Behavioral approaches to smoking cessation

INTRODUCTION — Smoking is associated with the development of cancers, cardiovascular diseases, chronic obstructive pulmonary disease, and other diseases. Most adults who smoke want to quit smoking [1]. Discontinuing smoking is an important goal for patients, and each year approximately two out of every three people who smoke in the United States make an attempt to quit [2]. One-half of people who have ever smoked have been able to quit. Additionally, older individuals are less likely to attempt to quit and, accordingly, less likely to be advised to quit [3].

Quitting smoking may be of increased importance to patients who have had coronavirus disease 2019 (COVID-19) [4], due to concerns over poorer health outcomes [5]. The COVID-19 pandemic presents an additional opportunity for clinicians to encourage patients to quit smoking and integrate smoking cessation interventions into patient care.

The behavioral approach to smoking cessation will be discussed in this topic. An overview of smoking cessation and pharmacologic therapies for smoking cessation are discussed separately. (See "Overview of smoking cessation management in adults" and "Pharmacotherapy for smoking cessation in adults".)

ASSESS READINESS — Assessment of willingness to quit smoking for every patient at every clinic visit offers an opportunity to encourage smoking cessation. One way to do this is using a model called the "5 A's" (table 1).

The 5 A’s model encourages clinicians to:

●Ask patients about smoking

●Advise all smokers to quit

●Assess their readiness to quit

●Assist them with their smoking cessation effort (table 2)

●Arrange for follow-up visits or contact

The 5 A’s model is described in detail separately. (See "Overview of smoking cessation management in adults".)

Another approach to encourage smoking cessation is to proactively offer treatment during the visit, as clinicians do routinely for other chronic conditions such as hypertension [6]. This method is described in detail separately. (See "Overview of smoking cessation management in adults".)

Brief counseling for smoking cessation has demonstrated efficacy. In a study at several primary care practices, one in five people who smoked and who attended a routine primary care appointment was willing to make a serious quit attempt with the help of treatment that incorporated evidence-based counseling and some form of pharmacologic aide [7].

However, there are numerous missed opportunities for counseling during office visits, as indicated by National Ambulatory Medical Care Survey (NAMCS) data that showed that the vast majority of people who smoke did not receive clinician counseling to quit during an office visit [8-10].

PATIENTS READY TO QUIT — A combination of behavioral approaches and pharmacotherapy is most helpful to patients trying to quit [11-15]. While behavioral approaches can be used to help cope with nicotine withdrawal symptoms, most people will also benefit from the use of pharmacotherapy. (See "Pharmacotherapy for smoking cessation in adults".)

Selection of behavioral therapy — All people who are ready to quit smoking should be encouraged to participate in behavioral counseling programs. Many different behavioral counseling formats are available, including face-to-face modalities (eg, individual patient-clinician encounters and group therapy) as well as other delivery formats, including telephone contact, text messaging, interactive web-based interventions, mobile apps, and website information resources. These other formats can be either standalone tools for patients who are unable to participate in face-to-face counseling or adjuncts to in-person counseling. The different formats generally have in common certain techniques and components of educational content. (See 'Content of therapy' below.)

Of most importance is selecting behavioral therapy modalities that will be most engaging and acceptable to the patient, considering patient preference, medical history, beliefs, and availability. Patients may benefit from using more than one modality, such as the combination of group therapy and text messaging. Those who choose not to access therapy can benefit from self-help information resources. Special considerations in selection of effective behavioral therapies for patients with severe mental illness are described separately. (See "Approach to managing increased risk for cardiovascular disease in patients with severe mental illness", section on 'Tobacco smoking'.)

Formats for behavioral counseling have been evaluated in numerous studies, and many methods of behavioral counseling and support used alone or in combination have been found to be effective. Both individual and group therapy are effective in achieving smoking cessation [16,17]. Availability and robustness of studies showing efficacy vary considerably among the different modalities [18].

In the United States, many health insurance plans cover tobacco-cessation interventions, including behavioral counseling as well as pharmacotherapies approved by the US Food and Drug Administration (FDA) [19].

Brief intervention — For many patients, face-to-face behavioral therapy will consist of only brief clinician counseling in the office. Busy clinicians of any specialty can effectively provide brief advice interventions that increase overall tobacco abstinence rates. This brief counseling should be offered to all people who smoke [20]. (See "Overview of smoking cessation management in adults", section on 'Advise smoking cessation'.)

The main components of counseling to include are education about withdrawal symptoms, identification of triggers for smoking and coping skills to address those triggers, and stress management techniques. These are discussed in detail separately. (See 'Content of therapy' below.)

Individual counseling — Some patients may engage in formal individual counseling for a period of time to support them through smoking cessation. In-person counseling may consist of multiple visits (often weekly) that start before the quit date. A follow-up visit should be scheduled within a week after the quit date. Visits should continue for one to at least three months after quitting to support a smoker through the quitting process. (See "Overview of smoking cessation management in adults", section on 'Arrange follow-up' and "Overview of psychotherapies", section on 'Cognitive and behavioral therapies'.)

A systematic review found that individual counseling compared with minimal support improved quit rates by 40 to 80 percent, with a small additional benefit associated with having more sessions [17]. Nevertheless, formal individual counseling is infrequently used, possibly because of the intensity of involvement required and the increasing availability of other resources.

Group counseling — Group therapy allows patients to learn behavioral techniques while mutually supporting others attempting to quit. Group programs typically include informational presentations about the quitting process, group interactions, exercises on identification of triggers to smoke and coping strategies to address those triggers, a tapering method leading to a "quit day," development of coping skills, and suggestions for relapse prevention (see 'Content of therapy' below). Only a minority of people are willing to attend such programs, citing the inconvenience, even though group counseling is offered by a number of commercial and voluntary health programs and by some employers and public health resources. The cost can vary from free to several hundred dollars.

Studies have found that group counseling is effective. One-year quit rates after smoking cessation group counseling programs were approximately 20 percent [20-22]. A systematic review found that group therapy was nearly twice as effective as self-help programs [23].

Telephone counseling — Telephone counseling can be used as the primary behavioral therapy approach or incorporated into a team-based approach to smoking cessation.

Proactive telephone counseling has been shown to be more effective than reactive telephone counseling. In the proactive approach, a counselor initiates a call on a prearranged schedule; in reactive counseling, an individual initiates the call to a counselor. Most quitlines offer proactive calls several times during the quitting process, and many quitlines offer smoker-initiated reactive counseling also. (See "Overview of smoking cessation management in adults", section on 'Variations of the 5A's approach'.)

Individuals can access free proactive telephone counseling throughout the United States at a toll-free number (1-800-QUIT-NOW). Some states in the United States have developed fax-referral programs to link clinician offices to their state telephone quitline. In some states, the quitline distributes free nicotine replacement therapy to eligible quitline callers [24].

Telephone counseling programs are more effective than simple self-help interventions, in which people are provided with take-home written or audiovisual material to aid them in quitting on their own [25]. In a clinical trial, among practices that were randomized to routinely refer people to a telephone quitline, patients had higher smoking cessation rates at 3 and 12 months compared with those who received standard general practitioner care [26].

Proactive telephone counseling has been shown to have efficacy in several studies, whereas data about reactive counseling are mixed [25,27]. One meta-analysis found quit rates were higher for those who received multiple proactive counselling calls after having called the quitline (risk ratio [RR] 1.38, 95% CI 1.28-1.49). Three or more proactive calls increased the chances of quitting, and there was some evidence of a dose response. A randomized trial of a proactive, personalized telephone counseling intervention in adolescents also found improved smoking abstinence at six months, particularly among those who smoked daily (10 versus 6 percent) [28]. By contrast, data on reactive telephone counseling provide only limited evidence as to whether there is any improvement in quit rates among those receiving reactive counseling compared with non-telephone-based controls [27,29].

Text messaging — Mobile phone text messaging consists of personalized smoking cessation support through a series of automated motivational messages. Messages suggest behavioral changes and provide positive feedback while allowing patients to request additional assistance as needed. Automated text messages provide immediate cessation support and assistance when cravings occur [30].

The National Cancer Institute has developed a mobile phone smoking cessation service for adolescents and young adults: SmokeFreeTXT program.

Several randomized trials have found that text messaging is effective for short- and long-term abstinence. In a 2019 meta-analysis including 13 randomized or quasi-randomized trials and 14,000 participants, automated text-based interventions increased six-month abstinence compared with minimal smoking cessation support (RR 1.54, 95% CI 1.19-2.00) [31]. Furthermore, the addition of text messaging to another smoking cessation intervention was more effective than the other intervention alone (RR 1.59, 95% CI 1.09 to 2.33).

Web resources and interventions — Smoking cessation interventions that are delivered in more than one format increase abstinence rates. Thus, supplementing information discussed during interventions with self-help materials can serve both as a reinforcement and a time-saving resource for the clinician.

Several organizations provide patient resource areas or learning centers where patients can access additional materials. Web-based tools may assist in smoking cessation, most notably if the materials are tailored to the user, interactive, and accessed frequently [32,33].

Website resources include the following:

●The Great American Smokeout – Offers telephone, text, tailored email web-based support and apps to support smoking cessation. Includes information and resources from the American Cancer Society to help with quitting smoking.

●Stop Smoking – Offers information and resources, as well as contact with a counselor via telephone, email, or a chat function. Includes an online guide by the American Lung Association on smoking cessation.

●National Cancer Institute – Offers telephone and online support. Includes information on smoking cessation in English and Spanish and general information on health effects of tobacco.

●Smokefree.gov – Offers free texting programs, telephonic and chat support, access to smartphone applications (apps), information on healthy habits, the effects of smoking on health, and tips on preparing to quit, including resources specifically for women and teens, in English and Spanish on a website of the US Department of Health and Human Services. Includes a tool patients may use to build their quit plan.

•How Much Will You Save? – Calculates how much money is saved after one day, one month, or up to 10 years of not buying cigarettes; offered through Smokefree.gov.

Systematic reviews have found that interactive or individually tailored web-based approaches are more effective than non-interactive approaches [32,33]. A systematic review and meta-analysis of randomized and quasi-randomized trials found that, compared with usual care or self-help, interactive or individually tailored web interventions improved smoking cessation rates at six months (RR 1.48, 95% CI 1.11-2.78), particularly when the intervention included phone contacts (RR 2.05, 95% CI 1.42-2.97) [32]. Web-based interventions may be less effective compared with telephone counseling via quitlines [34]. (See 'Telephone counseling' above.)

Interventions leveraging social network platforms (eg, Twitter, Facebook, Whatsapp) to deliver smoking cessation treatment have shown promising results in helping motivated smokers to quit and avoid relapse [35,36].

Phone and mobile apps — Mobile smoking cessation applications (apps) have the potential to be useful as behavioral therapy tools; however, studies of smoking cessation apps have determined there is often low adherence to clinical practice guidelines [37-40].

Mobile app resources include the following:

●QuitGuide – Tracks timing and location of cravings. Includes features to help identify triggers and reasons for quitting. Offers motivational messaging and monitors progress toward achieving smoking cessation goals.

●quitSTART – Offers resources to prepare for smoking cessation. Includes games and challenges to distract from cravings and badges to show off achievements. Keeps track of helpful tips and information.

●Stay Quit Coach 2 – Offers smoking cessation resources for veterans with posttraumatic stress disorder (PTSD). Includes medication reminders, motivational messaging, and coping strategies from the National Center for PTSD.

A review of free mobile apps available in 2014 showed that, compared with apps available two years earlier, the newer apps were less likely to use behavioral change techniques associated with success in quitting smoking and more likely to offer information about pharmacotherapy and coping with cravings [41].

Several types of behavioral interventions through mobile phones are being studied, including short video clips and cognitive behavioral tips to quit smoking; however, rigorous studies of the long-term effects of mobile phone apps on smoking cessation are needed [42-44].

Of note, findings from a 2021 cross-sectional trends analysis study suggest that there may be increased interest in digital smoking cessation platforms (eg, SMS text messaging, mobile application interventions) since the onset of the COVID-19 pandemic [45].

Self-help — For patients who do not have time or access to face to-face counseling, telephonic, text or web-based individualized therapies, self-help materials can be helpful.

Self-help materials, including pamphlets, audiotapes, or videotapes, have been found to be slightly more effective than no treatment intervention [46]. A randomized controlled trial found that 10 mailings of booklets and additional material over 18 months produced a higher abstinence rate at two years than providing only one booklet at the onset of the study (30 versus 19 percent abstinence rate) [47]. In addition, in a 2019 Cochrane review, when tailored and non-tailored materials were matched to non-tailored materials in terms of contact, there was no conclusive evidence of benefit of the tailored materials in assisting patients with smoking cessation [48].

However, when used as an adjunct to counseling or nicotine replacement therapy, there is no evidence of additional benefit from self-help materials [46].

Content of therapy — A common feature of the various formats of smoking cessation therapy is that they equip the individual with information about expected challenges during quit attempts and strategies to deal with them. Effective therapies generally begin before the patient's quit date to educate about withdrawal symptoms and effective techniques to use while stopping smoking, as well as techniques to use to maintain abstinence.

Techniques from cognitive-behavioral therapy (CBT) offer keys to successful quitting. These techniques include learning to identify and avoid smoking triggers and developing tools to deal with situations that may tempt smoking. Other components of CBT include education about self-monitoring, reducing cigarette intake gradually in preparation for quitting (although some people choose to quit abruptly), and setting a quit date. Effective therapy includes social support delivered as part of treatment to reinforce an individual's confidence in their ability to quit [20,23,49]. Ideally, all the elements of CBT for smoking cessation should be incorporated into a treatment plan. (See "Overview of smoking cessation management in adults", section on 'Set a quit date' and "Overview of psychotherapies", section on 'Cognitive and behavioral therapies'.)

Components of Acceptance and Commitment Therapy (ACT) may be useful in behavioral smoking cessation interventions [50]. ACT teaches acceptance of aversive physical experiences (eg, cravings), thoughts, and emotions. ACT teaches a focus on emphasizing personal values (eg, being healthy and quitting smoking) and acting in alignment with one’s values. Through acceptance and commitment, individuals may be able to be more flexible in their response to smoking urges and then make behavior changes.

Since the onset of the COVID-19 pandemic, smoking cessation treatment content focused on coping with the stress and boredom associated with self-isolation may be particularly beneficial [51].

Education about withdrawal symptoms — Education to expect symptoms of nicotine withdrawal reminds patients that smoking is addictive and that tobacco dependence should be treated as a chronic disease. Individuals should be educated that withdrawal symptoms typically peak one to two weeks after quitting but may continue for months. A fact sheet from the National Cancer Institute explains how to handle nicotine withdrawal symptoms and triggers. (See "Benefits and consequences of smoking cessation", section on 'Nicotine withdrawal syndrome'.)

Identification of triggers — An important goal of therapy is to help people identify their triggers to smoke. The person anticipating quitting should be encouraged to identify situations, internal states, or activities that may increase the risk of continuing to smoke or of relapsing [20]. Examples of common triggers include stressful situations, being around others who smoke, consuming alcohol, or drinking coffee.

Problem solving and coping skills — Once people have identified situations that trigger them to smoke, they should engage in problem solving and practice coping skills to deal with such problems.

Problem solving is a process to generate potential solutions to address each trigger to smoke, and then evaluate and select among the solutions. Coping skills to address smoking triggers include strategies to avoid, change, or escape (ACE strategies) from high-risk situations (table 3). These coping skills help a smoker to avoid temptation, reduce negative moods, and enact lifestyle changes that reduce stress and improve quality of life.

Examples of coping strategies include [52]:

●Exercise – Use exercise as an outlet and a way to address post-smoking cessation weight gain.

●No-smoking zones – Enact no-smoking policies for home and car to minimize time spent with smokers.

●Behavioral distraction – Engage in repetitive or simple activities (eg, doodling, knitting).

●Cognitive distraction – Think about what needs to be done (eg, for work, errands). Make a to-do list of priorities.

●Oral strategies – Chew gum, drink a glass of water or have a small, healthy snack.

●Positive self-talk and visualization – Think "this will get easier," or visualize yourself not smoking.

●Benefits of quitting – Remember the health benefits of quitting. Think of being able to save the money you now spend on smoking. (See "Benefits and consequences of smoking cessation".)

Although no specific coping strategy has been proven effective, some studies suggest that combining exercise programs with programs for smoking cessation may improve quit rates, and involving a friend in a walking routine can help increase the sense of support [52,53]. Inconsistency among exercise study results may reflect small sample sizes and variable intensities of recommended exercise programs.

Stress management and relaxation strategies — Stress is a commonly reported barrier to quitting smoking and maintaining abstinence. Clinicians can encourage patients to be aware of stress-related symptoms that they experience as a significant trigger to smoke (eg, muscle tension, irritability, difficulty concentrating, drinking alcohol), and to practice strategies to counter stress and avoid smoking.

Stress management strategies that may be helpful include deep breathing, guided imagery, progressive muscle relaxation, brief meditation, or stretching. Mindfulness interventions focused on decoupling associations between cravings and smoking have also been used increasingly in smoking cessation treatment. (See "Complementary and alternative treatments for anxiety symptoms and disorders: Physical, cognitive, and spiritual interventions".)

There is limited evidence that mindfulness interventions are efficacious as a standalone treatment for smoking. According to a 2022 Cochrane review, individuals who received mindfulness training were no more likely to quit smoking than individuals who received intensity-matched smoking cessation treatments or no support [54]. Mindfulness interventions showed benefits (eg, stress reduction) as a complementary treatment with other smoking cessation treatments [55].

If the patient is experiencing nicotine symptoms that are contributing to the feelings of stress, nicotine replacement therapy (NRT) may be added or adjusted. (See "Pharmacotherapy for smoking cessation in adults", section on 'Nicotine replacement therapy'.)

Supportive therapy — Positive encouragement and support are crucial in promoting healthy behavior change [20]. Clinicians can provide encouragement in many ways during a quit attempt, including:

●Communicating belief in the patient’s ability to quit

●Providing education about quitting, such as explaining that one-half of people who ever smoked have now successfully quit

●Communicating caring and concern by asking about emotions and fears about quitting and offering willingness to help

●Discussing the quitting process, including concerns, motivators, and difficulties throughout the process

Duration of therapy — We typically encourage a patient to use behavioral therapy weekly or biweekly while preparing to quit and through the quitting process, which may take up to a few months. After quitting, we encourage the patient to have up to three monthly check-ins to maintain smoke-free status. Studies support the benefit of continued counseling for six months. During this period, the patient is likely to be experiencing withdrawal symptoms and adjusting to changes in lifestyle and may be particularly vulnerable to relapse. For a patient using a different method of delivery of behavioral therapy (eg, text messaging, mobile apps, web resources, self-help), although data are limited as to the effects of duration on quit rates, these methods are generally easily accessible for a patient and typically available at no cost.

Meta-analyses of randomized trials found a dose-response relationship between the duration of counseling (both number of sessions and length of each session) and abstinence rates [17]. Counseling that lasted more than 10 minutes and consisted of four or more sessions was particularly effective [17,20,56]. However, a randomized controlled trial found that extending CBT to 48 weeks, after receiving 26 weeks of CBT along with initial or extended pharmacotherapy, offered no additional benefit compared with having a briefly monthly call, with 40 percent seven-day smoking abstinence rates for both groups [16]. In a systematic review, results were mixed as to whether number of calls in a telephone counseling program influenced smoking cessation rates; most of the studies used three or more calls [27].

PATIENTS WHO RECENTLY QUIT — People who successfully quit smoking may also experience a variety of symptoms which can benefit from behavioral therapies, including depression or a sense of lack of support. Continuing to follow patients after they discontinue smoking offers the clinician the opportunity to identify these symptoms and provide counseling and/or medication for depression, as well as advice about support organizations such as the national quitline network (1-800-QUIT-NOW) for support [20].

Follow-up after quitting is described separately (See "Overview of smoking cessation management in adults", section on 'Successful smoking cessation' and "Overview of smoking cessation management in adults", section on 'Arrange follow-up'.)

Techniques to address nicotine withdrawal symptoms or weight gain, are addressed separately. (See "Pharmacotherapy for smoking cessation in adults".)

Relapse is discussed separately. (See "Overview of smoking cessation management in adults", section on 'Relapse'.)

DIFFICULTY QUITTING — Patients may have difficulty quitting smoking for many reasons. Positive support, along with other behavioral techniques and, when needed, pharmacotherapy adjustments to address nicotine withdrawal or other symptoms are described separately. (See "Pharmacotherapy for smoking cessation in adults", section on 'Assess and respond to adherence issues and side effects' and "Overview of smoking cessation management in adults", section on 'Address barriers to quit'.)

PATIENTS NOT READY TO QUIT — For smokers who are not ready to quit, motivational interviewing can create and amplify the discrepancy between present behavior and broader goals by exploring feelings, beliefs, ideas, and values regarding tobacco use [57,58].

In addition, smokers who are not ready to quit in the next month may be willing to take pharmacotherapy to help them to reduce cigarettes smoked in preparation for quitting in the future [59]. This is reviewed in detail elsewhere. (See "Pharmacotherapy for smoking cessation in adults", section on 'Individuals less committed to quitting'.)

Techniques for motivational interviewing — In motivational interviewing, a clinician uses a series of directive and nondirective approaches. Motivational interviewing aims to build intrinsic motivation to change and to resolve ambivalence about change, and to contrast where a patient is with where a patient wants to be (eg, smoke-free). Through trained strategic questioning and listening, a clinician can help patients resolve their ambivalence about behavior change such as quitting smoking.

Several models and techniques are available to help guide any of a patient’s clinicians through a useful set of questions that constitutes a motivational interview [60].

The 5 R's model — For patients unwilling to quit smoking, the "5 R's" model (table 4) can be useful [61]. This is a brief motivational interviewing technique aiming to increase motivation and future quit attempts:

●Relevance – Use motivational information that is personally relevant to a patient’s circumstances, such as their disease status or risk, prior quitting experience, and personal barriers to cessation.

●Risks – Ask the patient to identify potential negative consequences associated with tobacco use. Stress the risks most applicable to the patient, including:

•Acute health risks – Shortness of breath, harm to pregnancy

•Long-term risks – Heart attacks and stroke, lung, and other cancers

•Environmental risks – Increased risk of lung cancer in partners, respiratory infections in children of those who smoke

●Rewards – Encourage the patient to identify potential benefits of quitting smoking and highlight those most relevant to the patient, such as improved health in themselves and their family members, saving money, improved performance in sports, etc.

●Roadblocks – Invite the patient to identify barriers or impediments to quitting and suggest treatments (problem solving counseling, medication) that could address such barriers.

●Repetition – Repeat the motivational intervention every time an unmotivated patient visits the clinic setting. Tobacco users who have failed in previous quit attempts should be reminded that the majority of people make repeated quit attempts before they achieve success.

Reassessing reasons for smoking — Another useful approach to understand a patient's motivation for smoking is to explore the patient’s likes and dislikes about smoking. Questions a clinician can ask to elicit reasons for smoking or quitting include:

●What do you like/not like about smoking?

●What do you worry will happen if you quit smoking? If you don't quit?

●What are some of the benefits that you would hope to gain by quitting?

A numerical or descriptive scale can elicit current thinking about making a smoking behavior change. A scale can also provide valuable information on how to best direct efforts with the patient. With a 0 to 10 scale, the clinician asks:

●"On a scale of 0 to 10, with 0 being not at all important and 10 being very important, how important is it for you to quit smoking?" The patient's response is used for the next questions, eg, if the patient selects '6,' ask:

•"Why is it a 6 and not a 3?"

•"Why is it a 6 and not an 8?"

Alternatively, with a descriptive scale, adjectives are used:

●"Can you tell me how important it is to quit smoking?" The clinician then uses the patient’s adjective in the next question:

•"Why is it 'very important' and not just 'somewhat important'?"

•"What would have to happen to make it extremely or really, really important to you?"

Providing information about harms of smoking — The “elicit-provide-elicit” strategy is an effective way to share information about a patient's health and the harms of smoking. With this collaborative approach, a clinician finds out what a patient wants to know and how a patient interprets the information provided by exploring a patient's concerns, knowledge, and questions about smoking. The strategy assumes that patients will value information that they request and perceive it as relevant.

●Elicit a patient's perspective on smoking:

•"What do you think is the connection between your smoking and your illness?"

•"Would you like to know about how smoking affects your illness?"

•"What do you know about how smoking affects you?"

●Provide information on what "usually" happens to patients who smoke:

•"Usually, patients who smoke a pack a day have some difficulty breathing."

●Elicit the patient's interpretation of this information:

•"What do you think of this information about your smoking?"

•"Would you like more information about smoking?"

Change talk and commitment to change — The clinician can help the patient by listening for or eliciting "change talk," which consists of statements by the patient indicating they are contemplating change. The clinician's goal is to move a patient into commitment talk and commitment to quit smoking.

The different levels of change talk can be categorized as desire, ability, reasons and need (DARN). When patients express such statements, they may be likely to move toward commitment. (See "Brief intervention for unhealthy alcohol and other drug use: Goals and components", section on 'Change talk'.):

●Desire – "I wish I could stop smoking… I want to explore medications to stop smoking…"

●Ability – "I could quit… I might be able to cut back on smoking…"

●Reasons – "I want to quit because… It would be good for my health."

●Need – "I need to quit… I must stop smoking."

Another approach to elicit DARN statements is to ask:

●Desire – "Why do you want to quit smoking?"

●Ability – "What makes you feel able to quit?"

●Reasons – "What are a few reasons for quitting?"

●Need – "Why do you think that you need to quit now?"

Specific principles and techniques of motivational interviewing are described in detail separately. (See "Substance use disorders: Motivational interviewing".)

Efficacy — Despite results of earlier systematic reviews which suggested a benefit of motivational interviewing (MI) [62-64], the efficacy of this approach is unclear. In a 2019 Cochrane review that included 36 trials, there was insufficient evidence to conclude if MI is more effective than other behavioral support for smoking cessation or if more intensive MI is more effective than less intensive MI [65].

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 5^th to 6^th 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 10^th to 12^th 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 e-mail 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 (The Basics)")

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

SUMMARY AND RECOMMENDATIONS

●Combination of behavioral support and pharmacotherapy recommended for smoking cessation – For smokers who are willing to quit, we recommend management with a combination of behavioral support and pharmacologic therapy (Grade 1B). Combination therapy is superior to either behavioral intervention or pharmacologic therapy alone. (See "Overview of smoking cessation management in adults", section on 'Treatments'.)

●Selection of behavioral intervention – Many different behavioral counseling formats are available, including face-to-face modalities (eg, individual patient-clinician encounters and group therapy) as well as other delivery formats, including telephone contact, text messaging, interactive web-based interventions, mobile apps, and website information resources. These other formats can be either standalone tools for patients who are unable to participate in face-to-face counseling or adjuncts to in-person counseling. We encourage the use of behavioral therapy modalities that will be most engaging and acceptable to the patient, and for the patient to use the maximal behavioral intervention available. (See 'Selection of behavioral therapy' above.)

•In most settings, behavioral intervention generally consists of brief clinician counseling in the office, but smokers can also be referred to other resources such as a free telephone quitline for continued counseling support. In the United States, this can be accessed through a national toll-free number (1-800-QUIT-NOW). For patients who have the time and access, formal individual or group counseling are effective options.

●Content of behavioral interventions – A key to successful quitting is to equip the smoker with as much information as possible about what to expect during quit attempts, including expectations about nicotine withdrawal. Effective behavioral therapies generally use cognitive-behavioral techniques to provide practical counseling to avoid triggers and deal with situations that may tempt smoking. (See 'Content of therapy' above.)

●Motivational interviewing for patients who are not yet ready to quit – For smokers who are not ready to quit, the clinician's role is to assess the patient's perspective of the risks and benefits of continuing to smoke in order to help the smoker to begin to think about quitting. Motivational interviewing techniques explore a smoker's feelings, beliefs, ideas, and values regarding tobacco use. The "5 R's" model (Relevance, Risks, Rewards, Roadblocks, Repetition) is a technique to promote motivation in patients who are unwilling to quit (table 4). (See 'Patients not ready to quit' above.)