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Overview of smoking cessation management in adults

Overview of smoking cessation management in adults
Author:
Nancy A Rigotti, MD
Section Editors:
Mark D Aronson, MD
Hasmeena Kathuria, MD
Deputy Editor:
Sara Swenson, MD
Literature review current through: Apr 2025. | This topic last updated: Mar 07, 2025.

INTRODUCTION — 

Cigarette smoking is the leading preventable cause of mortality in the United States and worldwide [1]. Individuals who quit smoking reduce their risk of developing and dying from tobacco-related diseases, gaining up to an estimated 10 years of life expectancy [2,3]. Effective treatments are available to help individuals stop smoking, and clinicians who use them increase the likelihood that their patients who use tobacco will successfully quit smoking [4,5].

This topic provides an overview of smoking cessation management in adults.

Pharmacologic treatments and behavioral counseling to support smoking cessation, benefits of smoking cessation, smoking cessation during pregnancy, vaping and e-cigarettes, and smoking cessation in adolescents are discussed separately:

●(See "Pharmacotherapy for smoking cessation in adults".)

●(See "Behavioral approaches to smoking cessation".)

●(See "Benefits and consequences of smoking cessation".)

●(See "Vaping and e-cigarettes".)

●(See "Tobacco and nicotine use in pregnancy: Cessation strategies and treatment options".)

●(See "Management of smoking and vaping cessation in adolescents".)

FRAMEWORK FOR SMOKING CESSATION MANAGEMENT

Treating smoking as chronic disease — Cigarette smoking is a chronic relapsing disorder sustained by a physical dependence on nicotine and learned behaviors that are rewarding for the individual [6,7]. The model of chronic disease management used for other chronic conditions (eg, diabetes, hypertension, and depression) provides an overarching approach to guide smoking cessation treatment [8]. It includes routine screening, advice to quit tobacco use, repeated offers of treatment, and regular monitoring of progress over time.

Chronic disease management is a team-based approach in which the health care team shares responsibility for managing patients' tobacco use. The clinician's unique role includes offering advice, initiating referrals, and initiating and managing pharmacotherapy for smoking cessation. If feasible, staff document the patient's smoking status before the visit and, after the visit, actively connect patients to care resources (primarily ongoing smoking cessation counseling) that can offer ongoing treatment between office visits. These adaptations help to address the time constraints of busy clinicians and may reduce the number of follow-up visits for smoking cessation. Redistributing some smoking cessation management tasks to clinic staff can help alleviate the time pressures on busy outpatient clinicians [6].

Treatment models

Three-step model — We generally use a three-step model, such as Ask-Advise-Connect or Ask-Advise-Refer, as a framework for smoking cessation management (figure 1) [9]. These models consist of the following steps, which are outlined in detail below (see 'Interventions for all patients' below):

●Ask all patients about tobacco use

●Advise all patients who smoke to stop tobacco use

●Offer all patients who smoke both pharmacotherapy and behavioral treatments at the visit, then Refer or Connect them to resources to sustain treatment after the visit

The three-step model differs from earlier frameworks for smoking cessation management by using an opt-out approach in which clinicians offer treatment to all patients who smoke, rather than presenting treatment as an option only for those who have indicated readiness to quit. With this model, the clinician does not assess the patient's readiness to quit or use stage-specific smoking cessation interventions before offering treatment. However, clinicians can use motivational enhancement techniques for individuals who are not interested in the proffered treatment options.

Limited evidence supports the efficacy of the three-step model. In a meta-analysis of 13 randomized trials, models that utilized very brief advice, such as the three-step model, increased self-reported tobacco abstinence at six months or longer, compared with control interventions (adjusted relative risk [RR] 1.17, 95% CI 1.07-1.27) [10]. Proactive outreach programs that offer smoking cessation interventions to patients regardless of their readiness to set a quit date also increase smoking cessation rates, compared with usual care [11-13].

In contrast, the Stages of Change model assesses the patient's readiness to quit up front and then tailors smoking cessation advice to the individual's stage of change (see 'Alternative models' below). The Stages of Change model has been widely validated and incorporated into earlier models of smoking cessation intervention. However, not all individuals who achieve tobacco abstinence move through these stages, and some may not need stage-based interventions [14].

It is unclear whether using motivational interviewing and stage-specific interventions offer additional benefit over a non-stage-based approach. As an example, a 2010 systematic review of 41 trials concluded that non-stage-based interventions for smoking cessation were comparable to their stage-based equivalents [15]. However, the certainty of this conclusion was limited by wide confidence intervals, suggesting that stage-based interventions could be either more or less effective than non-stage-based interventions. Similarly, in a meta-analysis of 19 trials, smoking cessation interventions with motivational interviewing appeared more effective for achieving abstinence than interventions without motivational interviewing; however, the result was not statistically significant (RR 1.24, 95% CI 0.91-1.69) [16].

Several professional organizations have adopted the three-step model in their guidelines on smoking cessation management [5,17,18].

Alternative models

●Five A's approach – The Five A's approach is an alternative framework for smoking cessation management (table 1). It was developed in the 1990s as the initial tobacco treatment model for clinical practice in the United States. It was subsequently updated in a 2008 United States Public Health Service clinical practice guideline and recommended by the 2021 United States Preventive Services Task Force guidelines [4,5,19,20].

The Five A's steps are:

•Ask about tobacco use

•Advise quitting

•Assess readiness to quit

•Assist smokers ready to quit

•Arrange follow-up

Assessing the individual's readiness to quit (step three) typically utilizes the Stages of Change model.

●Stages of Change model – The Stages of Change model helps to tailor treatment interventions to an individual's readiness to change. This model proposes that people who smoke move through five stages as they progress from smoking to abstinence [21]. These include:

•Precontemplation (not considering quitting in the next six months)

•Contemplation (considering quitting in the next six months but not in the next month)

•Preparation (planning to make a quit attempt in the next month)

•Action (in the process of making a quit attempt or quit smoking within the past six months)

•Maintenance (achieved smoking cessation, often defined as at least six months of abstinence)

These approaches provide a framework that is patient centered and facilitates providing stage-specific interventions and advice. It may also enable clinicians to identify those patients who are most likely to accept and follow through with smoking cessation treatment and thereby most effectively prioritize visit and staff time. However, despite the robust theoretical framework of the Stages of Change model and motivational interviewing more generally, it is unclear if it is more effective in clinical practice than an "opt out" approach, such as the three-step model. (See 'Three-step model' above.)

Assessing a patient's readiness to change for smoking cessation and motivational interviewing more generally are discussed separately. (See "Behavioral approaches to smoking cessation", section on 'Techniques for motivational interviewing' and "Brief intervention for unhealthy alcohol and other drug use: Goals and components", section on 'Readiness to change' and "Substance use disorders: Motivational interviewing".)

INTERVENTIONS FOR ALL PATIENTS

Ask about tobacco use — We ask all individuals about current and past tobacco use, including use of e-cigarettes, and document smoking status. For those who smoke, we assess their history of use and quit attempts and level of nicotine dependence.

●Identify current use – We begin by asking individuals if they have ever smoked cigarettes or used a tobacco product. We typically ask: "In the past year, how often have you used tobacco products?"

This question is part of the "TAPS" (Tobacco, Alcohol, Prescription medication, and other Substance use Tool) screening questionnaire, which is a validated tool for tobacco and other substance use screening [22-24].

Asking in this way can identify individuals who smoke intermittently or use noncombustible tobacco products [6]. Eighteen percent of United States adults who used tobacco in 2021 consumed more than one type of tobacco product, such as cigars, pipes, smokeless tobacco, water pipes/hookahs, and electronic cigarettes [25]. While use of noncombustible tobacco products, such as smokeless tobacco or electronic cigarettes, poses fewer health risks than cigarettes, they are not harmless and deserve the clinician's attention [26]. (See "Patterns of tobacco use" and "Vaping and e-cigarettes".)

Routinely and frequently asking about tobacco use increases quit rates, smoking-related discussions, and rates of receiving a prescription or referral for smoking cessation [4,19,20,27,28].

●Document smoking status – It is important to document smoking status in the electronic medical record to improve identification of those who use tobacco and potentially increase the use of smoking cessation interventions [29,30]. Ideally, office staff can ask about tobacco use and document it while they prepare the patient for the visit.

Evaluation and documentation of smoking status at every health encounter is consistent with recommendations from the United States Preventive Services Task Force [5].

●Assess nicotine dependence – The clinician should assess the patient's degree of nicotine dependence [6,31]. Clinicians can use the Heaviness of Smoking Index to gauge nicotine dependence by asking the following two questions (table 2) [17,32]:

•How many cigarettes do you smoke each day?

•How soon after waking up in the morning do you smoke your first cigarette?

Individuals with higher nicotine dependence typically smoke more cigarettes daily and smoke within the first 30 minutes of awakening [31,33,34]. Higher levels of nicotine dependence are associated with more difficulty in stopping smoking and the need for more intensive cessation interventions.

●Assess use history and quit attempts – Assessing the individual's duration of smoking, number of cigarettes smoked daily, types of tobacco products used, and history of quit attempts can guide counseling and treatment. Clinicians should ask what cessation measures the patient has tried and the degree of success with specific behavior changes and medications.

Advise to stop tobacco use

●Deliver clear advice – Clinicians should offer brief, clear advice to quit at each patient encounter. This can increase smoking abstinence rates, even though not every patient will be prepared to make a quit attempt [16,20]. In a meta-analysis of 42 trials, verbal instructions by a physician to stop smoking increased quit rates at six months or longer compared with no advice or usual care (mean quit rates 8 versus 4.8 percent; relative risk 1.76; 95% CI 1.58-1.96) [16].

Even patients who are not ready to quit report greater satisfaction with their care when they are asked about their tobacco use or are advised to quit smoking [35].

●Focus on patient-specific benefits – Advice to quit is most effective when it has a positive frame that focuses on the benefits of quitting. A simple example is: "Stopping smoking is the most important action that you can take for your health" [6]. For individuals who feel that quitting will no longer benefit them, clinicians can emphasize that "it's never too late to benefit from quitting smoking."

We try to link advice to the patient's specific medical concerns or reasons for the visit. As an example, clinicians can inform patients who present with respiratory symptoms that quitting smoking can reduce the severity of respiratory infections or frequency of asthma exacerbations.

Eliciting the individual's non-health-related reasons to stop smoking also informs patient-specific counseling because personal issues often motivate smoking cessation efforts [36-39]. Reasons that patients cite for quitting may include saving money, being free from nicotine addiction, setting a nonsmoking example for their children, or increasing their chances of seeing children or grandchildren reach adulthood [6].

●Recommend smoke-free home and car – Regardless of smoking status, we advise all patients to set a strict smoke-free policy for their home and car. Smoke-free environments can help individuals who smoke reduce the number of cigarettes smoked daily; minimize temptations to smoke; and avoid exposing family (especially children), friends, and household members to secondhand smoke [40,41]. Secondhand smoke exposure is associated with adverse health outcomes (eg, coronary heart disease and lung cancer) in nonsmokers. (See "Secondhand smoke exposure: Effects in adults" and "Secondhand smoke exposure: Effects in children".)

Offer treatment

Offer smoking cessation treatment — We offer smoking cessation treatment to all patients who smoke. Clinicians should acknowledge that quitting smoking is challenging, inform patients that effective treatments exist, and emphasize that they are prepared to work with the patient to achieve (or move toward) abstinence. An example is: "Stopping smoking can be difficult, but we have effective treatments to help you quit or cut down on your smoking. I am prepared to work with you to find a plan that works for you. Can I tell you more about these options?"

This proactive approach communicates that treatment options exist even for those who are not ready to quit completely. It may also be more efficient and effective than assessing each patient's readiness to quit and tailoring interventions to the patient's stage of change. (See 'Three-step model' above.)

Individuals who smoke are often not aware of all available options to help them quit. Many have not engaged in formal smoking cessation counseling or had an adequate trial of evidence-based pharmacotherapy. Approximately two-thirds of patients who smoke say that they want to quit, and over half of those who smoke have tried to quit in the past year [42]. However, less than one-third of adults who try to quit seek help, and even fewer use the most effective treatments.

Connect to resources — Clinicians or office staff should proactively offer referrals for behavioral support to all individuals who smoke. Behavioral support can include:

●Smoking cessation clinical services – Smoking cessation programs located in the health care system or community can provide a robust level of support for individuals who want to stop smoking.

●Telephone quitlines – In the United States, state-based quitlines offer free community-based resources that include telephone counseling and medication samples to anyone who smokes. Patients can self-refer by calling 1-800-QUIT-NOW. In the United States and Canada, clinicians and patients can access additional information at map.naquitline.org. Most state quitlines offer free samples of medication: usually nicotine patches, gum, and/or lozenges; this can help to motivate individuals to accept a quitline referral.

In some health care systems, an electronic direct referral can be made from a patient's electronic health record to the state quitline [43,44]. The quitline staff then proactively contacts the patient to offer smoking cessation support and links to local available resources [45].

Telephone counseling and quitlines are discussed separately. (See "Behavioral approaches to smoking cessation", section on 'Telehealth counseling'.)

●Web-based resources and interventions – Clinicians can supplement in-office counseling by providing patients with web-based tools or resources to assist with smoking cessation, such as text messaging and phone apps. A wide range of these can be accessed via the website www.smokefree.gov. Web-based resources are discussed separately. (See "Behavioral approaches to smoking cessation", section on 'Web resources and interventions'.)

We typically make a referral at the end of the visit. Patients are more likely to use behavioral support resources if the referral is to a specific resource or clinic and office staff proactively contact the patient to schedule an appointment.

Behavioral strategies for specific groups of patients are discussed below. (See 'Patients who are ready to quit' below and 'Patients who are not ready to take action' below and 'Treatment considerations for specific populations' below.)

General approaches to behavioral counseling, including the selection, content, and benefits of specific interventions, are discussed separately. (See "Behavioral approaches to smoking cessation".)

Assess patient's willingness to take action — After offering treatment, we ask if the patient is willing to quit smoking or change their smoking behavior. All individuals who are open to smoking cessation treatment should receive a combination of behavioral support and pharmacologic therapy (see 'Patients who are ready to quit' below). We modify our approach to smoking cessation treatment for patients who are willing to change their smoking behavior but not quit or who are not currently interested in any treatment. (See 'Patients who are not ready to quit' below and 'Patients who are not ready to take action' below.)

Individualizing smoking cessation interventions matches treatment to patients' preferences, specific needs and goals, tobacco use pattern, and prior quit attempts. It may also increase patient engagement and optimize efficient use of staff time. Changing deeply ingrained behavioral patterns is a gradual process, and understanding patients' perspectives about their behavior can guide more effective treatment recommendations.

PATIENTS WHO ARE READY TO QUIT

Initial steps — For individuals who are ready to stop smoking, initial steps include setting a quit date, reinforcing benefits of quitting, addressing barriers to quitting, and developing a treatment plan. The primary clinician typically sets a quit date and develops a treatment plan. In some practice settings, office staff can assist with the remaining tasks. Additionally, hospital or community-based cessation programs, state-based telephone quitlines, and digital health resources can provide components of behavioral counseling.

Set a quit date — We begin by helping the patient set a quit date within two to four weeks. This time frame ensures adequate time to get smoking cessation medications and prepare for a quit attempt [46]. We typically advise patients to quit on the quit date, but gradual reduction prior to the quit date is an acceptable alternative. In a systematic review including 22 randomized trials and over 9000 participants, those who reduced smoking before the quit date (ie, "reduction to quit") demonstrated comparable rates of abstinence to those who quit abruptly (relative risk [RR] 1.01, 95% CI 0.87-1.17) [47].

Reinforce reasons to quit — Eliciting patient-specific reasons for quitting and reinforcing those may support quit attempts and inform the timeline and intensity of treatment. As an example, a patient who wants to quit to minimize second-hand smoke exposure to family members may choose a quit date on an upcoming holiday or family member's birthday or anniversary. Individuals whose motivation to quit stems from their desire to improve their health may link quitting with starting or resuming exercise that could help them cope with triggers to smoke. For some individuals, sharing their reasons for quitting with close friends and family provides additional support.

Address barriers to quit — Clinicians can help the patient anticipate and address barriers to quitting. Although barriers vary for individual patients, common barriers include nicotine withdrawal symptoms and specific triggers to smoke. (See "Behavioral approaches to smoking cessation", section on 'Content of therapy'.)

Nicotine withdrawal — Because physical dependence on nicotine sustains and reinforces smoking behavior, teaching patients how to recognize and manage symptoms of nicotine withdrawal is important for successful abstinence. Symptoms include craving for a cigarette, difficulty concentrating, irritability, restlessness, mood changes (dysphoria, anxiety, or depression), insomnia, increased appetite, and weight gain. Because most symptoms are nonspecific, patients often do not recognize them as representing nicotine withdrawal. (See "Behavioral approaches to smoking cessation", section on 'Education about withdrawal symptoms'.)

Nicotine withdrawal symptoms occur when a person who is physiologically dependent on nicotine stops smoking or refrains from smoking for a few hours. They peak in the first three days of smoking cessation and gradually subside over the next four weeks. Patients who learn to manage withdrawal symptoms are more likely to successfully sustain abstinence, especially early in a quit attempt. (See "Benefits and consequences of smoking cessation", section on 'Nicotine withdrawal syndrome'.)

Nicotine withdrawal symptoms are alleviated by any of the first-line smoking cessation medications (eg, nicotine replacement, varenicline, or bupropion). Although most individuals use pharmacotherapy to relieve nicotine withdrawal symptoms, behavioral approaches can supplement management. (See "Pharmacotherapy for smoking cessation in adults", section on 'Initial therapy selection' and "Behavioral approaches to smoking cessation", section on 'Content of therapy'.)

Other barriers

●Triggers for smoking – Identifying and counseling patients about specific triggers for smoking is a key part of smoking cessation management because triggers contribute to patients' difficulties in remaining abstinent from nicotine (table 3) [48]. People who use tobacco become conditioned to associate the pleasurable effects of tobacco use with environmental triggers, such as their morning coffee, an alcoholic drink, or the end of a meal. (See "Behavioral approaches to smoking cessation", section on 'Identification of triggers' and "Behavioral approaches to smoking cessation", section on 'Content of therapy'.)

●Fear of weight gain – Fear of weight gain is also a barrier. Although weight gain can occur with smoking cessation, behavioral approaches and some smoking cessation medications, such as bupropion, may help limit weight gain. (See "Benefits and consequences of smoking cessation", section on 'Weight gain' and "Behavioral approaches to smoking cessation", section on 'Content of therapy'.)

●Costs of treatment – Some patients are concerned about costs of treatments. In the United States, insurance plans are required to cover tobacco-cessation interventions, including behavioral counseling and medications approved by the US Food and Drug Administration [49]. Providing cost-free medications may increase rates of smoking cessation. In a meta-analysis of 10 randomized trials in primary care settings, providing free medications increased abstinence rates at six months compared with usual care (17 versus 12 percent; RR 1.36; 95% CI 1.05-1.76) [50]. Smoking cessation programs that include proactive outreach to patients and facilitate receipt of smoking cessation medications may also increase quit rates among individuals with low income and education [51-53].

Develop a treatment plan

Combined behavioral treatment and pharmacotherapy preferred — We suggest a combination of behavioral and pharmacologic treatments for smoking cessation management [16]. Medications are started before or on the quit date.

The combination of behavioral counseling and pharmacotherapy is more efficacious than brief advice or usual care and modestly more efficacious than medications or counseling alone [54-57]. Data supporting the efficacy of combination treatment come from meta-analyses of randomized trials.

●In a meta-analysis including 52 trials and 19,488 participants, combined behavioral and pharmacotherapy produced greater smoking abstinence at six months or more, compared with usual care or brief advice (15.7 versus 8.6 percent; RR 1.83; 95% CI 1.68-1.98) [58].

●In a meta-analysis of 65 trials of individuals receiving pharmacotherapy and minimal behavioral support, adding additional behavioral interventions increased quit rates at 6 to 12 months (20 versus 17 percent; RR 1.15; 95% CI 1.08-1.22) [54].

With optimal treatment, 15 to 35 percent of people who smoke and try to quit can succeed for six months or more [59,60]. By contrast, only 3 to 6 percent of those who make an unaided quit attempt are still abstinent one year later [42].

Pharmacotherapies — For individuals who are ready to quit, we suggest either varenicline or a combination of two nicotine replacement therapy (NRT) products (a patch used daily plus a short-acting form, such as the gum or lozenge, to control cravings) (table 4) [17,61]. If either of these are not acceptable or appropriate, bupropion or single-agent NRT is a reasonable alternative. Combining different categories of smoking cessation medications is an option for patients unable to succeed in quitting with a single agent [6]. The selection, efficacy, and safety of specific pharmacotherapies are discussed separately. (See "Pharmacotherapy for smoking cessation in adults".)

These medications have efficacy for smoking cessation based on data from meta-analyses of randomized trials (table 5) [16]. The use of pharmacotherapy for smoking cessation is consistent with guidelines from the United States Preventive Services Task Force, the American College of Cardiology, and the American Thoracic Society [5,17,61,62].

Behavioral counseling — The clinician's brief office-based counseling should be supplemented by referral and connection to resources that provide behavioral interventions for smoking cessation. Optimal behavioral interventions include referrals to special clinics or smoking cessation programs located in the health care system or community. In situations where such programs are not available or feasible, telephone quitlines provide valuable, free community-based resources to support an individual's smoking cessation efforts. (See 'Offer treatment' above.)

Behavioral counseling is superior to usual care in helping patients stop smoking. A network meta-analysis of 194 randomized trials with over 70,000 participants found high-certainty evidence that behavioral counseling increased quit rates compared with usual care (odds ratio 1.44, 95% credible interval 1.22-1.70) [63]. Counseling was effective when provided by physicians, nurses, pharmacists, or oral health professionals.

Adjunctive counseling (ie, counseling added to minimal behavioral support) also improves rates of smoking cessation. In a meta-analysis of 22 studies with 18,150 participants, adjunctive counseling by a health professional other than the primary clinician increased rates of smoking cessation compared with standard smoking cessation support (9 versus 7 percent; RR 1.31; 95% CI 1.10-1.55) [50]. In general, quit rates increase as the intensity (frequency, duration) of behavioral support increases [5,64].

Specific approaches to behavioral counseling, efficacy of individual counseling strategies, and web resources are discussed separately. (See "Behavioral approaches to smoking cessation".)

Other interventions — We do not typically recommend other interventions for smoking cessation but provide information about these for individuals who ask. Financial incentives have the best evidence of efficacy whereas limited evidence exists for acupuncture, hypnotherapy, and transcranial magnetic stimulation.

●Financial incentives – Financial incentives, both with and without support from a patient navigator, can improve rates of smoking cessation but are not widely implemented in medical practice [65-69]. In a meta-analysis of randomized trials including 18,303 participants, financial incentives improved quit rates at the longest follow-up (≥6 months), compared with control conditions (108 versus 71 per 1000 persons; RR 1.52; 95% CI 1.33-1.74) [70]. Included studies offered a range of incentive types, amounts, and durations, and some studies were conducted in populations with lower socioeconomic status.

●Acupuncture – In a meta-analysis of randomized trials, acupuncture achieved a possible short-term benefit but no consistent evidence of a long-term effect on abstinence, compared with sham acupuncture or placebo [71]. Acupuncture was less effective than NRT [71]. (See "Overview of the clinical uses of acupuncture".)

●Hypnotherapy – A systematic review of 11 randomized trials of hypnotherapy found insufficient data to demonstrate consistent efficacy for smoking cessation [72]. In a subsequent randomized trial of 360 adults who were willing to quit smoking, a group smoking cessation program using hypnotherapy was comparable to one using cognitive-behavioral therapy [73].

●Transcranial magnetic stimulation – Emerging evidence suggests that repetitive transcranial magnetic stimulation may improve smoking abstinence rates compared with placebo (sham intervention), although insufficient evidence exists to recommend its use [74,75]. Repetitive transcranial magnetic stimulation has only been studied in small, randomized trials of individuals who had tried pharmacotherapy without success. It has not yet been compared with standard pharmacotherapy for smoking cessation [76].

Ongoing monitoring — We follow up with individuals who commit to a quit attempt within four weeks of their planned quit date to assess their success with quitting and provide ongoing management. Follow-up can be in person, via telehealth, or through online messaging.

Relapse prevention for those who quit — For individuals who successfully quit, follow-up is essential because early relapse is common.

●Tasks at follow-up – Follow-up enables clinicians to perform several important smoking cessation tasks [5]:

•Assess medication adherence, side effects, and need for continued use

•Monitor response to pharmacotherapy and alter it if needed

•Congratulate the patient and reinforce positive behavior changes

•Encourage continued abstinence, noting that even a single puff on a cigarette may lead to relapse

•Assess the patient's confidence in being able to sustain abstinence, identify problems encountered, and anticipate upcoming challenges

•Offer additional available resources and follow up on referrals for smoking cessation management

These issues are discussed in detail separately. (See "Pharmacotherapy for smoking cessation in adults", section on 'Follow-up' and "Behavioral approaches to smoking cessation", section on 'Patients who recently quit'.)

Clinicians should assess smoking status during every encounter with a patient who has recently quit, especially during the first three months, when most relapses occur (table 6). One study estimated that 72 percent of individuals who smoke were no longer abstinent three months after making a quit attempt [77]. Subsequent follow-up should continue at least annually because those who successfully quit remain at high risk of relapse for several years after smoking cessation. (See 'Ask about tobacco use' above.)

●Duration of pharmacotherapy – We continue pharmacotherapy for at least three months after a quit date. (See "Pharmacotherapy for smoking cessation in adults", section on 'Duration of pharmacotherapy'.)

Patients with relapse or difficulty quitting — Most individuals have difficulty permanently quitting smoking and may require multiple quit attempts before successful smoking cessation. Steps to support these patients include reframing prior quit attempts as partial successes, re-evaluation of what made it difficult to quit, and adding or adjusting pharmacotherapy (table 6).

●Relapse – Addressing relapse is a key component of smoking cessation management. Individuals who achieve a period of abstinence but then resume smoking should be evaluated to determine what additional interventions can enhance their chance of success and encouraged to make another quit attempt. In one study, nearly two-thirds of smokers who relapsed reported wanting to quit again within 30 days [78].

●Reframing – Patients who have difficulty quitting smoking or relapse after a quit attempt often feel discouraged and interpret it as a failure. Clinicians can help patients reframe attempts to quit or cut down as a partial success. We focus on any small positive steps that the patient accomplished, such as the number of hours or days without smoking. We also remind them that most individuals who smoke require multiple quit attempts before permanently stopping tobacco use.

●Re-evaluation – Patients who relapse or have difficulty quitting often had insufficient behavioral or social support or inadequate pharmacotherapy or stopped medications too soon (table 6). It is important to ascertain what problems occurred in a nonjudgmental manner and determine the individual's insight regarding the possible reasons for relapse or failure to quit. We often ask about the circumstances surrounding the first cigarette smoked after the quit date. The clinician should also assess how the patient coped with withdrawal symptoms and ongoing triggers for smoking.

Based on these discussions, clinicians and patients can develop strategies to make a future quit attempt more successful. Patients may be highly dependent on nicotine, have low self-confidence or little social support for quitting, or have comorbid psychiatric illness or a substance use disorder. We typically address these issues, including the need to optimize treatment for comorbidities, before setting another quit date. (See "Behavioral approaches to smoking cessation".)

●Adjusting pharmacotherapy – If a previous smoking cessation medication was helpful, we typically recommend continuing or restarting it, either alone or in combination with a different medication. If the initial pharmacotherapy was unhelpful, we optimize medication doses, select a different medication, or consider combinations of pharmacologic agents, as discussed separately. (See "Pharmacotherapy for smoking cessation in adults", section on 'Persistent smoking'.)

We couple pharmacotherapy with frequent follow-up and more robust behavioral support.

●Harm reduction with electronic cigarettes – Patients who have been unable to stop smoking despite multiple attempts may benefit from switching to electronic cigarettes. (See 'Harm reduction with electronic cigarettes' below.)

PATIENTS WHO ARE NOT READY TO QUIT

Patients who are willing to "cut down" or make changes — For individuals who are contemplating quitting but not ready to stop smoking entirely, we recommend a "reduce-to-quit" strategy over waiting until the patient is ready to stop smoking. A reduce-to-quit strategy results in higher quit rates and may increase motivation to quit and decrease withdrawal symptoms with only a possible increase in adverse medication side effects [61]. Medication selection for a reduce-to-quit strategy is discussed separately. (See "Pharmacotherapy for smoking cessation in adults", section on 'Patients who are willing to "cut down" or make changes'.)

Individuals who are unsuccessful using a reduce-to-quit approach or who are unwilling to try this approach may benefit from a strategy of switching completely from cigarettes to electronic cigarettes, as discussed below. (See 'Harm reduction with electronic cigarettes' below.)

Apart from setting a quit date and specific medications, specific management steps for these individuals are similar to those for patients who are ready to quit. (See 'Initial steps' above.)

For patients who start pharmacotherapy or decide to switch from smoking cigarettes to e-cigarettes, we typically follow up within four weeks to monitor response to treatment and assess for side effects (see 'Ongoing monitoring' above). Clinicians should also assess any changes in smoking behavior or the number of cigarettes smoked and address the patient's willingness to set a quit date.

Evidence from randomized trials suggests that varenicline and nicotine replacement therapy (NRT) improve rates of smoking cessation when used as part of a "reduce-to-quit" strategy in patients not ready to quit immediately [47,79,80]. As an example, in a meta-analysis of three trials of participants not ready to quit smoking, pretreatment with varenicline improved tobacco abstinence at 6 to 12 months, compared with waiting to initiate treatment until the patient was ready to quit (35 versus 17 percent; relative risk 2.00; 95% CI 1.70-2.35) [61]. The use of varenicline and NRT are discussed separately. (See "Pharmacotherapy for smoking cessation in adults", section on 'Patients who are willing to "cut down" or make changes'.)

Patients who are not ready to take action — Some individuals who use tobacco are not ready or willing to change their smoking. The goal of smoking cessation management with these patients is to help move them toward a future attempt to quit, cut down, or try behavioral interventions and/or pharmacotherapies that will support smoking cessation. Strategies that may facilitate this include:

●Understand patient's perspective – We try to understand the patient's perspective about the risks and benefits of continuing to smoke. Most people who smoke have a general desire to stop smoking, but for a variety of reasons, they may not be ready to take specific actions to quit. Asking a patient what they like and do not like about smoking helps to explore those reasons. Asking the question "What do you enjoy about smoking?" can help to defuse patients' defensiveness and provide important insights into individual barriers to quitting. (See "Behavioral approaches to smoking cessation", section on 'Reassessing reasons for smoking'.)

●Develop tailored messages to support action – Clinicians who understand why a patient continues to smoke can more easily develop smoking cessation messages and strategies that are tailored to that patient's needs, medical conditions, and priorities [81]. (See "Behavioral approaches to smoking cessation", section on 'Providing information about harms of smoking'.)

Motivational interviewing techniques can help clinicians explore a patient's feelings, beliefs, ideas, and values regarding tobacco use. The "Five R's" model is one framework for this type of assessment (table 7). The Five R's and other motivational interviewing techniques for smoking cessation are described separately. (See 'Alternative models' above and "Behavioral approaches to smoking cessation", section on 'Techniques for motivational interviewing'.)

We encourage individuals who continue to smoke to protect other people from exposure to secondhand smoke. (See 'Advise to stop tobacco use' above.)

●Follow-up – Similar to any chronic disease management, individuals who are not ready to change their smoking at a visit should have their smoking status readdressed at subsequent clinical visits, as described previously. (See 'Interventions for all patients' above.)

HARM REDUCTION WITH ELECTRONIC CIGARETTES — 

Harm reduction is an alternative strategy for individuals who are unable to quit despite using standard pharmacotherapies (eg, varenicline, bupropion, nicotine replacement therapy) or are unable or unwilling to use them [26,82,83]. Harm reduction strategies may mitigate tobacco-related health risks and help individuals move toward quitting smoking entirely.

Electronic cigarettes are the most widely used harm reduction product in the United States; however, uncertainty about their possible long-term health risks makes their use as smoking cessation aids controversial [26,84]. Patients who adopt this strategy should stop e-cigarette use when they can do so without threatening their abstinence from combustible tobacco products. The role of electronic cigarettes in smoking cessation and their safety and efficacy are discussed separately. (See "Vaping and e-cigarettes", section on 'Role in smoking cessation'.)

TREATMENT CONSIDERATIONS FOR SPECIFIC POPULATIONS — 

The overall approach to smoking cessation in these groups of patients resembles that outlined above with additional considerations as discussed below. Tailoring the selection of pharmacotherapy for specific patient populations is discussed separately. (See "Pharmacotherapy for smoking cessation in adults", section on 'Considerations for special populations'.)

●Individuals with cancer – Individuals diagnosed with cancer can benefit substantially from smoking cessation. Continued smoking after a cancer diagnosis is associated with increased mortality and an increased risk of a subsequent primary cancer [1,62,85]. The optimal timing of smoking cessation interventions may be at the time of cancer diagnosis [86,87]. For individuals who are undergoing surgical treatment of cancer, quitting smoking at least four weeks prior to surgery is associated with a lower risk of postoperative complications, compared with quitting closer to the time of surgery [88]. More intensive, longer-duration interventions may be particularly effective in this population [87].

In the United States, multiple organizations recommend tobacco treatment as a fundamental part of cancer care [85,89,90]. The benefits of smoking cessation for preventing cancer and improving cancer-related outcomes are discussed separately. (See "Benefits and consequences of smoking cessation", section on 'Malignancy'.)

●Psychiatric illness – Smoking is highly prevalent among individuals with psychiatric illness. Smoking cessation is effective in these patients, with both behavioral and pharmacologic therapies increasing quit rates. Proactive outreach effectively engages patients with significant mental illness in smoking cessation treatment and increases quit attempts and abstinence from smoking [91-94].

Although the same medications are generally effective for those with and without psychiatric comorbidities, the choice among specific pharmacotherapies may vary depending on the specific condition. Recommendations about specific pharmacotherapies for those with psychiatric illness are discussed separately. (See "Pharmacotherapy for smoking cessation in adults", section on 'Psychiatric illness' and "Cardiovascular risk in patients with serious mental illness: Managing antipsychotic-associated obesity", section on 'Benefits of lifestyle intervention'.)

Smoking cessation does not appear to exacerbate psychiatric symptoms either in those with or without underlying psychiatric illness. This is discussed separately. (See "Benefits and consequences of smoking cessation", section on 'Psychiatric symptoms'.)

●Substance use disorder – Among individuals who smoke and have substance use disorders, participating in a smoking cessation program does not increase the use of other substances [95,96]. Smoking is common among individuals in treatment for or in recovery from alcohol or substance use disorders, and a significant proportion of these patients are motivated to stop smoking [97]. Data from randomized trials suggest that smoking cessation interventions in these individuals increase their odds of quitting smoking without adversely affecting substance use outcomes [98,99]. Effective interventions included nicotine replacement therapy (NRT), bupropion, behavioral supports, and combined interventions.

●Cardiovascular disease – The management of smoking cessation in individuals with stable cardiovascular disease (CVD) is similar to the management of those without CVD [17]. Pharmacotherapy and behavioral approaches for smoking cessation in patients with CVD are discussed separately. (See "Pharmacotherapy for smoking cessation in adults", section on 'Cardiovascular disease' and "Behavioral approaches to smoking cessation", section on 'Patients ready to quit'.)

●Hospitalized patients – We encourage individuals who smoke to use hospitalization as an opportunity to quit smoking permanently. Smoke-free policies in a hospital environment provide a setting that is free of usual cues to smoke. The illness or procedure precipitating the admission may reinforce the patient's perceived vulnerability to the harms of tobacco use. Hospitalization can motivate a quit attempt even if the reason for hospitalization is not directly related to smoking-induced disease [100-102]. Surgery is also associated with increased rates of quitting smoking, and quit rates are higher after major surgery than after outpatient procedures [103].

An "opt-out" approach to smoking cessation interventions with hospitalized adults may increase quit attempts and treatment engagement, although it is unclear whether this approach improves long-term rates of smoking cessation. A randomized trial of 990 hospitalized adults compared an opt-out approach (receipt of inpatient NRT, treatment planning with a medication starter kit and prescriptions for use postdischarge, and postdischarge telephone counseling) with an opt-in approach (patients willing to quit were offered each element of treatment and those unwilling to quit received motivational counseling) [104]. Compared with the opt-in group, the opt-out group had higher one-month quit rates (22 versus 16 percent) and use of postdischarge cessation medications (60 versus 34 percent) but equivalent smoking cessation at six months (19 versus 18 percent).

To produce long-term smoking cessation, interventions that start in the hospital must continue after hospital discharge. A meta-analysis of 71 randomized trials of hospitalized individuals who smoked found that intensive counseling (≥1 contact during the hospital stay with continued support for ≥1 month after discharge) increased the likelihood of smoking cessation (relative risk [RR] 1.36, 95% CI 1.24-1.49) [105]. Strong evidence supported the benefit of supplementing counseling with NRT after discharge, while moderate evidence supported using varenicline in this setting. In one trial, automated postdischarge telephone calls that offered free smoking cessation medications and the opportunity to speak with a counselor increased smoking cessation rates by 71 percent, compared with discharge recommendations to use counseling and a prescription for pharmacotherapy [106].

NRT is often used during hospitalization to reduce nicotine withdrawal symptoms caused by temporary tobacco abstinence. The choice of pharmacotherapy in hospitalized patients is discussed separately. (See "Pharmacotherapy for smoking cessation in adults", section on 'Hospitalized patients'.)

●Preoperative management – Individuals undergoing preoperative evaluation should be assessed for tobacco use and supported to quit smoking before surgery [107]. Those who smoke are at risk for postoperative pulmonary and other complications, and smoking cessation prior to surgery may improve outcomes. Pharmacotherapy for preoperative smoking cessation is discussed separately. (See "Pharmacotherapy for smoking cessation in adults", section on 'Preoperative management' and "Strategies to reduce postoperative pulmonary complications in adults", section on 'Smoking cessation' and "Smoking or vaping: Perioperative management".)

Behavioral therapy and pharmacotherapy for smoking cessation can reduce smoking and surgical complications. In a meta-analysis of 13 trials, intensive preoperative behavioral interventions (typically combined with NRT) increased perioperative rates of smoking cessation (53 versus 4.7 percent; RR 10.76; 95% CI 4.55-25.46) and reduced postoperative complications (RR 0.42, 95% CI 0.27-0.65), compared with usual care [108]. Brief interventions (eg, 15 to 90 minutes of counselling) showed smaller reductions in smoking cessation and did not reduce complications. (See 'Advise to stop tobacco use' above and "Behavioral approaches to smoking cessation", section on 'Patients ready to quit'.)

Preoperative smoking cessation interventions may enhance long-term smoking cessation. In one randomized trial, a perioperative smoking cessation intervention improved rates of smoking cessation at one year follow-up, compared with usual care (25 versus 8 percent) [109].

●Light or intermittent tobacco use – Those with light (<10 cigarettes per day) and intermittent (who do not smoke daily) tobacco use benefit from smoking cessation [5]. Although the adverse effects of smoking are dose dependent, even light smoking is associated with increased mortality and several smoking-related diseases, especially among Black individuals in the United States [110-114].

Behavioral counseling is the first-line treatment for those with light tobacco use. (See "Behavioral approaches to smoking cessation".)

The role of pharmacotherapy is less clear; however, medications effective for those with heavier tobacco use may be effective for those with light or intermittent use. This is discussed separately. (See "Pharmacotherapy for smoking cessation in adults".)

●Pregnancy – Behavioral interventions tailored specifically to pregnant persons are effective in increasing smoking cessation rates. Management of smoking cessation in pregnant persons is discussed in detail separately. (See "Tobacco and nicotine use in pregnancy: Cessation strategies and treatment options".)

●Adolescents – Strategies to support adolescents in smoking cessation should be adapted to the special concerns of this age group. Management of smoking cessation in adolescents is discussed separately. (See "Management of smoking and vaping cessation in adolescents".)

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Smoking cessation, e-cigarettes, and tobacco control".)

INFORMATION FOR PATIENTS — 

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Quitting smoking for adults (The Basics)" and "Patient education: Harmful health effects of smoking (The Basics)" and "Patient education: Vaping (The Basics)" and "Patient education: Secondhand smoke and children (The Basics)" and "Patient education: Smoking in pregnancy (The Basics)")

●Beyond the Basics topic (see "Patient education: Quitting smoking (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Ask, advise, offer treatment framework – We typically use the three-step "ask, advise, offer and refer to treatment" model to address smoking cessation with all patients who smoke (figure 1). At each visit, clinicians should assess patients' tobacco use, advise them to quit, and offer smoking cessation treatment and referrals for behavioral support. (See 'Three-step model' above and 'Interventions for all patients' above.)

●Opt-out approach – We use an "opt-out" offer of smoking cessation treatment to all patients rather than an approach that offers counseling and treatment only to those who express readiness to quit. This approach may improve quit rates compared with approaches that only offer smoking cessation interventions to patients who are ready to quit. (See 'Three-step model' above and 'Offer treatment' above.)

For individuals who accept the offer of smoking cessation treatment, we address barriers to quit; develop an individualized treatment plan; and for those who are willing to quit, set a quit date. (See 'Initial steps' above.)

●Patients who are ready to quit

•Combination treatment preferred – For patients who are willing to make changes to their smoking, we suggest combined treatment with medications and behavioral support rather than either intervention alone (Grade 2B). Evidence from randomized trials suggests that combination interventions (eg, pharmacotherapy plus behavioral counseling) are superior to usual care or brief advice and may modestly improve rates of quitting smoking compared with either medications or behavioral interventions alone. (See 'Combined behavioral treatment and pharmacotherapy preferred' above.)

The choice of a specific medication for smoking cessation treatment is discussed separately. (See "Pharmacotherapy for smoking cessation in adults", section on 'Initial therapy selection'.)

•Behavioral interventions – We encourage patients to use the maximal behavioral intervention acceptable to them. Behavioral interventions include brief clinician counseling and referral to smoking cessation clinics, telephone quitlines, and web-based resources. (See 'Connect to resources' above and 'Behavioral counseling' above and "Behavioral approaches to smoking cessation".)

•Ongoing monitoring – We follow up with patients within four weeks of their quit date or of starting medications to assess medication adherence, side effects, and response; reinforce positive behavior changes; anticipate challenges; and follow up on referrals for behavioral support (table 6). (See 'Ongoing monitoring' above.)

●Patients who are not yet ready to quit

•Reduce-to-quit strategy – For individuals who are ready to make some changes but not yet ready to quit, we recommend a "reduce-to-quit" strategy rather than waiting to initiate medication until the patient is ready to set a quit date (Grade 1B). This strategy results in higher quit rates and may increase motivation to quit and decrease withdrawal symptoms. Either varenicline or nicotine replacement therapy can be used with a "reduce-to-quit" strategy. (See "Pharmacotherapy for smoking cessation in adults", section on 'Patients who are willing to "cut down" or make changes'.)

•Motivational interviewing – For individuals who are not ready to change their smoking behavior, we use motivational interviewing to understand the patient's perspective and develop tailored messages to encourage them to take action combined with ongoing follow-up and reassessment. (See 'Patients who are not ready to take action' above and "Behavioral approaches to smoking cessation", section on 'Patients not ready to quit'.)

•Harm reduction – For individuals who are unable to quit despite using standard pharmacotherapies or are unwilling to use them, a harm reduction strategy using electronic cigarettes is an acceptable option. (See 'Harm reduction with electronic cigarettes' above and "Vaping and e-cigarettes", section on 'Role in smoking cessation'.)

●Patients with difficulty quitting – Patients who relapse or are unsuccessful in quitting may benefit from positively reframing their quit attempts, re-evaluating barriers to quit, adjusting pharmacotherapy, and/or intensifying behavioral support. Patients who are unable to quit despite repeated efforts using evidence-based treatments merit consideration of a harm reduction strategy. (See 'Patients with relapse or difficulty quitting' above and "Pharmacotherapy for smoking cessation in adults", section on 'Persistent smoking'.)

ACKNOWLEDGMENTS — 

The UpToDate editorial staff acknowledges Stephen Rennard, MD, and David Daughton, MS, who contributed to earlier versions of this topic review.

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  94. Japuntich SJ, Sherman SE, Joseph AM, et al. Proactive tobacco treatment for individuals with and without a mental health diagnosis: Secondary analysis of a pragmatic randomized controlled trial. Addict Behav 2018; 76:15.
  95. Derefinko KJ, Salgado García FI, Sumrok DD. Smoking Cessation for Those Pursuing Recovery from Substance Use Disorders. Med Clin North Am 2018; 102:781.
  96. McKelvey K, Thrul J, Ramo D. Impact of quitting smoking and smoking cessation treatment on substance use outcomes: An updated and narrative review. Addict Behav 2017; 65:161.
  97. Gass JC, Morris DH, Winters J, et al. Characteristics and clinical treatment of tobacco smokers enrolled in a VA substance use disorders clinic. J Subst Abuse Treat 2018; 84:1.
  98. Thurgood SL, McNeill A, Clark-Carter D, Brose LS. A Systematic Review of Smoking Cessation Interventions for Adults in Substance Abuse Treatment or Recovery. Nicotine Tob Res 2016; 18:993.
  99. Apollonio D, Philipps R, Bero L. Interventions for tobacco use cessation in people in treatment for or recovery from substance use disorders. Cochrane Database Syst Rev 2016; 11:CD010274.
  100. Keenan PS. Smoking and weight change after new health diagnoses in older adults. Arch Intern Med 2009; 169:237.
  101. Rigotti NA, Clair C, Munafò MR, Stead LF. Interventions for smoking cessation in hospitalised patients. Cochrane Database Syst Rev 2012; :CD001837.
  102. O'Malley SS, Zweben A, Fucito LM, et al. Effect of Varenicline Combined With Medical Management on Alcohol Use Disorder With Comorbid Cigarette Smoking: A Randomized Clinical Trial. JAMA Psychiatry 2018; 75:129.
  103. Shi Y, Warner DO. Surgery as a teachable moment for smoking cessation. Anesthesiology 2010; 112:102.
  104. Richter KP, Catley D, Gajewski BJ, et al. The Effects of Opt-out vs Opt-in Tobacco Treatment on Engagement, Cessation, and Costs: A Randomized Clinical Trial. JAMA Intern Med 2023; 183:331.
  105. Streck JM, Rigotti NA, Livingstone-Banks J, et al. Interventions for smoking cessation in hospitalised patients. Cochrane Database Syst Rev 2024; 5:CD001837.
  106. Rigotti NA, Regan S, Levy DE, et al. Sustained care intervention and postdischarge smoking cessation among hospitalized adults: a randomized clinical trial. JAMA 2014; 312:719.
  107. Vu JV, Lussiez A. Smoking Cessation for Preoperative Optimization. Clin Colon Rectal Surg 2023; 36:175.
  108. Thomsen T, Villebro N, Møller AM. Interventions for preoperative smoking cessation. Cochrane Database Syst Rev 2014; :CD002294.
  109. Lee SM, Landry J, Jones PM, et al. Long-term quit rates after a perioperative smoking cessation randomized controlled trial. Anesth Analg 2015; 120:582.
  110. Prescott E, Scharling H, Osler M, Schnohr P. Importance of light smoking and inhalation habits on risk of myocardial infarction and all cause mortality. A 22 year follow up of 12 149 men and women in The Copenhagen City Heart Study. J Epidemiol Community Health 2002; 56:702.
  111. Pinsky PF. Racial and ethnic differences in lung cancer incidence: how much is explained by differences in smoking patterns? (United States). Cancer Causes Control 2006; 17:1017.
  112. Haiman CA, Stram DO, Wilkens LR, et al. Ethnic and racial differences in the smoking-related risk of lung cancer. N Engl J Med 2006; 354:333.
  113. Oshunbade AA, Yimer WK, Valle KA, et al. Cigarette Smoking and Incident Stroke in Blacks of the Jackson Heart Study. J Am Heart Assoc 2020; 9:e014990.
  114. Oshunbade AA, Kassahun-Yimer W, Valle KA, et al. Cigarette Smoking, Incident Coronary Heart Disease, and Coronary Artery Calcification in Black Adults: The Jackson Heart Study. J Am Heart Assoc 2021; 10:e017320.
Topic 16634 Version 60.0

References

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6 : Treatment of Tobacco Smoking: A Review.

7 : Tobacco Addiction.

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11 : Proactive tobacco cessation outreach to smokers of low socioeconomic status: a randomized clinical trial.

12 : Proactive tobacco treatment and population-level cessation: a pragmatic randomized clinical trial.

13 : Does Motivation Matter? Analysis of a Randomized Trial of Proactive Outreach to VA Smokers.

14 : Time for a change: putting the Transtheoretical (Stages of Change) Model to rest.

15 : Stage-based interventions for smoking cessation.

16 : Stage-based interventions for smoking cessation.

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18 : 2018 ACC Expert Consensus Decision Pathway on Tobacco Cessation Treatment: A Report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents.

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20 : Physician advice for smoking cessation.

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23 : Validation of the TAPS-1: A Four-Item Screening Tool to Identify Unhealthy Substance Use in Primary Care.

24 : Performance of the Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS) Tool for Substance Use Screening in Primary Care Patients.

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26 : Nicotine e-cigarettes as a tool for smoking cessation.

27 : Electronic medical records to increase the clinical treatment of tobacco dependence: a systematic review.

28 : Ask and Ask Again: Repeated Screening for Smoking Increases Likelihood of Prescription for Cessation Treatment Among Women Veterans.

29 : Increases in smoking cessation interventions after a feedback and improvement initiative using electronic health records -- 19 community health centers, New York City, October 2010-March 2012.

30 : Use of electronic health records to support smoking cessation.

31 : Assessment of dependence and motivation to stop smoking.

32 : Measuring the heaviness of smoking: using self-reported time to the first cigarette of the day and number of cigarettes smoked per day.

33 : The Fagerström Test for Nicotine Dependence: a revision of the Fagerström Tolerance Questionnaire.

34 : The Fagerström Test for Nicotine Dependence: a revision of the Fagerström Tolerance Questionnaire.

35 : Patient satisfaction and discussion of smoking cessation during clinical visits.

36 : Ethnic comparison of attitudes and beliefs about cigarette smoking.

37 : Hispanic/Latinx individuals' attributions for abstinence and smoking: A content analysis of open-ended responses from a randomized cessation trial.

38 : An overview of systematic reviews on predictors of smoking cessation among young people.

39 : Reasons to quit and barriers to quitting smoking in US young adults.

40 : The effect of smoke-free homes on adult smoking behavior: a review.

41 : Factors associated with successful smoking cessation in the United States, 2000.

42 : Quitting Smoking Among Adults - United States, 2000-2015.

43 : Psychological Distress in Bullied Deaf and Hard of Hearing Adolescents.

44 : Implementation, Maintenance, and Outcomes of an Electronic Referral to a Tobacco Quitline Across Five Health Systems.

45 : eReferral Between Hospitals and Quitlines: An Emerging Tobacco Control Strategy.

46 : Higher quality quit-date goal setting enhances quit attempts among quitline callers.

47 : Smoking reduction interventions for smoking cessation.

48 : Strategies to help a smoker who is struggling to quit.

49 : Helping smokers quit--opportunities created by the Affordable Care Act.

50 : Strategies to improve smoking cessation rates in primary care.

51 : The Equity Impact of Proactive Outreach to Smokers: Analysis of a Randomized Trial.

52 : A Proactive Outreach Strategy Using a Local Area Code to Refer Unassisted Smokers in a Safety Net Health System to a Quitline: A Pragmatic Randomized Trial.

53 : Proactive tobacco treatment offering free nicotine replacement therapy and telephone counselling for socioeconomically disadvantaged smokers: a randomised clinical trial.

54 : Additional behavioural support as an adjunct to pharmacotherapy for smoking cessation.

55 : Effects of different interventions on smoking cessation in chronic obstructive pulmonary disease patients: A systematic review and network meta-analysis.

56 : Do medications increase the efficacy of digital interventions for smoking cessation? Secondary results from the iCanQuit randomized trial.

57 : Smoking Cessation Interventions in the Lung Cancer Screening Setting: A Randomized Clinical Trial.

58 : Combined pharmacotherapy and behavioural interventions for smoking cessation.

59 : Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial.

60 : Assessment of Racial Differences in Pharmacotherapy Efficacy for Smoking Cessation: Secondary Analysis of the EAGLES Randomized Clinical Trial.

61 : Initiating Pharmacologic Treatment in Tobacco-Dependent Adults. An Official American Thoracic Society Clinical Practice Guideline.

62 : Initiating Pharmacologic Treatment in Tobacco-Dependent Adults. An Official American Thoracic Society Clinical Practice Guideline.

63 : Behavioural interventions for smoking cessation: an overview and network meta-analysis.

64 : Prospective cohort study of the effectiveness of smoking cessation treatments used in the "real world".

65 : Effects of Large Financial Incentives for Long-Term Smoking Cessation: A Randomized Trial.

66 : A randomized, controlled trial of financial incentives for smoking cessation.

67 : Randomized trial of four financial-incentive programs for smoking cessation.

68 : Effect of Patient Navigation and Financial Incentives on Smoking Cessation Among Primary Care Patients at an Urban Safety-Net Hospital: A Randomized Clinical Trial.

69 : Effect of 3 months and 12 months of financial incentives on 12-month postpartum smoking cessation maintenance: A randomized controlled trial.

70 : Incentives for smoking cessation.

71 : Acupuncture and related interventions for smoking cessation.

72 : Hypnotherapy for smoking cessation.

73 : Hypnotherapy compared to cognitive-behavioral therapy for smoking cessation in a randomized controlled trial.

74 : Smoking cessation induced by deep repetitive transcranial magnetic stimulation of the prefrontal and insular cortices: a prospective, randomized controlled trial.

75 : Repetitive transcranial magnetic stimulation for smoking cessation: a pivotal multicenter double-blind randomized controlled trial.

76 : Repetitive transcranial magnetic stimulation for smoking cessation.

77 : Relapse prevention interventions for smoking cessation.

78 : Promoting repeat tobacco dependence treatment: are relapsed smokers interested?

79 : Effect of varenicline on smoking cessation through smoking reduction: a randomized clinical trial.

80 : Effectiveness and safety of nicotine replacement therapy assisted reduction to stop smoking: systematic review and meta-analysis.

81 : Effectiveness of culturally tailoring smoking cessation interventions for reducing or quitting combustible tobacco: A systematic review and meta-analyses.

82 : Effectiveness of culturally tailoring smoking cessation interventions for reducing or quitting combustible tobacco: A systematic review and meta-analyses.

83 : E-Cigarettes as a Smoking Cessation Aid - Toward Common Ground and a Rational Approach.

84 : England Is Handing out E-Cigarettes: Is the "Swap to Stop" Tobacco Control Scheme Harm Reduction or Harm Production?

85 : Addressing a Core Gap in Cancer Care - The NCI Moonshot Program to Help Oncology Patients Stop Smoking.

86 : Grasping the 'teachable moment': time since diagnosis, symptom burden and health behaviors in breast, colorectal and prostate cancer survivors.

87 : Effect of Sustained Smoking Cessation Counseling and Provision of Medication vs Shorter-term Counseling and Medication Advice on Smoking Abstinence in Patients Recently Diagnosed With Cancer: A Randomized Clinical Trial.

88 : Smoking and Complications After Cancer Surgery: A Systematic Review and Meta-Analysis.

89 : Assessing tobacco use by cancer patients and facilitating cessation: an American Association for Cancer Research policy statement.

90 : Perspective on the National Comprehensive Cancer Network's Clinical Practice Guidelines for Smoking Cessation.

91 : Proactive Tobacco Treatment for Smokers Using Veterans Administration Mental Health Clinics.

92 : Proactive tobacco treatment for veterans with posttraumatic stress disorder.

93 : Effectiveness of Proactive Tobacco Cessation Treatment Outreach Among Smokers With Serious Mental Illness.

94 : Proactive tobacco treatment for individuals with and without a mental health diagnosis: Secondary analysis of a pragmatic randomized controlled trial.

95 : Smoking Cessation for Those Pursuing Recovery from Substance Use Disorders.

96 : Impact of quitting smoking and smoking cessation treatment on substance use outcomes: An updated and narrative review.

97 : Characteristics and clinical treatment of tobacco smokers enrolled in a VA substance use disorders clinic.

98 : A Systematic Review of Smoking Cessation Interventions for Adults in Substance Abuse Treatment or Recovery.

99 : Interventions for tobacco use cessation in people in treatment for or recovery from substance use disorders.

100 : Smoking and weight change after new health diagnoses in older adults.

101 : Interventions for smoking cessation in hospitalised patients.

102 : Effect of Varenicline Combined With Medical Management on Alcohol Use Disorder With Comorbid Cigarette Smoking: A Randomized Clinical Trial.

103 : Surgery as a teachable moment for smoking cessation.

104 : The Effects of Opt-out vs Opt-in Tobacco Treatment on Engagement, Cessation, and Costs: A Randomized Clinical Trial.

105 : Interventions for smoking cessation in hospitalised patients.

106 : Sustained care intervention and postdischarge smoking cessation among hospitalized adults: a randomized clinical trial.

107 : Smoking Cessation for Preoperative Optimization.

108 : Interventions for preoperative smoking cessation.

109 : Long-term quit rates after a perioperative smoking cessation randomized controlled trial.

110 : Importance of light smoking and inhalation habits on risk of myocardial infarction and all cause mortality. A 22 year follow up of 12 149 men and women in The Copenhagen City Heart Study.

111 : Racial and ethnic differences in lung cancer incidence: how much is explained by differences in smoking patterns? (United States).

112 : Ethnic and racial differences in the smoking-related risk of lung cancer.

113 : Cigarette Smoking and Incident Stroke in Blacks of the Jackson Heart Study.

114 : Cigarette Smoking, Incident Coronary Heart Disease, and Coronary Artery Calcification in Black Adults: The Jackson Heart Study.