Recommendations

Recommendation 1 - All patients who smoke should be offered brief advice to quit smoking

Strong recommendation, high certainty

Recommendation 2 – A system for identifying all people who smoke and documenting tobacco use should be used in every practice or healthcare service.

Strong recommendation, high certainty

Recommendation 3 – Offer brief cessation advice in routine consultations and appointments, whenever possible.

Strong recommendation, high certainty

Recommendation 4 – Offer follow-up to all people who are attempting to quit smoking.

Strong recommendation, high certainty

Recommendation 5 – In the absence of contraindications, pharmacotherapy (nicotine replacement therapy, varenicline or bupropion) is an effective aid when accompanied by behavioural support, and should be recommended to all people who smoke who have evidence of nicotine dependence. Choice of pharmacotherapy is based on efficacy, clinical suitability and patient preference.

Strong recommendation, high certainty

Recommendation 6 – Combination nicotine replacement therapy (NRT) (ie patch and oral form) accompanied by behavioural support is more effective than NRT monotherapy accompanied by behavioural support, and should be recommended to people who smoke who have evidence of nicotine dependence.

Strong recommendation, moderate certainty

Recommendation 7 – For people who have stopped smoking at the end of a standard course of nicotine replacement therapy (NRT), clinicians may consider recommending an additional course of NRT to reduce relapse.

Conditional recommendation for the intervention, low certainty

Recommendation 8 –
a) Nicotine replacement therapy (NRT) is safe to use in patients with stable cardiovascular disease.

Strong recommendation, high certainty

b) NRT should be used with caution in patients who have had a recent myocardial infarction, unstable angina, severe arrhythmias or recent cerebrovascular events.

Strong recommendation, moderate certainty

Recommendation 9 – For women who are pregnant and unable to quit smoking with behavioural support alone, clinicians might recommend nicotine replacement therapy (NRT), compared with no NRT. Behavioural support and monitoring should also be provided.

Conditional recommendation for the intervention, low certainty

Recommendation 10 – Varenicline should be recommended to people who smoke and who have been assessed as clinically suitable for this medication; it should be provided in combination with behavioural support.

Strong recommendation, high certainty

Recommendation 11 – For people who have abstained from smoking after a standard course of varenicline in combination with behavioural support, clinicians may consider a further course of varenicline to reduce relapse.

Conditional recommendation for the intervention, low certainty

Recommendation 12 – For people who are attempting to quit smoking using varenicline accompanied by behavioural support, clinicians might recommend the use of varenicline in combination with nicotine replacement therapy, compared with varenicline alone.

Conditional recommendation for the intervention, moderate certainty

Recommendation 13 – Bupropion sustained release should be recommended to people who have been assessed as clinically suitable for this medication; it should be provided in combination with behavioural support. Bupropion is less effective than either varenicline or combination nicotine replacement therapy.

Strong recommendation, high certainty

Recommendation 14 – Nortriptyline should be considered as a second-line pharmacotherapy agent because of its adverse effects profile.

Strong recommendation, moderate certainty

Recommendation 15 – For people who have tried to achieve smoking cessation with first-line therapy (combination of behavioural support and TGA-approved pharmacotherapy) but failed and are still motivated to quit smoking, NVPs may be a reasonable intervention to recommend along with behavioural support. However, this needs to be preceded by an evidence-informed shared-decision making process, whereby the patient is aware of the following caveats:

• Due to the lack of available evidence, the long-term health effects of NVPs are unknown.
• NVPs are not registered therapeutic goods in Australia and therefore their safety, efficacy and quality have not been established.
• There is a lack of uniformity in vaping devices and NVPs, which increases the uncertainties associated with their use.
• To maximise possible benefit and minimise risk of harms, dual use should be avoided and long-term use should be minimised.
• It is important for the patient to return for regular review and monitoring.

Conditional recommendation for intervention, low certainty

Recommendation 3 – Offer brief cessation advice in routine consultations and appointments, whenever possible.

Strong recommendation, high certainty

Recommendation 16 – Referral to telephone call-back counselling services should be offered to all people who smoke.

Strong recommendation, high certainty