Smoking cessation

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

All people who are current smokers should be advised of the benefits of smoking cessation regardless of age, comorbidities, or current health problems. Clinicians should offer a menu of cessation resources (pharmacotherapy and behavioural support) to those who are ready to stop. Overall, the combination of behavioural support plus an evidence-based pharmacotherapy for smoking cessation has the best evidence for smoking cessation.[2][96][97][98] [ ]

Service models and common approaches to smoking cessation vary according to location of practice. Two commonly used smoking cessation models are:[71]

Very brief advice for smoking, based on an 'Ask, Advise, Assist' structure, which encourages clinicians to ask patients about tobacco use, advise them to stop, and assist them by signposting them to specialist smoking cessation services offering pharmacotherapy and behavioural support.
A more comprehensive intervention for smoking cessation, which can be provided using the '5 A's' structure: 1) ask about tobacco use; 2) advise to stop through clear, personalised messages; 3) assess willingness to stop; 4) assist in stopping; and 5) arrange follow-up and support.

Evidence directly comparing different smoking cessation models is limited. It suggests that both brief and comprehensive models can be effective, but that their effectiveness may vary depending on the individual, and according to the clinical setting.[1] According to one Cochrane review, assuming an unassisted stopping rate of 2% to 3%, a very brief advice intervention can increase stopping by a further 1% to 3%.[99] Although this effect is low at an individual level, a brief intervention has the potential to reach many people who smoke. These actions are therefore likely to be economical and effective in increasing cessation rates at a population level.[3] Although more intensive interventions may result in slightly better outcomes overall, they may be less practical in some clinical contexts.[71][72][99][100] Clinicians may chose to prioritise comprehensive interventions for those with greater nicotine dependence, or previous unsuccessful stopping attempts.

In locations such as the UK and New Zealand, a very brief intervention (also known as 'very brief advice') for smoking cessation is usually recommended at the initial point of patient contact.[63][72][101] People who wish to stop smoking are then referred to specialist local smoking cessation services following this.[63]

The more comprehensive 5 A's approach is adopted in full or as a modified form in many international smoking cessation guidelines, and is frequently used within the US.[2][71][102] Some professional organisations in the US recommend using a briefer initial approach to smoking cessation, the rationale being that an abbreviated version incorporating more members of the wider care team is likely to be more feasible to deliver in real-world clinical settings.[71][89]

A variant of the 5 A's approach that is endorsed by the American College of Cardiology is to omit the step of offering readiness to stop, and instead to proactively offer smoking cessation treatment to every smoker, with people having the option to refuse treatment.[89] This approach echoes a typical chronic condition management strategy, where the expectation is that patients will be offered treatment. There is some randomised controlled trial (RCT) evidence to suggest that this more proactive approach to the 5 A's increases rates of smoking cessation compared with usual care in some patient groups.[103][104][105][106]

Very brief advice for smoking cessation

A brief advice intervention for smoking cessation may be given in as little as 30 seconds, and involves:[63]

Asking about current and past smoking behaviour
Advising on the risks of smoking and the benefits of stopping smoking by providing verbal and written information
Advising on the options for stopping smoking, including behavioural support and evidence-based medication for smoking cessation
Referring the person to a specialist service (e.g., local smoking cessation service, tobacco dependence specialist, and/or telephone quitline), if they wish to stop smoking.

Physicians may be more effective in promoting attempts to stop smoking if they offer assistance to all smokers rather than only those who are motivated to stop smoking.[107] If the offer of a brief advice intervention for smoking is declined, it may still be offered at future consultations, as brief advice interventions are designed to be given repeatedly without antagonising the individual.[63] It is not uncommon for life events and changes in circumstances to precipitate stopping attempts even by people who appear to be entrenched smokers.[108]

The 5 A's

The 5 A's steps are as follows:

1) Ask about a patient's smoking status.

2) Advise those who smoke to stop.

3) Assess their readiness to stop.

4) Assist smokers in their stopping attempts.

5) Arrange for follow-up on these attempts.

Because it may be challenging for one person to implement all of the 5 A's within a single clinical encounter, healthcare professionals and clinic staff may work together as a team to address different parts of the list.

Ask

Step 1 of the 5 A's is to ask all patients about tobacco usage.

Tobacco usage should be assessed at every healthcare encounter.[2][71] Use of a smoking status identification system questionnaire should be standard. See Diagnostic approach.

Advise

Step 2 of the 5 A's is to advise smoking cessation.

There is robust evidence to suggest that brief advice (less than 5 minutes' duration) from a clinician to stop smoking at each clinical encounter increases smoking abstinence rates.[71][99]

Those who are actively smoking every day or most days should be advised to stop.[2] An open, reflective, patient-centred discussion may begin with asking permission to discuss smoking. The physician can then identify the patient's personal goals that would be furthered by stopping. If not ready to stop, the patient can be invited to discuss again at the following visit.

Discussing smoking cessation in the context of smoking-related medical disease specific to the individual patient is recommended by clinicians. For people with smoking-related disease, it may be appropriate to offer more intensive clinical advice.[71]

The use of physiological measurements such as cotinine and carbon monoxide (CO) testing may be considered as an additional motivational tool in specific clinical scenarios. See Investigations.

Assess

Step 3 of the 5 A's is to assess readiness to stop.

The following questions may be used to assess readiness to stop smoking:[2]

How important is it for you to try to stop smoking now?
If you decide to stop, how confident are you that you can succeed?
What has worked for you in the past? What hasn’t?
Are you willing to try to stop in the next month?

An alternative to assessing readiness to stop is to use a proactive approach and offer treatment to all smokers.

Assist

Step 4 of the 5 A's is to assist smokers who are ready to stop.

Overall, the combination of behavioural support plus an evidence-based medication for smoking cessation has the best evidence for smoking cessation (see below).[2][96] [ ]

The following are some simple recommendations that healthcare providers can offer to help people build a stopping plan, in addition to referral to a behavioural support programme and offering pharmacotherapy:[63][109]

Identify your reasons for smoking
Set a stop date and commit to it
Let family members, friends, and colleagues know you are stopping
Remove reminders of smoking
Identify your smoking triggers (e.g., stress, seeing others smoking, becoming intoxicated) and develop coping strategies
Explore ways to manage cravings, e.g., distraction strategies, talking to a friend or family members
Explore ways to avoid relapse, e.g., by avoiding situations in which you would usually smoke
Have places you can turn to for immediate help.

Education about the likely timing of withdrawal symptoms and strategies for management (using medication and/or behavioural techniques) is also important.

Arrange follow-up

Step 5 of the 5 A's is to arrange follow-up.

The risk of relapse is highest in the 2 weeks following cessation. Physicians should arrange follow-up for a smoker attempting to stop within 1 week of the planned stopping date. Setting up follow-up with a behavioural support service (quitline or in-person one-to-one or group behavioural support) is both feasible and encouraged if available.[110][111] [ ]

The motivational intervention should be repeated every time an unmotivated patient visits the clinic setting. Tobacco users who have been unsuccessful in previous stopping attempts should be told that most people make repeated stopping attempts before they are successful.

Behavioural support

Behavioural support encompasses multimodal approaches that can require significant time and expertise. It has consistently shown benefit for smoking cessation, compared with receiving minimal support, or receiving pharmacotherapy alone.[111][112] There is evidence from one Cochrane review that increasing the amount of behavioural support available increases the chance of success by about 10% to 20%.[98] Another Cochrane review determined that group-based interventions in adults appear to be more promising than self-help and other less intensive interventions. There was not enough evidence to evaluate whether groups are more effective than intensive individual behavioural support.[110] There is moderate-certainty evidence that the provision of adjunctive counselling by a health professional other than the physician (e.g., nurse, smoking cessation specialist, smoking quitline) increases smoking cessation rates in primary care.[113]

Internet-based interventions are available that increase the likelihood of cessation and help patients avoid relapse.[114][115] [ ] Text messaging interventions have been shown to have a beneficial impact on 6-month cessation outcomes.[116][117] [ ] Financial-incentive programmes have been shown to improve tobacco cessation rates in both low- and high-income groups.[118][119][120] Reward-based programmes are more commonly accepted than deposit-based programmes and have led to higher smoking cessation rates.[121]

In some locations (e.g., the UK), behavioural support is typically offered via weekly sessions delivered by a specialist service for a minimum of 4 weeks.[63][72] In the US, behavioural support is often given simply via brief clinician counselling in the clinic; in this context, supplementation via telephone quitline, internet or text message support, or more intensive behavioural support may increase efficacy, given evidence suggesting that more intensive interventions are more effective than less intensive interventions.[110][113]

First-line pharmacotherapy

Two types of medicine have amassed the greatest volume of data demonstrating safety and efficacy for smoking cessation: nicotine replacement therapy (NRT) with a combination of short-acting and long-acting NRT (e.g., patches, gum, lozenges, and nasal spray), and varenicline.[122][123][124][125] Both NRT and varenicline have US Food and Drug Administration (FDA) approval for smoking cessation. In the UK, they are recommended by the National Institute for Health and Care Excellence (NICE).[63] Both are considered first-line treatments and produce significantly higher stop rates for 6 months or more than does placebo alone.[63][76]

Nicotine replacement therapy (NRT)

All NRT is safer than smoking a cigarette. NRT with patches, gum, lozenges, oral inhaler, or nasal spray more than doubles the success rate of a stopping attempt compared with placebo.[124] NRTs attenuate withdrawal symptoms, and can provide a coping strategy for the behavioural aspects of withdrawal, such as oral (gum, lozenge) and hand-to-mouth (inhaler) stimulation.
There is strong evidence that adding a short-acting 'on-demand' form of NRT (e.g., gum, lozenge) to a long-acting nicotine patch increases success rates, and so this strategy is preferred over monotherapy where possible.[53][63][122][124][126] Evidence from one Cochrane review suggests that lower-dose nicotine patches and gum may be less effective than higher-dose products.[53]
The choice of nicotine delivery method is guided by patient preferences, prior experience, and availability. In most countries, the patch, gum, and lozenges are available without a prescription. The nasal spray generally requires a prescription. An inhaler and nicotine mouth spray may be available in some countries, but they are not currently available in the US.[76]
Ensure that the person has NRT ready to start the day before the stopping date.[63]

Varenicline

Varenicline attenuates withdrawal symptoms and blocks the reinforcing effects of nicotine. It has been shown to increase the chances of successful long-term smoking cessation by 2-3 times compared with placebo.[127] More people stop successfully with varenicline than with bupropion or with a single form of NRT. Varenicline may be as effective as or more effective than dual-form NRT.[127][128] [ ] [ ] Guidance from the American Thoracic Society (ATS) and a statement from the American College of Cardiology both recommend varenicline over bupropion or NRT.[89][129] Varenicline combined with behavioural support increases abstinence more than other pharmacotherapy with behavioural support combinations.[130]
Early reports of possible links of varenicline to cardiovascular and psychiatric events have not been confirmed by current research.[90][128][131] There is evidence from one Cochrane review that people taking varenicline may be at increased risk of adverse cardiac events, but at decreased risk of neuropsychiatric adverse events, although the evidence was equivocal and compatible with both benefit and harm.[127]
Varenicline is relatively slow-acting, and so should be started 1-2 weeks in advance of the stopping date.[63]

Second-line pharmacotherapy

Bupropion

Has received FDA approval for smoking cessation, and is recommended in the UK by NICE as one potential option for smoking cessation, although NICE notes that this is ‘off-label’ use of bupropion, and that it is less effective than other types of smoking cessation pharmacotherapy including combination NRT and varenicline.[63]
Demonstrated to increase smoking cessation rates; it is as effective as single NRT, and has been shown to increase the chances of long-term abstinence by approximately 50% to 80% compared with placebo.[122][123]
Less effective than varenicline.[122][123]
Use of bupropion increases the risk of psychiatric adverse events, and is less well tolerated than placebo.[123]
Significant contraindications include seizures, eating disorders, and use of monoamine oxidase inhibitors.
Bupropion is relatively slow-acting, and so should be started 1-2 weeks in advance of the stopping date.[63]

Nortriptyline[2][132]

Has not received FDA approval for smoking cessation, and is not recommended by NICE in the UK.[63]
Second-line therapy for smoking cessation due to higher rates of adverse events; these include arrhythmias and changes in contractility and blood flow.
Nortriptyline has demonstrated low-moderate efficacy for smoking cessation.[123][125]
One Cochrane review found evidence that nortriptyline aided smoking cessation when compared with placebo, but also some evidence that it was inferior to bupropion; findings were sparse and inconsistent as to whether nortriptyline had a particular benefit for people with current or previous depression. Data on harms and tolerability were limited.[123]
Begin 12-28 days before the stopping date, and continue for 12 weeks then taper.

Combination pharmacotherapy

Most tobacco cessation monotherapies and combination therapies are more effective than placebo at helping participants to achieve sustained abstinence.[133] Combining drugs with different mechanisms of action may increase stopping rates more than single agents.[76] One network meta-analysis showed a high probability that the combination of varenicline and NRT is more likely to achieve sustained abstinence than NRT or bupropion as monotherapies.[133] However, one RCT showed no significant difference in abstinence among those treated with combined varenicline plus nicotine patch therapy versus varenicline monotherapy.[134] Combining varenicline with NRT has been associated with higher rates of adverse effects (e.g., nausea, headaches).[2]

Evidence to support the use of combination therapy with bupropion and NRT is not strong and its use is somewhat controversial. The US Public Health Service guidelines recommend combination of the nicotine patch with bupropion, although this combination is not recommended in other countries.[2]

Nicotine electronic cigarettes (e-cigarettes or vapes)

Nicotine electronic cigarettes (also known as e-cigarettes or vaping) vaporise nicotine fluid formulation with a feel that approximates regular smoking. In some locations, such as the UK, nicotine e-cigarettes may be considered in specific circumstances as an alternative option to conventional NRT in adults.

Efficacy of nicotine e-cigarettes

There is a mounting body of evidence demonstrating that nicotine e-cigarettes are an effective method of nicotine delivery and can be used as NRT.[63][135][136]

In one Cochrane review, smoking cessation rates were higher in people randomised to nicotine e-cigarettes than in those randomised to NRT.[137] [ ] Another Cochrane review found high-certainty evidence that e-cigarettes are equal in efficacy to varenicline for smoking cessation, and slightly more effective than combination NRT.[125]

Safety of nicotine e-cigarettes

A report on the public health consequences of e-cigarettes by the National Academies of Sciences, Engineering, and Medicine found that exposure to nicotine from e-cigarettes is highly variable and depends on product characteristics (including device and e-liquid characteristics), as well as how the device is operated.[138] It also found that, in addition to nicotine, most e-cigarette products contain and emit numerous potentially toxic substances. However, the report found conclusive evidence that completely substituting combustible tobacco cigarettes for e-cigarettes reduces users' exposure to numerous toxicants and carcinogens present in combustible tobacco cigarettes. Early molecular and clinical evidence suggests various acute physiological effects on the circulatory system from nicotine e-cigarettes (e.g., increases in heart rate and blood pressure, endothelial dysfunction, and platelet aggregation), which may pose harms to users, especially those with pre-existing cardiovascular disease.[139]

Dual use of nicotine e-cigarettes and combustible tobacco smoking has been highlighted as a particular cause for concern, and there is some evidence to suggest that it may increase the risk of respiratory and cardiovascular disease compared with conventional tobacco smoking.[32][140][141][142]

Current evidence on safety suggests that the incidence of death or serious adverse events is low across RCTs undertaken to date.[135] However, arguments that e-cigarettes have not caused extensive disease in the past decade are premature, and it is currently unknown what diseases may develop following longer-term use.[57][138]

An assessment of the published data on emissions from cigarettes and e-cigarettes calculated the lifetime cancer risks.[143] It concluded that the cancer potencies of e-cigarette emissions were largely under 0.5% of the risk of smoking tobacco cigarettes.[143][144]

An outbreak of severe lung injury associated with vaping was reported in 2019 in the US. Although this was related to tetrahydrocannabinol (THC)-containing e-cigarettes that contained vitamin E acetate and not to commercial nicotine e-cigarettes, further contamination cannot be ruled out.[76][86]

Nicotine e-cigarettes: variation in recommendations worldwide

Unlike conventional NRT, nicotine e-cigarettes are not licensed medicines, and their regulation and quality control varies across different countries and regions. Their use for smoking cessation is a topic of ongoing debate and research. While they are generally considered to be less harmful than combustible cigarettes, their use as tobacco cessation aids is controversial due to limited evidence on current devices, and uncertainty about safety of long-term use.[137]

Professional medical bodies in different countries have different stances on e-cigarettes based on the available evidence and public health considerations.[1][63][71][145] The US Preventive Services Task Force (USPSTF) and the 2020 Surgeon General’s report note insufficient evidence to evaluate the balance of benefits and risks of nicotine e-cigarettes for smoking cessation, and that clinicians should direct smokers to FDA-approved smoking cessation medicines instead.[1][71] Use of e-cigarettes for smoking cessation is not typically recommended by guidelines or professional medical bodies in Europe (excluding the UK).[146][147]

In the UK, recommendations are generally more supportive; NICE and the Royal College of Physicians (RCP) support the use of nicotine electronic cigarettes as a smoking cessation tool in adults in certain circumstances, when licensed treatments are not sufficient.[63][148][149] Although NICE does not specifically recommend nicotine e-cigarettes and emphasises that they cannot be offered on prescription, it does recommend ways in which health professionals may increase their accessibility.[63] Ultimately, the aim should be to stop all forms of nicotine (including nicotine e-cigarettes), but this should not be done at the expense of relapsing to smoking.[150]

There is universal agreement among professional medical bodies worldwide that use of e-cigarettes should be discouraged in people who have never smoked, and that they should not be used for smoking cessation in children and adolescents, owing to safety risks in this age group, and a lack of evidence supporting their efficacy compared with behavioural support and NRT.

Harm reduction

For people who are unwilling or not ready to stop smoking, harm reduction may be considered.[63][129]

Approaches to harm reduction vary and include:[63]

Cutting down before stopping smoking, with or without pharmacotherapy (varenicline or NRT)
Smoking reduction, with or without pharmacotherapy (varenicline or NRT)
Temporary abstinence from smoking, with or without pharmacotherapy (varenicline or NRT).

Shared decision making is key to selecting the most suitable approach for the individual.

Many people ask if stopping abruptly is harder than tapering smoking, also known as the reduction-to-quit method. This approach provides NRT to support a reduction in cigarette consumption as a first step towards abstinence. Some trials of 'NRT-assisted reduction to stop' (or cut down to stop) demonstrate that long-term abstinence rates among smokers provided with NRT for this purpose are double those among smokers given placebo, and that adverse events are not increased despite receiving nicotine from both the NRT and cigarettes.[151][152][153] Forms of NRT that have been studied include the use of nicotine gum or inhaler for up to 18 months and the use of nicotine patches for 6 weeks before a stopping date.[151][152][153] Many of these studies include behavioural support.

For patients who are not willing to stop in the next month but are willing to reduce cigarette consumption and stop in 3 months, varenicline therapy for 24 weeks has been shown to significantly increase smoking cessation rates.[154] However, neither reduction-to-quit nor abrupt stopping interventions result in superior long-term stopping rates when compared with one another.[155]

Smoking cessation management in specific patient groups

Pregnant/breastfeeding women

Smoking in pregnancy represents a special circumstance with additional considerations. Smoking during pregnancy is a well-established risk factor for adverse pregnancy outcomes including preterm deliveries, low birth weight, and preterm-related deaths, and it is prevalent to varying degrees globally.[7][156] All pregnant women who smoke should be advised on the adverse effects of smoking on their fetus (low birth weight, preterm birth) and offered access to smoking cessation interventions.[157]
The USPSTF recommends that clinicians ask all pregnant persons about tobacco use, advise them to stop using tobacco, and provide behavioural interventions of cessation to pregnant persons who use tobacco.[71]
In this population, behavioural and psychological interventions are considered first-line treatments in some locations, including the US.[71][157]
One Cochrane review determined that NRT used for smoking cessation in pregnancy may increase smoking cessation rates in late pregnancy; however, the evidence is of low certainty and there was no conclusive evidence on either positive or negative effects on birth outcomes.[158] There is insufficient evidence on either the effectiveness or the safety of bupropion or varenicline for smoking cessation in pregnancy.[158]
While not expressly recommending against using medicines, the USPSTF concluded that the current evidence was insufficient to assess the balance of benefits and harms of pharmacological interventions, including NRT, bupropion, and varenicline for tobacco cessation in pregnant or breastfeeding women.[71] The American College of Obstetrics and Gynecology recommends using NRT only after a detailed discussion with the patient of the known risks of continued smoking, the possible risks of NRT, and need for close supervision.[159]
In the UK, NICE recommends that NRT be considered alongside behavioural support in pregnant women who use tobacco, as most smoking-related health problems are caused by other components in tobacco smoke, not by the nicotine.[63] Use of NRT instead of smoking reduces their nicotine exposure.[160] NICE advises against using other pharmacotherapy options for smoking cessation, such as varenicline or bupropion, during pregnancy and breastfeeding.[63]

Adolescents aged <18 years

Data on efficacy of cessation treatments in adolescents are limited.[62][161] [ ] This is due, in part, to challenges in conducting studies in this population. In addition, the experience of smoking and smoking cessation may differ between this age group and adults. For instance, levels of nicotine dependence may not be equal to those of adult smokers.
One Cochrane review found evidence to suggest that behavioural support delivered via a group setting is effective in increasing smoking cessation among adolescents.[161]
The US Preventive Services Task Force (USPSTF) concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary-care feasible interventions for smoking cessation in children and adolescents younger than 18 years.[62] The American Academy of Pediatrics (AAP) recommends that for adolescents who smoke and who wish to stop using tobacco, clinicians offer referral for a behavioural intervention for smoking cessation. They recommend that smoking cessation pharmacotherapy (NRT) may be considered for adolescents who are moderately to severely dependent on tobacco.[60] UK guidance from NICE recommends that clinicians consider NRT for children and adolescents aged 12 years and over who are smoking and dependent on tobacco, in conjunction with behavioural support.[63]
E-cigarettes are not recommended for smoking cessation in children and adolescents.[60]
In one Cochrane review, there was no clear evidence for the effectiveness of pharmacological (NRT, bupropion) interventions in young people.[161] However, a review of studies of pharmacotherapy for smoking cessation in adolescents concluded that if an adolescent shows signs of dependence, a nicotine patch may be prescribed in addition to a behavioural intervention.[162] One trial suggested that a combination of NRT and cognitive behavioural therapy is associated with significantly higher abstinence rates in adolescent smokers at 6 months.[163] In one meta-analysis, bupropion was found to improve sustained smoking abstinence, but a pooled analysis of pharmacotherapy overall showed increased abstinence rates for only 4 weeks of follow-up.[164] Data for varenicline suggested safety and early abstinence, but no sustained effect.[165]
Clinicians should consult local prescribing recommendations and guidance, but note that in some locations (e.g., the UK), commonly used pharmacotherapies for smoking cessation, such as varenicline and bupropion, should not be prescribed to those aged under 18 years.[63]

Active smokers admitted to hospital

Hospital admissions present a window of opportunity to initiate cessation interventions in active smokers for several reasons:
1. If admitted for a smoking-related illness, active smokers may have increased motivation to stop.
2. As most hospitals are smoke-free, smokers have enforced abstinence from smoking.
3. Some hospitals have trained specialist clinicians to assist with smoking cessation.
4. Those eligible to receive pharmacotherapy can be instructed on its use and can experience pharmacotherapy while being observed.
For people diagnosed with many types of cancer including lung cancer, post-diagnosis smoking cessation is associated with increased survival rates.[166][167] An argument can be made for routine integration of smoking cessation services within oncology care.[168]
There is high-certainty evidence to suggest that behavioural support by a trained cessation specialist initiated during the admission to hospital and continued for more than 1 month after discharge is effective in increasing stopping rates in hospitalised patients, regardless of the admitting diagnosis.[169] Behavioural support provided only in hospital, without post-discharge support, may have a modest impact on stopping rates, but the evidence is less certain.[169] Therefore, active smokers should be connected with outpatient behavioural support resources at discharge, where possible.[170] When patients receive behavioural support in hospital, high‐certainty evidence indicates that providing both behavioural support and pharmacotherapy after discharge increases stopping rates compared with no post‐discharge intervention.[169]
Evidence suggests an improvement in stopping rates when NRT is used in patients admitted to hospital.[169] [ ] NRT may also help relieve withdrawal symptoms during the enforced abstinence from smoking. A retrospective review of observational studies demonstrated that perioperative NRT is not associated with adverse outcomes after surgery.[171] An RCT comparing the relative cardiovascular safety risk of varenicline, bupropion, and NRT showed no evidence that the use of any of these smoking cessation pharmacotherapies increased the risk of serious cardiovascular adverse events.[90]
One effective programme for inpatient smoking cessation is the Ottawa Model for Smoking Cessation, which improves long-term stopping rates by 11%, and involves identification of smoking status for all admitted patients, brief advice, personalised bedside smoking cessation, behavioural support, timely pharmacotherapy, and follow-up after discharge.[172] University of Ottawa Heart Institute: Ottawa model for smoking cessation Opens in new window
The relative lack of evidence regarding safety and efficacy of NRT in acute coronary syndrome (ACS) and the theoretical concern for nicotine’s vasoconstrictive properties mean that NRT use may be limited during hospitalisation for patients with ACS and life-threatening arrhythmias. The American College of Cardiology notes, however, that given the robust safety profile and efficacy of NRT in the general population, and the clear dangers of smoking, NRT is recommended as first-line therapy in hospitalised patients with ACS.[89]
There is moderate-certainty evidence to suggest that starting varenicline in hospitalised patients helps more patients to stop smoking than placebo or no medication. There is less evidence of benefit for bupropion in this setting.[169]

Perioperative patients

Patients who smoke who require surgery represent a special opportunity for smoking cessation. The perioperative risks of smoking have been well established, and include infection, ACS, neurological complications, prolonged length of stay, and death, among others.[173][174] Although optimal timing for smoking cessation prior to surgery has been suggested to be as long as 4 weeks, even short durations of abstinence may be helpful.[175]
Among patients scheduled for elective non-cardiac surgery, varenicline combined with a 10- to 15-minute behavioural support session, educational material, and referral to a quitline was found to increase long-term abstinence by 62% compared with brief behavioural support and self-referral to a quitline alone.[176] Both bupropion and varenicline are relatively slow-acting, and so should be started at least 1-2 weeks in advance of the scheduled surgery. If cessation does not occur preoperatively, NRT used in the immediate postoperative period can mitigate the nicotine withdrawal symptoms, due to its rapid onset of action.[177]
Intensive multicomponent interventions appear to be more effective than brief interventions in achieving abstinence and reducing post-surgical complications.[178] Concomitant preoperative intensive behavioural support has been shown to improve outcomes in perioperative patients, usually in conjunction with NRT, according to one Cochrane review.[179] Brief interventions of 90 minutes or less have been associated with a small reduction in smoking by the time of surgery.[179]
There is some evidence to suggest that preoperative smoking cessation interventions result in longer-term smoking cessation after 1 year, compared with usual care (25% vs. 8%).[180]

Active smokers presenting to the accident and emergency department

In some locations such as the US, people without insurance coverage may present to the emergency department rather than to primary care, reducing opportunities for primary care-based smoking cessation interventions. One study showed that an intensive 6-week intervention (including motivational interview by a trained research assistant, a supply of nicotine transdermal patches and gum started in the emergency department, a referral to a smoker's quitline, a booster call, and a brochure) improved tobacco abstinence rates in low-income patients presenting to the accident and emergency department.[181]

People with co-existing mental health conditions

People with mental health conditions are several times more likely to smoke than the general population, and smoking is believed to be the single largest contributor to the 7-25 year reduced life expectancy within this group.[182] However, people with mental health conditions are less likely to be offered smoking cessation treatment compared with the general population without mental illness.[183]
Concerns are sometimes noted that smoking cessation could exacerbate symptoms of psychiatric illness. In fact, the evidence suggests that smoking cessation results in improved physical and mental health within a few months, among those with and without a pre-existing mental health condition.[182][184][185] However, owing to a theoretical risk that nicotine withdrawal may negatively impact mood in the short term, it is advisable to monitor mental health during smoking cessation in people with pre-existing mental illness.
Smoking increases metabolism of many psychotropic medications, and a dose reduction may be required immediately on smoking cessation in order to prevent toxicity. Careful monitoring of psychiatric medications is therefore required. Examples include a number of commonly used antidepressants, antipsychotics, and benzodiazepines, as well as carbamazepine. If smoking is resumed, original doses may need to be reinstated.[182]
In those with current depression, use of the antidepressants bupropion or nortriptyline may be considered, as they also have efficacy in improving cessation rates, although data to support this approach are limited, and as a general guide, first-line treatments for smoking cessation should be considered preferentially. Nortriptyline and bupropion are second-line therapies for smoking cessation because of higher rates of adverse events.[2][132]
Treatment with bupropion and contingent reinforcement (e.g., with money) has been shown to be helpful for smoking cessation in people with schizophrenia. There is no evidence to suggest that NRT, bupropion, or varenicline lead to worsening of psychiatric symptoms; these agents are effective and are not associated with changes in psychiatric symptoms.[186][187]

Substance use disorder

Over 53% of people with substance use disorder die of tobacco-related causes.[44]
People with a history of substance use should be encouraged to pursue smoking cessation as they undergo treatment for other drug dependencies.[87][188][189] [ ]
Given the challenges with this group of patients, all should receive behavioural support, ideally with therapists with training in both tobacco and substance use disorder.
Some medications prescribed for substance use disorders (e.g., methadone) may be affected by smoking cessation; in people with opioid use disorder requiring treatment with methadone, careful monitoring for opioid toxicity is required, with consideration of dose reduction.[190]
People with active alcohol or substance use disorder may have a reduced threshold for seizures, increasing the risk of this complication from treatment with bupropion.
There is no evidence to suggest that receiving treatment for smoking increases use of other substances.[191]
In one systematic review, varenicline had a significant effect on short-term smoking cessation when used in people with alcohol dependence, but the number of studies was small.[192] Of interest, in studies of varenicline for the treatment of alcohol dependence, a concomitant reduction of both smoking and alcohol use was seen.[193]
There is also evidence for NRT, behavioural support, and bupropion for smoking cessation, as well as for combination treatment, in this patient group.[194][195]

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