Challenges & best practices in smoking cessation: global experiences

September 28, 2022

Smoking is an addictive behaviour and quitting without assistance is very hard. Smoking cessation clinics can help, but it is not always straightforward how to develop and sustain a comprehensive clinic, and success rates differ enormously amongst clinics. Sharing experiences and best practices is an important means to improve smoking cessation clinics effectiveness.

Experienced experts in smoking cessation participated in a panel discussion moderated by Dr. Fares Mili, where they focused on strategies that have shown strong or promising evidence of effectiveness and can provide valuable insights or offer recommendations and evidence for essential components of effective programs for helping people quit tobacco use.

Smoking has a truly devastating effect on cardiovascular health, Dr. Kallirrhoe Kourea, cardiologist, said. Our smoking cessation clinic offers consultation and the right medication to help patients stop smoking, as well as the opportunity and empowerment to participate to the comprehensive smoking cessation programs operated in our open day setting. Additionally, since passive smoking is also a significant risk factor for cardiovascular disease, we work also with the families to eliminate passive smoking and to elevate the success of our consultation. Unfortunately, she pointed out, despite our efforts and the fact that almost all cardiovascular patients declare their will to quit smoking after a heart attack, relapses are very often―six months after their discharge, nearly 85% of patients are regular smokers.

Relapse is a huge problem that should be addressed, Dr. Michael G. Toumbis agreed. Pulmonologists face the same problem, he explained; despite the consultation and the very effective medications our clinic offers to patients, at the end of the year 60-70% of our patients have relapsed to smoking. For that reason, we started taking into account the addiction parameter; we follow up with our patients―every two weeks ―to see if they face any problems and ask them to come back if they have already relapsed. In order to increase our success, we use a behavioural approach, and we educate our patients to recognize and manage the risk factors for relapse. Thanks to this educational strategy, we have seen a reduction of relapses in our clinic patients, Dr. Toumbis said. The key point is the smoker’s behaviour, he concluded, since nicotine withdrawal symptoms can be managed with the available medications.

Patients with mental disorders are particularly vulnerable to smoking, Dr. Uta Ouali said, and the prevalence of smoking in this population is extremely high. As we all know, it is very hard to persuade mentally ill patients to stop smoking, she continued, but in our department the situation has been improved, since we succeeded to convince them to smoke only in the smoking rooms, and not in the whole department; we also started motivation interviews for smoking cessation with our patients. We use cognitive behavioural therapy techniques, Dr. Ouali explained; we try to identify together with our patients the smoking triggers―the situations that lead them to relapse or cravings―and we teach them skills and strategies to cope with cravings. Unfortunately, she added, relapse is part of the addiction, and smoking cessation success rates in these patients are quite low, since cravings often lead to relapse. Alternative to cigarettes products, she concluded, could be a very useful tool for reducing the harm caused by smoking in these extremely hard to quit patients.


Answering a question Dr. Mili asked about nicotine replacement therapies, Dr. Toumbis said that medications are separated into two categories, the “relievers”, which include nicotine replacement therapies, and the “controllers”. For the management of relapses, he explained, we suggest the use of inhalers or sprays, and pastilles, but it depends on the patient; if a person has teeth problems, then we prefer to give him a nasal or oral spray. If we succeed to manage the relapse, then we procced to the other category, the “controllers”, such as varenicline, he concluded.

The first question asked by all patients who are willing to quit, Dr. Kourea said, is what are their options instead of combustible cigarettes. To her opinion it is better not to give patients the choice of a replacement product from the beginning, but to start with medications that will allow them to quit nicotine in any form. Of course, when patients fail to quit, we have to inform them about harm reduction, she concluded.

Practitioners and addictologists use in fact very different approaches, commented Dr. Mili. Addictologists see smokers as addicted people and they work hard to give them the confidence to be self-engaged in quitting smoking; to make them feel capable that they can succeed to change their behaviour. For that reason, they offer smokers all the possibilities and they inform them about the risks of every option, so that each will choose the one that they prefer.

Self-confidence and self-esteem are a general problem in people who use any kind of product and wish to stop, Dr. Ouali agreed; to succeed, you must believe that you have the strength to do it.

According to Cochrane, the behavioural approach is not effective in the prevention of relapses, Dr Toumbis said and expressed his disagreement to this statement. In his opinion it is not understandable, since change of the patient’s behaviour is a method that can stop relapse. Also, he added, since we see that the 3-month pharmacotherapy approach is quite insufficient to prevent relapses, maybe we have to prolong the therapy duration for smokers who fail to quit.