Risk Factors

A Pragmatic Guide to Smoking Cessation

Michael J. Bloch, MD
Associate Professor, University of Nevada School of Medicine
Medical Director, Vascular Care, Renown Institute for Heart and Vascular Health
President, Blue Spruce Medical Consultants, PLLC
Reno, Nevada

Bloch, MJ. A pragmatic guide to smoking cessation. Consultant360. Published online August 15, 2022.


According to the 2022 American Heart Association Heart Disease and Stroke Statistics,1 general tobacco use and smoking cigarettes remain independent risk factors for coronary heart disease (CHD) and stroke. It is also a prevalent risk factor with 15.3% of US adults smoking every day or some days.1  Quitting smoking at any age reduces mortality. People who smoke and quit at 25 to 34 years of age gain an average of 10 years of life, compared with those who continue to smoke their entire lives. Those who quit at 35 to 44 years of age gain an average of 9 years of life, those who quit at 45 to 54 years of age gain an average of 6 years, and those who quit at 55 to 64 years of age gain an average of 4 years.1,2 Based on these and other data, getting our patients to quit smoking has at least as great of an impact as aggressive management of other cardiovascular (CV) risk factors. Yet, little precious time or resources are devoted to smoking cessation interventions in usual office practice.

A recent publication by Selby and Zawertailo, which appears in a recent edition of the New England Journal of Medicine,3 defines tobacco addiction as a “chronic relapsing disorder that accounts for more than 480,000 deaths annually in the United States and is characterized by frequent attempts to quit and subsequent relapses.” While this review is not a guideline or a scientific statement, it provides a useful road map for an integrated approach to counseling and medical therapy analogous to how we treat other CV risk factors. As the authors point out, nicotine is an exceptionally addictive substance. Inhaling cigarette smoke delivers a bolus of nicotine, at an average of about 1 mg per cigarette, to the pleasure centers of the brain within seconds.

The article goes on to make the following recommendations supported by commonly accepted guidelines:

  • Screen all patients starting at 9 years of age for use of tobacco products
  • All patients who smoke should be advised to stop as soon as possible. One of the greatest predictors of successful smoking cessation is a health care provider’s advice to quit
  • Refer all patients to smoking cessation counseling, either in person or via telephone (hotline). Behavioral counseling has routinely demonstrated to increase cessation rates
  • Prescribe approved medications to all patients, regardless of their willingness to pick a quit date
  • In the absence of contraindications, first-line therapy includes either varenicline, nicotine replacement, or preferably both
  • Use varenicline for at least 12 weeks but consider increasing to as long as 52 weeks in patients at high risk for relapse
  • Nicotine patches by themselves do not achieve equivalent plasma levels as smoking 20 cigarettes per day. For greater efficacy, combine a 14-21 microgram patch with as-needed nicotine gum, lozenge, mist,or inhaler
  • Vaping products are not approved or recommended as first-line therapy for smoking cessation. Further research is needed on their CV effect

Each of these interventions has been demonstrated to increase the chances of quitting by at least 50% and in the case of varenicline, >100%. And, while the risk of relapse remains high, in many ways, this is no different than the chronic management of other CV risk factors where patients may be intermittently adherent to medications and the lifestyle modifications we recommend. The potential for absolute benefit in CV health and mortality demands that we be active partners with our patients who use tobacco and take a systematic approach to tobacco cessation, with at least as much dedication of time and resources as we apply to other CV risk factors.


  1. Tsao CW, Aday AW, Almarzooq ZI, et al. Heart disease and stroke statistics-2022 update: a report from the American Heart Association. Circulation. 2022;145(8):e153-e639. doi:10.1161/CIR.0000000000001052
  2. Jha P, Ramasundarahettige C, Landsman V, et al. 21st-century hazards of smoking and benefits of cessation in the United States. N Engl J Med. 2013;368(4):341-50. doi:10.1056/NEJMsa1211128
  3. Selby P, Zawertailo L. Tobacco Addiction. New Engl J Med 2022;387:345-54. doi:10.1056/NEJMcp2032393