What are the best strategies to help a patient quit smoking?

Effective Strategies for Smoking Cessation

The most effective approach to help patients quit smoking is combining pharmacotherapy (preferably varenicline or combination nicotine replacement therapy) with intensive behavioral counseling, which can increase abstinence rates to 18-28% compared to 8.6% with brief advice alone. 1

Initial Assessment and Approach

1. Implement the 5 A's framework:

   • Ask about tobacco use at every visit
   • Advise all tobacco users to quit in a clear, strong, personalized manner
   • Assess willingness to make a quit attempt
   • Assist with developing a quit plan
   • Arrange follow-up 2

2. For patients unwilling to quit, use the 5 R's motivational approach:

   • Relevance: Personalize reasons to quit
   • Risks: Discuss negative consequences of smoking
   • Rewards: Highlight benefits of quitting
   • Roadblocks: Identify barriers to quitting
   • Repetition: Revisit at each encounter 2

Pharmacotherapy Options

First-line medications (in order of effectiveness):

1. Varenicline (Chantix):

   • Most effective single agent with 28% abstinence rate 1
   • Dosing: Start 1 week before quit date
     • Days 1-3: 0.5 mg once daily
     • Days 4-7: 0.5 mg twice daily
     • Day 8-end: 1 mg twice daily 3
   • Duration: 12 weeks; consider additional 12 weeks for successful quitters 3

2. Combination Nicotine Replacement Therapy (NRT):

   • Long-acting (patch) + short-acting (gum, lozenge, inhaler, or nasal spray)
   • 17% abstinence rate 1
   • Use patch with behavioral support program 4

3. Bupropion SR:

   • 19% abstinence rate 1
   • Can be used alone or with NRT
   • Monitor for neuropsychiatric side effects 1

Behavioral Counseling Approaches

1. Intensive counseling (optimal):

   • Four or more sessions during 12-week pharmacotherapy
   • First session within 2-3 weeks of quit date
   • 10-30+ minutes per session 2
   • Focus on problem-solving skills, social support, and coping strategies 2

2. Brief counseling (minimal but effective):

   • Even 3-minute counseling can produce long-term quit rates 2
   • Ask two key questions:
     • "Are you willing to make a quit attempt now?"
     • "What worked or didn't work when you tried to quit before?" 2

3. Support resources:

   • Telephone quitlines (1-800-QUIT-NOW)
   • Web-based programs (Smokefree.gov, BecomeAnEX)
   • Text messaging programs (SmokefreeTXT)
   • Mobile apps (QuitGuide, quitSTART) 2

Practical Counseling Elements

1. Help identify smoking triggers 2
2. Develop coping strategies for stressful situations 2
3. Provide practical problem-solving skills 2
   • Removing tobacco products from home/work
   • Changing routines associated with smoking
   • Deep breathing techniques for relaxation

Follow-up and Relapse Prevention

1. Schedule follow-up within first 2 weeks of cessation, then periodically 2
2. Address withdrawal symptoms (peak within 1-2 weeks after quitting) 2
3. For relapse: Try a different medication or combination therapy 2

Common Pitfalls to Avoid

1. Inadequate treatment duration - Ensure at least 12 weeks of pharmacotherapy 1
2. Neglecting behavioral support - Pharmacotherapy alone is less effective 2
3. Underestimating withdrawal management - Provide specific coping strategies 1
4. Ignoring cost barriers - Inform about insurance coverage or free resources 1
5. Not addressing comorbid conditions - Depression and anxiety can trigger relapse 2

Special Considerations

1. For highly dependent smokers: Consider 4 mg gum instead of 2 mg 5
2. For patients who failed previous attempts: Try a different medication or combination approach 3
3. For gradual quitters: Consider reducing smoking by 50% in first 4 weeks, another 50% in next 4 weeks, with complete abstinence by 12 weeks 3

By implementing this comprehensive approach combining appropriate pharmacotherapy with behavioral support tailored to the patient's level of dependence and previous quit attempts, you can significantly improve their chances of successfully quitting smoking and reducing their risk of smoking-related morbidity and mortality.