What is the role of therapeutic alliance in smoking cessation behavior change for adult patients with a history of smoking and underlying health conditions such as cardiovascular disease or Chronic Obstructive Pulmonary Disease (COPD)?

What is Therapeutic Alliance in Smoking Cessation Behavior Change?

Therapeutic alliance in smoking cessation refers to the collaborative relationship between the healthcare provider and patient that encompasses mutual trust, agreement on treatment goals, and shared commitment to the cessation process—a relationship that has been validated as measurable and significantly associated with quit attempts and successful cessation outcomes. 1

Definition and Core Components

Therapeutic alliance in tobacco dependence counseling consists of three validated dimensions 1:

• Goal agreement: The patient and counselor share understanding and commitment to cessation objectives 1
• Task collaboration: Both parties agree on the specific behavioral strategies and pharmacological interventions needed 1
• Relational bond: A foundation of trust, empathy, and mutual respect that facilitates honest communication about barriers and relapses 1

These components have been psychometrically validated through tobacco-specific instruments (WAIT-12 and WAIT-3) that demonstrate excellent internal consistency (0.88-0.96) and significant associations with reduced cigarettes per day, increased quit attempts, and successful cessation 1.

Clinical Significance in High-Risk Populations

For patients with COPD or cardiovascular disease, therapeutic alliance becomes particularly critical because these populations face unique challenges including stronger nicotine dependence, higher relapse rates, and disease-specific psychological barriers. 2

Evidence in COPD Patients

• Smokers with COPD demonstrate particularly strong nicotine dependence compared to general smoking populations 2
• Despite this, they respond equally well to pharmacotherapy when combined with counseling support 2
• The intensity of counseling directly correlates with quit rates in COPD patients receiving nicotine replacement therapy—one study showed that higher-intensity counseling (individual sessions, telephone contacts, small-group sessions) achieved 19% continuous abstinence versus 9% with medium-intensity approaches 2, 3
• This high-intensity alliance-based approach reduced exacerbations (0.38 vs 0.60 per patient) and hospital days (0.39 vs 1.00 per patient) 2, 3

Evidence in Cardiovascular Disease Patients

• Cardiovascular disease does not negatively impact responsiveness to smoking cessation interventions, unlike depression which does 2
• The American College of Cardiology acknowledges that varenicline may be preferred for these patients, but emphasizes that patient preferences and previous experiences must be incorporated into treatment decisions 4

Practical Implementation Framework

Essential Alliance-Building Elements

Effective smoking cessation programs must address behavioral, physiologic, and psychological consequences of smoking while being cognizant of prior unsuccessful quit attempts. 2

The evidence supports this specific approach:

1. Initial engagement: Acknowledge current smoking status and provide direct advice to quit, establishing the foundation for goal agreement 2

2. Barrier identification and resolution: Systematically address patient-specific concerns 5:

   • Breaking the habit (36% cite this as relapse reason) 5
   • Stress management (27% relapse due to stressful situations) 5
   • Weight gain concerns 5
   • Social environment (25% relapse from being around other smokers) 5

3. Pharmacotherapy integration with counseling support: The combination of pharmacotherapy plus counseling improves cessation compared to either alone 2

4. Ongoing therapeutic contact: Provide intratreatment social support, which is critically underutilized (only 17.5% of patients report receiving it) 5

Optimal Intensity Recommendations

For patients with COPD or cardiovascular disease, implement high-intensity cessation strategies that include combination pharmacotherapy (nicotine replacement therapy plus bupropion or varenicline) with intensive behavioral counseling. 3

This should consist of 2, 3:

• Individual counseling sessions
• Telephone follow-up contacts
• Small-group counseling sessions
• Pharmacologic support tailored to nicotine dependence severity

Stage-Appropriate Alliance Strategies

Most smokers present in precontemplation (22.7%) or contemplation (44.0%) stages, requiring targeted interventions before action-oriented approaches 5:

• Precontemplation/Contemplation stages: Focus alliance-building on exploring ambivalence, addressing barriers, and building motivation rather than immediate quit attempts 5
• Preparation/Action stages: Shift to concrete behavioral strategies and pharmacotherapy initiation 5
• Maintenance stage: Emphasize relapse prevention and sustained support 5

Evidence Quality and Nuances

The evidence for therapeutic alliance in smoking cessation shows important distinctions:

• Group therapy versus self-help: Moderate-quality evidence (RR 1.88,95% CI 1.52-2.33) supports group programs over self-help, demonstrating the value of interpersonal therapeutic relationships 6
• Group therapy versus brief provider support: Low-quality evidence shows modest benefit (RR 1.22,95% CI 1.03-1.43) with considerable heterogeneity (I² = 59%) 6
• Group versus individual counseling: No evidence of superiority (RR 0.99,95% CI 0.76-1.28), suggesting alliance quality matters more than format 6

Cognitive Behavioral Therapy (CBT) demonstrates particular effectiveness when therapeutic alliance is established, especially in patients with smoking-related conditions like COPD and cardiovascular disease. 7 This 2025 meta-analysis of 16 RCTs (N=2,531) found CBT significantly improves long-term cessation rates with moderate-quality evidence, and showed greater effectiveness in high-risk populations 7.

Critical Clinical Pitfalls

Do not rely solely on pharmacotherapy without establishing therapeutic alliance through counseling—the combination is consistently more effective than either alone. 2, 8

Additional pitfalls to avoid:

• Inadequate social support: Only 17.5% of patients report receiving intratreatment support, yet this is critical for behavior change 5
• Premature pharmacotherapy discontinuation: 31.5% discontinue due to adverse events when alliance is insufficient to support medication adjustment rather than abandonment 5
• Ignoring stage of change: Providing action-oriented interventions to patients in precontemplation/contemplation stages undermines alliance and wastes resources 5
• Underestimating relapse risk: Approximately 80% or more of patients return to smoking within one year, requiring sustained therapeutic relationship and multiple quit attempts 8

Special Considerations for Pharmacotherapy

When therapeutic alliance is established, pharmacotherapy selection should consider 9:

• Varenicline: Provide appropriate counseling about neuropsychiatric monitoring, cardiovascular symptom awareness, and the need to report adverse events immediately 9
• Combination therapy: Some guidelines recommend dual controller agents (e.g., nicotine patch plus bupropion or varenicline) for improved efficacy, though optimal combinations remain unstudied 2
• Dose adjustment within alliance: Consider dose reduction for tolerability rather than discontinuation when strong therapeutic relationship exists 9