The Canadian Task Force on Preventive Health Care has released practical guidance, along with a menu of options, to help adults quit smoking tobacco.
The guideline includes evidence-based behavioral and drug therapies -- and for the first time, a natural health product, cytisine -- that can be tailored and combined to personalize treatment.
"There is a dizzying array of options for smokers who are considering quitting tobacco," guideline co-author Eddy Lang, MD, head of emergency medicine at the University of Calgary, Calgary, told Medscape Medical News. "Our recommendations highlight the importance of focusing on options that are supported by evidence and on those that...[patients] should not waste their time and money on."
Most physicians are aware of the common interventions, he said. "A surprising addition is cytisine, which works like varenicline, is effective for smoking cessation, and may be preferred by some patients.
"Importantly," he added, "we have clarified the role of e-cigarettes [electronic cigarettes] and shone a light on approaches that remain unproven (ie, hypnotherapy, St. John's wort, laser therapy, and acupuncture)."
The guideline was published on August 25 in CMAJ.
Key Recommendations
The task force commissioned systematic reviews on the benefits and harms of smoking cessation interventions, focusing on Cochrane reviews of behavioral interventions, pharmacotherapy, and other strategies, plus a systematic review of e-cigarettes.
The task force asked patients who smoke or who had recently quit smoking to help rate potential outcomes, such as success in quitting and quality of life. The guideline working group also engaged two external content experts: a physician-scientist who treats people with tobacco addiction and another physician-scientist with expertise in implementing hospital-based smoking cessation programs. Organizational interest holders also provided input into the guideline.
The guideline included the following key recommendations:
* Providers should be knowledgeable about their patients' smoking status.
* All people who smoke tobacco cigarettes should be encouraged to stop and offered one or more of the recommended smoking cessation interventions. Shared decision-making should be used to determine patients' cessation preferences.
* Behavioral interventions include primary care advice, individual or group counseling by a trained cessation counselor in person or on the telephone, text messaging interventions, and self-help materials.
* Pharmacotherapy intervention options include nicotine replacement therapy (eg, patch, gum, lozenges, inhaler, or spray, used alone or together), varenicline, bupropion, and cytisine.
* Behavioral and pharmacotherapy interventions may be combined.
* E-cigarettes should be reserved for patients who could not quit using other ways or who express a strong preference for e-cigarettes. Uncertainties to be considered include the lack of approved products with consistent formulations, the lack of long-term safety information, and the fact that e-cigarettes may not address nicotine addiction.
The task force recommends against acupuncture, hypnosis, laser therapy, electric current stimulation to the head, ear acupressure, St. John's wort, or S-adenosyl-L-methionine for smoking cessation. They also note that their recommendations do not apply to traditional or ceremonial tobacco use by Indigenous peoples.
"Quitting is hard, and getting it right the first time is rare," Lang said. "We have outlined a series of effective options that can be tailored to a patient's circumstances. This [approach] will empower motivated patients to achieve a cigarette-free life, even if it requires well more than one attempt."
The limitations of the guideline included its reliance on Cochrane systematic reviews for interventions and limited diversity in the patient-engagement activities, which potentially reduced their generalizability to the broader population, according to the task force.
'Only Effective if Utilized'
In a related editorial, Matthew B. Stanbrook, MD, PhD, respirologist at Toronto Western Hospital, Toronto, and deputy editor of CMAJ, wrote, "Every time clinicians encounter a person who smokes tobacco, they have an important opportunity to act by advising their patient to quit smoking... [D]oing so confers a small but significant increase in the likelihood that a patient will quit."
Commenting on the guideline for Medscape Medical News, Paxton Bach, MD, clinical assistant professor of medicine at the University of British Columbia and co-medical director for the British Columbia Centre on Substance Use in Vancouver, said, "The new guidelines are a timely update and a helpful reminder of the importance of discussing smoking cessation with all patients on a routine basis." Bach did not participate in the guideline task force.
"The recommendation on providers being expected to be knowledgeable about their patients' smoking status is an important addition, highlighting this discussion as a fundamental part of routine primary care," he said. "The inclusion of public engagement efforts to help develop clinical outcomes and key messages that are important to the public is a unique strength of these guidelines."
The guidelines will also help ensure that effective treatments for smoking cessation are widely accessible, Bach said. "It is imperative that barriers to access, including things such as medication coverage, be addressed to maximize the availability and impact of effective interventions."
Most of the tools are already well known, he acknowledged, "but up-to-date guidelines offering a succinct summary of the evidence are welcome. Some of the included treatments, such as cytisine, and newer harm-reduction tools, such as e-cigarettes, are more novel and will be of great interest to primary care providers, who will welcome new tools to address the harms of tobacco use in primary care.
"Smoking cessation tools are only effective if they are utilized," he added. "These guidelines are a call to action for all Canadian healthcare providers to ensure that we are being proactive in addressing one of the leading causes of preventable disease in Canada."
Funding for the Canadian Task Force on Preventive Health Care is provided by the Public Health Agency of Canada. The views expressed in the article are those of the task force and do not necessarily represent those of the Public Health Agency of Canada. Lang and Bach reported having no relevant financial relationships. Stanbrook is a staff member of CMAJ.
Marilynn Larkin, MA, is an award-winning medical writer and editor whose work has appeared in numerous publications, including Medscape Medical News and its sister publication MDedge, The Lancet (where she was a contributing editor), and Reuters Health.