Even brief advice to quit offered by a physician produces abstinence rates of up to 5%-10%, which would have a significant public health impact if it were provided routinely [19, 20]. Unfortunately, surveys of smokers indicate that less then 50% receive such advice from their physicians [16, 19]. One reason why physicians hesitate to advise smoking cessation is that they be-

Table 1 The "5 A's" for smoking cessation intervention (from [2])

Ask about tobacco use

Identify and document tobacco use status for every patient at every visit

Advise to quit

In a clear, strong and personalized manner urge every tobacco user to quit

Assess willingness to make a quit attempt

Is the tobacco user willing to make a quit attempt at this time?

Assist in quit attempt

For the patient willing to make a quit attempt, use counselling and pharmacotherapy to help him or her quit

Arrange follow-up

Schedule follow-up contact, preferably within the first week after the quit date

come demoralized because they see that only few of their patients follow their advice. Although this is an understandable reaction due to an unrewarded behaviour, physicians should realize that even when their advice does not produce an immediate quit attempt by a patient, it may very well move the patient further towards the decision to quit smoking. Smoking cessation should be considered as a process of change through successive stages requiring counselling tailored to smokers' motivation to quit. Application of this model improves physicians' performance and the effect on 1-year smoking cessation [21].

Each smoker should therefore be encouraged to completely abstain from smoking and should be warned that other tobacco products, such as smokeless tobacco, are associated with significant health risks. Recently, smoking reduction has also been proposed as an alternative approach for smokers [22]. Even though such an approach seems promising, especially for heavy smokers who suffer from tobacco-related diseases such as chronic obstructive pulmonary disease, its effectiveness has still to be demonstrated. Before getting such evidence, the recommended clinical attitude should be to advise smokers to quit. Indeed, it is unlikely that a once-heavy smoker would be able to maintain light or infrequent smoking without resorting to his or her old smoking patterns. Even lighter smoking (fewer than five cigarettes per day) has been associated with elevated health risks [23]. Strategies aimed at gradual reduction of smoking, versus quitting "cold turkey", appear to lead to continued craving and prolonged withdrawal symptoms in tobacco users; and smokers compensate by taking more and/or deeper puffs per cigarette when they attempt to reduce their smoking.

Clinical practice guidelines recommend that physicians follow the "5 A's" (see Table 1) in initiating assessment and intervention with tobacco users [15].

Every patient should be asked about his/her smoking status during each visit/consultation. As the guidelines stipulate, the physician then advises the patient to quit smoking with a clear ("It is important for you to quit smoking now, and I can help you. Cutting down while you are ill is not enough.") and strong statement ("As your physician, I need you to know that quitting smoking is the most important thing you can do to protect your health now and in the future. The clinic staff and I will help you."). The advice should also be personalized for the patient, highlighting his/her particular situation. For example, the advice may be tied to the patient's health ("Your smoking is not only prolonging your cough, it is putting you also at risk for long-term respiratory problems, such as chronic bronchitis or emphysema.") or the impact smoking might have on children ("You are putting your children at risk of asthma, ear infections and other diseases by exposing them to second-hand smoke").

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