Behavioral approaches to smoking cessation
- Elyse R Park, PhD, MPH
Elyse R Park, PhD, MPH
- Associate Professor of Psychiatry, Harvard Medical School
- Director of Behavioral Sciences, MGH Tobacco Research & Treatment Center
- Director of Behavioral Science Research, Center for Psychiatric & Behavioral Sciences, MGH Cancer Center
- Director of Behavioral Health Research, MGH Benson-Henry Inst
- Section Editors
- Mark D Aronson, MD
Mark D Aronson, MD
- Editor-in-Chief — Primary Care (Adult); Hospital Medicine
- Section Editor — General Medicine
- Professor of Medicine
- Harvard Medical School
- James K Stoller, MD, MS
James K Stoller, MD, MS
- Section Editor — Chronic Obstructive Pulmonary Disease
- Jean Wall Bennett Professor of Medicine, Samson Global Leadership Academy Endowed Chair
- Cleveland Clinic Lerner College of Medicine
- Chairman, Education Institute, Cleveland Clinic
Each year, approximately two out of every three smokers make an attempt to quit . Health care clinicians miss many opportunities to provide counseling for smoking cessation despite patient interest and the demonstrated efficacy of brief counseling in office practice . An analysis of 2001 to 2004 National Ambulatory Medical Care Survey (NAMCS) data showed that approximately 80 percent of smokers did not receive physician counseling to quit during an office visit [2,3]. The low rates of counseling are unfortunate, as one study based at several primary care practices found that one in five smokers attending a routine primary care appointment were willing to make a serious quit attempt with the help of treatment that incorporated evidence-based counseling and some form of pharmacologic aide .
Meta-analysis and systematic reviews of clinical trials have found that a combination of behavioral counseling and pharmacotherapy produce the best results for smoking cessation [5-7]. In the United States, insurance plans are required to cover tobacco-cessation interventions, including behavioral counseling and medications approved by the US Food and Drug Administration (FDA) .
The behavioral approach to smoking cessation will be discussed in this topic. An overview of smoking cessation, including the 5 A's approach (table 1 and table 2), and pharmacologic therapy for smoking cessation, are discussed separately. (See "Overview of smoking cessation management in adults" and "Pharmacotherapy for smoking cessation in adults".)
For every patient at every clinic visit, we suggest using a clinician intervention model called the "5 A's" (table 1). This 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), and arrange for follow-up visits or contact. (See "Overview of smoking cessation management in adults".)
PATIENTS READY TO QUIT
All smokers who are ready to quit should be offered assistance in quitting that includes referral to the most intensive smoking cessation counseling program that is available and acceptable to the smoker. All smokers making a quit attempt should receive behavioral counseling. Behavioral counseling strategies that are elements of successful smoking cessation treatment include practical counseling (problem solving/skills training) and intratreatment supportive intervention (social support delivered as part of treatment) . Ideally, these elements should be included in a treatment plan.
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- INITIAL ASSESSMENT
- PATIENTS READY TO QUIT
- Counseling content
- - Nicotine dependence and withdrawal
- - Cognitive based therapy
- Identifying triggers
- Problem solving and skills training
- - Stress management and relaxation strategies
- - Intratreatment supportive intervention
- Duration and frequency
- Types of counseling
- - Clinician counseling
- - Group programs
- - Telephone counseling
- Other strategies
- - Web-interventions
- - Text messaging
- - Phone apps
- - Self-help
- - Website resources
- PATIENTS NOT READY TO QUIT: MOTIVATIONAL INTERVIEWING
- Specific strategies
- - The model of 5 R's
- - Reassessing reasons for smoking
- - Providing information about harms of smoking
- - Change talk and commitment to change
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS