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Clinical guidelines

Supporting smoking cessationA guide for health professionals

Appendix 1

Summary of evidence and recommendations

  1. Evidence Smoking cessation advice from health professionals is effective in increasing quit rates. The major effect is to help motivate a quit attempt. Level I

    All health professionals can be effective in providing smoking cessation advice. Level I

    Recommendation All smokers should be offered brief advice to quit. Strength A

  2. Evidence Instituting a system designed to identify and document tobacco use almost doubles the rate of health professional intervention and results in higher rates of cessation. Level II

    Recommendation A system for identifying all smokers and documenting tobacco use should be used in every practice or healthcare service. Strength A

  3. Evidence Factors consistently associated with higher abstinence rates are high motivation, readiness to quit, moderate to high self-efficacy and supportive social networks. Level III

    Recommendation Assessment of readiness to quit is a valuable step in planning treatment. Strength C

  4. EvidenceBrief smoking cessation advice from health professionals delivered opportunistically during routine consultations has a modest effect size, but substantial potential public health benefit. Level I

    Recommendation Offer brief cessation advice in routine consultations and appointments whenever possible (at least annually). Strength A

  5. Evidence Follow-up is effective in increasing quit rates. Level I

    Recommendation All smokers attempting to quit should be offered follow-up. Strength A

  6. EvidencePharmacotherapy with nicotine replacement therapy, varenicline or bupropion is an effective aid to assisting motivated smokers to quit. Level I

    Recommendation In the absence of contraindications, pharmacotherapy should be offered to all motivated smokers who have evidence of nicotine dependence. Choice of pharmacotherapy is based on clinical suitability and patient choice. Strength A

  7. Evidence Nicotine replacement used as monotherapy increases quit rates by 50–70% at a minimum of 6 months, follow-up compared with placebo, and regardless of the setting. Level I

    There is no evidence of increased risk for use of NRT in people with stable cardiovascular disease. Level II

    There is no evidence of an association between use of nicotine patch and acute cardiac events. Level II

    There is currently a lack of evidence on the safety of NRT in pregnancy, but international guidelines recommend use of NRT in certain circumstances. Level V

    Combinations of different forms of NRT (eg. patch plus gum) are more effective than one form alone. Level I

    Recommendations NRT should be recommended to nicotine-dependent smokers. There is no significant difference in effectiveness of different forms of NRT in achieving cessation so choice of product depends on clinical and personal considerations. Strength A

    NRT is safe to use in patients with stable cardiovascular disease. Strength A

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

    Use of NRT should be considered when a pregnant woman is otherwise unable to quit. Intermittent NRT is preferred to patches (lower total daily nicotine dose). Strength C

    Combination NRT should be offered to more-dependent smokers and those are unable to remain abstinent or continue to experience withdrawal symptoms using one type of therapy. Strength A

  8. Evidence Varenicline is an efficacious smoking cessation treatment. Level I

    Recommendation Varenicline should be recommended to smokers who have been assessed as clinically suitable for this medication and should be provided in combination with counselling. Strength A

  9. Evidence Bupropion sustained release is an efficacious smoking cessation treatment. Level I

    Recommendation Bupropion sustained release should be recommended to smokers who have been assessed as clinically suitable for this medication and provided in combination with counselling. Strength A

  10. Evidence Nortriptyline is an efficacious smoking cessation treatment in people with and without a history of depression. Level I

    Recommendation Nortriptyline should only be considered as a second line agent due to its adverse effects profile. Strength B

  11. EvidenceBrief smoking cessation advice from health professionals delivered opportunistically during routine consultations has a modest effect size, 
but substantial potential public health benefit. Level I

    Recommendation Offer brief cessation advice in routine consultations whenever possible (at least annually). Strength A

  12. Evidence Telephone callback counselling services are effective in assisting cessation for smokers who are ready to quit. Level II

    Recommendation Referral to such services should be considered for this group of smokers. Strength A

  13. Evidence There is no significant effect of acupuncture or hypnotherapy in smoking cessation. Level I

    Recommendation On the evidence available, acupuncture and hypnotherapy are not recommended as aids to smoking cessation. Strength A

  14. EvidenceThere is currently a lack of evidence on the safety of pharmacotherapy in pregnancy, but international guidelines recommend use of NRT in certain circumstances. Level V

    Recommendation Use of NRT should be considered when a pregnant woman is otherwise unable to quit. Intermittent NRT is preferred to patches (lower total daily nicotine dose). Strength C

  15. Evidence Continued smoking is a major factor in the recurrence or increasing severity of smoking-related diseases. Overwhelming epidemiological evidence.

    Recommendation Smoking cessation should be a major focus of the management of people with smoking-related diseases. Strength A

  16. Evidence Introducing smoking restrictions into the home can assist quitting smoking successfully. Level IV

    Recommendation People attempting to quit should be advised to ban or restrict smoking by others in their homes. Strength C

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