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In Reply: I agree with Dr Kaufman that physicians should work closely with smokers in the role of a coach. Coaching is, in fact, an integral part of the "5A approach" that is so highly recommended but so seldom used.^1-2 The very nature of such coaching mandates that it be tailored to the specific circumstances of the smoker. Kaufman advocates gradual reduction of tobacco use as the usual approach to helping patients quit. While this may work in some cases, the science base regarding tapering is still incomplete; as a result, tapering was not recommended in the Public Health Service’s clinical practice guideline.¹ One concern about tapering is that smokers may adjust the intensity and style of smoking to extract maximal nicotine and thus maintain desired brain nicotine levels.³ In support of Kaufman’s approach, Cinciripini et al have shown that scheduled gradual reduction is preferable to nonscheduled reduction.⁴ Clearly it . . . [Full Text of this Article]

Steven A. Schroeder, MD
schroeder@medicine.ucsf.edu
Smoking Cessation Leadership Center
University of California, San Francisco

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