient evidence of effectiveness, such as pregnant women and adolescents.

The use of any of these medications as a single agent nearly doubles the likelihood of success compared with placebo, with an average cessation rate of 25% (TABLE 1).4

Combination therapy (pairing a nicotine patch and an additional agent) was found to be even more effective, with some combinations attaining success rates as high as 65%.4

Second-line therapies, including clonidine and nortriptyline, were also cited as effective, with an average cessation rate of 24%.4 Although the meta-analyses that these averages were based on did not include head-to-head comparisons, subsequent studies that also showed efficacy did include such comparisons.

Counseling is an essential component

In one of the meta-analyses on which the guideline was based, the combination of counseling and medication proved to be more effective than either intervention alone. Individual, group, and telephone counseling were all effective (odds ratio [OR]=1.7 [1.4-2.0], 1.3 [1.1-1.6], and 1.2 [1.1-1.4], respectively), provided they included practical help that emphasized problem solving and skills training, as well as social support. The benefits of a team-based approach were evident from the finding that counseling provided by more than one type of clinician had higher effect sizes (OR=2.5 [1.9-3.4] when 2 different clinical disciplines were involved and 2.4 [2.1-2.9] for 3 or more disciplines).4

The guideline also found state-sponsored quit lines, accessible at no charge via 800-QUIT-NOW, are an effective option. (For more information about this and other resources, see TABLE W2.)

For patients who aren’t ready to stop smoking, the guideline recommends motivational interviewing4—a direct, patient-centered technique used to explore and work through ambivalence. Further information about this method is available at motivational

In counseling patients considering a quit attempt, it is important to present all options. A smoking history is needed, too, because factors such as the number of cigarettes smoked per day, how long a patient is typically awake before smoking the first cigarette of the day, and level of dependence are important factors in determining medication and dosage. Consider the advantages and disadvantages of the various medications (TABLE 2)4,6,7 or methods used for prior quit attempts and reasons for relapse, if appropriate; and patient preference.


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