Background: Most smokers want to quit smoking, however not all are able to do so. There are now new strategies to help smokers who are resistant to treatment, both psychological and pharmacological. Intensive combination pharmacotherapies have shown good long-term abstinence outcomes. Reducing the harm that is caused by smoking using nicotine replacement therapies to smoke less is a strategy that should also be considered for smokers who do not want to quit or have found it too difficult. There has been a need for specific instructions for clinicians on how to treat “difficult” smokers who may be medically and/or psychologically resistant to treatment and who do poorly with conventional smoking cessation pharmacological interventions.

Strategy: A flow chart for clinicians has been developed, based on clinical practice and published outcomes, which includes currently available medications. This flow-chart incorporates best-practice and eventual “harm-reduction” strategies where required.

Conclusion: The evidence-based, best practice flow-chart is useful for those clinicians with limited experience in dealing with the complexities of the “treatment-resistant” smoker.