Background: Evidence-based smoking cessation guidelines recommend nicotine replacement therapy (NRT), bupropion SR and varenicline as first-line therapy in combination with behavioural interventions. However, there are limited data to guide clinicians in recommending one form over another, using combinations, or matching individual smokers to particular forms.
Objective: To develop decision rules for clinicians to guide differential prescribing practices and tailoring of pharmacotherapy for smoking cessation.
Methods: A Delphi approach was used to build consensus among a panel of 37 international experts from various health disciplines. Through an iterative process, panellists responded to three rounds of questionnaires. Participants identified and ranked “best practices” used by them to tailor pharmacotherapy to aid smoking cessation. An independent panel of 10 experts provided cross-validation of findings.
Results: There was a 100% response rate to all three rounds. A high level of consensus was achieved in determining the most important priorities: (1) factors to consider in prescribing pharmacotherapy: evidence, patient preference, patient experience; (2) combinations based on: failed attempt with monotherapy, patients with breakthrough cravings, level of tobacco dependence; (3) specific combinations, main categories: (a) two or more forms of NRT, (b) bupropion + form of NRT; (4) specific combinations, subcategories: (1a) patch + gum, (1b) patch + inhaler, (1c) patch + lozenge; (2a) bupropion + patch, (2b) bupropion + gum; (5) impact of comorbidities on selection of pharmacotherapy: contraindications, specific pharmacotherapy useful for certain comorbidities, dual purpose medications; (6) frequency of monitoring determined by patient needs and type of pharmacotherapy.
Conclusion: An algorithm and guide were developed to assist clinicians in prescribing pharmacotherapy for smoking cessation. There appears to be good justification for “off-label” use such as higher doses of NRT or combination therapy in certain circumstances. This practical tool reflects best evidence to date of experts in tobacco cessation.
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Competing interests: PS has received funds from Schering Canada to provide buprenorphine training (2000); he is a paid consultant and advisory board member, Pfizer Consumer Health Care Canada, Johnson and Johnson Consumer Health Care, Pfizer Inc, Sanofi-Synthelabo, Canada, GSK, Canada; Genpharm and Prempharm, Canada, CTI.
Funding: This study was funded by the Heart and Stroke Foundation of Ontario. The funding source had no role in the writing of the paper. Grants: Health Canada, SFO, CIHR. No tobacco industry funds.
Contributors: PB, principal author, took the lead in the study design and implementation, and was responsible for writing the manuscript. PMcD helped with the study design and manuscript preparation. PS was responsible for the conception of the study and contributed to the design, implementation and manuscript preparation. Each author approved the manuscript.
Data access and responsibility: PB, the principal author, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
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