Supporting smoking cessation: A guide for health professionals

Recommendations

Last revised: 06 Jan 2020

Supporting smoking cessation
A guide for health professionals 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 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
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 – Nicotine-containing e-cigarettes are not first-line treatments for smoking cessation. The strongest evidence base for efficacy and safety is for currently approved pharmacological therapies combined with behavioural support. The lack of approved nicotine-containing e-cigarettes products creates an uncertain environment for patients and clinicians, as the constituents of the vapour produced have not been tested and standardised. However, for people who have tried to achieve smoking cessation with approved pharmacotherapies but failed, but who are still motivated to quit smoking and have brought up e-cigarette usage with their healthcare practitioner, nicotine containing e-cigarettes may be a reasonable intervention to recommend. This needs to be preceded by an evidence-informed shared decision-making process, whereby the patient is aware of the following:
  • no tested and approved e-cigarette products are available
  • the long-term health effects of vaping are unknown
  • possession of nicotine-containing e-liquid without a prescription is illegal
  • in order to maximise possible benefit and minimise risk of harms, only short-term use should be recommended
  • dual use (ie with continued tobacco smoking) needs to be avoided. 
Conditional recommendation for intervention, low certainty