Smoking cessation — Frequently asked questions (FAQ)
1) What does this algorithm cover?
The algorithm guides a structured approach to tobacco use in clinical practice, from identifying smoking and providing brief advice to assessing readiness to quit, defining the treatment plan and arranging follow-up. It integrates strategies for very brief intervention, motivational intervention — including the 5Rs —, criteria for prioritisation for intensive support, indications for pharmacotherapy and measures for relapse prevention.
2) What initial assessment should I perform?
The clinician should confirm smoking status and characterise the pattern of tobacco use — cigarettes/day and type of product —, as well as estimate nicotine dependence, for which the time to the first cigarette after waking is particularly useful. It is important to document previous quit attempts — what worked and what did not —, withdrawal symptoms, psychosocial context, comorbidities and medication, and to identify situations requiring closer follow-up, such as pregnancy, decompensated mental illness, polysubstance use or unstable cardiac disease.
3) What does “very brief intervention” mean and when should it be used?
A very brief intervention is used when time is limited and consists of three steps: identify tobacco use, advise cessation clearly and empathetically, and offer help, including follow-up or a dedicated appointment. Even in a few seconds, this approach increases the likelihood of cessation by keeping the topic active and facilitating an action plan at the next consultation.
4) How should I formulate the advice?
Advice should be clear, personalised and non-judgemental. It should explicitly recommend stopping smoking and link the recommendation to the patient’s context — symptoms, disease, cardiovascular or respiratory risk, pregnancy or personal goals — while reinforcing that effective help is available. A simple phrase may be enough: “Stopping smoking is the best decision for your health; I can help you achieve it.”
5) How do I assess readiness to quit in practice?
Assessment can be performed with a direct question and a time-based classification: intends to quit within the next 30 days, is considering quitting within the next 6 months or does not currently intend to quit. This distinction helps select the strategy: a quit plan and treatment when there is readiness, motivational intervention when there is ambivalence, and reinforcement/follow-up when there is no current intention.
6) What are the 5Rs and when should they be applied?
The 5Rs — Relevance, Risks, Rewards, Roadblocks and Repetition — are a brief motivational approach indicated when the patient is not ready to quit. They involve exploring personal reasons for change, the risks of tobacco use, expected benefits, perceived barriers — such as stress, weight gain or fear of failure — and returning to the topic in future contacts. The aim is to reduce ambivalence and keep a support pathway open.
7) When should I offer pharmacotherapy?
Pharmacotherapy should be offered to smokers who intend to quit, particularly when there is moderate to high dependence, such as time to first cigarette ≤ 30 minutes, high consumption — for example, ≥ 10 cigarettes/day — or a history of withdrawal symptoms during previous quit attempts. The decision should take into account contraindications, patient preferences and local availability, and is particularly useful when combined with behavioural support.
8) What are the most commonly used pharmacological options and how should I choose?
Options include nicotine replacement therapy (NRT) — ideally combination NRT: patch + rapid-acting formulation —, varenicline and, depending on context and availability, bupropion and/or cytisine. The choice should consider clinical profile, previous experience, adverse effects, patient preferences and the need for craving control. In case of failure, it is reasonable to adjust dose/adherence, switch option or intensify support, rather than abandoning the strategy.
9) How often should follow-up be arranged after the quit date?
Follow-up should be early and scheduled: ideally contact in the first week — or 1–2 weeks after the quit date — and then at regular intervals, for example 4–6 weeks and 3 months, adjusted according to risk. At each contact, abstinence, craving, adverse effects, adherence and psychosocial context should be assessed, while reinforcing progress and preventing relapse with practical strategies.
10) What should be done in case of relapse?
Relapse should be viewed as part of the process, without blame. The trigger should be explored — stress, alcohol, routine or social context —, and the plan and pharmacotherapy should be reviewed, including adherence, dose and tolerability. Support should be intensified when necessary. It is usually useful to propose a new quit date and adjust coping strategies, while keeping the patient in follow-up to reduce the likelihood of further relapses.
11) Who should be prioritised for intensive support?
Patients with high dependence — short TTFC, high consumption —, repeated relapses, significant withdrawal symptoms, relevant comorbidity — COPD, cardiovascular disease, diabetes —, severe or unstable mental illness or polysubstance use should be prioritised for an intensive consultation or programme, as should pregnant patients, especially after previous failed attempts. The patient’s preference for intensive support is also a valid criterion.
12) Who is this content intended for?
The algorithm and this FAQ are intended for healthcare professionals. The final decision should integrate the clinical context, comorbidities, risk, patient preferences and local resource availability, following current guidelines and adapting the intervention to the care setting.
