Smoking cessa- tion is associated with a rapid reduction in the risk of stroke and other cardiovascular events to a level that approaches, but does not reach, that of those who never smoked.354,360 362 Although sustained smoking cessation is difficult to achieve, effective behavioral and pharmacological treatments for nicotine dependence are available.363 365 Comprehensive reviews and recommendations for smoking cessation are pro- vided in the 2008 Surgeon General s report,363 the 2008 update from the Public Health Service,366 and the 2009 affirmation of these recommendations from the US Preventive Services Task The combination of counseling and medications is more effective than either therapy alone.367 With regard to specific pharmacotherapy, in a meta-anal- ysis current to January 2012, nicotine replacement therapy, bupropion, and varenicline were all superior to inert control medications, but varenicline was superior to each of the other active interventions in direct comparisons.368 Emerging evi- dence suggests that varenicline may be more cost-effective than nicotine replacement therapy.369 Cigarette Smoking: Summary and Gaps Cigarette smoking increases the risk of ischemic stroke and SAH, but the data on ICH are inconclusive. Epidemiological studies show a reduction in stroke risk with smoking cessation and with community-wide smoking bans. Although effective programs to facilitate smoking cessation exist, data show- ing that participation in these programs leads to a long-term reduction in stroke are lacking. Cigarette Smoking: Recommendations 1. Counseling, in combination with drug therapy using nicotine replacement, bupropion, or varenicline, is recommended for active smokers to assist in quitting smoking (Class I; Level of Evidence A). 2. Abstention from cigarette smoking is recommended for patients who have never smoked on the basis of epidemiological studies showing a consistent and overwhelming relationship between smoking and both ischemic stroke and SAH (Class I; Level of Evidence B). 