Tobacco use poses a major global public health threat, resulting in over 8 million deaths annually, including approximately 1.2 million deaths due to secondhand smoke exposure. The Global Burden of Disease Study 2020 reported a total of 8.71 million worldwide deaths attributed to tobacco use, with tobacco use having the highest mortality rate among males [1].

In South Korea, as of 2020, the smoking rate among adults aged 19 and older was 20.6% (34.0% for males and 6.6% for females). In 1998, the smoking rate for adult males was 66.3%; however, by 2020, it had decreased to 34.0%, marking a substantial reduction by half. However, the declining trend has slowed since 2008, and the smoking rate among adult females has not changed considerably over the past 20 years [2]. The number of smoking-related deaths has steadily increased from approximately 44,000 in 2010 to 52,000 in 2019. Since 1998, smoking has been consistently ranked as the leading cause of death [3]. Despite the decrease in smoking rates, the recent increase in smoking-related deaths is attributed to population-level health consequences of tobacco use, which can persist for several years to decades [3].

Early detection of tobacco use increases the likelihood of intervention, ultimately leading to a higher chance of reducing tobacco use or achieving cessation. The risks associated with tobacco use are higher with a younger age of initiation, more frequent use, and longer duration of use. Therefore, the early identification of tobacco use contributes to reducing health hazards [4]. However, because of the highly addictive nature of nicotine in cigarettes, most smokers require multiple attempts to quit successfully [4]. Primary care physicians, who serve as the first point of contact in the healthcare system and provide continuous and comprehensive care, play a vital role in identifying and evaluating tobacco use and offering interventions. This review aimed to investigate the importance of early detection and evidence-based interventions in promoting tobacco cessation, particularly emphasizing the effectiveness of physician-led identification and advice as well as behavioral and pharmacological interventions.

The Lifetime Health Maintenance Program (LHMP) is a health initiative for asymptomatic individuals that employs an evidence-based approach to identify and address disease risks at an early stage [5]. This article serves as an update to the previous edition of the LHMP released in 2009 [6] and focuses on tobacco use identification and interventions for cessation.

In accordance with the earlier iteration of the LHMP and recent recommendations from the U.S. Preventive Services Task Force (USPSTF) (2021), two specific themes were chosen for investigation, including the identification of and interventions for tobacco use: Key Question 1 (Does identification and primary care physician advice enhance tobacco cessation?) and Key Question 2 (Are tobacco cessation interventions effective among the general population?). For evidential support, the LHMP for tobacco use integrated key content and literature from the USPSTF 2021 recommendations [7], which served as a developmental model. The USPSTF recommendations were formulated by conducting an overview of reviews. The methodology for the overview concentrates on the comprehensive assessment of a broad condition or problem that presents two or more potential interventions. Systematic reviews published until April 2019 were included [8]. This review focused on the cessation of conventional cigarettes, excluding considerations related to electronic cigarettes and heat-not-burn tobacco products.

Subsequent literature searches focusing on publications since 2019 were conducted for updates. Experts performed the search using PubMed, the Cochrane Database of Systematic Reviews, and PsycINFO-EBSCO search engines. A literature search was conducted through July 2023. A search for international tobacco cessation guidelines was conducted to identify recommendations via pertinent URL (uniform resource locator) sources using key words including “smoking/nicotine-addiction/tobacco-use.” The inclusion criteria were as follows: (1) studies published in either Korean or English; (2) studies focusing on adults; and (3) recommendations and guidelines developed by national and academic societies, systematic reviews, and meta-analyses. The exclusion criteria were as follows: (1) studies published in languages other than Korean or English; (2) studies concentrating on adolescents or children; (3) instances where the original text could not be accessed; and (4) guidelines authored individually and lacking representativeness. Three reviewers completed the Assessment of Multiple Systematic Reviews (AMSTAR-2) tool to rate the credibility of the systematic reviews under consideration for inclusion [9]. Each review was assigned a quality rating of “high,” “moderate,” or “low,” and reviews with low credibility were excluded (Figure 1). The quality of evidence assigned to the primary systematic review was reported. In most cases, these grades were based on the definitions provided by the Grading of Recommendations Assessment, Development, and Evaluation Working Group [10]. Where evidence grades were not provided in the primary systematic review, grading was adopted from guidelines incorporating the review as the basis for evidence.

Regarding health benefits, sufficient evidence infers that tobacco cessation reduces the risk of cancer, cardiovascular disease, chronic obstructive pulmonary disease, and asthma and that it is beneficial for reproductive health in pregnant women [4]. Additionally, substantial evidence suggests that tobacco cessation improves well-being, including a higher quality of life and reduced mortality. Moreover, it is cost-effective considering the high costs associated with tobacco dependence for individuals and society [4]. To attain optimal tobacco cessation rates, it is essential to systematically identify all smokers during any medical encounter, irrespective of the reason for their visit. The clinical assessment of tobacco use status should be documented in the medical records. Physicians should offer behavioral and pharmacological interventions for tobacco cessation to the general population. Moderate- to high-certainty evidence indicates that behavioral and pharmacological interventions benefit tobacco cessation, whether used alone or in combination.

In clinical settings, the 5As (Ask, Advise, Assess, Assist, Arrange) have been recommended as a standard approach for supporting tobacco cessation [12,38]. The 5As include all activities a primary care provider can undertake to assist a smoker within a brief 3−5-minute encounter in a primary care setting. This model guides physicians through an appropriate process to engage with patients who are prepared to quit smoking, address tobacco use, and deliver advice (Figure 2A) [14]. However, despite the effectiveness and recommendations of identification and interventions for tobacco dependence, they are not fully implemented in primary care. According to a systematic literature review of self-reported tobacco cessation counseling by primary care physicians [39], behavior corresponding to the 5A’s was reported by 65% of physicians for “Ask,” 63% for “Advise,” 36% for “Assess,” 44% for “Assist,” and 22% for “Arrange.” However, the measurement and reporting of each of these counseling practices varied across studies. Recently, “very brief advice” was introduced by the National Center for Smoking Cessation Training in the United Kingdom. Very brief advice on smoking involves asking patients about their current smoking status, advising them on the best methods for smoking cessation available to them, and helping them access evidence-based stop-smoking support (Figure 2B) [40]. This approach can be adapted in various clinical situations to prompt quitting attempts even within limited medical consultation time, as is often the case in Korea.

Primary care physicians are in the unique position of assisting tobacco users. According to World Health Organization data [38], if all primary care providers routinely inquire about tobacco use and advise users to quit, they have the potential to reach over 80% of all tobacco users annually, prompt 40% of individuals to attempt to quit, and help 2%–3% of those receiving brief advice to quit successfully. In particular, owing to the higher frequency of hospital visits in Korea compared with other Organization for Economic Cooperation and Development member countries, implementing tobacco cessation interventions by healthcare professionals can yield even greater benefits.

In addition to identification and advice, it is crucial for primary healthcare providers to offer interventions for tobacco cessation or facilitate links to tobacco cessation clinics to effectively support individuals in this endeavor. However, a substantial number of smokers perceive tobacco use as a simple personal habit rather than a chronic condition requiring treatment and often lack awareness of tobacco cessation counseling and pharmacotherapy [41]. According to recent results from the Korea National Health and Nutrition Survey, more than half of smokers have attempted to quit smoking in the past year [42]. However, only 14.7% have utilized national tobacco cessation support services, suggesting that a considerable majority rely on their willpower for cessation [42]. The success rate of self-reliant quitting attempts is merely 3%–6%, which is significantly lower than the success rates observed with behavioral and pharmaceutical interventions [43,44]. Therefore, it is crucial to disseminate information on evidence-based interventions to enhance the likelihood of successful tobacco cessation.