Ask, Advise to quit and Assess are the steps in approaching patients regarding smoking cessation.
All patients should be asked if they use tobacco and should have their tobacco status documented on a regular basis.
Patient with nicotine dependence is characterized by smoking within 30 minutes of waking, consuming >10 cigarettes/day and had withdrawal symptoms in previous attempts of quitting smoking.
Smokers should be strongly urged to quit at every physician encounter. 
Advice should be clear, personalized, supportive and non-judgmental.
Determine the willingness of smoker to make a quit attempt.

Relapse Prevention

  • Smoking relapse is common and usually occurs within the first 3 months of quitting and can occur months to years after the quit date
    • Risks include stress, frequent cravings, alcohol consumption, drug use or abuse (eg stimulants, narcotics), being with family or friends who smoke, <1 year since stopping smoking, or currently on medical therapy for smoking cessation
  • May restart primary therapy with combination NRT or Varenicline
    • Use the pharmacotherapeutic agent that was previously effective for the patient as repeated attempts at quitting using the same therapy are needed to obtain long-term cessation 
    • May consider switching to other 1st-line agents before trying 2nd-line agents 
  • Physicians need to continually be involved in relapse prevention interventions especially if risk for relapse is high 
    • Continue counseling and behavioral therapy, consider medical therapy to maintain abstinence, and review the benefits of remaining abstinent from smoking 
  • In patients who have recently quit smoking, the physician should:
    • Reinforce the patient’s decision to quit
    • Review the benefits of quitting
    • Help the patient with any residual problems arising from quitting


  • Smokers should be strongly urged to quit at every physician encounter
    • Studies have shown that unplanned efforts to quit is as successful as planned attempts, stressing the risks of smoking as well as the benefits of quitting whenever opportunity arises
  • Advice should be clear, personalized, supportive and non-judgmental
  • Increasing the number of attempts to quit plays an important role in improving abstinence rates
  • A minimum of short counseling is recommended, though several sessions are most effective with intensive behavior therapy 
  • Provide practical problem-solving or skills training that may include total abstinence from smoking, identifying factors that helped in the past quitting experience, anticipating problems that may be encountered, limiting or abstaining from alcohol, and encouraging other household members to also quit smoking
  • Combined counseling and medication is more effective than when either intervention is used alone
    • Both counseling and medication should be offered provided there are no contraindications or evidence of ineffectiveness in particular patient populations
  • Person-to-person treatment (eg individual, group or telephone support) delivered ≥4 sessions are proven effective in increasing abstinence rates

Follow Up

  • The principle for follow-up is to monitor the status of the program that was given to the patient
  • Patient/physician follow-up should be arranged soon after the quit date (within the first 2 weeks after initiating medical therapy), at 12-week intervals, then at therapy completion
  • Points for assessment during follow-up visits:
    • Success of smoking cessation
      • Patient should be congratulated if successful and strongly encouraged to remain abstinent
    • Motivational level
    • Presence of withdrawal symptoms should be discussed and pointers on what to do should be given
      • Symptoms of Nicotine withdrawal usually peak within 1-2 weeks and then diminish
    • Discuss problems encountered and challenges that may occur in the futur
    • Assess pharmacotherapy use and problems
    • If required, consider specialist referral for more intensive treatment
  • If patient smoked, review circumstances and encourage recommitment to complete abstinence
    • Lapse should be seen as a learning experience
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