A meta-analysis of 20 pros- pective cohort studies found a 30% reduction in RR of mortality for those who quit compared with those who continued smoking, and a similar reduction was noted in nonfatal MIs.650 Some studies suggest that most of the reduction in risk occurs within 2 or 3 years of quitting.660,661 The most effective smoking-cessation therapies include both nonpharmacological and medical interventions. Physi- cian advice has a significant effect on quit rates.662 Self-help programs, telephone counseling, behavioral therapy, and perhaps exercise programs also have modest efficacy in increasing cessation rates.663 667 Nicotine-replacement ther- apy (gum, patch, tablet, lozenge, or nasal spray) approxi- mately doubles the chances of success of a quit attempt.668 Similar efficacy has been demonstrated with bupropion sustained-release.669 Varenicline, a partial agonist of the a4b2 nicotinic receptor, is the most recent FDA-approved agent for smoking cessation and compares favorably with placebo and with bupropion in clinical trials.670,671 There have, however, been concerns about possible worsening of preexisting depression and the risk of suicide due to vareni- cline, and the FDA has issued an alert warning that serious neuropsychiatric symptoms can occur in patients taking this Physicians should approach smoking cessation by using the 6 A s framework: Ask each patient about tobacco use at every visit; Advise each smoker to quit; Assess each smoker s willingness to make a quit attempt; Assist each smoker in making a quit attempt by offering medication and referral for counseling; Arrange for follow-up; and Avoid exposure to environmental tobacco smoke. 4.4.1.7. Management of Psychological Factors Class IIa 1. It is reasonable to consider screening SIHD patients for depression and to refer or treat when indi- cated.237,239,323,457,463,674,675 (Level of Evidence: B) Class IIb 1. 