What are the recommendations for a patient with multiple sclerosis (MS) who smokes?

Smoking Cessation in Multiple Sclerosis Patients

Patients with MS who smoke must quit immediately, as smoking cessation is the single most important modifiable intervention to slow disease progression and reduce disability in MS. While the provided guidelines focus on cardiovascular disease and stroke prevention, the principles of aggressive smoking cessation apply with even greater urgency to MS patients, where smoking accelerates neurodegeneration and worsens outcomes.

Immediate Assessment and Intervention

Document Smoking Status at Every Visit

• Assess tobacco use status at every clinical encounter, as this is the foundation for intervention 1
• Record current smoking habits, pack-years, and readiness to quit 1
• Screen for environmental tobacco smoke exposure at home and work 1

Provide Unambiguous Advice to Quit

• Advise the patient to quit at every visit with clear, non-judgmental, patient-specific messaging about the importance of cessation 1
• Emphasize that continued smoking will accelerate MS progression and increase disability risk beyond the cardiovascular consequences addressed in general smoking cessation guidelines 1
• Counsel family members to quit as well and avoid exposing the patient to secondhand smoke 1

Comprehensive Cessation Strategy

Combine Pharmacotherapy with Behavioral Support

Use combination therapy with both pharmacological agents and behavioral counseling, as this approach maximizes cessation rates 1

First-Line Pharmacotherapy Options

• Varenicline: Consider as first choice, as it may increase cessation rates compared to bupropion or nicotine replacement therapy 1
• Combination nicotine replacement therapy: Use both long-acting (patch) and short-acting (gum, lozenge) formulations together 1
• Bupropion: Effective alternative, particularly if varenicline is contraindicated 1

The choice should account for the patient's medical stability, other medications (particularly MS disease-modifying therapies), and patient preference 1

Behavioral Interventions

• Provide formal smoking cessation counseling or refer to a structured cessation program 1
• For patients not ready to quit immediately, use motivational interviewing techniques to enhance readiness 1
• Develop a specific quit plan with the patient, including a quit date and strategies for managing triggers 1

Address Nicotine Withdrawal

• If the patient requires hospitalization for MS relapse or other reasons, implement protocols to manage nicotine withdrawal during the hospital stay 1
• This prevents withdrawal symptoms from complicating the clinical picture and maintains engagement with cessation efforts 1

Follow-Up and Maintenance

Arrange Systematic Follow-Up

• Schedule follow-up visits specifically to assess cessation progress 1
• At each subsequent visit, reassess smoking status and adherence to the cessation plan 1
• Provide ongoing support, as most successful quitters require multiple attempts 2

Monitor for Relapse

• Continue to assess smoking status even after successful cessation, as relapse risk remains elevated 1
• If relapse occurs, immediately reinitiate cessation interventions without judgment 1

Critical Pitfalls to Avoid

Do Not Delay Intervention

• Never wait for the patient to express readiness to quit before providing advice and assistance 1
• Even patients in the precontemplation stage benefit from physician intervention that can move them toward readiness 3

Do Not Provide Advice Alone

• Simple advice to quit without assistance yields poor results 4
• Always offer pharmacotherapy and behavioral support, not just verbal encouragement 1

Do Not Accept E-Cigarettes as Long-Term Solution

• While short-term use of nicotine-containing e-cigarettes may aid initial cessation, the risk of sustained use and unknown long-term safety outweigh benefits 1
• E-cigarettes should only be considered as a bridge to complete cessation, not as a permanent alternative 1

Do Not Ignore Environmental Exposure

• Counsel patients to avoid all secondhand smoke exposure, as this also increases cardiovascular and potentially neurological risk 1
• Address smoking by household members and workplace exposure 1

Special Considerations for MS Patients

While the evidence provided focuses on cardiovascular disease, the imperative for smoking cessation in MS is even stronger. Smoking in MS patients accelerates conversion from relapsing-remitting to secondary progressive disease, reduces efficacy of disease-modifying therapies, and increases disability accumulation. The cardiovascular benefits of cessation 1 compound with MS-specific benefits, making this intervention critical for both mortality and quality of life outcomes.