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Although cigarette smoking remains an enormous health problem, great progress has been made in tobacco control over the past 40 years. The clearest evidence of this progress is that the current US adult smoking prevalence is less than half the rate that it was in the 1960s.¹ There are many reasons for the decline in smoking prevalence. One reason is a change in culture whereby smoking is seen by most people as an undesirable and unhealthy lifestyle choice. This change in how smoking is perceived is a significant public health achievement. Another contributor to declining smoking rates is the ongoing improvement in smoking cessation techniques and medications. More is now known about how to help smokers to quit, and the variety and quality of smoking cessation services and medications has increased.

The current article is divided into two parts. The first part is an update and summary of current evidence-based smoking cessation techniques and medications, based upon the recently published Clinical Practice Guideline Treating Tobacco Use and Dependence: 2008 Update.² The updated Clinical Guideline was sponsored by a consortium of eight federal and nonprofit organizations, and reflects the synthesis of more than 8,700 research articles. The second part of this article discusses the often neglected topic of unplanned “cold turkey” smoking cessation.

Clinical Practice Guideline Treating Tobacco Use and Dependence: 2008 Update

The Clinical Practice Guideline is the consummate source of information regarding contemporary smoking cessation techniques and medications. However, it is a very lengthy document at 256 pages. The current article summarizes a few of the most important recommendations emphasized in the Clinical Guideline. Readers are encouraged to access the Guideline for more detail regarding specific topics of interest (http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf). The five most important recommendations in the Guideline are as follows:

1. Cigarette smoking and tobacco dependence usually require multiple cessation attempts before long-term abstinence is achieved. Clinicians and smokers should not be discouraged by any individual unsuccessful attempt to quit smoking. There are many different treatments now available, so smokers should be encouraged to keep trying to quit and to try different cessation methods as appropriate to their medical status.

2. Clinicians and other medical professionals always should assess for smoking status and treat every tobacco user. Even a very brief intervention can have an effect. The vast majority of smokers have at least some interest in quitting.³ Therefore, timely information and encouragement from a clinician can have an effect.

3. Counseling for smoking cessation can take a variety of forms. Group counseling with multiple smokers is effective. Individual counseling and telephone counseling also are effective. The most important ingredients of counseling are (a) practical advice about how to quit smoking, and (b) social support and encouragement for the cessation attempt.

4. There are many effective medications available for smoking cessation. Each of these medications has different strengths, weaknesses, and potential side effects. Some of these medications can be taken in combination, whereas other combinations are not recommended. The Clinical Guideline provides details regarding various combinations of medications. There are five types of nicotine replacement therapies: gum, inhaler, lozenge, nasal spray, and transdermal patch. Each of these products is designed to reduce craving for smoking by providing nicotine to the body without smoking. In addition to nicotine replacement therapies, there are two non-nicotine products that are taken in pill form: Buproprion SR and Varenicline. All of the products mentioned in this section increase the probability of sustained smoking abstinence.

5. Counseling and medications are most effective when combined. Thus, for optimum results, clinicians should recommend a combination of counseling and medications whenever possible.

Unplanned “Cold Turkey” Quitting

The Clinical Practice Guideline provides comprehensive advice regarding available treatments for tobacco dependence. However, the majority of ex-smokers quit smoking without counseling and without medications.⁴ Thus, it is important for clinicians to understand that smokers might quit “on their own.” Recent research has illuminated this issue of unplanned or “cold turkey” quitting. These studies reveal that smoking cessation is often a sudden, unplanned event.^5–7 Each quitter's experience is different, but usually there is some event in a smoker's life that causes that person to quit smoking suddenly. In many cases, the smoker already was struggling with the idea of quitting smoking, but had no specific plan regarding how or when to quit smoking.³

The phenomenon of sudden, “cold turkey” quitting has implications for clinicians treating smokers. First, it is important to realize that all smokers, even those who profess no plans of quitting, could become quitters at any time. This is an additional reason why physicians should assess and discuss a client's smoking wherever possible. One can never know when a brief piece of advice or feedback regarding a client's smoking could trigger a quit attempt.

Second, it is helpful to inform smokers about the phenomenon of sudden, unplanned smoking cessation, so that they will be ready to “seize the moment,” should they experience a sudden motivation to quit smoking. In short, if a smoker has a sudden desire to make a quit attempt, they should be encouraged to quit without delay. These moments of high motivation represent excellent opportunities for cessation. In fact, research has shown that unplanned cessation attempts are, on average, more successful than planned cessation attempts.^5–7 Smokers can seek additional assistance such as counseling and nicotine replacement therapy after the cessation attempt is underway.

Conclusion

Our understanding of how to help smokers to quit has increased markedly over the past 40 years. There now are many effective options for smokers who want to quit. At the same time, there is no one right way to quit smoking. Smokers and clinicians should work together to find the appropriate strategy for each smoker. In addition, smokers and clinicians should be alert to the possibility of unplanned “cold turkey” cessation attempts, and should seize these moments of high motivation to quit as opportunities for sustained smoking abstinence.