Int. J. Environ. Res. Public Health 2009, 6 216 which the counselor initiates client contact, enhances the benefit of telephone counseling in comparison to reactive counseling, in which the client initiates contact. Multiple sessions of telephone counseling improve quit rates [80]. Web-based cessation programs have as well been found to be effective in smoking cessation [81, 82], however, more research is needed in this area [83]. 9. Combined Therapy Pharmacotherapy and counseling should be used in conjunction to further improve the chances of successful cessation [42]. Brief counseling combined with NRT has been found to be more effective than counseling alone in a randomized study of hospital patients receiving smoking cessation interventions [84, 85]. In a randomized study of telephone counseling combined with nicotine patch therapy, individuals who received both counseling and NRT had significantly greater abstinence rates compared with those who received NRT alone [86, 87]. How effective are the smoking cessation interventions in COPD patients? As mentioned the Lung Health Study (that included asymptomatic smokers with airway obstruction) reported that at 5 years, 21.7% of special intervention participants had stopped smoking since study entry, compared with 5.4% of usual care participants [28]. A recent Crochane review revealed the effectiveness of psychosocial interventions combined with pharmacological intervention compared to no treatment in COPD patients: psychosocial interventions combined with NRT versus no treatment increased the probability of success at a 5 year follow-up by four-fold (Relative risk= 4.19, 95% CI 3.41 to 5.15) [88]. 10. Strategy for Smoking Cessation Health care providers are key to the delivery of smoking cessation messages and interventions. Health care workers should encourage all patients who smoke to quit, even those patients who come to the health care provider for unrelated reasons and do not have symptoms of COPD, evidence of airflow limitation, or other smoking related disease. The strategy for smoking cessation has utilized a mnemonic system based on the five “A’s” [4]: 1. ASK: Systematically identify all tobacco users at every visit. Write a patient's smoking status in the medical chart under vital signs. Implement a system that ensures that, for every patient at every clinic visit, tobacco-use status is queried and documented. Ask patients about their desire to quit, and reinforce their intentions. 2. ADVISE: Strongly urge all tobacco users to quit. In a clear, strong, and personalized manner, urge every tobacco user to quit. Motivate patients who are reluctant to quit. 3. ASSESS: Most individuals go through several stages (precontemplation, contemplation, recycling) before they stop smoking. Determine willingness to make a quit attempt. Ask every tobacco user if he or she is willing to make a quit attempt at this time. 4. ASSIST: Aid the patient in quitting. Help the patient with a quit plan; help motivated smokers set a quit date. Provide practical counseling; provide, if available, intra-treatment social support; six first-line pharmacotherapies for tobacco dependence— bupropion SR, varenicline,