Context: Evidence-based smoking cessation guidelines recommend nicotine replacement therapy, bupropion and varenicline as first line therapy in combination with behavioral interventions. However, there is 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.
Design: A Delphi approach was used to build consensus among a panel of 37 international experts from various health disciplines. Through an iterative process, panelists 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: 1) two or more forms of NRT, 2) 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, 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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