Smoking cessation should be a priority for all smokers and healthcare providers should routinely evaluate smoking status and offer treatments. The document outlines smoking as an addiction that requires both brief interventions and more intensive behavioral and pharmacological treatments to increase chances of long term abstinence. It emphasizes treating tobacco dependence as a primary disorder and implementing systems to ensure all smokers are identified and receive evidence-based cessation support.

2. Smoking should be routinely evaluated whenever a patient presents to a healthcare facility

3. All smokers should be offered the best chance to treat this disorder.

4. Permanent remissions can be achieved in a substantial percentage of smokers with currently available treatments.

5. Successful treatment of this disorder can have a substantial benefit in reducing many secondary complications of which chronic obstructive pulmonary disease (COPD) is one.

7. enforced programmes which limit access to cigarettes

8. society can have a major effect on smoking behaviour and it is hoped that

10. Advise: strongly urge all tobacco users to quit, in a clear, strong and personalized manner.

11. Assess: determine willingness to make a quit attempt.

12. Assist: help the patient with a quit plan, provide practical counselling, provide intratreatment social support, help the patient obtain extra-treatment social support, recommend use of approved pharmacotherapy (except in special circumstances) and provide supplementary materials.

14. Risks: both acute (i.e. dyspnoea, cough, exacerbations, increased carbon monoxide), chronic (i.e. COPD progression, cancer, cardiovascular disease, osteoporosis, peptic ulcer) and other environmental risks (i.e. disease risk to spouse, household members, increased risk of smoking in children).

15. Rewards: such as improved health, improved self image, regaining sense of taste and smell, and saving money.

16. Roadblocks: such as withdrawal symptoms, fear of failure, weight gain, lack of support, depression and the enjoyment of tobacco.

18. Nicotine polacrilex (gum) contains nicotine bound to a polacrilex resin together with a buffering agent. Chewing releases the nicotine from the polacrilex. Varying the rate of chewing varies the rate of nicotine release. Once released, nicotine is present in the saliva and is absorbed across the buccal mucosa. Low oral pH causes the nicotine base to ionise and the charged form is absorbed much more slowly. Both 2- and 4-mg formulations are available. Eight to 10 gums per day should be recommended, but are often difficult to chew. Treatment for 3–6 months is recommended, but some smokers will substitute gum for smoking and sustain their addiction with gum.

19. Transdermal nicotine system or “patch” is applied to the skin in a nonhairy area of the torso or proximal area of the extremities. Each device contains an adhesive, a reservoir that contains nicotine and an impermeable backing. Nicotine diffuses from the reservoir through the skin and is absorbed into the capillary blood of the skin. Absorption is continuous and relatively slow. Several formulations are available. Transdermal nicotine reduces the intensity, but does not eliminate, withdrawal symptoms. Treatment with nicotine patches is generally recommended at “full dose” for 4–6 weeks. This is often followed by a tapering regimen for several additional weeks.

20. Nicotine inhaler consists of a mouthpiece and a nicotine-containing cartridge. Nicotine is released when air is inhaled through the device. Most of the nicotine is deposited in the mouth and absorbed through the buccal mucosa. The device should not, therefore, be inhaled like a cigarette as very little nicotine will reach the lower respiratory tract. Because the nicotine is absorbed through the buccal mucosa, absorption is into the venous circulation. The device contains ~10 mg of nicotine, of which ~1 mg is released with ~100 inhalations.

21. Nicotine nasal spray consists of an aqueous solution of nicotine. It is delivered by direct spray to the nasal mucosa [23]. One spray in each nostril delivers 1 mg of nicotine. The nicotine is absorbed into the venous blood in the nasal mucosa. Absorption, however, is relatively rapid with peak levels being achieved in ~10 min. This comes closest to that observed with smoking. As a result, the nicotine nasal spray has increased potential for prolonging nicotine dependence as compared to other nicotine replacement therapies. Local irritation is exceedingly common and can be severe, although most individuals are able to adjust to the local effects with continued use.

22. Nicotine lozenges are the most recently approved formulation of nicotine as an aid for smoking cessation [24]. It is approved for over-the-counter use in the USA and is available in 2- and 4-mg nicotine doses. The smoker is allowed to select the dose based on the time from awakening to the first cigarette, a measure of intensity of addiction. Those who use a cigarette within 30 min of awakening are advised to use the 4-mg nicotine dose. Dosing is recommended at nine lozenges per day, one every 1–2 h for up to 6 weeks, followed by tapering of daily use with discontinuation after 6 months.

23. Combined modality treatment with several formulations, while not approved by regulatory agencies, has been reported to improve efficacy. Retreatment after a failed attempt can be successful. Treatment is generally started on the quit day. Variable durations of treatment have been suggested. Nicotine replacement can be discontinued abruptly, but gradual tapering is generally preferred. Concurrent cardiac disease should always engender caution, but evidence does not demonstrate an increase in acute cardiac events with the use of nicotine replacement.

24. Bupropion is a non-nicotine drug previously approved for use as an anti-depressant .

25. It approximately doubles quit rates compared to placebo.

26. Treatment is usually initiated at 150 mg daily and increased to 150 mg twice daily after 3 days, if tolerated.

27. The quit day should be after 1 week of treatment.

28. Treatment is generally continued for 7–12 weeks.

29. Bupropion may be more effective than nicotine replacement therapy for individuals with a past history of depression.

30. It may also be useful for those concerned about weight gain since it has been shown to delay but not prevent weight gain during cessation.

31. Bupropion may cause insomnia and dry mouth. It has been reported to cause seizure in patients with known history of seizure disorder.

32. Bupropion can be combined with nicotine replacement treatment, although this may lead to worsening of hypertension.

34. Nortriptyline is also supported by two studies. Neither second-line treatment currently has an indication for smoking cessation approved by regulatory agencies, but both are approved for other indications and may be used by the experienced clinician “off label” for smoking cessation. Use of other medications for smoking cessation is not supported by currently available data.8. Harm Reduction For the smoker who is unable or unwilling to quit, there are few options. The concept that the toxic effects of smoking can be partially mitigated while smoking continues is termed harm reduction . Several strategies are possible, including partial nicotine replacement, substituting cigarettes for less harmful tobacco products and engineering the cigarette to produce less toxins. None of these approaches have been demonstrated to have clinical benefit.