Treating Tobacco Use and Dependence HPB-MOH Clinical Practice Guidelines 1/2013 Academy of Medicine, College of Family Physicians, Ministry of Health, Singapore Singapore Singapore Singapore Armed Forces Pharmaceutical Society Singapore Dental Medical Corps of Singapore Association Singapore Medical Singapore Nursing Singapore Psychological Association Association Society May 2013 Levels of evidence and grades of recommendation Levels of evidence Level Type of Evidence 1++ High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias. 1+ Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias. 1- Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias. 2++ High quality systematic reviews of case control or cohort studies. High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal. 2+ Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal. 2- Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal. 3 Non-analytic studies, e.g. case reports, case series 4 Expert opinion Grades of recommendation Grade Recommendation A At least one meta-analysis, systematic review of RCTs, or RCT rated as 1++ and directly applicable to the target population; or A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results. B A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 1++ or 1+ C A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 2++ D Evidence level 3 or 4; or Extrapolated evidence from studies rated as 2+ GPP Recommended best practice based on the clinical experience of the guideline (Good Practice development group. Points) CLINICAL PRACTICE GUIDELINES Treating Tobacco Use and Dependence HPB-MOH Clinical Practice Guidelines 1/2013 Published by Health Promotion Board, Singapore 3 Second Hospital Avenue Singapore 168937 Copyright © 2013 by Health Promotion Board, Singapore ISBN 978-981-07-6314-5 Available on the Health Promotion Board website: http://www.hpb.gov.sg/cpg-smoking-cessation and Ministry of Health website: http://www.moh.gov.sg/cpg Statement of Intent These guidelines are not intended to serve as a standard of medical care. Standards of medical care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge advances and patterns of care evolve. The contents of this publication are guidelines to clinical practice, based on the best available evidence at the time of development. Adherence to these guidelines may not ensure a successful outcome in every case. These guidelines should neither be construed as including all proper methods of care, nor exclude other acceptable methods of care. Each physician is ultimately responsible for the management of his/her unique patient, in the light of the clinical data presented by the patient and the diagnostic and treatment options available. Contents Page Executive Summary and Key Guideline Recommendations 1 1 Introduction 6 2 Suggested Framework for Treating Tobacco Use and Dependence 13 3 Tobacco Use and Dependence Treatment Approaches: 19 Non-pharmacological Interventions 4 Tobacco Use and Dependence Treatment Approaches: 27 Pharmacotherapy Interventions 5 Treatment and Management of Specific Populations a. Hospitalised & Pre-operative Patients 33 b. Adolescents 36 c. Pregnant Women 37 d. Patients with Psychiatric Disorders 39 e. Patients with Cardiovascular Disease 40 f. Patients with Co-morbid Alcohol Abuse 42 6 Clinical Quality Improvement 43 7 Cost-effectiveness of Tobacco Use and Dependence Interventions 44 Annexes a. Annex A: Drug Dosages and Adverse Effects 45 b. Annex B: List of Tobacco Use and Dependence 48 Treatment Services References 59 Self-assessment (MCQs) 68 Workgroup Members 70 Acknowledgment 72 List of Endorsing Agencies 73 Foreword Globally, the use of tobacco continues to cause significant harm to human health and is a leading cause of preventable death. Tobacco use increases the risk of diseases such as lung cancer, chronic obstructive airway disease and cardiovascular disease, which are key contributors to the burden of disease in Singapore. Since the 1970s, Singapore has been active in combating tobacco use and has implemented policies on tobacco control as part of the National Tobacco Control Programme. In our latest national health survey in 2010, we achieved a smoking prevalence of 14.3% – one of the world’s lowest. This is a testament to our efforts and strategies towards tobacco control. In our continuing battle against tobacco use, health professionals play a unique role in encouraging Singaporeans to live a smoke-free lifestyle. These revised guidelines aim to equip health professionals with current scientific evidence and knowledge on interventions to help smokers quit tobacco use. I hope these guidelines will assist all health professionals to deliver effective interventions to help tobacco users become tobacco-free. PROFESSOR K SATKU DIRECTOR OF MEDICAL SERVICES Foreword Over the years, the Health Promotion Board (HPB) has established comprehensive tobacco control measures together with the Ministry of Health to promote smoke- free lifestyle among Singaporeans. The multi-pronged strategy consists of four main areas, namely taxation and legislation, public education, collaborative partnerships and capacity building, and provision of smoking cessation services. The development of Clinical Practice Guidelines (CPG) is a key strategy introduced to build the capacity of health professionals to guide their practice. The first CPG on smoking cessation was published in 2002 and the current CPG updates the evidence and recommendations for non-pharmacological and pharmacological interventions. It also focuses on specific populations that may require additional considerations (for example, pre-operative patients, adolescents, and pregnant women). A panel of health experts was convened to develop this CPG and I would like to take this opportunity to thank the CPG workgroup for their valuable contribution. In addition to medical doctors, these guidelines were produced with allied health professionals like pharmacists, nurses, and counsellors in mind. We hope that the guidelines will prove useful for all in their daily practice. MR ZEE YOONG KANG CEO, HEALTH PROMOTION BOARD Executive Summary and Key Guideline Recommendations Executive Summary Treating tobacco use and dependence is an important public health goal that will improve the quality of care and the health of all Singaporeans. The primary goal of the clinical practice guidelines is to reduce the prevalence of tobacco use and dependence through cessation treatments. There is strong evidence to show that tobacco use causes many chronic diseases such as ischaemic heart disease, stroke, multiple cancers, respiratory diseases and complications during pregnancy, that affect the population and the health delivery system. This updated Clinical Practice Guidelines on Treating Tobacco Use and Dependence is developed to act as a resource and guide for all health professionals to identify and screen tobacco users, to deliver evidence-based tobacco use cessation treatments for patients and specific population groups who use tobacco. Specific populations include hospitalised and pre-operative patients, adolescents, pregnant women, and patients with psychiatric disorders, cardiovascular diseases or alcohol abuse disorder. The guidelines are developed based on comprehensive literature reviews on recent evidence on tobacco use and dependence treatments. A suggested framework for treating tobacco use and dependence has also been developed to provide a simple step-by-step approach that all health professionals can use. The important message to every health professional is to make treating tobacco use and dependence a priority during the patient’s visit. It is important that you ask your patient two key questions: a) “Do you smoke?” b) “Do you want to quit?” – followed by the use of the recommendations as listed in the various sections of the guidelines. 1 Key Guideline Recommendations Details of recommendations can be found in the main text at the pages indicated. Non-pharmacological interventions Different forms of person-to-person behavioural support including individual, A group and telephone support may be used as interventions to treat tobacco use and dependence. (pg 20) Grade A, Level 1+ If resources are available, telephone support provided separately or as part of A tobacco use and cessation intervention, should be offered to smokers undergoing a quit attempt. (pg 20) Grade A, Level 1+ Where feasible, health professionals should provide multiple behavioural A support sessions to treat tobacco use and dependence; with each session lasting more than 10 minutes. (pg 21) Grade A, Level 1+ Behavioural interventions such as motivational interviewing or cognitive B behavioural therapy may be used to help tobacco users