Every year, nearly half a million smokers die from smoking-related causes. (1) Fortunately, a large percentage of those deaths could be prevented through pharmacological and behavioral smoking cessation interventions. Pharmacological approaches, such as nicotine replacement therapies (NRT) and bupropion, have helped increase abstinence rates among smokers. Some individuals, however, cannot afford or do not respond well to pharmacotherapies or are strongly encouraged to avoid the use of pharmocotherapies for medical reasons (eg, pregnant smokers or smokers with medical contraindications such as post-myocardial infarction or seizure disorder). (1,3)

Behavioral interventions for smoking offer important alternatives to quitting on one's own. Even more important, behavioral and pharmacological interventions appear to have an additive effect on abstinence. (4) Thus, not only may behavioral approaches be the only viable alternative for some smokers, but the combination of behavioral and pharmacological treatments maximizes overall quit rates. Part 1 of this 3-part review (5) focused on pharmacological therapies for smoking cessation. We present evidence regarding the efficacy of behavioral treatments for both the general population and within special populations of smokers here in Part 2. We also discuss specific treatment elements that are particularly relevant to current clinical practice.

Behavioral approaches to smoking cessation have received considerable attention since the publication of the first surgeon general's report on smoking and health in 1964. (6,7) Since that time, smoking prevalence in the United States has declined dramatically and the availability of effective behavioral smoking-cessation interventions has likely contributed to this decline. (8)

The content of most behavioral interventions is based on a skills-training approach derived from social learning theory (9) and other cognitive-behavioral models of addiction. (10) Key components of social learning models typically included in behavioral smoking cessation interventions are coping skills training, self-efficacy enhancement, and modeling or observational learning. The term skills training is general in that it describes a group of interventions that emphasize the acquisition of skills critical for preventing lapses (ie, initial return to substance use following a period of abstinence) and relapses to smoking. (11)

Marlatt and Gordon's (12) relapse prevention (RP) model has been a particularly influential approach to skills training. According to the model, common cognitive, behavioral, and affective events can lead to high-risk situations that threaten abstinence. A core assumption is that individuals can prevent both lapses and progression to relapse by learning to anticipate and cope with these events, thereby increasing the odds of achieving and maintaining long-term abstinence. The RP model has considerable intuitive clinical and theoretical appeal and has generated enthusiasm within the treatment community. (13,14) Moreover, RP interventions are increasingly being exported outside the clinic to the community. (15-19) This expansion also reflects a more fundamental shift in behavioral treatments for smoking cessation from more narrowly focused clinical approaches to more broadly based public health approaches.

The clinic-based, or clinical, approach to smoking cessation emphasizes intensive, multisession interventions that target smokers who actively seek assistance in quitting. These interventions often boast the highest success rates. The public health approach casts a wider net to reach a larger number of smokers; it is usually less intensive and targets the population of smokers as a whole rather than as individuals. Despite producing lower overall quit rates than clinical interventions do, public health interventions have greater potential to reduce rates of morbidity and mortality because they reach more people. (14)

A second widely influential theoretical model intended to describe and explain processes that underlie smoking cessation is the transtheoretical model (TTM). (20) According to this model, people progress logically through a series of progressive stages of readiness to change prior to making actual behavior changes, such as quitting smoking. Prior to taking action, people first transition through stages of pre-contemplation, contemplation, and preparation. These 3 stages reflect the transition from being unmotivated to quit smoking to planning to quit in the future. At the time of an actual quit attempt, individuals enter the action stage and later move into the maintenance stage after the initial behavior change has been accomplished. The TTM lends itself well to both the clinical and public health approaches and has provided the theoretical basis for the majority of tailored cessation interventions.

Another therapeutic approach that is being increasingly applied to smoking cessation is motivational interviewing (MI). MI is a directive but client-centered therapeutic approach intended to enhance motivation for change through the exploration and resolution of ambivalence. (21,22) The emphasis of the MI approach on the use of client-centered techniques to build trust and minimize resistance is based on Rogers' (23) humanistic approach. Its focus on considering a person's readiness to change and exploration of ambivalence draws from the TTM. (20) Basic principles of MI include expressing empathy, developing discrepancy, avoiding argumentation, rolling with resistance, and supporting self-efficacy.