National guidelines for smoking cessation in primary care: A literature review and evidence analysis

Abstract

Smoking cessation support in primary care:
UNIVERSAL GUIDELINES SOUGHT: An international team call for a universal guideline for primary-care practitioners who help patients to stop smoking. Although many nations have such guidelines, no studies have examined whether these guidelines are consistent with the current evidence. Marjolein Verbiest at the National Institute for Health Innovation, The University of Auckland, New Zealand, and co-workers of the International Primary Care Respiratory Group and the National Centre for Smoking Cessation and Training reviewed, evaluated and compared 26 national guidelines. Almost all guidelines place importance on identifying smokers, advising them to quit and providing behavioural and medication-based support. However, there were discrepancies in the support offered, which could be due to different interpretations of evidence, costs of medication and cultural differences. The authors offer a checklist for primary care that can inform future universal guidelines suitable for primary care.

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ARTICLE OPEN
National guidelines for smoking cessation in primary care: a
literature review and evidence analysis
Marjolein Verbiest
1,2
, Evelyn Brakema
3
, Rianne van der Kleij
3
, Kate Sheals
4
, Georgia Allistone
5
, Siân Williams
6
, Andy McEwen
4
and
Niels Chavannes
3
National guidelines for smoking cessation in primary care can be effective in improving clinical practice. This study assessed which
parties are involved in the development of such guidelines worldwide, which national guidelines address primary care, what
recommendations are made for primary care settings, and how these recommendations correlate with each other and with current
evidence. We identified national guidelines using an online resource. Only the most recent version of a guideline was included. If an
English version was not available, we requested a translation or summary of the recommendations from the authors. Two
researchers independently extracted data on funding sources, development methodologies, involved parties, and
recommendations made within the guidelines. These recommendations were categorised using the pile-sort method. Each
recommendation was cross-checked with the latest evidence and was awarded an evidence-rating. We identified 43 guidelines
from 39 countries and after exclusion, we analysed 26 guidelines (22 targeting general population, 4 targeted subpopulations).
Twelve categories of recommendations for primary care were identified. There was almost universal agreement regarding the need
to identify smokers, advice them to quit and offer behavioural and pharmacological quit smoking support. Discrepancies were
greatest for specific recommendations regarding behavioural and pharmacological support, which are likely to be due to different
interpretations of evidence and/or differences in contextual health environments. Based on these findings, we developed a
universal checklist of guideline recommendations as a practice tool for primary care professionals and future guideline developers.
npj Primary Care Respiratory Medicine (2017) 27:2 ; doi:10.1038/s41533-016-0004-8
INTRODUCTION
Tobacco smoking is a major preventable risk factor for the
development of non-communicable diseases, including cancers,
cardiovascular and respiratory diseases.
1
Consequently, 12% of all
adult deaths worldwide are attributable to tobacco use.
2
Overall,
among those aged 15 years and over, the worldwide prevalence
of tobacco use is 22%. Smoking prevalence is, however,
substantially higher among males (36%) than females (8%) (ref.
3), with large variation across countries ranging between 22%
(Brazil) and 60.6% (Russia) among males, and between 0.6%
(Egypt) and 28.7% (Bangladesh) among females.
3,4
Long-term smoking cessation substantially reduces health risks
5,6
and leads to a decrease in the risk of early mortality.
7
Nationally
implemented services for smoking cessation support, such as face-
to-face support
8
and quit lines,
9
have been found to be effective in
helping smokers to quit. Easy access to such smoking cessation
treatment and support has also shown to increase quit rates.
10
In many countries, smokers are most often identified, advised
and offered quit support in a primary care setting.
11
In countries
with established specialist cessation services (e.g., face-to-face
services and/or quit lines), general practice is the optimum
environment for the identification and referral of smokers to take
place. For example, in the UK almost 300 million smoking cessation
consultations a year and around 90% of all National Health Service
contacts take place in a general practice setting.
12
Evidence for the
effectiveness of interventions in this setting is well established
13
;
rates of smoking abstinence are increased when health profes-
sionals identify smokers, prompt quit attempts,
13
and provide
assistance to quit smoking, including pharmacotherapy.
14,15
Guidelines in which this evidence is communicated to health
professionals can be effective in improving clinical practice,
16
although the effects depend upon factors such as guideline
quality, context and professional experience.
17–19
Guidelines also
offer an opportunity for raising the profile of smoking cessation
and facilitate the implementation of the WHO Framework
Convention on Tobacco Control.
20
This study aims to assess the nature and extent of the current
national guidelines available for the treatment of tobacco
dependence in primary care. As such, the objective of the study
is threefold and includes an assessment of: (1) the parties involved
in the development of these guidelines, (2) the recommendations
made within these guidelines for primary care and (3) how these
recommendations correlate with each other (consistency) and
with the state-of-the-art evidence of what is effective (validity).
RESULTS
Guideline inclusion
We identified a total of 43 guidelines from 39 countries. After
initial review, we excluded three guidelines. Reasons for exclusion
Received: 20 May 2016 Revised: 30 October 2016 Accepted: 25 November 2016
1
National Institute for Health Innovation, School of Population Health, The University of Auckland, Auckland, New Zealand;
2
Centre for Longitudinal Research - He Ara ki Mua,
School of Population Health, The University of Auckland, Auckland, New Zealand;
3
Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, The
Netherlands;
4
Department of Clinical, Educational and Health Psychology, University College London, London, UK;
5
National Centre for Smoking Cessation and Training, London,
UK and
6
International Primary Care Respiratory Group (IPCRG), Westhill, Scotland, UK
Correspondence: Marjolein Verbiest (m.verbiest@auckland.ac.nz)
www.nature.com/npjpcrm
Published in partnership with Primary Care Respiratory Society UK

were that they either merely presented minimum specifications
for a national smoking cessation service (Northern Ireland and
Spain), or they focused on treatment of asthma and chronic
obstructive pulmonary disease (COPD) other than on smoking
cessation (Greece). Of the remaining 40 guidelines, only 16
guidelines were initially available in English. Authors of another 10
guidelines were willing to complete our coding framework on the
key recommendations made within the guidelines, resulting in a
total of 26 guidelines that were fully assessed for this review
(Fig. 1). Table 1provides a detailed overview of the final inclusion.
Parties involved in guideline development
Most guidelines were produced/commissioned by governmental
organisations, followed by medical societies, multiple organisa-
tions, research networks and research centers. General practi-
tioners (GPs) were involved in the development of the majority of
the included guidelines (19/26); in six guidelines the lead-author
of the guideline was a GP. In three guidelines, the development
was led by an association of GPs and in ten guidelines at least one
GP was involved in the development among many other authors.
Only four guidelines were developed without any involvements of
GPs and for the remaining three guidelines it was not possible to
identify the profession of the authors and, therefore, GP
involvement remains unclear (Japan, India, South Africa).
Guideline recommendations for primary care
The majority of the included guidelines focused on smoking
cessation in the general population (n= 22), two focused
specifically on smoking cessation during pregnancy (France and
Canada), one on smoking cessation among COPD patients
(Germany) and one on smoking cessation among perioperative
patients (France). Table 1presents brief details on the funding
sources and methodologies used for the development of these
guidelines. A list of references for each of the guidelines can be
found in Appendix A.
Search results
Online search results
•Countries n=37/guidelines n=40
Consultation colleagues
•Countries n=2/guidelines n=3
Exclusion
Lack of focus primary care
•Countries n=2/guidelines n=2
Smoking only part of guideline
•Countries n=1/guidelines n=1
Inclusion
Countries n=36
Guidelines n=40
Exclusion
No English-language version or
completed coding framework on key
recommendations made
•Countries n=14/guidelines n=14
Analysis
Countries n=22
Guidelines n=26
Fig. 1 Flowchart of the study
Guidelines for smoking cessation in primary care
M Verbiest et al
2
npj Primary Care Respiratory Medicine (2017) 2 Published in partnership with Primary Care Respiratory Society UK

Table 1. Details of identified national guidelines for smoking cessation in primary care
Country Income region Guideline focus Most recent publication Lead organisation Author(s) Funding source Development methodology
Argentina Upper middle General 2011 Ministry of Health,
National Quality
Assurance Program in
Health Care
Casetta, B. and
Videla, A
None reported Systematic literature review
(guidelines and meta-analysis).
Levels of evidence assigned to
recommendations. Reviewed by
expert panel.
Australia High General 2011 Royal Australian College
of General Practitioners
Zwart et al. Private Not described. Levels of evidence
and strength of recommendation
categories assigned to
recommendations
Canada High General 2011 The Canadian Action
Network for the
Advancement,
Dissemination and
Adoption of Practice-
informed Tobacco
Treatment (CAN-
ADAPPT); Centre for
Addiction and Mental
Health
Selby et al. Drugs and Tobacco Initiative,
Health Canada
Review and appraisal of existing
English-language clinical practice
guidelines and systematic search
for evidence. Levels of evidence
assigned to recommendations
Pregnancy 2010 CAN-ADAPPT; Centre for
Addiction and Mental
Health
Ordean, A. Drugs and Tobacco Initiative,
Health Canada
Review and appraisal of existing
English-language clinical practice
guidelines and systematic search
for evidence. Evidence levels
assigned to each recommendation
Chile High General 2003 Ministry of Health, Pan
American Health
Organisation
Marisol Acuña None reported Not reported
Czech Republic High General 2005 —Králíková, E. None reported Not reported
Denmark High General 2011 Danish Health and
Medicines Authority
Pisinger et al. Ministry of Health Based on thorough review of
available guidelines from England,
US, Canada, Australia and New
Zealand and Cochrane reviews on
smoking cessation. Tailored for
Danish conditions. Written by
tobacco research expert in
cooperation with a general
practitioner, a representative from
the municipalities and a
representative from smoking
cessation counsellors network
France High General 2007 Health authority Scemama et al. Public funds Document review, expert panel
Pregnancy 2004 Alliance against tobacco Delcroix et al. State Insurance Fund for Free-
lance
Professionals, Nord-Pas-de-
Calais Regional
Council, Health Protection
Branch, National
League against Cancer,
Presentation of evidence by experts
to a jury responsible for drafting
the guidelines
Guidelines for smoking cessation in primary care
M Verbiest et al
3
Published in partnership with Primary Care Respiratory Society UK npj Primary Care Respiratory Medicine (2017) 2

Table 1 continued
Country Income region Guideline focus Most recent publication Lead organisation Author(s) Funding source Development methodology
National Mutual Insurance
Company of Hospital Staff,
Aventis; EOLYS; FIM;
GlaxoSmithKline; Novartis
Santé Familiale; Pfizer
Pierre Fabre Santé; Roche
Nicholas
Peri-operative 2005 French Association of
Surgery
Cohendy et al. Ministère de la Santé DGS;
Pfizer; AltanaPharma;
Sanofi-Aventis; Glaxo
SmithKline; Novartis; Pierre
Fabre Santé
Literature review
Germany High General 2004 Association of the
Scientific Medical
Societies in Germany
(AWMF)
Batra et al. Donations: DG Sucht and
DGPPN, Support: Central
Institute of Mental Health,
department Addiction
Research and Addiction
Medicine in Tübingen. No
third-parties or private
companies
Systematic literature and critical
appraisal. Level of evidence
assigned to recommendations.
Afterwards reviewed by an expert
panel
COPD 2008 German Society for
Pneumology and
Respiratory Medicine
Andreas et al. None reported Literature review and review by
expert panel
India Lower-middle General 2011 National Tobacco
Control Programme,
Directorate General of
Health Services, Ministry
of Health and Family
Welfare, Government of
India
Rajkumar et al. None reported Not described
Japan High General 2010 Japanese Circulation
Society
Japanese Circulation
Society Joint Working
Group
None reported Not described. Levels of evidence
assigned to recommendations
Jordan Upper-middle General 2014 King Hussein Cancer
Foundation, King
Hussein Cancer Center
Hawari et al. None reported Literature review
Kyrgyzstan Lower-middle General 2004 Ministry of Healthcare of
Kyrgyz Republic
Brikulov et al. None reported Not described
Malaysia Upper-middle General 2003 Ministry of Health
Malaysia
Aziahbt Mahayiddin
et al.
None reported Adaptation of US (2000), New
Zealand (2001) and American
Psychiatric Association (1996)
guidelines with incorporation of a
systematic literature review. Levels
of evidence assigned to
recommendations.
Netherlands High General 2007 Dutch Association of
General Practitioners
Chavannes et al. Stop Smoking Partnership Alignment with the
multidisciplinary guideline
regarding tobacco addiction
developed by the Dutch Institite for
Guidelines for smoking cessation in primary care
M Verbiest et al
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npj Primary Care Respiratory Medicine (2017) 2 Published in partnership with Primary Care Respiratory Society UK

Table 1 continued
Country Income region Guideline focus Most recent publication Lead organisation Author(s) Funding source Development methodology
Healthcare Improvement and
adapted for use in general practice
(2004)
New Zealand High General 2014 Clinical Trials Research
Unit (now: the National
Institute for Health
Innovation [NIHI]), the
University of Auckland
McRobbie et al. Ministry of Health Literature review undertaken by a
consortium. Guidelines developed
in accordance with the AGREE tool.
Levels of evidence assigned to
recommendations according to the
New Zealand Guidelines Group.
Norway High General 2004 Health and Social Affairs
Agency
Huseby et al. None reported Not described
Portugal High General 2008 Centre for Evidence
Based Medicine,
University of Lisbon
School of Medicine
Reis et al. Pfizer (unrestricted grant) Not described
Scotland High General 2004 Health Scotland, Action
on Smoking and Health
Scotland
West et al. None reported Not described
South Africa Upper-middle General 2013 South African Thoracic
Society
van Zyl-Smit et al. Pfizer Review and appraisal of existing
international clinical practice
guidelines, applying them specific
national needs. Evidence assigned
to each recommendation
Sweden High General 2011 The National Board of
Health and Welfare
Axelsen et al. None reported
UK High General 2000 Health Education
Authority
West et al. Health Education Authority;
Health Development Agency
Based on meta-analytic reviews and
other relevant evidence. Levels of
evidence assigned to
recommendations
USA High General 2008 U.S. Department of
Health and Human
Services
Fiore et al. Agency for Healthcare
Research and Quality; Centers
for Disease Control and
Prevention; National Cancer
Institute; National Heart, Lung,
and Blood Institute; National
Institute on Drug Abuse;
American Legacy Foundation;
Robert Wood Johnson
Foundation; University of
Wisconsin School of Medicine;
Public Health’s Center for
Tobacco Research and
Intervention
Systematic literature review. Levels
of evidence assigned to
recommendations
Guidelines for smoking cessation in primary care
M Verbiest et al
5
Published in partnership with Primary Care Respiratory Society UK npj Primary Care Respiratory Medicine (2017) 2

General population. With regard to guidelines that focus on the
treatment of tobacco dependence in the general population
(n= 22), we were able to categorise recommendations into 12
intervention types recommended for primary care:
●Each patient’s smoking status should be identified and
recorded (20/22);
●All smokers should be given brief advice to stop (20/22);
●Smokers’motivation to quit should be assessed (17/22);
●All smokers wishing to stop should be offered assistance
(22/22);
●All smokers wishing to stop should be offered/encouraged to
use pharmacotherapy (22/22);
●All smokers wishing to stop should be offered behavioural
support (19/22);
●Self-help materials should be offered as part of tobacco
dependence treatment (12/22);
●Smoking abstinence should be evaluated following treatment
(5/22);
●The ‘5A’s Framework’should be used to guide brief
intervention (16/22);
●The ‘ABC Framework’should be used to guide brief
intervention (3/22);
●Health-care professionals should be trained in delivering
tobacco dependence treatment (13/22);
●Hypnotherapy and acupuncture are not effective smoking
cessation treatments (6/22).
Table 2provides an overview of these recommendations put
forth in each national guideline. Full details on the types of
pharmacotherapy recommended in each national guideline are
presented in Table 3.
Subpopulations. The majority of the guidelines include sections
concerning the treatment of tobacco dependence among specific
subpopulations (e.g., pregnant women, children and adolescents,
COPD patients). Moreover, several countries developed specific
guidelines for the treatment of tobacco dependence among such
subpopulations. The most frequently mentioned recommenda-
tions across guidelines are described in this section (details on
recommendations for specific subpopulations in each national
guideline are presented in Table 4).
Pregnant women. In total, 19 guidelines targeting the general
population provided recommendations for the treatment of
tobacco dependence among pregnant women. In addition, France
and Canada developed a specific guideline for this subpopulation.
Overall, guidelines recommend that all pregnant smokers should
be offered brief advice to quit and should be provided with
counselling, including behavioural and pharmacological support.
Of the 21 guidelines that address smoking cessation treatment
among pregnant women, 16 guidelines recommended that
nicotine replacement therapy (NRT) can be used to assist smoking
cessation attempts made by pregnant women. In several
countries, intermittent-dosage forms of NRT (e.g., gum, nasal
and oral sprays) are recommended as a preferred pharmacother-
apy over patches (Australia, Canada (pregnancy-specific guide-
line), New Zealand, Portugal and India). In contrast, guidelines
from Norway, Scotland, the United States, Japan and Kyrgyzstan
all recommended that NRT should not be given to pregnant
women.
Black and minority ethnic groups. Guidelines from five countries
made recommendations for black and minority ethnic (BME)
groups: Canada, New Zealand, Norway, Portugal and Sweden. All
recommend that wherever possible, culturally appropriate smok-
ing cessation support should be offered. These guidelines also
recommend that health-care workers should receive additional
training in delivering smoking cessation support to BME groups.
Table 2. Recommendations in national guidelines for smoking cessation in primary care
Argentina Australia Canada Chile Czech
Republic
Denmark France Germany India Japan Jordan Kyrgyzstan Malaysia Netherlands New
Zealand
Norway Portugal Scotland South
Africa
Sweden UK USA
Identify ✓✓✓✓✓✓✓✓✓✓✓✓ ✓ ✓✓ ✓✓✓✓✓
Brief advice ✓✓✓✓✓✓ ✓✓✓✓ ✓✓ ✓✓✓✓✓✓✓✓
Assess motivation ✓✓✓✓✓✓✓ ✓✓✓✓ ✓✓ ✓ ✓✓ ✓
Offer assistance ✓✓✓✓✓✓✓✓✓✓✓✓ ✓✓ ✓✓✓✓✓✓✓✓
Offer
pharmacotherapy
✓✓✓✓✓✓✓✓✓✓✓✓ ✓✓ ✓✓✓✓✓✓✓✓
Offer behavioural
support
✓✓✓✓✓✓✓ ✓✓✓✓ ✓✓ ✓✓✓ ✓✓ ✓
Self-help ✓✓✓✓✓✓✓ ✓✓✓✓✓
Evaluate
abstinence
✓✓ ✓ ✓ ✓
5A’s Framework ✓✓✓✓✓✓ ✓✓✓ ✓✓ ✓✓ ✓ ✓✓
ABC Framework ✓✓ ✓
Appropriate
training
✓✓✓✓✓✓✓✓✓✓✓✓
Hypnotherapy and
acupuncture not
effective
✓✓ ✓
a
✓✓✓
Note: 5A’s=Ask, Advise, Assess, Assist, Arrange, ABC Ask, provide Brief advice, offer/refer to/provide evidence-based Counselling. Excluding guidelines targeting specific population
a
The German guideline recommends hypnotherapy; acupuncture is not recommended as an effective treatment
Guidelines for smoking cessation in primary care
M Verbiest et al
6
npj Primary Care Respiratory Medicine (2017) 2 Published in partnership with Primary Care Respiratory Society UK

Children and adolescents. In total, 16 guidelines made specific
recommendations for children and adolescents. Overall, these
include: (1) information about tobacco use among children and
adolescents should be obtained on a regular basis, (2) children
and adolescents should be counselled to encourage abstinence
and (3) parents who smoke should be offered smoking cessation
support in order to limit children's exposure to secondhand
tobacco smoke. Of these guidelines, 11 guidelines recommend
that NRT could be offered to adolescents who show evidence of
nicotine dependence. In contrast, several other guidelines
recommend that pharmacotherapy should not be offered to
children and adolescents (Canada, Norway, Portugal and the USA).
Mental illness/other addiction. Eleven guidelines made specific
recommendations for smokers with a mental illness or other
substance addiction. Most commonly, guidelines recommend to
offer counselling that incorporates all known effective compo-
nents and to carefully monitor smoking cessation in which
medication dosages should be adjusted if necessary. The types of
pharmacotherapy recommended for the treatment of tobacco
dependence among these patients differed across countries
(Table 4).
Chronic illness. In total, 15 guidelines made specific recommen-
dations for people with a chronic illness. Most guidelines
recommend that NRT is safe to use in people with stable
cardiovascular disease. However, NRT should be used with caution
in patients with unstable cardiovascular disease (e.g., severe or
unstable angina, recent myocardial infarction). Additionally,
several guidelines also recommend bupropion as a safe treatment
for nicotine dependence in people with cardiovascular disease
(Argentina, Chile, Czech Republic, India, the Netherlands, New
Zealand and Portugal).
Validity of guideline recommendations
Table 4lists all recommendations made in the included guidelines
and shows the level of evidence we assigned to them according to
the Scottish Intercollegiate Guidelines Network (SIGN) system. Of
all recommendations, only three (‘provide brief advice’,‘provide
behavioural support’, and ‘offer/encourage pharmacotherapy’)
were included in the Service and Delivery Guidance and as such
were assigned an evidence rating. We assigned the evidence
rating ‘A’(strong evidence) to ‘provide brief advice’and ‘provide
behavioural support’. With some exceptions, the majority of the
included guidelines recommend the use of NRT, a combination of
several forms of NRT, bupropion and varenicline; all of which we
assigned the evidence rating ‘A’. Fewer guidelines recommended
combined treatment with NRT and bupropion, or the use of
nortryptiline or clonidine as second-line treatments. These
recommendations were not included in the Service and Delivery
guidance and as such have not been assigned an evidence rating.
Recommendations concerning pregnant women, BME groups
and people with mental illness were assigned an evidence rating
‘B’(supported by reasonable evidence). People with other
addictions were assigned the rating ‘C’(supported by expert
opinion only). For the purposes of our review, mental illness and
other substance addictions were placed in a single group to reflect
the content of the national guidelines; these groups are treated
separately in the Service and Delivery Guidance. Children and
adolescents were not assigned an evidence rating as a priority
group. Rather, the Service and Delivery Guidance assigned a rating
of ‘I’(insufficient evidence to make a recommendation) to stop
smoking interventions and ‘B’to prevention and tobacco control.
The use of NRT for pregnant women was assigned the evidence
rating ‘C’. The use of pharmacotherapy for children and
adolescents, people with cardiovascular disease and people with
Table 3. Types of pharmacotherapy recommended in national guidelines for smoking cessation in primary care
Argentina Australia Canada
a
Chile Czech
Republic
Denmark France Germany India Japan Jordan Kyrgyzstan Malaysia Netherlands New
Zealand
Norway Portugal Scotland
b
South
Africa
Sweden UK USA
NRT ✓✓ ✓✓✓✓✓✓✓✓✓ ✓✓ ✓✓✓ ✓✓✓✓
Bupropion ✓✓ ✓✓✓✓✓✓✓ ✓ ✓✓ ✓✓✓ ✓✓✓
Varenicline ✓✓ ✓✓✓✓✓✓ ✓ ✓ ✓ ✓✓✓✓
Combination
NRT
✓✓ ✓✓✓✓✓ ✓✓✓ ✓✓ ✓✓✓ ✓✓✓✓
Combined NRT
+ Bupropion
✓✓✓✓✓✓✓ ✓✓
Nortriptyline ✓
c
✓
c
✓✓
c
✓✓ ✓ ✓ ✓
c
Clonidine ✓
c
✓
c
✓
c
✓
c
Note: NRT nicotine replacement therapy. Excluding guidelines targeting specific populations
a
The Canadian guideline did not include a section of recommendations regarding pharmacotherapy. It was noted within these guideline that the development of these recommendations was in progress. At the
time of writing this paper an update including recommendations for pharmacotherapy had not been released
b
The Scottish guidelines did include recommendations for pharmacotherapy, however, these were included within recommendations for Specialist Stop Smoking Services which were not extracted for the
purpose of this review. These recommended NRT, combination NRT and bupropion
c
Second line
Guidelines for smoking cessation in primary care
M Verbiest et al
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Published in partnership with Primary Care Respiratory Society UK npj Primary Care Respiratory Medicine (2017) 2

Table 4. Evidence ratings assigned to recommendations from included guidelines
S&D
Guidance
(Y/N)
Evidence
rating
a
Argentina Australia Canada
b
Canada
pregnancy
Chile Czech
Republic
Denmark France France
pregnancy
France
peri-
operative
Germany Germany
COPD
India Japan Jordan Kyrgyzstan Malaysia Netherlands New
Zealand
Norway Portugal Scotland
c
South
Africa
Sweden UK USA
General population
Identify N –✓✓✓ ✓✓✓✓ ✓ ✓✓✓✓ ✓ ✓✓ ✓✓✓✓✓
Brief advice Y A ✓✓✓ ✓✓✓ ✓ ✓✓✓ ✓✓ ✓✓✓✓✓✓✓✓
Assess
motivation
N—✓✓✓ ✓✓✓✓ ✓✓✓✓ ✓✓ ✓ ✓✓ ✓
Offer assistance N —✓✓✓ ✓✓✓✓ ✓ ✓✓✓✓ ✓✓ ✓✓✓✓✓✓✓✓
Offer
pharmacotherapy
Y—✓✓✓ ✓✓✓✓ ✓ ✓✓✓✓ ✓✓ ✓✓✓✓✓✓✓✓
NRT Y A ✓✓ ✓✓✓✓ ✓ ✓✓✓✓ ✓✓ ✓✓✓ ✓✓✓✓
Bupropion Y A ✓✓ ✓✓✓✓ ✓ ✓ ✓ ✓✓ ✓✓✓ ✓✓✓
Varenicline Y A ✓✓ ✓✓✓ ✓ ✓✓ ✓ ✓ ✓✓ ✓
Combination
NRT
YA✓✓ ✓✓✓✓ ✓ ✓✓✓ ✓ ✓✓✓ ✓✓✓✓
Combined NRT +
bupropion
N—✓✓✓ ✓✓✓✓ ✓✓
Nortriptyline N —✓
e
✓✓✓
e
✓✓ ✓ ✓ ✓
Clonidine N —✓
e
✓✓
e
✓✓
Offer behavioural
support
YA✓✓✓ ✓✓✓✓ ✓ ✓✓✓✓ ✓✓ ✓✓✓ ✓✓ ✓
Self-help N —✓✓✓✓✓✓✓✓✓✓✓✓✓
Evaluate
abstinence
YA ✓✓ ✓ ✓ ✓
5A’s framework N —✓✓✓ ✓✓✓ ✓✓✓ ✓✓ ✓✓ ✓ ✓✓
ABC framework N —✓✓ ✓
Appropriate
training
N—✓✓✓✓✓✓✓✓✓✓✓✓
Subpopulations
Pregnancy Y B ✓✓ ✓ ✓✓ ✓✓ ✓ ✓✓ ✓ ✓✓ ✓✓✓✓✓✓✓✓
Offer NRT Y C ✓✓ ✓ ✓✓ ✓✓ ✓ ✓ ✓✓ ✓ ✓ ✓✓✓
BME groups Y B ✓✓✓✓ ✓
Children and
adolescents
Y—✓✓ ✓✓✓✓ ✓ ✓✓✓✓✓✓✓ ✓✓
Offer NRT N —✓✓✓✓
d
✓✓✓✓✓✓ ✓
Mental illness/
other addiction
Y B/C ✓✓ ✓✓ ✓ ✓ ✓ ✓✓✓✓
Bupropion N —✓✓✓✓ ✓✓
Nortriptyline N —✓ ✓
Chronic somatic
illness
N—✓✓ ✓ ✓ ✓✓✓✓✓✓ ✓ ✓ ✓ ✓✓
Offer NRT (CVD) N —✓✓ ✓✓ ✓ ✓ ✓✓✓ ✓ ✓ ✓ ✓
Bupropion (CVD) N —✓✓✓ ✓✓✓✓
Note: S&D Service and Delivery Guidance, NRT nicotine replacement therapy, CVD cardiovascular disease, COPD chronic obstructive pulmonary disease, BME black and minority ethnic groups
a
Evidence rating based on the SIGN system: A=recommendation is supported by strong evidence, B=recommendation is supported by reasonable evidence, C=recommendation is supported by expert opinion
only, I=insufficient evidence to make a recommendation
b
The Canadian guideline did not include a section of recommendations regarding pharmacotherapy. It was noted within these guideline that the development of these recommendations was in progress. At
the time of writing this review an update including recommendations for pharmacotherapy had not been released
c
The Scottish guideline did include recommendations for pharmacotherapy, however, these were included within recommendations for Specialist Stop Smoking Services which were not extracted for the
purpose of this review. These recommended NRT, combination NRT and bupropion
d
The French guideline for the general population recommends NRT only for adolescent of 15 years and older
e
Second line
Guidelines for smoking cessation in primary care
M Verbiest et al
8
npj Primary Care Respiratory Medicine (2017) 2 Published in partnership with Primary Care Respiratory Society UK

mental illness were not assigned an evidence rating as these were
not included in the Service and Delivery Guidance.
DISCUSSION
This study aimed to assess: (1) the parties which were involved in
the development of national guidelines for smoking cessation, (2)
the recommendations that are made for primary care within these
guidelines and (3) how these recommendations correlate with
each other (consistency) and with the state-of-the arts evidence of
what is effective (validity).
Main findings
In our study, 26 guidelines from 22 countries were included in the
analyses. Four of these guidelines focused on the treatment of
tobacco dependence among specific subpopulations: pregnant
smokers (Canada and France), perioperative (France) and COPD
patients (Germany). Most guidelines were produced/commis-
sioned by governmental organisations, followed by medical
societies, multiple organisations, research networks and research
centers. Although most guidelines were developed in collabora-
tion with GPs, only a minority of the guidelines was developed by
a GP as the lead author.
Overall, recommendations that focused on the treatment of
tobacco dependence in primary care among the general
population corresponded well with each other across guidelines.
The majority of these guidelines recommended that smokers
should be identified, be offered a brief advice to quit, be assessed
for motivation to quit, and be offered assistance to quit with
behavioural support and pharmacotherapy. Also, the majority
recommended the use of the ‘5A’s’framework to guide brief
intervention.
We found more inconsistency across details of specific
recommendations. For example, the specific content (practical
counselling techniques vs. no details on content) and delivery
format (e.g., only telephone or face-to-face vs. multiple formats) of
behavioural support differed greatly throughout guidelines. These
inconsistencies can be partly explained by the differences in the
services available at the country level (e.g., the Australian
guideline mentioned telephone support since they have a
national quitline).
Other inconsistencies among recommendations were related to
the provision of pharmacotherapy for smoking cessation among
the general population. Excluding the Canadian and Scottish
guidelines, who did not make recommendations relating to the
use of pharmacotherapy, NRT was recommended by all guidelines.
Although a combination of NRT products was recommended by a
majority of the guidelines (19/22), varenicline was recommended
by only 15 of 22 guidelines. Recommendations to the use of
nortriptyline (9/22), a combination of NRT and bupropion (9/22),
and clonidine (4/22) were less common. The discrepancies
between these recommendations may be due to differences in
medication licensing across countries, or to a difference in access
or interpretation of the current available scientific evidence. Also,
we argue that costs of medication could be a possible barrier in
certain countries for uptake of certain recommendations into the
guideline.
Finally, recommendations for specific subpopulations were also
less consistent throughout guidelines. For example, 15 guidelines
recommended that NRT could be used when needed for pregnant
women, while five guidelines recommended that NRT should not
be used during pregnancy. Similarly, 10 guidelines recommended
that NRT could be used for children and adolescents, while four
recommended that NRT should not be used in this group. Possibly
these inconsistencies are related to the level of evidence available
for these subpopulations, which mostly undefined and otherwise
limited to level B or lower (Table 4). Cultural infuences—such as
the position of pharmacotherapy as well as the position of the
subpopulations in society—may play a role as well.
Strengths and limitations of this study
The current study is one of the first to systematically identify and
analyse the nature and extent of a large number of practice
guidelines for the treatment of tobacco dependence in primary
care. Moreover, it is the first to compare guideline recommenda-
tions across countries and with state-of-the-art evidence for both
the general population and specific subpopulations.
However, some limitations need to be taken into account when
interpreting the results. Firstly, we only included guidelines that
were written or translated into English. Non-English guidelines
that could not be translated were only included if the guideline
authors were willing to provide the necessary information, and
data was thus not derived directly from these guidelines.
Secondly, several guideline recommendations made in the
Service and Delivery Guidance were not mentioned in any of the
included national guidelines. These include types of pharma-
cotherapy treatment (nicotine-assisted reduction to stop—evi-
dence rating B), unlicensed stop smoking treatment (e.g.,
electronic cigarettes—evidence rating C), and the identification
of routine and manual workers as an additional priority group
(evidence rating B). The lack of uptake of recommendations
regarding electronic cigarettes can be explained by their recent
rapid rise on the market, which mainly started only after the
development of most of the included guidelines (most of them
dating from 2011 and earlier). It illustrates a need of frequent
updates of the national guidelines. The lack of inclusion of other
recommendations in the identified guidelines may indicate a
translational gap of the latest evidence. We, therefore, recom-
mend future studies that aim to identify this translational gap,
raise awareness among guideline developers and trigger them to
update guidelines and include the latest evidence.
Thirdly, we were unable to rate the quality of several
recommendations within the guidelines because they did not
match with the recommendations within the Service and Delivery
Guidance (identify smokers’,‘assess motivation’,‘offer assistance’
and ‘use the 5 A’s framework’). This was likely due to vague
descriptions of the recommendations within the guidelines.
Finally, although we managed to analyse the consistency and
validity of the guideline recommendations, this study does not
provide insight into how these guideline recommendations are
currently being implemented in each country.
Implications for future research and practice
Results of our study indicate that, although some consensus on
smoking cessation recommendations already exist, there is room
for improvement with regard to the inconsistencies we found.
Therefore, we suggest that the development of an international
smoking cessation guideline for primary care, drawing upon the
latest evidence and written by international clinical, policy and
academic experts could provide a template to optimise future
national guidelines. Based on our study findings, we developed a
checklist of recommended smoking cessation intervention com-
ponents as a ‘tool for practice’for primary care professionals
(Supplementary Material). Although this checklist presents uni-
versal key recommendations for the treatment of tobacco
dependence in primary care, both health professionals and
guideline developers need to take into consideration their own
national health- and economic context when applying these
recommendations. Among these considerations should be cultural
adaptations tailored to, for example, specific risk groups.
Guidelines for smoking cessation in primary care
M Verbiest et al
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Published in partnership with Primary Care Respiratory Society UK npj Primary Care Respiratory Medicine (2017) 2

CONCLUSIONS
Our study shows that there is almost universal agreement
between guidelines regarding the need in primary care to identify
smokers, to offer some form of advice to quit and to offer
behavioural and pharmacological support to quit. Discrepancies
between guideline recommendations were greatest for these
latter interventions, which are likely due to different interpreta-
tions of the evidence and/or differences in the contextual health
environments of countries. International primary care guidance for
smoking cessation that is dynamic, (co-) written by primary care
experts and drawing from the latest evidence would be a very
useful resource for clinicians and policy makers to develop and
optimise national guidelines.
METHODS
Search methods and inclusion criteria
To identify national guidelines for smoking cessation, we used an
independent online resource which hosts a compilation of national
treatment guidelines from across the world (www.treatobacco.net).
Additional search methods included the consultation of international
colleagues within the field of tobacco dependence treatment. The initial
search was performed in December 2014 and was updated in September
2015. Only the most recent version of each available national guideline
was included. If multiple guidelines for specific subpopulations (e.g.,
pregnant women) were available for one country, all those guidelines were
included.
Only English-language guidelines were eligible for analyses. If guidelines
were not available in English, we contacted the lead authors of the
guideline and asked if they could provide an English-language version. If
unsuccessful, we then asked if they were willing to provide details on the
key recommendations made within the guidelines (section ‘Guideline
recommendations’). In case the communication with an author resulted in
the availability of a more recent version of the guideline or to a version
with a more specific focus on primary care, this version of the guideline
replaced the initially included guidelines of this country.
We excluded guidelines where smoking cessation was only part of a
guideline on a different topic (e.g., a paragraph on tobacco treatment
within a guideline for asthma or COPD).
Data extraction
From each country’s guideline we extracted information regarding the lead
authors, the year of publication, and the lead organisation(s) involved in
commissioning and/or producing the guideline (e.g., Ministry of Health).
We also extracted information on funding sources for guideline develop-
ment and on the development methodology. We classified the country as
a high-, middle- or low-income country based on the information from the
World Bank income group (http://data.worldbank.org/about/country-and-
lending-groups).
Guideline recommendations
In order to identify the recommendations made, we extracted the main
recommendations put forth in each country's guideline. For each included
guideline, we created a coding framework consisting of the recommenda-
tions within the guideline. A segment of text was extracted as a
recommendation if it met the following criteria: (1) the text was explicitly
specified as a recommendation and (2) the recommendation was made
specifically for a primary care setting or primary healthcare practitioner, or
was relevant to either one of these. Recommendations were extracted in
their smallest, irreducible form. For example, a recommendation might
state that “pregnant women should only be offered NRT if they are unable
to quit otherwise, and intermittent forms of NRT are preferable to patches
in this population”. We recorded this as two separate recommendations:
(1) “pregnant women should only be offered NRT if they are unable to quit
otherwise”and (2) “intermittent forms of NRT are preferable to patches for
pregnant women”. Recording the recommendations in this way facilitated
the comparison of recommendations across guideline documents.
To ensure consistency in the extraction of recommendations, two
researchers (K.S. and G.A.) independently extracted the recommendations
from two pre-selected guidelines. These two researchers discussed any
discrepancies in their extraction and resolved them through discussion or
through arbitration with the third researcher (A.Mc.). After having agreed
upon a consistent approach to extraction, K.S. and G.A. extracted both 50%
of the remainder guideline recommendations.
Consistency of guideline recommendations
To establish how consistent the recommendations were internationally, we
compared each of the individual national recommendations and
contrasted them against all others. Those recommendations that were
identical, or very similar, were assigned to categories (e.g., ‘give all smokers
brief advice to quit’or ‘record and update tobacco use status for all
patients’). We used a ‘pile-sort’method in order to establish this
categorisation. Each individual recommendation was printed out on a
separate piece of card along with a unique identifier. The cards were
sorted independently by two researchers (K.S. and G.A.) into piles of
identical/very similar individual recommendations. Each researcher
assigned a category label to individual piles, and subsequently met to
discuss the categorisations. Disagreements in categorisation were dis-
cussed with the third author (A.Mc.) until resolved, with category labels
being finalised and agreed upon at this stage.
Validity of guidelines recommendations
To establish how well the recommendations in each of the guidelines
correspond to state-of-the-art evidence, recommendations were cross-
checked against the most recent English Service and Delivery Guidance for
local Stop Smoking Services.
21
This publication makes recommendations
for how stop smoking services in the UK should be commissioned,
delivered and monitored. Most importantly, it includes an updated
evidence review of a number of recommendations for the treatment of
tobacco dependence, including behavioural support, pharmacotherapy
and the treatment among specific subpopulations.
Each recommendation within the included national guidelines was
assigned an evidence rating using the SIGN rating system.
22
The SIGN
system includes five ratings: “A”(the recommendation is supported by
good/strong evidence), “B”(the recommendation is supported by fair/
reasonable evidence, but there may be minimal inconsistency or
uncertainty), “C”(the recommendation is supported by published expert
opinion only), “I”(there is insufficient evidence to make a recommenda-
tion) and “✓”(good practice point in the opinion of the guidance
development group).
Checklist of smoking cessation intervention components
We developed a checklist of components as a practice tool for primary care
professionals based on: (1) the analysis of recommendations in the
identified national guidelines, (2) the consistency and validity of these
recommendations and (3) experts’opinions from the International Primary
Care Respiratory Group.
FUNDING
The initial study was commissioned by the International Primary Care Respiratory
Group from the National Centre for Smoking Cessation and Training. The results of
this study were shared with the authors and the writing of this paper is unfunded.
AUTHOR CONTRIBUTIONS
M.V., E.B. and R.v.d.K. contributed to the interpretation of the data, drafting and
critical revision of the manuscript and gave final approval of the version to be
published. K.S. and G.A. contributed to the conception of the study, data collection,
data analysis and interpretation, and gave final approval of the manuscript version to
be published. S.W. and A.Mc. contributed to the conception of the study, data
collection, data analysis and interpretation, drafting and critical revision of the
manuscript and gave final approval of the version to be published. N.C. contributed
to the conception of the study, data analysis and interpretation, drafting and critical
revision of the manuscript and gave final approval of the version to be published.
COMPETING INTERESTS
A.Mc. has received travel funding, honorariums and consultancy payments from
manufacturers of smoking cessation products (Pfizer Ltd, Novartis UK and GSK
Consumer Healthcare Ltd). Other authors declare no conflict of interests.
Guidelines for smoking cessation in primary care
M Verbiest et al
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npj Primary Care Respiratory Medicine (2017) 2 Published in partnership with Primary Care Respiratory Society UK

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Guidelines for smoking cessation in primary care
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Published in partnership with Primary Care Respiratory Society UK npj Primary Care Respiratory Medicine (2017) 2