What preventative care recommendations are available for smokers?

Preventative Care for Smokers

All smokers should have their smoking status assessed at every clinical encounter, receive clear advice to quit, and be offered both pharmacotherapy (nicotine replacement therapy, varenicline, or bupropion) and behavioral counseling with scheduled follow-up. 1

Core Assessment and Documentation

• Document smoking status prominently in the medical record at every patient encounter, ensuring it is readily accessible for all healthcare team members. 2
• Ask about smoking at every opportunity, regardless of the reason for the visit, as this is the foundation of effective preventative care. 2, 1
• Assess readiness to quit and number of cigarettes per day to determine appropriate intervention intensity. 1

Universal Brief Intervention (All Smokers)

• Advise all smokers to stop at least once annually using clear, strong, and personalized language that links smoking to their current health concerns or conditions. 1
• Set a definite quit date within 1-2 weeks of the initial consultation when the patient expresses willingness to quit. 2, 1
• Emphasize complete abstinence as the goal rather than reduction strategies. 2, 1

Pharmacotherapy Recommendations

First-line medications should be offered to all smokers attempting to quit unless contraindicated:

• Combination nicotine replacement therapy (nicotine patch plus short-acting form like gum, lozenge, or inhaler) or varenicline are the preferred primary therapies. 1, 3
• Bupropion is an effective alternative first-line option. 1, 4
• Prescribe a minimum of 12 weeks of pharmacotherapy, with consideration for extension to 6 months or 1 year for sustained cessation. 1
• Provide clear instructions on medication use, including expected side effects, proper dosing, and realistic expectations about what the medication can achieve. 2, 1

The evidence strongly supports that pharmacotherapy doubles quit rates compared to self-quitting alone, with success rates reaching up to 24% when combining medication with behavioral support versus only 3-5% with willpower alone. 4

Behavioral Support Structure

Arrange structured follow-up sessions:

• Schedule weekly follow-up for at least 4 weeks after the quit date. 2, 1
• Provide at least 4 sessions during each 12-week pharmacotherapy course, with sessions lasting 10-30+ minutes. 1
• Include coping skills training, social support, and motivational interviewing with educational materials. 1
• Encourage finding a quit partner for additional social support during the cessation attempt. 2, 1
• Verify abstinence by measuring carbon monoxide in expired air at follow-up visits. 2

For patients unable to attend in-person sessions, refer to telephone quitlines, which provide effective behavioral support remotely. 1

Special Population Considerations

Pregnant smokers:

• Provide clear, accurate information on specific risks to the fetus and mother, with firm advice to stop throughout pregnancy. 2
• Offer specialist cessation support tailored to make it as convenient as possible for the mother. 2

Hospitalized patients:

• Assess smoking status on admission and advise patients of the hospital's smoke-free policy before admission. 2
• Provide cessation support including NRT or other pharmacotherapy during hospitalization, with continuation beyond discharge when possible. 2, 1
• Employ a smoking cessation specialist in each hospital to provide bedside counseling and extended support. 2

Low-income smokers:

• Increase availability of pharmacotherapy at reduced cost or free of charge, as this population has higher smoking rates but less access to treatment. 2

Healthcare System Implementation

• Train all healthcare professionals (physicians, nurses, respiratory therapists, practice nurses) in both theoretical knowledge and practical skills for delivering smoking cessation interventions. 2, 1
• Establish specialist smoking cessation clinics where feasible, staffed by specially trained individuals employed specifically for this purpose. 2
• Integrate smoking cessation into routine clinical care across all healthcare settings rather than treating it as an optional service. 2

Critical Pitfalls to Avoid

• Never provide advice without offering practical assistance for quitting—assessment and advice alone are insufficient. 1
• Do not neglect pharmacotherapy recommendations—many smokers attempt to quit without proven treatments, significantly reducing their success rates. 1, 3
• Avoid inadequate follow-up—single-session interventions have much lower success rates than structured follow-up over 4+ weeks. 1
• Do not provide incomplete medication counseling—patients need specific instructions on proper use, side effects, and realistic expectations to use pharmacotherapy effectively. 2, 1
• Never assume other healthcare team members are addressing smoking—all professionals should routinely ask about smoking and advise cessation. 2

The evidence is clear that treating tobacco dependence deserves as high a priority as managing other chronic diseases like diabetes and hypertension, given that it is the single largest preventable cause of death and disability. 2, 3