Behavioral Approaches To Smoking Cessation

11/07/2021 Behavioral approaches to smoking cessation - UpToDate
Official reprint from UpToDate®
www.uptodate.com
© 2021 UpToDate, Inc. and/or its affiliates. All Rights Reserved.
Behavioral approaches to smoking cessation

Author: Elyse R Park, PhD, MPH
Section Editors: Mark D Aronson, MD, Hasmeena Kathuria, MD
Deputy Editor: Lisa Kunins, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2021. | This topic last updated: Sep 30, 2020.
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 smokers 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
smokers are less likely to attempt to quit and, accordingly, less likely to be advised to quit [3].
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
https://www.uptodate.com/contents/behavioral-approaches-to-smoking-cessation/print?search=homeless&topicRef=103550&source=see_link 1/23
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 [4]. 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 smokers attending 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 [5].
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 smokers did not receive clinician counseling to quit during an office visit
[6,7].
PATIENTS READY TO QUIT
A combination of behavioral approaches and pharmacotherapy is most helpful to patients

trying to quit [8-12]. While behavioral approaches can be used to help cope with nicotine
withdrawal symptoms, most smokers will also benefit from the use of pharmacotherapy.
(See "Pharmacotherapy for smoking cessation in adults".)
Selection of behavioral therapy — All smokers who are ready to quit 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, phone 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, taking into account patient preference, medical history,
beliefs, and availability. Patients may benefit from using more than one modality, such as
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 [13,14]. Availability and robustness of studies showing efficacy vary considerably
among the different modalities.
In the United States, many insurance plans cover tobacco-cessation interventions, including
behavioral counseling and medications approved by the US Food and Drug Administration
(FDA) [15].
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 smokers [16]. (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 [14]. 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 smokers 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 to smokers 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 [16-18]. A systematic
review found that group therapy was nearly twice as effective as self-help programs [19].
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 to a smoker on a
prearranged schedule; in reactive counseling, a smoker 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'.)
Smokers 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 [20].
Telephone counseling programs are more effective than simple self-help interventions, in
which smokers are provided with take-home written or audiovisual material to aid them in
quitting on their own [21]. In a clinical trial, among practices that were randomized to
routinely refer smokers to a telephone quitline, patients had higher smoking cessation rates
at 3 and 12 months compared with those who received standard general practitioner care
[22].
Proactive telephone counseling has been shown to have efficacy in several studies, whereas
data about reactive counseling are mixed [23]. One meta-analysis found quit rates were
higher for those smokers who received multiple proactive counselling calls after the smoker
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
daily smokers (10 versus 6 percent) [24]. By contrast, data on reactive telephone counseling
provide only limited evidence as to whether there is any improvement in quit rates among
smokers receiving reactive counseling compared with non-telephone-based controls [23,25].
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, and allow patients to request additional
assistance as needed.
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)
[26]. 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 [27].
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 – 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.
Systematic reviews have found that interactive or individually tailored web-based

approaches are more effective than non-interactive approaches [27,28]. 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) [27]. Web-based
interventions may be less effective compared with telephone counseling via quitlines [29].
(See 'Telephone counseling' above.)
Interventions leveraging social network sites such as Twitter, Facebook, and Whatsapp to
deliver smoking cessation treatment have shown promising results in helping motivated
smokers to quit and avoid relapse [30,31].
Phone apps — Smoking cessation applications (apps) on smart phones 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 [32-35].
A review of free smartphone applications (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 [36].
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 [37-
39].
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 [40]. 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) [41]. 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 [42].
However, when used as an adjunct to counseling or nicotine replacement therapy, there is

no evidence of additional benefit from self-help materials [40].
Content of therapy — A common feature of the various formats of smoking cessation

therapy is that they equip the smoker 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 smokers choose to quit abruptly), and setting a quit date. Effective therapy
includes social support delivered as part of treatment to reinforce a smoker's confidence in
his or her ability to quit [16,43]. 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'.)
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. Smokers 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 to smokers 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 smokers identify

their triggers to smoke. The smoker anticipating quitting should be encouraged to identify
situations, internal states, or activities that may increase the risk of continuing to smoke or
of relapsing [16]. Examples of common triggers include stressful situations, being around
other smokers, consuming alcohol, or drinking coffee.
Problem solving and coping skills — Once smokers 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 [44]:
● 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 [44,45].
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".)
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 [16]. 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,
phone 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 [14]. Counseling that lasted more than 10 minutes and consisted of four or more
sessions was particularly effective [16,46]. 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 [13]. 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 [23].
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 [16].
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 'Assessment for persistent smoking' 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 [47,48].
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 [49]. 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 [50].
The 5 R's model — For patients unwilling to quit smoking, the "5 R's" model ( table 4)
can be useful [51]. 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 smokers
● 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 "Motivational interviewing for substance use disorders".)
Efficacy — Despite results of earlier systematic reviews which suggested a benefit of

motivational interviewing (MI) [52-54], 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 [55].
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 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
● 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'.)
● 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.)
● We encourage the patient to use the maximal behavioral intervention available and
acceptable to the patient. (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.
• Web-based interventions, text messaging, phone apps, and self-help websites are
formats to provide behavioral counseling in addition to face-to-face or telephonic
counseling.
● 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.)
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES
1. https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdf (Accessed on
September 20, 2020).
2. Walton K, Wang TW, Schauer GL, et al. State-Specific Prevalence of Quit Attempts
Among Adult Cigarette Smokers - United States, 2011-2017. MMWR Morb Mortal Wkly
Rep 2019; 68:621.
3. Jordan H, Hidajat M, Payne N, et al. What are older smokers' attitudes to quitting and
how are they managed in primary care? An analysis of the cross-sectional English
Smoking Toolkit Study. BMJ Open 2017; 7:e018150.
4. Barua RS, Rigotti NA, Benowitz NL, et al. 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. J Am Coll Cardiol 2018; 72:3332.
5. Smith SS, McCarthy DE, Japuntich SJ, et al. Comparative effectiveness of 5 smoking
cessation pharmacotherapies in primary care clinics. Arch Intern Med 2009; 169:2148.
6. Ferketich AK, Khan Y, Wewers ME. Are physicians asking about tobacco use and
assisting with cessation? Results from the 2001-2004 national ambulatory medical care
survey (NAMCS). Prev Med 2006; 43:472.
7. Thorndike AN, Regan S, Rigotti NA. The treatment of smoking by US physicians during
ambulatory visits: 1994 2003. Am J Public Health 2007; 97:1878.
8. Suls JM, Luger TM, Curry SJ, et al. Efficacy of smoking-cessation interventions for young
adults: a meta-analysis. Am J Prev Med 2012; 42:655.
9. Stead LF, Koilpillai P, Lancaster T. Additional behavioural support as an adjunct to
pharmacotherapy for smoking cessation. Cochrane Database Syst Rev 2015; :CD009670.
10. West R, Raw M, McNeill A, et al. Health-care interventions to promote and assist tobacco
cessation: a review of efficacy, effectiveness and affordability for use in national
guideline development. Addiction 2015; 110:1388.
11. US Preventive Services Task Force. Draft recommendation statement: Tobacco smoking
cessation in adults, including pregnant persons: Interventions. 2020. Available at: http
s://www.uspreventiveservicestaskforce.org/uspstf/draft-recommendation/tobacco-smok
ing-cessation-in-adults-including-pregnant-women-interventions (Accessed on July 22, 2
020).
12. Stead LF, Koilpillai P, Fanshawe TR, Lancaster T. Combined pharmacotherapy and
behavioural interventions for smoking cessation. Cochrane Database Syst Rev 2016;
3:CD008286.
13. Laude JR, Bailey SR, Crew E, et al. Extended treatment for cigarette smoking cessation: a
randomized control trial. Addiction 2017; 112:1451.
14. Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation.
Cochrane Database Syst Rev 2017; 3:CD001292.
15. McAfee T, Babb S, McNabb S, Fiore MC. Helping smokers quit--opportunities created by
the Affordable Care Act. N Engl J Med 2015; 372:5.
16. Fiore MC, Jaen C, Baker T, et al. Treating tobacco use and dependence: 2008 Update. Clin
ical Practice Guideline. Rockville, MD: US Department of Health and Human Services. Pu
blic Health Service; 2008.
17. Spice P. Setting up a cessation service. BMJ 2004; 328:699.
18. Jamrozik K. Population strategies to prevent smoking. BMJ 2004; 328:759.

19. Stead LF, Carroll AJ, Lancaster T. Group behaviour therapy programmes for smoking
cessation. Cochrane Database Syst Rev 2017; 3:CD001007.
20. Miller N, Frieden TR, Liu SY, et al. Effectiveness of a large-scale distribution programme
of free nicotine patches: a prospective evaluation. Lancet 2005; 365:1849.
21. Matkin W, Ordóñez-Mena JM, Hartmann-Boyce J. Telephone counselling for smoking
22. Borland R, Balmford J, Bishop N, et al. In-practice management versus quitline referral
for enhancing smoking cessation in general practice: a cluster randomized trial. Fam
Pract 2008; 25:382.
23. Stead LF, Hartmann-Boyce J, Perera R, Lancaster T. Telephone counselling for smoking
cessation. Cochrane Database Syst Rev 2013; :CD002850.
24. Peterson AV Jr, Kealey KA, Mann SL, et al. Group-randomized trial of a proactive,
personalized telephone counseling intervention for adolescent smoking cessation. J
Natl Cancer Inst 2009; 101:1378.
25. Sood A, Andoh J, Verhulst S, et al. "Real-world" effectiveness of reactive telephone
counseling for smoking cessation: a randomized controlled trial. Chest 2009; 136:1229.
26. Whittaker R, McRobbie H, Bullen C, et al. Mobile phone text messaging and app-based
interventions for smoking cessation. Cochrane Database Syst Rev 2019; 10:CD006611.
27. Civljak M, Stead LF, Hartmann-Boyce J, et al. Internet-based interventions for smoking
28. Taylor GMJ, Dalili MN, Semwal M, et al. Internet-based interventions for smoking
29. Neri AJ, Momin BR, Thompson TD, et al. Use and effectiveness of quitlines versus Web-
based tobacco cessation interventions among 4 state tobacco control programs. Cancer
2016; 122:1126.
30. Pechmann C, Delucchi K, Lakon CM, Prochaska JJ. Randomised controlled trial evaluation
of Tweet2Quit: a social network quit-smoking intervention. Tob Control 2017; 26:188.
31. Ramo DE, Thrul J, Chavez K, et al. Feasibility and Quit Rates of the Tobacco Status
Project: A Facebook Smoking Cessation Intervention for Young Adults. J Med Internet
Res 2015; 17:e291.

32. Abroms LC, Padmanabhan N, Thaweethai L, Phillips T. iPhone apps for smoking
cessation: a content analysis. Am J Prev Med 2011; 40:279.
33. Cheng F, Xu J, Su C, et al. Content Analysis of Smartphone Apps for Smoking Cessation in
China: Empirical Study. JMIR Mhealth Uhealth 2017; 5:e93.
34. Thornton L, Quinn C, Birrell L, et al. Free smoking cessation mobile apps available in
Australia: a quality review and content analysis. Aust N Z J Public Health 2017; 41:625.
35. Formagini TD, Ervilha RR, Machado NM, et al. A review of smartphone apps for smoking
cessation available in Portuguese. Cad Saude Publica 2017; 33:e00178215.
36. Ubhi HK, Kotz D, Michie S, et al. Comparative analysis of smoking cessation smartphone
applications available in 2012 versus 2014. Addict Behav 2016; 58:175.
37. Whittaker R, McRobbie H, Bullen C, et al. Mobile phone-based interventions for smoking
38. Effectiveness of Mobile Apps for Smoking Cessation: Α Review; Tob. Prev. Cessation 201
7;3(April):12. http://www.tobaccopreventioncessation.com/Effectiveness-of-Mobile-Apps
-for-Smoking-Cessation-Review,70088,0,2.html (Accessed on December 21, 2017).
39. Dar R. Effect of Real-Time Monitoring and Notification of Smoking Episodes on Smoking
Reduction: A Pilot Study of a Novel Smoking Cessation App. Nicotine Tob Res 2018;
20:1515.
40. Hartmann-Boyce J, Lancaster T, Stead LF. Print-based self-help interventions for smoking
41. Brandon TH, Simmons VN, Sutton SK, et al. Extended Self-Help for Smoking Cessation: A
Randomized Controlled Trial. Am J Prev Med 2016; 51:54.
42. Livingstone-Banks J, Ordóñez-Mena JM, Hartmann-Boyce J. Print-based self-help

interventions for smoking cessation. Cochrane Database Syst Rev 2019; 1:CD001118.
43. Stead LF, Lancaster T. Group behaviour therapy programmes for smoking cessation.
Cochrane Database Syst Rev 2005; :CD001007.
44. O'Connell KA, Gerkovich MM, Cook MR, et al. Coping in real time: using Ecological
Momentary Assessment techniques to assess coping with the urge to smoke. Res Nurs
Health 1998; 21:487.
45. Ussher MH, Taylor AH, Faulkner GE. Exercise interventions for smoking cessation.
46. Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation.
47. Rollnick S, Miller WR, Butler CC. Motivational Interviewing in Health Care, New York, NY,
The Guilford Press 2008.
48. Amrhein PC, Miller WR, Yahne CE, et al. Client commitment language during
motivational interviewing predicts drug use outcomes. J Consult Clin Psychol 2003;
71:862.
49. Leone FT, Zhang Y, Evers-Casey S, et al. Initiating Pharmacologic Treatment in Tobacco-
Dependent Adults. An Official American Thoracic Society Clinical Practice Guideline. Am J
Respir Crit Care Med 2020; 202:e5.
50. https://www.ncbi.nlm.nih.gov/books/NBK63948/table/A28272/?report=objectonly (Acces
sed on November 06, 2017).
51. Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel,
Liaisons, and Staff. A clinical practice guideline for treating tobacco use and
dependence: 2008 update. A U.S. Public Health Service report. Am J Prev Med 2008;
35:158.
52. Lindson-Hawley N, Thompson TP, Begh R. Motivational interviewing for smoking

53. Lundahl B, Burke BL. The effectiveness and applicability of motivational interviewing: a
practice-friendly review of four meta-analyses. J Clin Psychol 2009; 65:1232.
54. Rubak S, Sandbaek A, Lauritzen T, Christensen B. Motivational interviewing: a systematic
review and meta-analysis. Br J Gen Pract 2005; 55:305.
55. Lindson N, Thompson TP, Ferrey A, et al. Motivational interviewing for smoking
Topic 6920 Version 36.0
GRAPHICS
5A's for assessing for tobacco use and addressing smoking cessation
Intervention Technique
Ask Implement an officewide system that ensures that, for every patient at every clinic visit, tobacco-use
status is queried and documented. Repeated assessment is not necessary in the case of the adult who
has never used tobacco, or has not used tobacco for many years, and for whom this information is clearly
documented in the medical record.
Advise Strongly urge all tobacco users to quit in a clear, strong, personalized manner.
Advice should be:

Clear - "I think it is important for you to quit smoking now and I can help you." "Cutting down while you are ill is
not enough."
Strong - "As your clinician, I need you to know that quitting smoking is the most important thing you can do to
protect your health now and in the future. The clinic staff and I will help you."
Personalized - Tie tobacco use to current health/illness and/or its social and economic costs, motivation
level/readiness to quit, and/or the impact of tobacco use on children and others in the household.
Assess Determine the patient's willingness to quit smoking within the next 30 days:
If the patient is willing to make a quit attempt at this time, provide assistance.
If the patient will participate in an intensive treatment, deliver such a treatment or refer to an intensive
intervention.
If the patient clearly states that they are unwilling to make a quit attempt at this time, provide a motivational
intervention and/or offer the option of initiating pharmacotherapy rather than waiting until they are ready to quit.
If the patient is a member of a special population (eg, adolescent, pregnant smoker), provide additional
information specific to that population.
Assist Provide aid for the patient to quit. These actions are summarized in the accompanying table.
Arrange Schedule follow-up contact, either in person or by telephone. Follow-up contact should occur soon after
the quit date, preferably during the first week. A second follow-up contact is recommended within the
first month. Schedule further follow-up contacts as indicated.
Congratulate success during each follow-up. If tobacco use has occurred, review circumstances and elicit
recommitment to total abstinence. Remind the patient that a lapse can be used as a learning experience.
Identify problems already encountered and anticipate challenges in the immediate future. Assess
pharmacotherapy use and problems. Consider use or referral to more intensive treatment.
Adapted from: Fiore MC, Jaen C, Baker T, et al. Treating tobacco use and dependence: 2008 update. Clinical Practice Guideline. Rockville, MD:
US Department of Health and Human Services. Public Health Service. 2008.
Graphic 74402 Version 13.0
Assisting patients with smoking cessation
Action Strategies for implementation
Help the patient with a quit plan Set a quit date. Ideally, the quit date should be within 2 weeks.
Tell family, friends, and coworkers about quitting and request understanding and
support.
Anticipate challenges to planned quit attempt, particularly during the critical first few
weeks. These include nicotine withdrawal symptoms.
Remove tobacco products from your environment. Prior to quitting, avoid smoking in
places where you spend a lot of time (eg, work, home, car).
Provide practical counseling Abstinence - Total abstinence is essential. "Not even a single puff after the quit date."
(problem solving/training)
Past quit experience - Review past quit attempts, including identification of what helped
during the quit attempt and what factors contributed to relapse.
Anticipate triggers or challenges in upcoming attempt - Discuss challenges/triggers and

how patient will successfully overcome them. Advise patient to remove all tobacco from
home, car, and work environment.
Alcohol - Because alcohol can cause relapse, the patient should consider
limiting/abstaining from alcohol while quitting.
Other smokers in the household - Quitting is more difficult when there is another
smoker in the household. Patients should encourage housemates to quit with them or
not smoke in their presence.
Provide intra-treatment social Provide a supportive clinical environment while encouraging the patient in their quit
support attempt. "My office staff and I are available to assist you."
Help the patient obtain extra- Help the patient develop social support for their quit attempt in their environments
treatment social support outside of treatment. "Ask your spouse/partner, friends, and coworkers to support you
in your quit attempt."
Recommend the use of approved Recommend the use of pharmacotherapies found to be effective. Explain how these
pharmacotherapy, except in medications increase smoking cessation success and reduce withdrawal symptoms.
special circumstances
Provide supplementary materials Sources - Federal agencies, nonprofit agencies, or local/state health departments. Offer
a free telephone quitline (in the United States, 1-800-QUIT-NOW or
1-800-784-8669 can be used).
Type - Culturally/racially/educationally/age appropriate for the patient.
Location - Readily available at every clinician's workstation.
ACE: Avoid, Change, Escape. Strategies for coping with smoking triggers.
Strategy Helpful statements Helpful questions
Avoid - staying away from high-risk As smokers prepare or try to quit, it is What are the things that trigger you to
environments sometimes helpful to avoid people, smoke?
places, and events that may tempt Which of these do you think you can
them to smoke. avoid over the next week or so?
Change - altering a high-risk situation Sometimes it's not possible to avoid the What are a couple of situations that
things that trigger smoking. But trigger your smoking but that may be
another option is to change the hard to avoid?
situation, even a little, so that you feel What can you do to change the
less tempted to smoke. situation to make smoking less
tempting?
Escape - planning how to excuse Sometimes, situations catch you by Did you find yourself lately in a
oneself from high-risk situations surprise. Staying in the situation can situation like this?
make it too tempting to smoke. In What happened?
these cases, another option may be to
Would leaving have been an option?
leave the situation.
What would it be like to leave?
Five "R's" to motivate smokers unwilling to quit
Intervention Technique
Relevance Encourage the patient to indicate why quitting is personally relevant, being as specific as possible.
Motivational information has the greatest impact if it is relevant to a patient's disease status or risk,
family or social situation (eg, having children in the home), health concerns, age, gender, and other
important patient characteristics (eg, prior quitting experience, personal barriers to cessation).
Risks Ask the patient to identify potential negative consequences of tobacco use. The clinician may suggest and
highlight those that seem most relevant to the patient. The clinician should emphasize that smoking low-
tar/low-nicotine cigarettes or use of other forms of tobacco (eg, smokeless tobacco, cigars, and pipes) will
not eliminate these risks.
Examples of risks are:

Acute risks - Shortness of breath, exacerbation of asthma, harm to pregnancy, impotence, infertility, and increased
serum carbon monoxide.
Long-term risks - Heart attacks and strokes, lung and other cancers (larynx, oral cavity, pharynx, esophagus,
pancreas, bladder, cervix), chronic obstructive pulmonary diseases (chronic bronchitis and emphysema), long-term
disability, and need for extended care.
Environmental risks - Increased risk of lung cancer and heart disease in spouses; higher rates of smoking in
children of tobacco users; increased risk for low birth weight, Sudden Infant Death Syndrome, asthma, middle ear
disease, and respiratory infections in children of smokers.
Rewards Ask the patient to identify potential benefits of stopping tobacco use. The clinician may suggest and
highlight those that seem most relevant to the patient.
Examples of rewards include:

Improved health
Food will taste better
Improved sense of smell
Save money
Feel better about yourself
Home, car, clothing, breath will smell better
Can stop worrying about quitting
Set a good example for and have healthier babies and children
Not worry about exposing others to smoke
Feel better physically and perform better in physical activities
Reduced wrinkling/aging of skin
Roadblocks Ask the patient to identify barriers or impediments to quitting and note elements of treatment (problem
solving, pharmacotherapy) that could address barriers.
Typical barriers might include:

Withdrawal symptoms
Fear of failure
Weight gain
Lack of support
Depression
Enjoyment of tobacco
Repetition The motivational intervention should be repeated every time an unmotivated patient visits the clinic
setting. Tobacco users who have failed in previous quit attempts should be told that most people make
repeated quit attempts before they are successful.
Contributor Disclosures
Elyse R Park, PhD, MPH Nothing to disclose Mark D Aronson, MD Nothing to disclose Hasmeena
Kathuria, MD Consultant/Advisory Boards: Healthwise [Medical Reviewer]. Lisa Kunins, MD Nothing
to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for
references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.
Conflict of interest policy

Behavioral Approaches To Smoking Cessation - UpToDate

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Behavioral Approaches To Smoking Cessation - UpToDate

Uploaded by

Copyright:

Available Formats

11/07/2021 Behavioral approaches to smoking cessation - UpToDate

Official reprint from UpToDate®

Smoking is associated with the development of cancers, cardiovascular diseases, chronic

The 5 A’s model encourages clinicians to:

● Ask patients about smoking

Another approach to encourage smoking cessation is to proactively offer treatment during

PATIENTS READY TO QUIT

A combination of behavioral approaches and pharmacotherapy is most helpful to patients

Selection of behavioral therapy — All smokers who are ready to quit should be

Brief intervention — For many patients, face-to-face behavioral therapy will consist of

Individual counseling — Some patients may engage in formal individual counseling for a

Group counseling — Group therapy allows patients to learn behavioral techniques while

Telephone counseling — Telephone counseling can be used as the primary behavioral

Text messaging — Mobile phone text messaging consists of personalized smoking

Web resources and interventions — Smoking cessation interventions that are delivered

Website resources include the following:

Systematic reviews have found that interactive or individually tailored web-based

Self-help materials, including pamphlets, audiotapes, or videotapes, have been found to be

However, when used as an adjunct to counseling or nicotine replacement therapy, there is

Content of therapy — A common feature of the various formats of smoking cessation

Education about withdrawal symptoms — Education to expect symptoms of nicotine

Identification of triggers — An important goal of therapy is to help smokers identify

Problem solving is a process to generate potential solutions to address each trigger to

Examples of coping strategies include [44]:

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

Stress management and relaxation strategies — Stress is a commonly reported barrier

Supportive therapy — Positive encouragement and support are crucial in promoting

● Communicating belief in the patient’s ability to quit

Duration of therapy — We typically encourage a patient to use behavioral therapy weekly

Meta-analyses of randomized trials found a dose-response relationship between the

PATIENTS WHO RECENTLY QUIT

Follow-up after quitting is described separately (See "Overview of smoking cessation

Techniques to address nicotine withdrawal symptoms or weight gain, are addressed

Relapse is discussed separately. (See "Overview of smoking cessation management in

PATIENTS NOT READY TO QUIT

Techniques for motivational interviewing — In motivational interviewing, a clinician uses

motivation and future quit attempts:

● Relevance – Use motivational information that is personally relevant to a patient’s

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

● Roadblocks – Invite the patient to identify barriers or impediments to quitting and

● Repetition – Repeat the motivational intervention every time an unmotivated patient

Reassessing reasons for smoking — Another useful approach to understand a patient's

● What do you like/not like about smoking?

• "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:

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

Providing information about harms of smoking — The “elicit-provide-elicit” strategy is

● Elicit a patient's perspective on smoking:

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

● Elicit the patient's interpretation of this information:

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

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

Another approach to elicit DARN statements is to ask:

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

Specific principles and techniques of motivational interviewing are described in detail

Efficacy — Despite results of earlier systematic reviews which suggested a benefit of

SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

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

SUMMARY AND RECOMMENDATIONS

• In most settings, behavioral intervention generally consists of brief clinician