Canadian Smoking Cessation Clinical Practice Guideline

CANADIANSMOKING CESSATIONCLINICAL PRACTICE GUIDELINEFunding for CAN-ADAPTT has been made possible through a financialcontribution from the Drugs and Tobacco Initiatives Program, HealthCanada. The views expressed herein do not necessarily represent theviews of Health Canada.

CANADIAN SMOKING CESSATION GUIDELINE• SPECIFIC POPULATIONS: Aboriginal Peoples ........................................ 16OVERVIEW OF EVIDENCE ............................................................................. 16BACKGROUND ............................................................................................... 17CAN-ADAPTT SUMMARY STATEMENTS ........................................................ 17SUMMARY STATEMENT #1 .................................................................................... 17SUMMARY STATEMENT #2 .................................................................................... 17SUMMARY STATEMENT #3 .................................................................................... 17SUMMARY STATEMENT #4 .................................................................................... 17CLINICAL CONSIDERATIONS ........................................................................ 18TOOLS/RESOURCES ..................................................................................... 19RESEARCH GAPS .......................................................................................... 20• SPECIFIC POPULATIONS: Hospital-Based Populations .......................... 21OVERVIEW OF EVIDENCE ............................................................................. 21BACKGROUND ............................................................................................... 22CAN-ADAPTT SUMMARY STATEMENTS ........................................................ 23SUMMARY STATEMENT #1 .................................................................................... 23SUMMARY STATEMENT #2 .................................................................................... 23SUMMARY STATEMENT #3 .................................................................................... 23SUMMARY STATEMENT #4 .................................................................................... 23CLINICAL CONSIDERATIONS ........................................................................ 24PROCESSES IN SMOKING CESSATION INTERVENTIONS WITHHOSPITALIZED PATIENTS ................................................................................ 24PHARMACOTHERAPY ............................................................................................ 24HOSPITAL POLICIES .............................................................................................. 24TOOLS/RESOURCES ..................................................................................... 25RESEARCH GAPS .......................................................................................... 25• SPECIFIC POPULATIONS: Mental Health and/or Other Addiction(s) ...... 26OVERVIEW OF EVIDENCE ............................................................................. 26BACKGROUND ............................................................................................... 27PREVALENCE ........................................................................................................ 27NEED FOR EFFECTIVE AND SPECIALIZED TREATMENT ...................................... 28CAN-ADAPTT SUMMARY STATEMENTS ........................................................ 28SUMMARY STATEMENT #1 .................................................................................... 28SUMMARY STATEMENT #2 .................................................................................... 28SUMMARY STATEMENT #3 .................................................................................... 28CLINICAL CONSIDERATIONS ........................................................................ 29SCREEN ................................................................................................................. 29OFFER PHARMACOTHERAPY/COUNSELLING ...................................................... 29MONITOR ............................................................................................................... 29FOLLOW-UP ........................................................................................................... 29RESOURCES FOR HEALTHCARE PROVIDERS ..................................................... 29ADDITIONAL CONSIDERATIONS............................................................................ 30TOOLS/RESOURCES ..................................................................................... 31RESEARCH GAPS .......................................................................................... 31• SPECIFIC POPULATIONS: Pregnant & Breastfeeding Women ................ 32OVERVIEW OF EVIDENCE ............................................................................. 32CAN-ADAPTT SUMMARY STATEMENTS ........................................................ 33SUMMARY STATEMENT #1 .................................................................................... 33SUMMARY STATEMENT #2 .................................................................................... 33SUMMARY STATEMENT #3 .................................................................................... 33SUMMARY STATEMENT #4 .................................................................................... 33SUMMARY STATEMENT #5 .................................................................................... 33CLINICAL CONSIDERATIONS ........................................................................ 33TOOLS/RESOURCES ..................................................................................... 35RESEARCH GAPS .......................................................................................... 35

CANADIAN SMOKING CESSATION GUIDELINE• SPECIFIC POPULATIONS: Youth (Children and Adolescents) ................. 36OVERVIEW OF EVIDENCE ............................................................................. 36BACKGROUND ............................................................................................... 37CAN-ADAPTT SUMMARY STATEMENTS ........................................................ 38SUMMARY STATEMENT #1 .................................................................................... 38SUMMARY STATEMENT #2 .................................................................................... 38SUMMARY STATEMENT #3 .................................................................................... 38CLINICAL CONSIDERATIONS ........................................................................ 38TOOLS/RESOURCES ..................................................................................... 40RESEARCH GAPS .......................................................................................... 40• APPENDICES .......................................................................................... 41APPENDIX A – Guideline Development Process Flow Diagram ........................ 42APPENDIX B – Grade of Recommendation & Level of EvidenceSummary Table for CAN-ADAPTT Summary Statements .................................. 43APPENDIX C – Clinical Practice Guidelines Identified in November 2006 ......... 44APPENDIX D – Clinical Practice Guidelines Identified in December 2008 ......... 45APPENDIX E – Clinical Practice Guidelines Used as Evidence Base forGuideline Development ................................................................................... 46APPENDIX F – Strength of Evidence Classification Tables for ClinicalPractice Guidelines Used as Evidence Base for CAN-ADAPTT’sGuideline Development ................................................................................... 47APPENDIX G – List of Committees .................................................................. 49APPENDIX H – References ............................................................................. 50

CANADIAN SMOKING CESSATION GUIDELINENOTE TO USERSOVERVIEW• PREFACEThis guideline has been developed by the CanadianAction Network for the Advancement, Disseminationand Adoption of Practice-informed TobaccoTreatment (CAN-ADAPTT). CAN-ADAPTT’sGuideline for Smoking Cessation is intended to guidepractice and is not intended to serve as acomprehensive overview of smoking cessationmanagement. This guideline is intended to informprovision of evidence based smoking cessation care inCanada.FUNDINGCAN-ADAPTT has been made possible through afinancial contribution from the Drugs and TobaccoInitiatives Program, Health Canada. This guideline iseditorially independent of funding sources. The viewsexpressed herein do not necessarily represent theviews of Health Canada.REPRODUCTION OF THE GUIDELINEReproduction of the CAN-ADAPTT SmokingCessation Guideline is permitted for educational andnon-commercial purposes, in any form, includingelectronic form, without requiring the consent orpermission of the authors and/or the CAN-ADAPTTproject, provided that the following is noted on allelectronic or print versions:© CAN-ADAPTT/CAMH 2012CITATIONCAN-ADAPTT. (2011). Canadian Smoking CessationClinical Practice Guideline. Toronto, Canada: CanadianAction Network for the Advancement, Disseminationand Adoption of Practice-informed TobaccoTreatment, Centre for Addiction and Mental Health.WEBSITEThe guideline is available in its entirety or byindividual section online at www.can-adaptt.net.CONTRIBUTESections including the information icon above,indicate links to contribute to the guideline viaCAN-ADAPTT’s website (www.can-adaptt.net).Sections include:Clinical ConsiderationsTools/ResourcesResearch Gapsi

CANADIAN SMOKING CESSATION GUIDELINECAN-ADAPTT GUIDELINEDEVELOPMENT COMMITTEEAND SUPPORTGUIDELINE DEVELOPMENT GROUP COMMITTEEThe Guideline Development Group (GDG) wasdirectly responsible for the review of existingguidelines and evidence and the development ofsummary statements for the CAN-ADAPTT ClinicalPractice Guideline.Peter Selby, MBBS, CCFP, FCFP, MHSc, Dip ABAMPrincipal Investigator, CAN-ADAPTTChair, CAN-ADAPTT Guideline Development GroupSection Co-Lead: Mental Health and/or Other Addiction(s)Clinical Director, Addictions ProgramHead, Nicotine Dependence ClinicCentre for Addiction and Mental HealthAssociate ProfessorDepartments of Family and Community Medicine,Psychiatry and Dalla Lana School of Public HealthUniversity of TorontoToronto, OntarioGerry Brosky, MD, CCFPAlice Ordean MD, CCFP, MHScSection Lead: Pregnant and Breastfeeding WomenFamily Physician, Urban Family Health Team, St. Joseph's HealthCentreMedical Director, Toronto Centre for Substance Use in Pregnancy,St. Joseph's Health CentreAssistant Professor, Department of Family and CommunityMedicine, University of TorontoToronto, OntarioRobert D. Reid, PhD, MBASection Lead: Hospital-based PopulationsDeputy Chief, Division of Prevention and Rehabilitation, Universityof Ottawa Heart InstituteProfessor, Faculty of Medicine, University of OttawaOttawa, OntarioSection Lead: Counselling and Psychosocial ApproachesAssociate Professor, Department of Family MedicineDalhousie UniversityHalifax, Nova ScotiaSheila Cote-Meek, BScN, MBA, PhDSection Lead: Aboriginal PeoplesAssociate Vice-President, Academic & Indigenous ProgramsLaurentian UniversitySudbury, OntarioCharl Els, MBChB, FCPsych, MMedPsych (cum laude),ABAM, MROCCSection Co-Lead: Mental Health and/or Other Addiction(s)Addiction Psychiatrist, Medical Review OfficerAssociate Professor (adjunct), School of Public HealthAssociate Clinical Professor, Faculty of Medicine and DentistryAssociate Clinical Professor, John Dossetor Health Ethics CentreUniversity of AlbertaEdmonton, AlbertaJennifer O’Loughlin, PhD, CRC, CAHS fellowSection Lead: Youth (Children and Adolescents)Epidemiologist, CRCHUMProfessor, Department of Social and Preventive MedicineUniversity of MontrealMontreal, Quebecii

CANADIAN SMOKING CESSATION GUIDELINECAN-ADAPTT COORDINATING TEAMPeter Selby, MBBS, CCFP, FCFP, MHSc, Dip ABAMPrincipal Investigator, CAN-ADAPTTCentre for Addiction and Mental Health, Toronto, OntarioVirginia Chow, BScFormer Network Manager, CAN-ADAPTTCentre for Addiction and Mental Health, Toronto, OntarioMary-Jean Costello, MScFormer Evaluation Coordinator, CAN-ADAPTTCentre for Addiction and Mental Health, Toronto, OntarioRosa Dragonetti, MScManager, Nicotine Dependence ServiceCentre for Addiction and Mental Health, Toronto, OntarioStephanie ElliottAdministrative Secretary, CAN-ADAPTTCentre for Addiction and Mental Health, Toronto, OntarioKatie Hunter, MScAtlantic Canada Regional Coordinator, CAN-ADAPTTCentre for Addiction and Mental Health, Toronto, OntarioDenise Koubanioudakis, MAQuebec Provincial Coordinator, CAN-ADAPTTInstitut national de santé publique du Québec, CHUM ResearchCentre, Montreal, QuebecTamar Meyer, MAOntario Provincial Coordinator, CAN-ADAPTTCentre for Addiction and Mental Health, Toronto, OntarioJanet Ngo, MAWestern Canada Regional Coordinator, CAN-ADAPTTCentre for Addiction and Mental Health, Toronto, OntarioJenna Robinson, MAOutreach Coordinator, CAN-ADAPTTCentre for Addiction and Mental Health, Toronto, OntarioSophie Soklaridis, PhDKnowledge Translation Scientist, Nicotine Dependence ServiceCentre for Addiction and Mental Health, Toronto, OntarioAnna TapiaAdministrative Secretary, CAN-ADAPTTCentre for Addiction and Mental Health, Toronto, OntarioLouise Walker, BA, BSc(Hons)Former Manager, CAN-ADAPTTCentre for Addiction and Mental Health, Toronto, OntarioACKNOWLEDGEMENTSCAN-ADAPTT wishes to acknowledge the contributionto the Clinical Practice Guideline from PaulMcDonald. Dr. McDonald was involved in the earlyGuideline Development Group meetings but was notinvolved in the final review and approval of theClinical Practice Guideline.In addition to the work of the CAN-ADAPTTGuideline Development Group, CAN-ADAPTT wishesto acknowledge the Executive Committee andEvaluation Committee of CAN-ADAPTT for theircontribution to the development of the CanadianGuideline for Smoking Cessation and the support ofthe CAN-ADAPTT Project as a whole. A complete listof these Committees and a brief description of theirroles can be found in Appendix G.The development of this guideline would not havebeen possible without the efforts, knowledge andexpertise of the CAN-ADAPTT Network. TheNetwork provided valuable input into the guidelinethrough contributions on the discussion board,through attendance at CAN-ADAPTT’s AnnualGeneral Meetings and during partnership meetings/workshops. CAN-ADAPTT would like toacknowledge and thank these individuals for theirtime and support.Jess Rogers, BAManager, CAN-ADAPTT (secondment)Director, Centre for Effective Practice, Toronto, Ontarioiii

CANADIAN SMOKING CESSATION GUIDELINESUMMARY STATEMENT #4ASSIST: Every tobacco user who expressesthe willingness to begin treatment toquit should be offered assistance.GRADE*: 1A• EXECUTIVE SUMMARYa) Minimal interventions, of 1-3 minutes, areeffective and should be offered to everytobacco user. However, there is a strongdose-response relationship between thesession length and successful treatment,and so intensive interventions should beused whenever possible.GRADE*: 1ACOUNSELLING ANDPSYCHOSOCIAL APPROACHESSUMMARY STATEMENT #1ASK:Tobacco use status should beupdated, for all patients/clients, byall health care providers on aregular basis.GRADE*: 1ASUMMARY STATEMENT #2ADVISE: Health care providers should clearlyadvise patients/clients to quit.GRADE*: 1CSUMMARY STATEMENT #3ASSESS: Health care providers should assessthe willingness of patients/clients tobegin treatment to achieveabstinence (quitting).GRADE*: 1Cb) Counselling by a variety or combinationof delivery formats (self-help, individual,group, helpline, web-based) is effectiveand should be used to assistpatients/clients who express awillingness to quit.GRADE*: 1Ac) Because multiple counselling sessionsincrease the chances of prolongedabstinence, health care providers shouldprovide four or more counsellingsessions where possible.GRADE*: 1Ad) Combining counselling and smokingcessation medication is more effectivethan either alone, therefore both shouldbe provided to patients/clients trying tostop smoking where feasible.GRADE*: 1Ae) Motivational interviewing is encouragedto support patients/clients willingness toengage in treatment now and in thefuture.GRADE*: 1Biv

CANADIAN SMOKING CESSATION GUIDELINESUMMARY STATEMENT #4 (cont’d)f) Two types of counselling and behaviouraltherapies yield significantly higherabstinence rates and should be includedin smoking cessation treatment: 1)providing practical counselling onproblem solving skills or skill training and2) providing support as a part oftreatment.GRADE*: 1BSUMMARY STATEMENT #5ARRANGE: Health care providers:a) should conduct regular follow-up toassess response, provide support andmodify treatment as necessary.GRADE*: 1Cb) are encouraged to refer patients/clientsto relevant resources as part of theprovision of treatment, whereappropriate.GRADE*: 1AABORIGINAL PEOPLES †SUMMARY STATEMENT #1Tobacco misuse ∆ status should be updatedfor all Aboriginal peoples by all health careproviders on a regular basis.GRADE*: 1ASUMMARY STATEMENT #2All health care providers should offerassistance to Aboriginal peoples who misusetobacco with specific emphasis on culturallyappropriate methods.GRADE*: 1CSUMMARY STATEMENT #3All health care providers should be familiarwith available cessation support services forAboriginal peoples.GRADE*: 1CSUMMARY STATEMENT #4All individuals working with Aboriginalpeoples should seek appropriate training inproviding evidence-based smoking cessationsupport.GRADE*: 1C†Aboriginal peoples is used as an inclusive term whichincludes First Nations (both on and off reserve), Inuit, andMétis. This is not meant to take away from the diversity thatexists among Aboriginal peoples∆Tobacco misuse does not refer to tobacco use fortraditional/ceremonial purposes.v

CANADIAN SMOKING CESSATION GUIDELINEHOSPITAL-BASED POPULATIONSSUMMARY STATEMENT #1All patients should be made aware of hospitalsmoke-free policies.GRADE*: 1CSUMMARY STATEMENT #2All elective patients who smoke should bedirected to resources to assist them to quitsmoking prior to hospital admission orsurgery, where possible.GRADE*: 1BSUMMARY STATEMENT #3All hospitals should have systems in place to:a) identify all smokers;GRADE*: 1Ab) manage nicotine withdrawal duringhospitalization;GRADE*: 1Cc) promote attempts toward long-termcessation and;MENTAL HEALTH AND/OR OTHERADDICTION(S)SUMMARY STATEMENT #1Health care providers should screen personswith mental illness and/or addictions fortobacco use.GRADE*: 1ASUMMARY STATEMENT #2Health care providers should offercounselling and pharmacotherapy treatmentto persons who smoke and have a mentalillness and/or addiction to other substances.GRADE*: 1ASUMMARY STATEMENT #3While reducing smoking or abstaining(quitting), health care providers shouldmonitor the patients’/clients’ psychiatriccondition(s) (mental health status and/orother addiction(s)). Medication dosage shouldbe monitored and adjusted as necessary.GRADE*: 1AGRADE*: 1Ad) provide patients with follow-up supportpost-hospitalization.GRADE*: 1ASUMMARY STATEMENT #4Pharmacotherapy should be considered:a) to assist patients to manage nicotinewithdrawal in hospital;GRADE*: 1Cb) for use in-hospital and posthospitalizationto promote long termcessation.GRADE*: 1Bvi

CANADIAN SMOKING CESSATION GUIDELINEPREGNANT AND BREASTFEEDINGWOMENSUMMARY STATEMENT #1Smoking cessation should be encouraged forall pregnant, breastfeeding and postpartumwomen.GRADE*: 1ASUMMARY STATEMENT #2During pregnancy and breastfeeding,counselling is recommended as first linetreatment for smoking cessation.GRADE*: 1ASUMMARY STATEMENT #3If counselling is found ineffective, intermittentdosing nicotine replacement therapies (suchas lozenges, gum) are preferred overcontinuous dosing of the patch after a riskbenefitanalysis.GRADE*: 1CSUMMARY STATEMENT #4Partners, friends and family members shouldalso be offered smoking cessationinterventions.YOUTH (Children and Adolescents)SUMMARY STATEMENT #1Health care providers, who work with youth(children and adolescents) should obtaininformation about tobacco use (cigarettes,cigarillos, waterpipe, etc.) on a regular basis.GRADE*: 1ASUMMARY STATEMENT #2Health care providers are encouraged toprovide counselling that supports abstinencefrom tobacco and/or cessation to youth(children and adolescents) that use tobacco.GRADE*: 2CSUMMARY STATEMENT #3Health care providers in pediatric health caresettings should counsel parents/guardiansabout the potential harmful effects of secondhandsmoke on the health of their children.GRADE*: 2C 42* GRADE: See Appendix B for Grade of Recommendation andLevel of Evidence Summary Table.GRADE*: 2BSUMMARY STATEMENT #5A smoke-free home environment should beencouraged for pregnant and breastfeedingwomen to avoid exposure to second-handsmoke.GRADE*: 1Bvii

CANADIAN SMOKING CESSATION GUIDELINEGUIDELINE RATIONALE• INTRODUCTIONWhile approximately 17% of Canadians are currentsmokers 1 , a large proportion have been shown to bewilling to make a quit attempt 2 . Health careproviders have an important role to play in assistingindividuals to quit smoking. Moreover, even briefinterventions by providers are known to be effectivein increasing the likelihood of a quit attempt by aperson who smokes 3 . Clinical practice guidelines areknown to be an important and effective provider toolto close the gap between recommended care andactual care provided 4 .The need for national clinical practice guidelines hasalso been identified by the World HealthOrganization’s Framework Convention for TobaccoControl (FCTC), which states that parties to the treaty“…shall develop and disseminate appropriate,comprehensive and integrated guidelines based onscientific evidence and best practice, taking intoaccount national circumstances and priorities, andshall take effective measures to promote cessation oftobacco use and adequate treatment for tobaccodependence” 5 .BACKGROUND OF CAN-ADAPTTIn May 2007, the Tobacco Control Program of HealthCanada assembled selected members of the tobaccocontrol community for a roundtable discussionpertaining to tobacco cessation guidelines. Thisroundtable of experts highlighted several issues andneeds, including:Traditional methods of guidelinedevelopment have relied on a narrow field ofevidence, focusing mainly on randomizedcontrolled trials (that typically fail to accountfor conditions and factors that influencetreatment)Need to approach guideline/guidancedevelopment with inter-professionalcollaboration that significantly contributesboth clinically practical and population levelperspectivesNeed to engage stakeholders in guidelinedevelopment and implementation processesNeed for effective vehicles of communicationand knowledge translation between thedifferent audiences and stakeholdersTo address these needs, the Canadian Action Networkfor the Advancement, Dissemination, and Adoption ofPractice-informed Tobacco Treatment (CAN-ADAPTT) was established in 2008, with funding fromthe Drugs and Tobacco Initiatives Program of HealthCanada.INTRODUCTION 1

CANADIAN SMOKING CESSATION GUIDELINECAN-ADAPTT’s vision is to encourage a Canadawhere health care providers have access to the toolsneeded to deliver up to date evidence-basedsmoking cessation interventions to reduce theprevalence of tobacco use and dependence. Itsoverall goal is to establish a national Practice-BasedResearch Network (PBRN) to facilitate research andknowledge exchange to inform the development of adynamic cessation guideline for use in clinicalpractice and population-based strategies withinCanada.CAN-ADAPTT is committed to facilitating smokingcessation research and knowledge exchange amonghealth care providers, researchers, and policy/decision makers. CAN-ADAPTT aims to close the gapbetween research and practice by meeting thefollowing objectives:Create a PBRN to inform smoking cessationresearch and practice across CanadaDevelop a practice-informed research agendathat bridges the gaps between clinicalpractice, research and theoretical frameworksTranslate research evidence into a dynamicevidence-based guidelineDisseminate findings and engage stakeholdersto promote the adoption of the guidelineCollaborate with others involved in tobaccouse and dependenceEvaluate the impacts of the PBRNFrom 2008-2011, CAN-ADAPTT worked withstakeholders to develop a practice-informed ClinicalPractice Guideline (CPG) for Smoking Cessation inCanada. CAN-ADAPTT’s guideline developmentprocess reflects a dynamic opportunity to ensure thatits guideline is practice-informed and addressesissues of applicability in the Canadian context.CAN-ADAPTT, while building from recognizedstandards for guideline development (outlined in theAGREE Instrument 6 ), also integrated uniqueapproaches to guideline development, including:2. Using a practice-informed approach anddynamic processCAN-ADAPTT engaged stakeholders, healthcare providers from diverse practice settings,policy makers, health care managers and abroad range of researchers to provide input intothe development of the guideline.SCOPE AND PURPOSEThis guideline is intended for use by Canadian healthcare providers in diverse clinical or treatmentsettings. This guideline is also intended forresearchers and decision makers with an interest inunderstanding the key elements to a comprehensivesmoking cessation system in Canada. The guidelinecontains sections on both clinical and population levelapproaches to smoking cessation interventions forpersons who smoke or use tobacco. Sections of theguideline were also developed to address some of thequestions regarding specific populations such asAboriginal Peoples and Hospital Based Populations(see below for a complete list of topics).This guideline is not intended to be prescriptive. It isdesigned to support rather than replace the clinicaljudgment of health care providers. Informationcontained in this guideline may be less applicable incertain situations or with specific populations. Thisguideline is intended to provide a foundation fromwhich health care providers, researchers and decisionmakers (including health care managers) in Canadacan adapt and tailor the information andrecommendations to meet their own needs andsettings.The guideline is available in full text on the CAN-ADAPTT website (www.can-adaptt.net) in bothEnglish and French.1. Building from existing guidelinesCAN-ADAPTT subcontracted the GuidelinesAdvisory Committee (GAC) to independentlyidentify and evaluate existing CPGs using theAGREE Instrument. The recommendationscontained in the high quality guidelines(determined by AGREE scores) were used as theevidence base for the CAN-ADAPTT guidelinedevelopment process.INTRODUCTION 2

CANADIAN SMOKING CESSATION GUIDELINEFORMAT OF GUIDELINEThe guideline is organized into the following sections:Clinical ApproachesCounselling & Psychosocial ApproachesPharmacotherapy (in progress using adifferent guideline developmentmethodology)Specific PopulationsAboriginal PeoplesHospital Based PopulationsMental Health and/or Other Addiction(s)Pregnant & Breastfeeding WomenYouth (Children & Adolescents)Each section of the guideline is divided into thefollowing sub-sections:1. Overview of Evidence includes therecommendations and supporting evidenceextracted from relevant pre-existing highquality CPGs, which have contributed to theCAN-ADAPTT summary statements.2. Summary Statements are based on the bestevidence identified, and are the importantmessages for health care providers to considerimplementing in practice. Each SummaryStatement includes the Grade ofRecommendation and Level of Evidencesupporting the Statement.3. Clinical Considerations is informationsupporting the Summary Statements, such ashow to best implement the Statements,important implications for specific practicesettings and key considerations. ClinicalConsiderations were informed by the input ofthe Guideline Development Group and CAN-ADAPTT Network Members. It was notinformed by a systematic review of theliterature.4. Tools and Resources provides a list ofresources that health care providers can use tohelp implement the Summary Statements. Thelists are not intended to be comprehensive; theyare a starting point informed by the GuidelineDevelopment Group and CAN-ADAPTTNetwork Members.5. Research Gaps describes any gaps in theevidence and recommendations for futureresearch in the area. See the CAN-ADAPTTResearch Agenda for more information 7 .CLARIFICATION AND LIMITATIONSIn this document, the term “tobacco” refers tomanufactured, commercial tobacco productsincluding, but not limited to, cigarettes, smokelesstobacco such as snuff, snus, and chewing tobacco, andcigars. Tobacco misuse does not refer to tobacco usefor traditional or ceremonial purposes by AboriginalPeoples.Most research in the area of smoking cessation hasexamined cigarette use; it is important to note thislimitation when using this guideline with smokelesstobacco users. More research is needed on smokelesstobacco products and the people who use smokelesstobacco to understand the impact of smokingcessation interventions.The term patient/client is used throughout thisguideline to reflect the diverse clinical settings wheresmoking cessation treatment is provided. The termhealth care provider is used throughout and isintended to reflect a broad range of providers in arange of different settings, including hospital, clinic,home care, acute, community, primary and long termcare.INTRODUCTION 3

CANADIAN SMOKING CESSATION GUIDELINEGuideline Development Group (GDG)• METHODSThe Guideline Development Group (GDG) wasformed in 2009 by the CAN-ADAPTT CoordinatingTeam and the GDG Chair, Dr. Peter Selby. There areseven members of the GDG ranging from familyphysician to public health researcher to physicianspecialists (see page ii for a list of GDG members).Each GDG member was a Section Lead for one of thesections listed on page 3. GDG Members wereidentified by the Chair to include experts in each topicarea while ensuring a multi-disciplinary andnationally representative committee. Each GDGmember was contracted through CAMH for theirparticipation on the GDG, which included a modesthonorarium to support their attendance at meetingsand compensation for travel and accommodation forin-person meetings. Each GDG member confirmedthat they had not received funds from the TobaccoIndustry. No conflicts of interest were identified bymembers of the GDG that could have compromisedthe summary statements contained within thisdocument. The GDG recognizes that representationfrom all potential guideline target end users was notpossible. The intent was to leverage the CAN-ADAPTT Network members that represented agreater number of professional groups involved insmoking cessation throughout the guidelinedevelopment process to provide critical input into thedrafting of the guideline.IDENTIFYING AND EVALUATINGTHE EVIDENCEIDENTIFYING EXISTING CLINICAL PRACTICEGUIDELINESPrior to being engaged in the CAN-ADAPTT Project,the Guidelines Advisory Committee had conducted,in November 2006, a full review of CPGs in the area ofsmoking cessation published in the English language.At that time, nine guidelines met the basic predeterminedquality criteria: they containedrecommendations linked to the evidence, andincluded some indication that a systematic search ofthe literature had been conducted. [Appendix C]In December 2008, a new systematic search wasconducted for the CAN-ADAPTT Project, to identifyCPGs published since the previous review. Thissearch used the same terms as November 2006, suchas smoking, tobacco, or nicotine. The search wasconducted in Ovid MEDLINE, Ovid Embase,guideline repositories such as National GuidelineClearinghouse, renowned developers with a history ofMETHODS 4

CANADIAN SMOKING CESSATION GUIDELINEdeveloping high quality guidelines, as well aswebsites of national and international specialtysocieties. A general internet search was alsoconducted to ensure that no CPGs were missed. Fiveguidelines, which met the basic pre-determinedquality criteria (as above), were found to be publishedafter the initial search in 2006. [Appendix D]REVIEW AND APPRAISAL OF IDENTIFIEDCLINICAL PRACTICE GUIDELINESThe 14 guidelines (combining those from 2006 and2008) identified in both reviews were evaluated byfour independent reviewers using the AGREEInstrument. The reviewers were practicing familyphysicians in Ontario who had each been formallytrained in the application of the AGREE Instrument.In addition to the AGREE Instrument, 8 additionalquestions were included as part of the appraisal. Thisstep, called AGREE Plus was encouraged by the GACin order to better understand the applicability of theguidelines to the Canadian context. It has been theexperience of the GAC that the applicability section ofthe AGREE often misses important considerations forthe guidelines’ use once the guideline is put intopractice. The following additional questions wereprovided by the CAN-ADAPTT Coordinating Team.Each reviewer responded to the questions/statementsbelow using a 4-point Likert scale and/or comments,where appropriate.1. The recommendations made in the guideline areappropriate for the intended users (i.e., you andyour colleagues) to perform.2. The recommendations made in the guideline arepractical for the intended users (i.e., you andyour colleagues) to perform.3. The recommendations made in the guideline areconsistent with patient treatment expectations.4. The recommendations are compatible withexisting attitudes and beliefs of the guideline’sintended users (i.e., you and your colleagues).5. The recommendations can be performed by theguideline’s intended users (i.e., you and yourcolleagues) without the acquisition of newcompetencies (knowledge, skills, etc.).6. What new competencies, if any, would berequired?7. Criteria can be extracted from the guideline thatwould permit the measurement of specificoutcomes related to the recommendations.8. Criteria can be extracted from the guideline thatwould permit the measurement of adherence tothe recommendations.CAN-ADAPTT considered only those guidelines thatscored highly in multiple AGREE domains,particularly in the areas of Rigour of Developmentand Editorial Independence, as well as guidelines thatwere ‘strongly recommended’ by reviewers as beingapplicable to the Canadian context. The domains ofRigour of Development and Editorial Independenceaddress the majority of the methodological questionsthat help to determine quality of the guidelinedevelopment process. The GAC advised thatguidelines which do not adequately address theseitems should not be considered to be a high qualityclinical practice guideline and should not be includedin the development of CAN-ADAPTT’s guideline.Six guidelines met our criteria and were selected foruse in developing the dynamic CAN-ADAPTT CPG.[Appendix E] This process has been developed andwas recommended by the Guidelines AdvisoryCommittee (GAC).CAN-ADAPTT extracted key recommendations fromthe highest scoring guidelines, and used these as theformal evidence base to inform the development of itsguideline.NOTE: CAN-ADAPTT did not review the primaryliterature to inform the development of its SummaryStatements unless emerging evidence was identified by theGuideline Development Group.SUMMARY STATEMENTS ANDCLINICAL CONSIDERATIONSDEVELOPMENT AND APPROVAL:A Practice-Informed ApproachThe CAN-ADAPTT process of guideline developmentwas informed by the ADAPTE process 8 . Thismethodology was unique in that evidence wasextracted from existing high quality guidelines todevelop summary statements. Evidence tables werecreated for each of the guideline sections (as listed onpage 3). The existing CPGs identified for inclusionwere reviewed and relevant recommendationsextracted for each section along with the level ofevidence/grade of recommendation attributed to it bythe original guideline developer. The CAN-ADAPTTCoordinating Team developed draft summarystatements from the existing recommendations foreach theme and included it in the evidence tables. TheChair of the GDG reviewed the evidence tables andapproved for distribution to the GDG.The entire GDG reviewed the evidence tables andsuggested revisions independently. The CAN-ADAPTT Coordinating Team collated the revisionsMETHODS 5

CANADIAN SMOKING CESSATION GUIDELINEinto one document and re-circulated revisions to eachsection to the respective GDG lead for review. Theupdated evidence tables were then prepared for theAnnual General Meeting (AGM) of the CAN-ADAPTTNetwork held in Ottawa 2009. At the AGM, the GDGSection Leads were responsible for leading smallgroup breakout sessions with Network members toreview the evidence tables and invite input on theSummary Statements and Clinical Considerations forthe CAN-ADAPTT Guideline. The feedback wascaptured by designated recorders in each group aswell as in participant workbooks that were collectedat the end of the day. Following the AGM, all of thefeedback was collated by the CAN-ADAPTTCoordinating Team and re-circulated to the GDGSection Lead for review and presentation to the otherGDG members at the next GDG meeting.During this GDG meeting, each GDG Section Leadwas charged with facilitating discussion and elicitingfeedback from the other GDG members for theirrespective section including revision to the SummaryStatements, identification of relevant evidence toinclude in the background section, articulation of keyclinical considerations and in assigning a level ofevidence/grade of recommendation to each SummaryStatement. The GDG Section Leads were supported bythe CAN-ADAPTT Coordinating Team who assistedin drafting the content for review and confirmation bythe GDG Section Leads. Final revision and approvalof all Summary Statements and the level of evidence/grade of recommendation was accomplished at an inpersonGDG meeting where members were requiredto discuss and vote on final summary statements.Overall, there were seven GDG Meetings from 2009 to2010.GRADES OF RECOMMENDATION AND LEVELSOF EVIDENCESummary Statements were assigned Grades ofRecommendation (GR) and Levels of Evidence (LoE)using a modified GRADE approach 9 . Given that thisprocess built from existing clinical practiceguidelines, traditional GRADE evidence tables werenot used. The GDG utilized the Grading guide table,compiled by UptoDate 10 to help consider the level ofevidence and grade of recommendation for itsSummary Statements. The Guideline DevelopmentGroup Members reviewed each Summary Statementand weighed the clarity of risk and benefit, quality ofthe supporting evidence, and implications of theSummary Statement and assigned a GR and LoE foreach. Members of the Guideline Development Groupvoted on the wording of the Summary Statement andeach GR and LoE.Grades of Recommendation and Levels of Evidencecan be found in Appendix B.CAN-ADAPTT NETWORK PARTICIPATIONComposition of NetworkThe example of the AGM, as described above,demonstrates how the CAN-ADAPTT methodologyalso included engagement of the target end users;researchers, health care providers and manager/decision makers in its process of guidelinedevelopment. The feedback approach was iterativeallowing for ongoing participation and reflection fromthe target end users. The impact or effectiveness ofclinical practice guidelines is often limited by the lackof consideration given to implementation or theapplicability of the CPGs to local context andprovider needs 11 . It was the aim of CAN-ADAPTT toexplore the value and contribute to emergingguideline methods integrating implementationconsiderations into guideline development 12 .CAN-ADAPTT targeted a variety of groups and keystakeholders for membership in the Network andparticipation in the guideline development processthough a number of strategies. These includedconnecting with professional associations/organizations representing various related disciplinesand practices, presenting and displaying atconferences, sending out email blasts, conductingworkshops, and publishing articles in professionaljournals and newsletters, as well as other promotionalmaterials. Recruiting health providers committed tosmoking cessation was considered particularlyimportant, as they are in a unique position to engagein the delivery of smoking cessation interventions andthus are likely to use a revised, up-to-date, evidencebasedguideline on smoking cessation practices.Network members were recruited from acrossCanada, and almost all Canadian provinces andterritories had participants. Between 2008 and March2011, more than 800 individuals have joined CAN-ADAPTT’s Network, and were invited to participatein the development of these guidelines.Methods of ParticipationCAN-ADAPTT members were invited to contribute tothe guideline development and implementationprocess in a number of ways, including:Providing direct feedback to CAN-ADAPTTteamParticipating in CAN-ADAPTT workshopsParticipating in Annual General Meeting(s)Providing feedback via the GuidelineDiscussion BoardApplying for CAN-ADAPTT seed grantsContributing a tool or resourceMETHODS 6

CANADIAN SMOKING CESSATION GUIDELINEOVERVIEW OF EVIDENCEThe following recommendations, and supportingevidence, have been extracted from existing clinicalpractice guidelines to inform the development of the CAN-ADAPTT Summary Statements.• COUNSELLING ANDPSYCHOSOCIALAPPROACHESCAN-ADAPTT’s Clinical Practice GuidelineDevelopment Group;Section Lead: Gerry Brosky, MD, CCFPCAN-ADAPTT worked with the Guidelines AdvisoryCommittee (GAC) to conduct a literature search(years: 2002-2009) to identify existing clinical practiceguidelines (CPGs). Five existing clinical practiceguidelines were identified as meeting the high qualitycriteria set out in the AGREE Instrument. Therecommendations contained in these high-qualityCPGs have been used as the evidence base for theCAN-ADAPTT guideline development process.The strength of evidence classification for each ofthese existing CPGs can be found in Appendix F.Note that the grade of recommendation/strength ofevidence summary table for CAN-ADAPTT’ssummary statements can be found in Appendix B.U.S. Department of Health and Human ServicesPublic Health Service (2008) 13All patients should be asked if they usetobacco and should have their tobacco usestatus documented on a regular basis.Evidence has shown that clinic screeningsystems, such as expanding the vital signs toinclude tobacco use status or the use of otherreminder systems such as chart stickers orcomputer prompts, significantly increasesrates of clinician intervention. (Strength ofEvidence = A)Once a tobacco user is identified and advisedto quit, the clinician should assess thepatient’s willingness to quit at this time.(Strength of Evidence = C) US: Tobaccodependence treatment is effective and shouldbe delivered even if specialized assessmentsare not used or available. (Strength ofEvidence = A) All physicians should stronglyadvise every patient who smokes to quitbecause evidence shows that physician adviceto quit smoking increases abstinence rates.(Strength of Evidence = A)Minimal interventions lasting less than 3minutes increase overall tobacco abstinencerates. Every tobacco user should be offered atleast a minimal intervention, whether or nothe or she is referred to an intensiveintervention. (Strength of Evidence = A)There is a strong dose-response relationbetween the session length of person-topersoncontact and successful treatmentoutcomes. Intensive interventions are moreCOUNSELLING AND PSYCHOSOCIAL APPROACHES 8

CANADIAN SMOKING CESSATION GUIDELINEeffective than less intensive interventions andshould be used whenever possible. (Strengthof Evidence = A) Person-to-person treatmentdelivered for four or more sessions appearsespecially effective in increasing abstinencerates. Therefore, if feasible, clinicians shouldstrive to meet four or more times withindividuals quitting tobacco use. (Strength ofEvidence = A)Treatment delivered by a variety of cliniciantypes increases abstinence rates. Therefore,all clinicians should provide smokingcessation interventions. (Strength of Evidence= A) Treatments delivered by multiple typesof clinicians are more effective thaninterventions delivered by a single type ofclinician. Therefore, the delivery ofinterventions by more than one type ofclinician is encouraged.(Strength of Evidence = C)Proactive telephone counselling, groupcounselling, and individual counsellingformats are effective and should be used insmoking cessation interventions. (Strength ofEvidence = A) Smoking cessationinterventions that are delivered in multipleformats increase abstinence rates and shouldbe encouraged. (Strength of Evidence = A)Tailored materials, both print and Web-based,appear to be effective in helping people quit.Therefore, clinicians may choose to providetailored self-help materials to their patientswho want to quit.(Strength of Evidence = B)All patients who receive a tobaccodependence intervention should be assessedfor abstinence at the completion of treatmentand during subsequent contacts. (1)Abstinent patients should have their quittingsuccess acknowledged, and the clinicianshould offer to assist the patient withproblems associated with quitting. (2)Patients who have relapsed should beassessed to determine whether they arewilling to make another quit attempt.(Strength of Evidence = C)Two types of counselling and behaviouraltherapies result in higher abstinence rates: (1)providing smokers with practical counselling(problem-solving skills/skills training), and(2) providing support and encouragement aspart of treatment. These types of counsellingelements should be included in smokingcessation interventions. (Strength of Evidence= B)The combination of counselling andmedication is more effective for smokingcessation than either medication orcounselling alone. Therefore, wheneverfeasible and appropriate, both counsellingand medication should be provided topatients trying to quit smoking. (Strength ofEvidence = A) There is a strong relationbetween the number of sessions ofcounselling, when it is combined withmedication, and the likelihood of successfulsmoking cessation. Therefore, to the extentpossible, clinicians should provide multiplecounselling sessions, in addition tomedication, to their patients who are trying toquit smoking. (Strength of Evidence = A)Motivational intervention techniques appearto be effective in increasing a patient’slikelihood of making a future quit attempt.Therefore, clinicians should use motivationaltechniques to encourage smokers who are notcurrently willing to quit to consider making aquit attempt in the future. (Strength ofEvidence = B)New Zealand Ministry of Health (2007) 14Ask about and document smoking status forall patients. For people who smoke or haverecently stopped smoking, the smoking statusshould be checked and updated on a regularbasis. Systems should be in place in all healthcare settings (medical centres, clinics,hospitals, etc.) to ensure that smoking statusis accurately documented on a regular basis.(Grade = A)All doctors should provide brief advice toquit smoking at least once a year to allpatients who smoke. (Grade = A) All otherhealth care workers should also provide briefadvice to quit smoking at least once a year toall patients who smoke. (Grade = B) Recordthe provision of brief advice in patientrecords. (Grade = C) Aim to see people for atleast four cessation support sessions. (Grade =A)Health care workers providing evidencebasedcessation support (that is, more thanjust brief advice) should seek appropriatetraining. (Grade = C) Health care workerstrained as smoking cessation providersrequire dedicated time to provide cessationsupport. (Grade = C)Offer telephone counselling as an effectivemethod of stopping smoking. People whosmoke can be directed to Quitline (toll-free:0800 778 778). (Grade = A) Providing face-tofacesmoking cessation support either toindividual patients or to groups of smokers isan effective method of stopping smoking.(Grade = A) Make self-help materialsavailable, particularly those that are tailoredto individuals, but such materials should notbe the main focus of efforts to help peoplestop smoking. (Grade = √)COUNSELLING AND PSYCHOSOCIAL APPROACHES 9

CANADIAN SMOKING CESSATION GUIDELINEInstitute for Clinical Systems Improvement (ICSI)(2004) 15 Adults who have not used tobacco for at least12 months and who have an easily visiblemark on their chart to that effect should beasked about their tobacco use status yearlyuntil abstinent for five years. Everyonewithout a tobacco use mark on the chart orthose with a mark indicating use within thepast six months should be asked at nearlyevery visit. (Class = A, C, D, M, R)Ask a tobacco user who is ready to quit to sethis/her own quit date. (Class = C, R)All discussions with tobacco users should bedocumented. (No Grade)Consideration may also be given to making areferral to a tobacco cessation consultant or acenter with programs in tobacco cessation.Other resources include local tobaccocessation classes, community supportsystems, and self-help brochures andmaterials from drug companies. (Class = A)Compliment and reinforce non-use in formertobacco users. (Class = R)The first 12 months after quitting (especiallythe first two weeks) is when one is at thehighest risk for relapse. Follow-up optionsinclude a face-to-face, telephone, or mailed(postal or electronic)expression of support and willingness to help.(Class = M)A pre-contemplator (a user not ready toconsider quitting within the next six months)benefits from non-confrontational messagesabout the importance of quitting and theawareness that provider help is availablewhen ready.(No Class)A contemplator (who will consider quittingwithin the next 1-6 months) is accepting ofsupportive urging to quit and encouragementof a plan. (Class = C, R)Registered Nurses Association of Ontario (RNAO)(2007) 16 Nurses implement minimal tobacco useintervention using the “Ask, Advise, Assist,Arrange” protocol with all clients.(Strength of Evidence =A)Nurses introduce intensive smoking cessationintervention (more than 10 minutes duration)when their knowledge and time enables themto engage in more intensive counselling.(Strength of Evidence =A)Nurses recognize that tobacco users mayrelapse several times before achievingabstinence and need to re-engage clients inthe smoking cessation process.(Strength of Evidence = B)Nurses should be knowledgeable aboutcommunity smoking cessation resources, forreferral and follow-up.(Strength of Evidence = C)Nurses encourage persons who smoke, as wellas those who do not, to make their homessmoke-free, to protect children, families andthemselves from exposure to second-handsmoke. (Strength of Evidence = A)COUNSELLING AND PSYCHOSOCIAL APPROACHES 10

CANADIAN SMOKING CESSATION GUIDELINECAN-ADAPTT SUMMARYSTATEMENTSCAN-ADAPTT’s development process reflects adynamic opportunity to ensure that its guideline ispractice informed and addresses issues ofapplicability in the Canadian context. It has built fromthe evidence and recommendations contained inexisting guidelines. It did not review the primaryliterature to inform the development of its SummaryStatements unless emerging evidence was identifiedby the Guideline Development Group. The CAN-ADAPTT Guideline Development Group hasprovided the below Summary Statements forCounselling and Psychosocial Approaches.SUMMARY STATEMENT #1ASK:Tobacco use status should beupdated, for all patients/clients, byall health care providers on aregular basis.GRADE*: 1ASUMMARY STATEMENT #2ADVISE: Health care providers should clearlyadvise patients/clients to quit.GRADE*: 1CSUMMARY STATEMENT #3ASSESS: Health care providers should assessthe willingness of patients/clients tobegin treatment to achieveabstinence (quitting).GRADE*: 1CSUMMARY STATEMENT #4ASSIST: Every tobacco user who expressesthe willingness to begin treatment toquit should be offered assistance.GRADE*: 1Aa) Minimal interventions, of 1-3 minutes, areeffective and should be offered to everytobacco user. However, there is a strongdose-response relationship between thesession length and successful treatment,and so intensive interventions should beused whenever possible.GRADE*: 1Ab) Counselling by a variety or combinationof delivery formats (self-help, individual,group, helpline, web-based) is effectiveand should be used to assistpatients/clients who express awillingness to quit.GRADE*: 1Ac) Because multiple counselling sessionsincrease the chances of prolongedabstinence, health care providers shouldprovide four or more counsellingsessions where possible.GRADE*: 1Ad) Combining counselling and smokingcessation medication is more effectivethan either alone, therefore both shouldbe provided to patients/clients trying tostop smoking where feasible.GRADE*: 1Ae) Motivational interviewing is encouragedto support patients/clients willingness toengage in treatment now and in thefuture.GRADE*: 1BCOUNSELLING AND PSYCHOSOCIAL APPROACHES 11

CANADIAN SMOKING CESSATION GUIDELINESUMMARY STATEMENT #4 (Cont’d)f) Two types of counselling and behaviouraltherapies yield significantly higherabstinence rates and should be includedin smoking cessation treatment: 1)providing practical counselling onproblem solving skills or skill trainingand 2) providing support as a part oftreatment.GRADE*: 1BSUMMARY STATEMENT #5ARRANGE: Health care providers:a) should conduct regular follow-up toassess response, provide support andmodify treatment as necessary.GRADE*: 1Cb) are encouraged to refer patients/clientsto relevant resources as part of theprovision of treatment, whereappropriate.GRADE*: 1A* GRADE: See Appendix B for Grade of Recommendation andLevel of Evidence Summary Table.CLINICAL CONSIDERATIONSHealth care providers should be encouragedto ask about all forms of tobacco useincluding tobacco that is smoked (cigarettes,cigarillos, cigars, blunts, pipe, shisha, hookah,electronic cigarette) and smokeless (chewingtobacco, dipping tobacco, dissolvable tobacco,snus, snuff). This can be best asked by “Haveyou used any form of tobacco in the past sixmonths?”A systematic approach to asking abouttobacco use is best. Documenting tobaccostatus can involve medical questionnaires,stickers on client charts, electronic healthrecords, chart reminders or through computerreminder systems.Encourage smoke-free homes, including skillsto modify habits in order to minimize, avoidand/or counter triggers.Health care providers functioning within ateam should be encouraged to discuss theirsmoking cessation strategy for their practiceto ensure consistent application and toincrease effectiveness.Evidence demonstrates that tobaccodependence treatment can be effective andshould be considered even where specializedassessments are not used or available.Where appropriate, counselling can bedelegated by arranging for referral, whenbarriers to the provision of counselling exist(i.e. limited time, resources, staff etc.). Thereare effective programs available to supporthealth care providers and theirpatients/clients (see Tools/ResourcesSection).All health care providers should beencouraged to obtain training in cessationcounselling.Education of health care providers andpatients should have consistent messaging,align tools and services to serve both targets.This includes addressing collaboration acrossthe continuum of care (i.e. clinical orcommunity setting) and across disciplines.COUNSELLING AND PSYCHOSOCIAL APPROACHES 12

CANADIAN SMOKING CESSATION GUIDELINETOOLS/RESOURCES5A’s ToolsRESOURCEAlbertaQuits.caCentre for Addiction andMental Health (CAMH)Nicotine Dependence ClinicCost of smoking calculator(Canadian Cancer Society)Decisional Balance SheetFagerström Test forNicotine DependenceMotivational InterviewingWebsiteOn the Road to Quitting:Guide to becoming a nonsmokerOne Step at a time Series(Canadian Cancer Society)Ontario Tobacco ResearchUnit Online Course –Cessation ModulePartnership to Assist withCessation of Tobacco(PACT)Program Training andConsultation Centre (PTCC)Q.U.I.T.: Quit Using andInhaling TobaccoPREGNETS: The 5A’s ToolDETAILSOntario Medical Association: Clinical Tobacco Intervention: Smoking CessationGuideline Flow SheetTRac (Tobacco Reduction and Cessation) Safety Sensitive AlgorithmComprehensive online quit smoking service with access to counselling, selfassessments,medication guide, international community, and forumsThis clinic offers service to smokers and tobacco users who want to quit orreduce their tobacco use. It also provides specialized treatment services forsmokers who are pregnant and for people with other substance use issues,chronic mental illness and serious health concerns.Online tool to calculate the cost of smoking.A tool designed to facilitate a discussion between care providers andpatients/clients about the pros and cons of substance use.A validated tool for assessing initial dosing of NRT patches.These pages provide background information on the practice of MotivationalInterviewing.This guide will help individuals prepare and take action to successfully stopsmoking.For smokers who want to quit (English / French)For smokers who don’t want to quit (English / French)If you want to help a smoker quit (English / French)Free online courseCessation module deals with the complexities of quitting smoking, the roles thatnicotine addiction and motivation play in the quitting process, and bestpractices for smoking cessation.Smoking cessation workshops provided free of charge to groups, facilities andhealth regions with funding from Saskatchewan Health.Online information and training on brief tobacco interventions for healthprofessionals Variety of minimal contact tobacco trainings available. Free ofcharge.Canadian Pharmacists Association resource.QU.I.T. is a continuing education program, available in both live and onlineformats, that trains pharmacists to expand their role in patient care and offersmoking cessation services in their pharmacy.COUNSELLING AND PSYCHOSOCIAL APPROACHES 13

CANADIAN SMOKING CESSATION GUIDELINERESOURCEDETAILSSmokers’ Helpline OnlineAlberta– 1-866-332-2322(English)– Fax Referral formBritish Columbia– 1-877-455-2233(English, French +121 otherlanguages)– QuitNow.ca• Fax Referral form• Helping WomenQuit GuideManitoba– 1-877-513-5333(English, French)– Fax Referral formNewfoundland andLabrador– 1-800-363-5864(English)– CARE program(CommunityAction andReferral Effort)and fax referralformNew Brunswick– 1-877-513-5333(English, French)– Fax Referralprogram and form– Personalized QuitPlan: Tear OffPadsNorthwest Territories– 1-866-286-5099Nova Scotia– 1-877-513-5333(English, French)– Fax Referral formNunavut– 1-866-368-7848Ontario– 1-877-513-5333(English, French,Interpreterservice)– Fax Referral formPEI– 1-877-513-5333(English, French)– Fax Referral formQuebec– 1-866-527-7383(French, English)Saskatchewan– 1-877-513-5333(English, French)– Fax Referral formSmoking DiaryStages of Change DiagramTEACH (TrainingEnhancement in AppliedCessation Counselling andHealth) ProgramTRaC (Tobacco Reduction &Cessation) TrainingYukon– 1-877-513-5333A tool for tracking ongoing smoking when patients/clients are attempting toreduce or quit smoking. The tool is intended to enhance patients' awareness oftheir smoking behaviour.Diagram illustrating Prochaska and DiClemente’s Stages of Change ModelTEACH is geared toward training health care professionals providingcounselling services to tobacco users. The program is designed to enhanceknowledge and skills in the delivery of intensive tobacco cessationinterventions, including detection and treatment of people with concurrenttobacco dependence and mental health and/or addictive disorders andmotivational interviewing.Training program for health care professionals on tobacco cessationinterventionsTraining to help build capacity of health professionals in providing smokingcessation treatmentCOUNSELLING AND PSYCHOSOCIAL APPROACHES 14

CANADIAN SMOKING CESSATION GUIDELINERESEARCH GAPSWhen should the topic of smoking be raisedif a patient/client is dealing with multiplestressors? When is the optimal time toadvise someone to quit and how does aprofessional recognize this "optimal time"?Social network research and how this canbe used in practiceResearch on the social impact of smokingwithdrawal (what has been successful inassisting people to maintain their socialnetwork?)Effectiveness/efficacy of interventions andreferrals to programsEffectiveness of alternative treatments (i.e.hypnosis, laser therapy)The frequency and timing of healthprofessional interventions when it comes tothe effectiveness of brief providerinterventions, by more than one type ofhealth care provider.COUNSELLING AND PSYCHOSOCIAL APPROACHES 15

CANADIAN SMOKING CESSATION GUIDELINEOVERVIEW OF EVIDENCEThe following recommendations, and supportingevidence, have been extracted from existing clinicalpractice guidelines to inform the development of the CAN-ADAPTT Summary Statements.• SPECIFICPOPULATIONS:Aboriginal Peoples †CAN-ADAPTT’s Clinical PracticeGuideline Development Group;Section Lead: Sheila Cote-Meek,BScN, MBA, PhDCAN-ADAPTT worked with the Guidelines AdvisoryCommittee (GAC) to conduct a literature search(years: 2002-2009) to identify existing clinical practiceguidelines (CPGs). Five existing clinical practiceguidelines were identified as meeting the high qualitycriteria set out in the AGREE Instrument. Therecommendations contained in these high qualityCPGs have been used as the evidence base for theCAN-ADAPTT guideline development process.The strength of evidence classification for each ofthese existing CPGs can be found in Appendix F.Note that the grade of recommendation/strength ofevidence summary table for CAN-ADAPTT’ssummary statements can be found in Appendix B.New Zealand Ministry of Health (2007) 14Offer Ma¯ori who smoke cessation supportthat incorporates known effective components(such as medication). (Grade of Evidence = √)Where available, offer culturally appropriatecessation services to Ma¯ ori. (Grade ofEvidence = C)Health care workers should be familiar withthe cessation support services for Ma¯ ori thatare available in their area (such as localAukati Kai Paipa providers) and nationally(such as Quitline) so they can referappropriately.(Grade of Evidence = √)Health care workers providing cessationsupport to Ma¯ori should seek training inhow to deliver smoking cessation treatment toMa¯ ori. (Grade of Evidence = √)†Aboriginal peoples is used as an inclusive term whichincludes First Nations (both on and off reserve), Inuit, andMétis. This is not meant to take away from the diversity thatexists among Aboriginal peoplesABORIGINAL PEOPLES 16

CANADIAN SMOKING CESSATION GUIDELINEBACKGROUNDIt should be recognized by healthcare providers thattobacco has played an important part in traditionaland spiritual practices in many Aboriginalcommunities. Traditionally tobacco was used bymany First Nations for ceremonial and medicinalpurposes and is still practiced across many FirstNations.However, it is well documented that mis-use/abuseof tobacco is of growing concern not only to thegeneral Canadian population, but as well as to FirstNations. For example, studies have demonstrated thatsmoking rates amongst First Nations peoples are morethan double that of the general Canadian population.Furthermore, it has been documented that within FirstNations populations, there are instances of smokingbeginning as early as 6-8 years with an increase inuptake between the ages of 10-12, and peaking at 16years of age. The relevance of targetingchildren/youth within this population is thereforeevident.Not only are rates of smoking higher in thispopulation, but the poorer health status of FirstNations people in Canada has also been welldocumented in the literature which together points tosignificantly higher rates of smoking related illnessesin this population.There is limited evidence available demonstratingeffective strategies for smoking cessation withinAboriginal populations. It should be noted that thisdoes not suggest weak evidence of effective strategieswithin this population, but rather, a limited amountof research available (see Research Gaps section).However, generally those strategies which areeffective for the general Canadian population shouldbe considered effective within Aboriginal peoples.One recent Canadian study provides evidence thatquitlines are an effective option for Aboriginalpopulations 17 .Cultural adaptations should also be considered totailor interventions for this population. Similarly, allinterventions must consider the spiritual andtraditional role within the culture and acknowledgeother barriers to smoking cessation with the FirstNations population such as the concurrent high ratesof drug use and alcohol consumption.CAN-ADAPTT SUMMARYSTATEMENTSCAN-ADAPTT’s development process reflects adynamic opportunity to ensure that its guideline ispractice informed and addresses issues ofapplicability in the Canadian context. It has built fromthe evidence and recommendations contained inexisting guidelines. It did not review the primaryliterature to inform the development of its SummaryStatements unless emerging evidence was identifiedby the Guideline Development Group. The CAN-ADAPTT Guideline Development Group hasprovided the below Summary Statements forAboriginal Peoples.SUMMARY STATEMENT #1Tobacco misuse ∆ status should be updatedfor all Aboriginal peoples by all health careproviders on a regular basis.GRADE*: 1ASUMMARY STATEMENT #2All health care providers should offerassistance to Aboriginal peoples who misusetobacco with specific emphasis on culturallyappropriate methods.GRADE*: 1CSUMMARY STATEMENT #3All health care providers should be familiarwith available cessation support services forAboriginal peoples.GRADE*: 1CSUMMARY STATEMENT #4All individuals working with Aboriginalpeoples should seek appropriate training inproviding evidence-based smoking cessationsupport.GRADE*: 1C* GRADE: See Appendix B for Grade of Recommendation andLevel of Evidence Summary Table.∆Tobacco misuse does not refer to tobacco use fortraditional/ceremonial purposes.ABORIGINAL PEOPLES 17

CANADIAN SMOKING CESSATION GUIDELINECLINICAL CONSIDERATIONSThe Guideline Development group found thatthere was a significant gap in the research onAboriginal peoples and tobacco misuse.Guidelines developed in New Zealand wereutilized recognizing that these guidelines alsorequire further research. Despite the lack ofresearch there is evidence that there is adisproportionate burden of tobacco useamongst Aboriginal peoples. For example,youth uptake of tobacco is at a much earlierage than that of the general Canadianpopulation (See Youth Section).It should be emphasized that providersshould recognize and distinguish between useof traditional (ceremonial/sacred) tobaccoand misuse of commercial tobacco. Thereforeassessment and questions need to beconducted with care and respect for thisdifference.Health care practitioners should work withcommunity members including health careproviders, community health representatives,caregivers, elders and other leaders wherepossible, to deliver smoking cessationinterventions for Aboriginal peoples. Thereare a growing number of materials andmethods to assist with tobacco cessation andprevention that have been developed and/oradapted for Aboriginal peoples. (see Tools/Resources Section).Efforts should also be made to identify,engage and understand the range of resourcesavailable to provide appropriate referrals andconnectivity to the Aboriginal community.For example, local First Nations communities,urban Aboriginal programs, FriendshipCentres etc. (see Tools/Resources Section).In general, interventions that have beenproven to be effective in the generalpopulation are also likely to be effective forthese population groups. However, themanner in which these interventions aredelivered may need to be adapted for eachgroup in order to be as acceptable, accessibleand appropriate as possible. Therefore, toolsand strategies that have been developed forother populations should be tailoredappropriately with a full understanding of thecontext, barriers, and possible approacheswhen providing care to Aboriginal peopleswithin practice settings.Practitioners should recognize theheterogeneity of individuals and communitieswithin the Aboriginal population and tailorinterventions appropriately.ABORIGINAL PEOPLES 18

CANADIAN SMOKING CESSATION GUIDELINETOOLS/RESOURCESTITLECancer Care Ontario: Aboriginal TobaccoProgram (ATP)Program brochureFlu Shot and Tobacco UseTobacco-Wise Fact SheetCommercial Tobacco Fact SheetPoster SeriesInuit Tobacco-free Network (ITN)Kicking the Addiction:Facilitators Guide: Helping People to Live Smoke-Free in First Nations CommunitiesChoosing to Quit Z CardNational Association of Friendship Centres(NAFC)Locations: Alberta; British Columbia; Manitoba;Labrador; St. John's; Fort Smith; Rankin Inlet;Ontario; Quebec; Saskatchewan; YukonNational Indian & Inuit Community HealthRepresentatives Organization (NIICHRO)Tobacco Cessation Strategies During Pregnancyand Motherhood ($25)Taking the Lead for Change ($100)Protecting Our Families: The Non-Traditional Useof Tobacco ($75)NECHI: Training, Research and HealthPromotions InstituteIntegrated Tobacco Recovery for UrbanAboriginals Adults and AdolescentsTobacco: addiction & recovery – a spiritualjourneyTEACH Training Course:Tobacco Interventions with Aboriginal PeoplesWabano Centre for Aboriginal Health:Culture as Treatment - “ Mino-Babamadizin - AGood Healthy JourneyDESCRIPTIONMaterials developed by Cancer Care Ontario that tell you allabout the dangers of commercial tobacco and the sacredmeaning of tobacco.The Inuit Tobacco-free Network aims to keep Inuit healthworkers and their colleagues up-to-date on tobaccoreduction resources, research and events.Facilitator’s guide introduces the "Stages of Change" Modeland provides an overview of the 5A's (Ask, Advise, Assess,Assist and Arrange).Z card: A tool to help providers discuss benefits of quittingand quit tips with First Nations individuals.Available via Health Canada: 1(866) 318-1116 or tcpplt.questions@hc-sc.gc.caNAFC Acts as a central unifying body for the FriendshipCentre Movement: to promote and advocate the concerns ofAboriginal Peoples and represents the needs of localFriendship Centres across the country to the federalgovernment and to the public in general.Pregnancy Resource: Facilitators Guide onlyTaking the Lead for Change: Includes a training manual toassist CHRs with tobacco cessation programs andeducation as well as a video, activity book and flip chart.Protecting Our Families: Includes a manual, discussionguide for schools or community groups, video andaudiocassettesAll resources can be ordered via NIICHRO (450) 632-0892or this order formThe Nechi Training, Research and Health PromotionsInstitute offers specialized training to addictions counsellorsworking in Aboriginal communitiesCulturally appropriate self-help guides to smoking cessationResources available via (780) 459-1884Training course for healthcare professionals who providecounselling services to people who use tobacco.An Aboriginal Children’s Smoking Prevention ProgramResource available onlineABORIGINAL PEOPLES 19

CANADIAN SMOKING CESSATION GUIDELINERESEARCH GAPSMethods to integrate traditional practicesand spirituality into tobacco useinterventionsIdentify and evaluate programs in theAboriginal population to determine whichinterventions are effectiveResearch effective dissemination practicesGather surveillance data at thelocal/regional levels and with off-reserve,non-status and MétisABORIGINAL PEOPLES 20

CANADIAN SMOKING CESSATION GUIDELINEOVERVIEW OF EVIDENCEThe following recommendations, and supportingevidence, have been extracted from existing clinicalpractice guidelines to inform the development of the CAN-ADAPTT Summary Statements.• SPECIFICPOPULATIONS:Hospital-BasedPopulationsCAN-ADAPTT’s Clinical Practice GuidelineDevelopment Group;Section Lead: Robert Reid Ph.D., MBACAN-ADAPTT worked with the Guidelines AdvisoryCommittee (GAC) to conduct a literature search(years: 2002-2009) to identify existing clinical practiceguidelines (CPGs). Five existing clinical practiceguidelines were identified as meeting the high qualitycriteria set out in the AGREE Instrument. Therecommendations contained in these high-qualityCPGs have been used as the evidence base for theCAN-ADAPTT guideline development process.The strength of evidence classification for each ofthese existing CPGs can be found in Appendix F.Note that the grade of recommendation/strength ofevidence summary table for CAN-ADAPTT’ssummary statements can be found in Appendix B.U.S. Department of Health and Human ServicesPublic Health Service (2008) 13The interventions found to be effective in thisGuideline have been shown to be effective ina variety of populations. In addition, many ofthe studies supporting these interventionscomprised diverse samples of tobacco users.Therefore, interventions identified as effectivein this Guideline are recommended for allindividuals who use tobacco, except whenmedication use is contraindicated or withspecific populations in which medication hasnot been shown to be effective (pregnantwomen, smokeless tobacco users, lightsmokers, and adolescents). (Strength ofEvidence = B)Registered Nurses Association of Ontario (2007) 16Nurses implement smoking cessationinterventions, paying particular attention togender, ethnicity and age-related issues, andtailor strategies to the diverse needs of thepopulations. (Strength of Evidence = C)Organizations and Regional HealthAuthorities should consider smokingcessation as integral to nursing practice, andthereby integrate a variety of professionaldevelopment opportunities to support nursesin effectively developing skills in smokingcessation intervention and counselling.HOSPITAL-BASED POPULATIONS 21

CANADIAN SMOKING CESSATION GUIDELINEAll corporate hospital orientation programsshould include training to use brief smokingcessation interventions as well as informationon pharmacotherapy to support hospitalizedpersons who smoke.(Strength of Evidence = B)New Zealand Ministry of Health (2007) 14Provide brief advice to stop smoking to allhospitalized people who smoke. (Grade = A)Arrange multi-session intensive support,medication and follow up for at least 1 monthfor all hospitalized patients who smoke.(Grade = A)Briefly advise people awaiting surgery whosmoke to stop smoking and arrange support(such as NRT) prior to surgery. (Grade = A)All hospitals should have systems set up forhelping patients to stop smoking. Thisincludes routinely providing advice to stopsmoking and either providing a dedicatedsmoking cessation service within the hospitalor arranging for smoking cessation treatmentto be provided by an external service. (Grade= B)Advise parents and family members ofhospitalized children to stop smoking andoffer support to help them. (Grade = √)NRT can be provided to people withcardiovascular disease. However, wherepeople have suffered a serious cardiovascularevent (for example, people who have had amyocardial infarction or stroke) in the past 2weeks or have a poorly controlled disease,treatment should be discussed with aphysician. In these cases, oral NRT productsrather than patches are recommended as thepreferred option.(Grade = B)BACKGROUNDSmoking is known to have a significant negativeimpact on risks associated with hospitalization;quitting smoking prior to admission has been shownto be beneficial for postoperative complication rates 18 .Hospitalization provides an ideal window ofopportunity to deliver smoking cessation services andsupports for patients. Moreover, patients admitted fora smoking-related reason may be more receptive tosmoking cessation interventions 19 . A recent Cochranereview has demonstrated that smoking cessationinterventions, which begin during hospitalization andcontinue for at least one month post-discharge areeffective 19 .Furthermore, with the prevalence of hospital smokefreepolicies on the rise, the provision of nicotinewithdrawal treatment and availability of smokingcessation services to patients is becoming increasinglyvital.A model of systematic hospital interventions forsmoking cessation, The Ottawa model, has been shownto be effective in increasing abstinence rates forpatients 20 and has been implemented in nearly 70 sitesacross Canada to date 21 .HOSPITAL-BASED POPULATIONS 22

CANADIAN SMOKING CESSATION GUIDELINECAN-ADAPTT SUMMARYSTATEMENTSCAN-ADAPTT’s development process reflects adynamic opportunity to ensure that its guideline ispractice informed and addresses issues ofapplicability in the Canadian context. It has built fromthe evidence and recommendations contained inexisting guidelines. It did not review the primaryliterature to inform the development of its SummaryStatements unless emerging evidence was identifiedby the Guideline Development Group. The CAN-ADAPTT Guideline Development Group hasprovided the below Summary Statements forHospital-Based Populations.SUMMARY STATEMENT #1All patients should be made aware of hospitalsmoke-free policies.GRADE*: 1CSUMMARY STATEMENT #2All elective patients who smoke should bedirected to resources to assist them to quitsmoking prior to hospital admission orsurgery, where possible.GRADE*: 1BSUMMARY STATEMENT #3All hospitals should have systems in place to:a) identify all smokers;GRADE*: 1Ab) manage nicotine withdrawal duringhospitalization;GRADE*: 1Cc) promote attempts toward long-termcessation and;GRADE*: 1Ad) provide patients with follow-up supportpost-hospitalization.GRADE*: 1ASUMMARY STATEMENT #4Pharmacotherapy should be considered:a) to assist patients to manage nicotinewithdrawal in hospital;GRADE*: 1Cb) for use in-hospital and posthospitalizationto promote long termcessation.GRADE*: 1B* GRADE: See Appendix B for Grade of Recommendation andLevel of Evidence Summary TableHOSPITAL-BASED POPULATIONS 23

CANADIAN SMOKING CESSATION GUIDELINECLINICAL CONSIDERATIONSPROCESSES IN SMOKING CESSATIONINTERVENTIONS WITH HOSPITALIZED PATIENTSManaging nicotine withdrawal duringhospitalization should be distinguished froma long term cessation attempt.Mechanisms such as standing orders, medicaldirectives or order sets, should beimplemented where possible to ensure aconsistent process or approach for smokingcessation interventions across the hospitalsetting.A systematic approach to identify, treat andfollow up with all admitted smokers has beendemonstrated to be an effective model andshould be considered where possible. Oneexample of such an approach is the OttawaModel.Patient documentation/charting shouldinclude consistent data capture (performanceindicators) to track the intervention,pharmacotherapy and follow-up.Follow-up discharge planning and referral tocommunity supports/services will benefitsustained cessation efforts, as with supportivecounselling post-discharge.As to the duration for follow-up postdischarge,existing evidence suggests at leastone month 19 , however, continuous follow-upis preferable.Efforts should be made to link patients totheir primary healthcare provider upondischarge to ensure continuation of treatmentand follow-up.HOSPITAL POLICIESOpportunity to discuss or prioritize theimplementation of smoke-free policies inhospital settings can assist in establishing orsupporting smoking cessationprocesses/programming. Examples can bedrawn from institutions such as Centre forAddiction and Mental HealthHospital management teams and staff shouldbe encouraged to support smoking cessationfor hospitalized patients.Smoking Cessation interventions should alsobe made available for hospital staff.There are challenges determining whichpractitioner(s) are in a position or havecapacity to engage in the provision ofsmoking cessation interventions. Standingorders, medical directives could beconsidered and included in the developmentof a hospital smoking cessationsystem/process.To ensure and sustain capacity of smokingcessation program/services appropriateresource allocation is an importantconsideration.Approaches may differ for smokers admittedvia emergency vs. pre-admission, according topolicies. In addition, some approaches maydiffer for patients who stop smoking forhospitalizations versus those patients whohave a desire to quit while hospitalized.Hospital policies may support cessation fromthe perspective of harm reduction.PHARMACOTHERAPYIt should be recognized that pharmacotherapycan be provided to treat withdrawal duringhospitalization as well as to promote longterm cessation attempts.HOSPITAL-BASED POPULATIONS 24

CANADIAN SMOKING CESSATION GUIDELINETOOLS/RESOURCESTITLE DESCRIPTION RESOURCEOttawa Modelfor SmokingCessationStop SmokingBeforeSurgery(SSBS)Stop smokingfor SaferSurgeryOttawa Model for Smoking Cessation: The University ofOttawa Heart Institute (UOHI) has been operating a clinicalsmoking cessation program for the Ottawa community sincethe 1990s. In 2002, UOHI smoking cessation expertsdeveloped the OMSC – an institutional inpatient programthat systematically identifies, provides treatment, and offersfollow-up to all admitted smokers.Three Centres of Excellence for Clinical Smoking Cessationestablished:– New Brunswick's Horizon Health Network in EasternCanada;– Vancouver Coastal Health in British Columbia, and;– The University of Ottawa Heart Institute in OntarioTraining available in Ottawa (Workshop overview;Upcoming sessions in Ottawa)An intervention program for patients on surgical waitinglists in British Columbia. SSBS aims to deliver resources,such as referrals to the provinces’ QuitNow Services, tosmokers during the critical period when they are preparingfor surgery.Ontario's Anaesthesiologists’ Stop Smoking for SaferSurgery is a province-wide patient awareness campaignabout the benefits of stopping smoking prior to surgery.www.ottawamodel.cahttp://www.bccancer.bc.ca/PPI/Prevention/tobacco/ssbs.htmhttp://www.ontarioanesthesiologists.ca/stop-smoking-safe-surgery/RESEARCH GAPSEmerging evidence in pharmacotherapy inacute settingsEffectiveness of counselling and medicationswith hospitalized patientsEffectiveness of interventions provided bydifferent hospital personnel, includingnurses and respiratory therapistsRelapse prevention once the patient leavesthe hospitalSafety/risks/benefits of NRT use in perioperativepatientsImpact of hospital-based policy on smokingcessation rates among staff, patientsHOSPITAL-BASED POPULATIONS 25

CANADIAN SMOKING CESSATION GUIDELINEOVERVIEW OF EVIDENCEThe following recommendations and supporting evidencehave been extracted from existing clinical practiceguidelines to inform the development of the CAN-ADAPTTSummary Statements.• SPECIFICPOPULATIONS:Mental Health and/orOther Addiction(s)CAN-ADAPTT’s Clinical Practice GuidelineDevelopment Group;Section Leads: Charl Els, MBChB, FCPsych,MmedPsych (cum laude), ABAM, MROCC; andPeter Selby, CCFP, FCFP, MHSc, Dip ABAMAcknowledgments:Pamela Kaduri, MD Mmed(psych): Reviewed andadvised on background and clinical considerations,following confirmation of the summary statements bythe Guideline Development Group.CAN-ADAPTT worked with the Guidelines AdvisoryCommittee (GAC) to conduct a literature search(years: 2002-2009) to identify existing clinical practiceguidelines (CPGs). Five existing clinical practiceguidelines were identified as meeting the high qualitycriteria set out in the AGREE Instrument. Therecommendations contained in these high-qualityCPGs have been used as the evidence base for theCAN-ADAPTT guideline development process.The strength of evidence classification for each ofthese existing CPGs can be found in Appendix F.Note that the grade of recommendation/strength ofevidence summary table for CAN-ADAPTT’ssummary statements can be found in Appendix B.New Zealand Ministry of Health (2007) 14Provide brief advice to stop smoking to allusers of mental health services who smoke.(Grade = A) Offer smoking cessationinterventions that incorporate knowneffective components (such as those identifiedin the previous sections) to people withmental health disorders who smoke. (Grade =√) People with mental health disorders whostop smoking while taking medications fortheir illness should be monitored to determineif dosage reductions in their medication arenecessary. (Grade = A)Provide brief advice to stop smoking to allusers of addiction services who smoke.(Grade = A) Offer smoking cessationinterventions that incorporate knowneffective components (such as those identifiedin the previous sections) to people who smoketobacco and who use addiction services.(Grade = √)U.S. Department of Health and Human ServicesPublic Health Service (2008) 13Psychiatric comorbidity and substance use arevariables associated with lower abstinencerates, but treatment can be effective despitethe presence of risk factors for relapse. Allsmokers with psychiatric disorders, includingsubstance use disorders, should be offeredtobacco dependence treatment, and cliniciansmust overcome their reluctance to treat thisMENTAL HEALTH AND/OR OTHER ADDICTION(S) 26

CANADIAN SMOKING CESSATION GUIDELINEpopulation. Clinicians should closely monitorthe level or effects of psychiatric medicationsin smokers making a quit attempt. (no Gradeassigned)BACKGROUNDreinforcement effects of some addictive substances 29 .Consequently, people with mental illness may smokefor various reasons including to self medicate theeffects of their illness 29 .The high smoking rates among those with mentalillness and/or other addictions translate into morewidespread health consequences and deaths due tosmoking among this group 30 . People with mentalhealth and addictive disorders who smoke also faceenormous economic and social challenges. Studieshave also shown that up to 27% of their disabilityincome budget may be spent on tobacco products 31 .PREVALENCEPeople with mental illness are two to four times morelikely to smoke, are heavier smokers, smoke morenumbers of cigarettes per day, and have lower quitrates compared to smokers from the generalpopulation 22,23 .Prevalence of smoking among those diagnosed withmental disorders has been well documented. Smokingrates, differing by diagnoses, vary between 40 to 90%,compared to 17% in the general Canadianpopulation 24 . Studies have shown smoking ratesamongst people suffering from the followingdisorders: bipolar disorder 51 to 70%; majordepressive disorder 40 to 60%; anxiety disorders 8 to66% 25 Smoking prevalence for persons withschizophrenia has been found to be considerably high,ranging from 45 to 88% 25 . The burden in morbidityand mortality due to high smoking rates among thementally ill and addicted clients is alarming; thispopulation suffers disproportionately from smokingrelated disabilities and this causes great financialburden to the heath care system. It appears that thementally ill and addicted population are more likelyto suffer from various physical problems such ascardiovascular, lung diseases, and diabetes 26 , andtend to die much earlier than the generalpopulation 27 .Similarly, smoking prevalence within substanceabuse/addicted populations is also high; peoplereporting substance abuse problems have highersmoking prevalence than the general population, withnearly 50% having nicotine dependence 28 . Ratesranging from 11 to 48% have been found for thosewho abuse alcohol, cannabis, cocaine, amphetaminesand opioids 28 .There are various factors contributing to highersmoking rates among people with mental illnessand/or addictions including social, environmentaland biological factors. Self medication theory, sharedgenetic vulnerability and pathophysiologicalmechanisms may provide some explanations for highrates of comorbidity. Nicotine triggers release ofvarious neurotransmitters involved in somepsychiatric disorders and are associated with theMENTAL HEALTH AND/OR OTHER ADDICTION(S) 27

CANADIAN SMOKING CESSATION GUIDELINECLINICAL CONSIDERATIONSSCREENAn equally accurate term for ‘screening’ maybe ‘case finding’ given the prevalence oftobacco use among persons with mentalhealth diagnosis and/or addiction(s).The term ‘addictions’ refers to those addictedto substances other than nicotine.Asking about tobacco use should be anintegral part of a routine medical, mentalhealth and addiction screening in bothambulatory and inpatient settings.Due to the high prevalence of concurrentmental illness and addiction, allpatients/clients should be screened forunderlying, non-debilitating, undiagnosedmental health challenges.Conducting regular, brief screenings for moodchanges is encouraged since it may affectquitting and can be part of withdrawal, griefover loss of identity as a smoker, oremergence of a depressive disorder.OFFER PHARMACOTHERAPY/COUNSELLINGIt should be noted that no pharmacotherapyhas been contraindicated in persons withmental illness unless medicallycontraindicated.Pharmacotherapy and counselling approachesyield greater success rates than providingeither pharmacotherapy or counsellingapproach alone.Recently there have been advisories fromHealth Canada regarding the need forvigilance for neuropsychiatric side effectswhen quitting smoking especially whenassisted by bupropion SR 37 or varenicline 38 .Recognize that involuntary abstinence fromtobacco that occurs when smoker patients areadmitted to smoke free facilities requiresmanagement with an agonist at sufficientdoses.The withdrawal/anxiety experienced bypersons abstaining from smoking should berecognized and addressed, especially in acutecare facilities.Health care providers who work with patientswith mental health and/or addiction shouldnot promote smoking, provide cigarettes orsmoke with clients.MONITORFOLLOW-UPEmployers of health care professionals whosmoke should offer smoking cessationtreatment to their employees.Consider that persons with mental illnessand/or addiction(s) who smoke might needhigher doses of nicotine replacement therapy.Pharmacotherapy use may be required for alonger duration for persons with mentalillness and/ or addiction(s).Flexibility in the quit date can be tailored toindividual needs.Assess for interactions with medications usedfor treating comorbid conditions.Since caffeine levels can rise significantlywhen quitting smoking, caffeine intake needsto be monitored.Dose adjustments usually downwards may beneeded if client is on psychotropics(especially clozapine and olanzepine) that areaffected by smoking cessation.Clients’ psychiatric symptoms throughout thequitting process should be monitored.Clients should be encouraged to live in smokefree settings in the community.Clients should be followed by a health careprovider during the quitting process.Referral to appropriate healthcare services(community, program referral, other teammembers) for management/treatment andfollow-up can be considered when one isunable to offer the service.In-patient staff should be aware ofcommunity resources to support cessationand address nicotine dependence especiallyon discharge into community settings.RESOURCES FOR HEALTHCARE PROVIDERSTreatment facilities staff should increase theirunderstanding of mental health/addictionand nicotine dependence to effectively offercessation and to address stigma attached tomental illness and/or addiction.MENTAL HEALTH AND/OR OTHER ADDICTION(S) 29

CANADIAN SMOKING CESSATION GUIDELINEADDITIONAL CONSIDERATIONSGiven the culture of mental health andaddictions treatment facilities where staffoften smoked and thereby, clients’ smokingbehaviour was sustained, these facilities mustaddress smoking in their policies. Forexample, by becoming smoke-free indoorsand where possible on the facility’s grounds.All healthcare providers and staff in a practicesetting or treatment facilities should beoffered smoking cessation treatment.Financial resources for this “longer andstronger” counselling and/orpharmacotherapy are necessary. Persons withmental illness and/or addictions, due to alikelihood of lower disposable income andproportionally higher spending on tobacco,may especially benefit from subsidizedpharmacotherapy, in sufficient dose andduration.Limit out-of-pocket costs to smokers withmental illness and/or addictions to improveoutcomes.MENTAL HEALTH AND/OR OTHER ADDICTION(S) 30

CANADIAN SMOKING CESSATION GUIDELINETOOLS/RESOURCESTITLECanadian Mental HealthAssociationCanadian Psychiatry AssociationNicotine Dependence Clinic(Centre for Addiction and MentalHealth)TEACH ProgramHere to HelpDESCRIPTIONProvides resources for various mental health conditionsThis national professional association provides clinical practiceguidelines on various mental health conditions and other resources.This clinic offers service to smokers and tobacco users who want to quitor reduce their tobacco use. It also provides specialized treatmentservices for smokers with other substance use issues, chronic mentalillness and serious health concerns.No referral is requiredTobacco Interventions for patients with mental health and/or addictivedisordersOffers a specialized course about the detection and treatment ofconcurrent tobacco dependence and mental health and/or addictivedisorders.A partnership of seven leading mental health and addictions non-profitagencies working to help people prevent and manage mental health andsubstance use problems. Work is funded by the BC Mental Health andAddiction Services.RESEARCH GAPSNRT to assist with reducing to quit, highdose off label use and combination NRT inthis population.Safety and efficacy of varenicline in thispatient population.Efficacy of free pharmacotherapy forsmoking cessation in psychiatric patientsincluding those currently taking psychiatricmedication.Monitoring for consequences of long-termuse of smoking cessation medication.Whether approaches or interventions shouldbe tailored to different levels of mental healthand addiction services (e.g. crisis, firstpsychosis, etc.).Establish the efficacy and safety ofconcurrent or sequential quitting of tobaccouse in addiction treatment settings.MENTAL HEALTH AND/OR OTHER ADDICTION(S) 31

CANADIAN SMOKING CESSATION GUIDELINEOVERVIEW OF EVIDENCEThe following recommendations, and supportingevidence, have been extracted from existing clinicalpractice guidelines to inform the development of the CAN-ADAPTT Summary Statements.• SPECIFICPOPULATIONS:Pregnant &Breastfeeding WomenCAN-ADAPTT’s Clinical Practice GuidelineDevelopment Group;Section Lead: Alice Ordean, MD, CCFP, MHScCAN-ADAPTT worked with the Guidelines AdvisoryCommittee (GAC) to conduct a literature search(years: 2002-2009) to identify existing clinical practiceguidelines (CPGs). Five existing clinical practiceguidelines were identified as meeting the high qualitycriteria set out in the AGREE Instrument. Therecommendations contained in these high qualityCPGs have been used as the evidence base for theCAN-ADAPTT guideline development process.The strength of evidence classification for each ofthese existing CPGs can be found in Appendix F.Note that the grade of recommendation/strength ofevidence summary table for CAN-ADAPTT’ssummary statements can be found in Appendix B.U.S. Department of Health and Human ServicesPublic Health Service (2008) 13Because of the serious risks of smoking to thepregnant smoker and the fetus, wheneverpossible pregnant smokers should be offeredperson-to-person psychosocial interventionsthat exceed minimal advice to quit. (Strengthof Evidence = A)Although abstinence early in pregnancy willproduce the greatest benefits to the fetus andexpectant mother, quitting at any point inpregnancy can yield benefits. Therefore,clinicians should offer effective tobaccodependence interventions to pregnantsmokers at the first prenatal visit as well asthroughout the course of pregnancy.(Strength of Evidence = B)New Zealand Ministry of Health (2007) 14Offer all pregnant and breastfeeding womenwho smoke multi-session behaviouralsmoking cessation interventions from aspecialist/dedicated cessation service.(Grade=A)All health care workers should briefly advisepregnant and breastfeeding women whosmoke to stop smoking. (Grade = A)NRT can be used in pregnancy and duringbreastfeeding following a risk-benefitassessment. If NRT is used, oral NRTproducts (for example, gum, inhalers,microtabs and lozenges) are preferable tonicotine patches. (Grade=C)PREGNANT & BREASTFEEDING WOMEN 32

CANADIAN SMOKING CESSATION GUIDELINERegistered Nurses Association of Ontario (2007) 16Nurses implement, wherever possible,intensive intervention with women who arepregnant and postpartum. (Strength ofEvidence = A)SUMMARY STATEMENT #4Partners, friends and family members shouldalso be offered smoking cessationinterventions.GRADE*: 2BCAN-ADAPTT SUMMARYSTATEMENTSCAN-ADAPTT’s development process reflects adynamic opportunity to ensure that its guideline ispractice informed and addresses issues ofapplicability in the Canadian context. It has built fromthe evidence and recommendations contained inexisting guidelines. It did not review the primaryliterature to inform the development of its SummaryStatements unless emerging evidence was identifiedby the Guideline Development Group. The CAN-ADAPTT Guideline Development Group hasprovided the below Summary Statements for Pregnantand Breastfeeding Women.SUMMARY STATEMENT #1Smoking cessation should be encouraged forall pregnant, breastfeeding and postpartumwomen.GRADE*: 1ASUMMARY STATEMENT #2During pregnancy and breastfeeding,counselling is recommended as first linetreatment for smoking cessation.GRADE*: 1ASUMMARY STATEMENT #3If counselling is found ineffective, intermittentdosing nicotine replacement therapies (suchas lozenges, gum) are preferred overcontinuous dosing of the patch after a riskbenefitanalysis.GRADE*: 1CSUMMARY STATEMENT #5A smoke-free home environment should beencouraged for pregnant and breastfeedingwomen to avoid exposure to second-handsmoke.GRADE*: 1B* GRADE: See Appendix B for Grade of Recommendation andLevel of Evidence Summary Table.CLINICAL CONSIDERATIONSThere is limited evidence on harms associatedwith the use of NRT during pregnancy. Twoprospective studies found no adversematernal or fetal effects from the use ofnicotine patch during pregnancy; however,one recent study demonstrated potentialassociation between NRT and congenitaldefects. This data cannot support or excludean association between first trimester NRTuse and an increased risk of congenital defectsdue to several methodological issues.Therefore, until further information isavailable, the risks and benefits of smokingversus the use of NRT during pregnancy mustbe considered when counselling aboutsmoking cessation options.There is some evidence from RCTs that NRTmay be efficacious in pregnancy in terms ofdecreasing tobacco use and improvingpregnancy outcomes. No safety concernswere identified in these trials. Therefore,benefits of NRT seem to outweigh potentialrisks; NRT should be considered whencounselling has been ineffective.Despite preliminary evidence that continuedsmoking and relapse are more likely amongPREGNANT & BREASTFEEDING WOMEN 33

NEONATALEFFECTSLONG-TERMEFFECTSPREGNANCYCOMPLICATIONSCANADIAN SMOKING CESSATION GUIDELINEpregnant women who have a smokingpartner, there is limited data regarding thebenefits of partner involvement in smokingcessation interventions for pregnant smokers.In non-pregnant populations, interventions toincrease support did not find increasedquitting rates.Evidence from a recent systematic review andmeta-analysis demonstrated negativeperinatal outcomes (e.g. trend towards lowerbirth weight, smaller head circumference andcongenital anomalies) associated with secondhandsmoke exposure. Therefore, pregnantand breastfeeding women should avoid thisenvironmental risk.Challenges in identification due to stigmaassociated with smoking during pregnancy.Smoking cessation interventions should beconsidered for the full spectrum of care frompreconception visit to 1 year postpartum.Smoking cessation counselling and care ofpregnant smokers may be conducted byphysicians, allied healthcare professionals(e.g. social worker, pharmacist, communityhealth representatives), midwives, doulas,prenatal advisors, postpartum supports,family home visitors, and others.Nicotine replacement therapy (NRT) can beconsidered as a second line option forindividuals who cannot quit after counsellinginterventions.Depression during pregnancy is a commonoccurrence and the use of Zyban (bupropion)may be appropriate to treat both smoking anddepression. There is limited evidence on theeffectiveness of bupropion for smokingcessation during pregnancy. In addition,there is no evidence of harm related to the useof bupropion during pregnancy and therefore,it may be considered for use as an alternativeto NRT for a subpopulation of pregnantsmokers (see Table 1 below).Including partners, friends, and/or family ina pregnant smoker’s quit attempt is essentialto increase the likelihood of successfulsmoking cessation interventions.A smoke-free home environment should beencouraged for partners, friends, familymembers of pregnant and breastfeedingwomen to ensure safety from second-handsmoke/environmental tobacco smoke.Table 1 – Negative Effects Associated with CigaretteSmoking During Pregnancy and BreastfeedingCigarette smoking during pregnancy andbreastfeeding is associated with numerous negativeeffects on mother, fetus, infant and adolescent. 39Subfertility (female and male)Ectopic pregnancy (outside the uterus)Spontaneous abortion (miscarriage)Preterm labourPremature rupture of membranesPlacental problems (previa & abruption)Growth restrictionLow birth weight (on average ~200grams smaller)Increased perinatal mortalityIncreased admission to the neonatalintensive care unit (NICU)Sudden infant death syndrome (SIDS)Decreased volume of breast milk andduration of breastfeedingChildhood respiratory illnesses(asthma, pneumonia, bronchitis)Other childhood medical problems(ear infections)Learning problems(reading, mathematics, general ability)Behavioral problemsAttention deficit hyperactivity disorder(ADHD)PREGNANT & BREASTFEEDING WOMEN 34

CANADIAN SMOKING CESSATION GUIDELINETOOLS/RESOURCESTITLE DESCRIPTION RESOURCECouples and Smoking:What you need to knowwhen you are pregnantHelping Women QuitPREGNETSTEACH training course:Helping PregnantSmokers Stop Smoking:An Interactive CaseBased CourseMotheriskThe Right Time...TheRight Reasons...Dadstalk about Reducing andQuitting Smoking.This is a self-help booklet for pregnant women who smoke. Inthis booklet you will learn how routines, habits, and ways ofinteracting with your partner influence smoking.Understanding how smoking is influenced by others andeveryday routines is an important first step in changingsmoking behaviours. If you decide to reduce or stop smoking,you can use this booklet along with other resources tosupport you in reaching your goals.A guide giving background on tobacco cessation for women,and step by step instructions to helping women quit smoking.It tells you what questions to ask to identify a cessationapproach for each woman, and it points you to resources toaddress her needs.Website with the mission to improve the health of mothers,fetuses, babies and children.Goals: To eliminate smoking in pregnant and postpartumwomen by increasing the capacity to quit and stay quit usinga woman centred model of care.This specialty course manual will allow clinicians to increasetheir knowledge about tobacco use, screening, assessment,and interventions with pregnant and postnatal women. Theprice of this manual reflects only the development and laborcosts associated with its production.Connected to Sick Children’s Hospital in Toronto, Motheriskprovides online information on the risks of using substances(including tobacco) while pregnant. It also offers telephonecounselling for women, and consultation for serviceproviders.This booklet is based on fathers’ experiences of reducing andquitting smoking. The quotes in the booklet are fromexpectant and new dads who smoke or have recently reducedor quit and offer their thoughts and ideas. This booklet is formen who identify with the challenges around being anexpectant or new dad who smokes.Self-help bookletGuide – Alcohol,Drug andEducationService, BCOnline resource,discussion boardCourse manualand in-persontrainingWebsite,telephonecounselling1-877-327-4636Self-help bookletRESEARCH GAPSRelationship between smoking and infertilityUse of bupropion and varenicline as asmoking cessation aid – need more researchon the effectiveness and safetyNeed more evidence of risk/benefit analysisof various smoking cessation aidsPREGNANT & BREASTFEEDING WOMEN 35

CANADIAN SMOKING CESSATION GUIDELINEOVERVIEW OF EVIDENCEThe following recommendations, and supportingevidence, have been extracted from existing clinicalpractice guidelines to inform the development of the CAN-ADAPTT Summary Statements.• SPECIFICPOPULATIONS: Youth(Children andAdolescents)CAN-ADAPTT’s Clinical Practice GuidelineDevelopment Group;Section Lead: Jennifer O'Loughlin, PhD, CRC,CAHS fellowCAN-ADAPTT worked with the Guidelines AdvisoryCommittee (GAC) to conduct a literature search(years: 2002-2009) to identify existing clinical practiceguidelines (CPGs). Five existing clinical practiceguidelines were identified as meeting the high qualitycriteria set out in the AGREE Instrument. Therecommendations contained in these high qualityCPGs have been used as the evidence base for theCAN-ADAPTT guideline development process.The strength of evidence classification for each ofthese existing CPGs can be found in Appendix F.Note that the grade of recommendation/strength ofevidence summary table for CAN-ADAPTT’ssummary statements can be found in Appendix B.U.S. Department of Health and Human ServicesPublic Health Service (2008) 13Clinicians should ask pediatric and adolescentpatients about tobacco use and provide astrong message regarding the importance oftotally abstaining from tobacco use. (Strengthof Evidence = C)Counselling has been shown to be effective intreatment of adolescent smokers. Therefore,adolescent smokers should be provided withcounselling interventions to aid them inquitting smoking. (Strength of Evidence = B)Secondhand smoke is harmful to children.Cessation counselling delivered in pediatricsettings has been shown to be effective inincreasing abstinence among parents whosmoke. Therefore, to protect children fromsecondhand smoke, clinicians should askparents about tobacco use and offer themcessation advice and assistance. (Strength ofEvidence = B)Institute for Clinical Systems Improvement (2004) 40(Birth to 10 years): Smoke exposure (in home,at day care, etc.) should be established atnearly every visit. Tobacco use status of allpatients (and in the case of infants andchildren, the use status of everyone in thehome) should be established. (Class ofEvidence = D, M, R, X)YOUTH (CHILDREN AND ADOLESCENTS) 36

CANADIAN SMOKING CESSATION GUIDELINE(10 years and above): Patient’s tobacco use andsecond hand smoke exposure should beestablished at nearly every visit. (Class ofEvidence = D, M, R, X)Adolescents should have usage re-assessed atnearly every visit, regardless of whether thereis a chart notation of non-use. (Class ofEvidence = A, C, D, M, R)(10 years and above): “Pre-contemplators”benefit from non-confrontational messagesabout the importance of quitting and theawareness that provider help is availablewhen ready. (Class of Evidence = R)(10 years and above): “Contemplators” shouldreceive support and respectful urging to quit.A patient in “preparation” should set a quitdate, receive self-help information and beencouraged to accept follow-up after the quitdate. (Class of Evidence = A, M, R)(10 years and above): If a patient’s parent,sibling or friend uses tobacco, patients shouldbe assisted in developing refusal skills andgiven educational materials. (Class ofEvidence = A)New Zealand Ministry of Health (2007) 14Offer smoking cessation interventions thatincorporate known effective components(such as those identified in the previoussections) to young people who smoke.(Grade = √)NRT can be used by young people (12-18 yearolds) who are dependent on nicotine (that is,NRT is not recommended for use byoccasional smokers) if it is believed that NRTmay aid the quit attempt. (Grade = C)BACKGROUNDYouth have their own social network of individualswhom they trust and who exert influence over them.Healthcare practitioners may or may not be part ofthese networks. Cooperative efforts to provide nonsmokingmessages between adults other thanhealthcare practitioners might increase effectiveness.Community mobilization in tobacco use preventionprovides a model for shared efforts between parties.Tobacco use habits among youth evolve duringadolescence and the timing and trajectory of smokingand addiction differ between youth depending onfactors such as access to tobacco, geneticpredisposition, family and peer influence etc. Thereare no guidelines as to what constitutes “smoking” inyouth so consensus is needed as to when a youth isconsidered to be a smoker (the recommendation isthat first puff be viewed as a risk factor for continuedsmoking).There is as yet, no widely accepted, standardizedyouth-specific definition of nicotine dependence foruse by clinicians. Similarly there are no validatedscreening tools, which would help practitionersidentify when a youth is dependent. What is neededis a tool that helps clinicians identify youth at risk ofsustained smoking and nicotine dependence beforethese outcomes are established (i.e., before it is toolate), since successful intervention among dependentyouth is challenging. Research is needed to betterunderstand what clinicians should ask about inidentifying youth at risk for sustained smoking. Workis ongoing to develop a prognostic tool for identifyingadolescents at risk of becoming daily smokers, whomay benefit from counselling aimed at preventingsustained smoking 41 .Regarding the effectiveness of treatments for youth,more research needs to be done. There are few RCTstesting cessation interventions for youth. Among 16trials reviewed recently 42 , three school-basedprograms and one in a clinic setting providedevidence of effectiveness. An intervention thatcombined NRT and behavioural counselling alsoshowed promise.There is little evidence to date on whether or not torecommend NRT to youth and this issue requiresfurther research. As indicated in the UK and NewZealand guidelines, however, measures for treatingsmoking cessation in adults may be suitable for youth.YOUTH (CHILDREN AND ADOLESCENTS) 37

CANADIAN SMOKING CESSATION GUIDELINECAN-ADAPTT SUMMARYSTATEMENTSCAN-ADAPTT’s development process reflects adynamic opportunity to ensure that its guideline ispractice informed and addresses issues ofapplicability in the Canadian context. It has built fromthe evidence and recommendations contained inexisting guidelines. It did not review the primaryliterature to inform the development of its SummaryStatements unless emerging evidence was identifiedby the Guideline Development Group. The CAN-ADAPTT Guideline Development Group hasprovided the below Summary Statements for Youth(Children and Adolescents).SUMMARY STATEMENT #1Health care providers, who work with youth(children and adolescents) should obtaininformation about tobacco use (cigarettes,cigarillos, waterpipe, etc.) on a regular basis.GRADE*: 1ASUMMARY STATEMENT #2Health care providers are encouraged toprovide counselling that supports abstinencefrom tobacco and/or cessation to youth(children and adolescents) that use tobacco.GRADE*: 2CSUMMARY STATEMENT #3Health care providers in pediatric health caresettings should counsel parents/guardiansabout the potential harmful effects of secondhandsmoke on the health of their children.GRADE*: 2C 43* GRADE: See Appendix B for Grade of Recommendation andLevel of Evidence Summary Table.CLINICAL CONSIDERATIONSYouth, unlike adults who are usuallyestablished in their pattern of tobacco use, aremore likely to be in the process of acquiringthe smoking habit with its concomitantnicotine dependence. In addition to notbeginning to smoke, prevention of transitionfrom intermittent to regular smoking may bekey in helping youth stop smoking. Thefollowing recommendations are relevant toinquiry about youth smoking.Ask questions to ascertain use of tobaccoproducts in multiple ways; use languageand terminology that youth are familiarwith.Be aware of the natural history of tobaccouse onset since there are importantmilestones from “first puff” to nicotinedependence that may signal transition toregular or daily smoking. Smoking onsettrajectories should be closely monitored,since intermittent smoking can quicklybecome regular smoking. Ask, for exampleabout “puffing” or “trying” in addition toregular or daily use (which indicatesustained smoking).Use direct inquiry or a validatedprognostic or screening tool to identifythose at high risk of sustained smoking.Identify those with additional health risks(e.g. Asthma).Any child or adolescent who consumestobacco products should be advised tostop. The effectiveness of the 5 As has notbeen established in youth. However,asking and advising “are generallyconsidered to be the entry points forproviding effective individualintervention” 13 .Types of Smoking Cessation Treatments.Community-based (i.e., non-clinical)tobacco control programs for youth may bean important resource for referral purposesThere are few studies that evaluate if briefcounselling by health professionals iseffective in youth.Motivational interviewing techniques canbe adapted for youth 13 .To date, there is little empirical evidencethat either NRT 14 or bupropion SR use 13 areeffective in young smokers. However theyhave been shown to be safe.The New Zealand guidelines recommendinterventions for youth that are effective inadults (i.e., interventions that incorporatemulti-session support) 14 .YOUTH (CHILDREN AND ADOLESCENTS) 38

CANADIAN SMOKING CESSATION GUIDELINETo date, there is little empirical evidence thatadvising parents about the potential harmfuleffects of their smoking or of secondhandsmoke on their child(ren), is effective.However, counselling parents in pediatricsettings or “…during child hospitalizationsmay increase parents’ interest in stoppingsmoking, parents’ quit attempts and parents’quit rates…” 13 .YOUTH (CHILDREN AND ADOLESCENTS) 39

CANADIAN SMOKING CESSATION GUIDELINETOOLS/RESOURCESTITLE DESCRIPTION RESOURCEBLAST programLeave the Pack BehindMyLastDip.comQuit4LifeStupid.caTalk with your childrenabout smokingBLAST (Building Leadership for Action in SchoolsToday) is a youth leadership tobacco preventionprogram developed by the Lung Association ofAlberta & NWT. It challenges youth to think criticallyabout the tobacco industry and its products, and thesocial and health effects from tobacco.LTPB delivers smoking cessation and preventionsupport to post-secondary students who smoke orare at risk of starting to smoke.A free, best-practices Web-based treatment programdesigned to help young smokeless tobacco usersquit.Health-Canada sponsored website with profiles andactivities to support youth in smoking cessation.An anti-tobacco movement created for youth, byyouth, funded by Ontario’s Ministry of HealthPromotion.A pamphlet suggesting how to approach thediscussion about smoking with childrenProgram to empoweryouth to become leadersand advocates in theirschools and communitiesResources for smokers,friends of smokers andhealth professionals.Web-based treatmentprogramInteractive andpersonalized 4 week webprogram.Educational resource forYouth.Educational pamphletRESEARCH GAPSEvaluate the effectiveness of using the 5A’s inpaediatric clinics to treat both adolescents andparents. With youth, at what points shouldclinicians intervene and how often?Explore the safety and effectiveness ofmedications in adolescents, including bupropionSR, NRT, varenicline, and a nicotine vaccineInvestigate the effectiveness of counsellinginterventions to motivate youth to stop usingtobaccoInvestigate the effectiveness of child-focusedversus family-focused or peer-focusedinterventions as well as interventions accessedvia the Internet, quitlines, and school-basedprogramsResearch strategies for increasing theefficacy, appeal, and reach of counsellingtreatments for adolescent smokersEvaluate interventions that preventsustained smoking in youthWhat should clinicians ask about inidentifying youth at risk for sustainedsmoking?To what extent should other addictions beaddressed?How to develop best practices thatacknowledge the range of specific situationsencountered by youthYOUTH (CHILDREN AND ADOLESCENTS) 40

CANADIAN SMOKING CESSATION GUIDELINE• APPENDICESAPPENDICES 41

CANADIAN SMOKING CESSATION GUIDELINEAPPENDIX A – Guideline Development Process Flow DiagramAPPENDICES 42

CANADIAN SMOKING CESSATION GUIDELINEAPPENDIX B – Grade of Recommendation & Level of Evidence Summary Tablefor CAN-ADAPTT Summary Statements**GR/LOE*1AStrongRecommendationHigh QualityEvidenceCLARITY OFRISK/BENEFITBenefits clearlyoutweigh risk andburdens, or vice versaQUALITY OFSUPPORTING EVIDENCEConsistent evidence from well performedrandomized, controlled trials oroverwhelming evidence of some otherform. Further research is unlikely tochange our confidence in the estimate ofbenefit and risk.IMPLICATIONSStrong recommendations, canapply to most patients in mostcircumstances withoutreservation. Clinicians shouldfollow a strong recommendationunless a clear andcompelling rationale for analternative approach ispresent.1BStrongRecommendationModerate QualityEvidenceBenefits clearlyoutweigh risk andburdens, or vice versaEvidence from randomized, controlledtrials with important limitations(inconsistent results, methodologic flaws,indirect or imprecise), or very strongevidence of some other research design.Further research (if performed) is likely tohave an impact on our confidence in theestimate of benefit and risk and maychange the estimate.Strong recommendation andapplies to most patients.Clinicians should follow astrong recommendationunless a clear and compellingrationale for an alternativeapproach is present.1CStrongRecommendationLow QualityEvidenceBenefits appear tooutweigh risk andburdens, or vice versaEvidence from observational studies,unsystematic clinical experience, or fromrandomized, controlled trials with seriousflaws. Any estimate of effect is uncertain.Strong recommendation, andapplies to most patients.Some of the evidence basesupporting the recommendationis, however, of lowquality.2AWeakRecommendationHigh QualityEvidenceBenefits closelybalanced with risksand burdensConsistent evidence from well performedrandomized, controlled trials oroverwhelming evidence of some otherform. Further research is unlikely tochange our confidence in the estimate ofbenefit and risk.Weak recommendation, bestaction may differ dependingon circumstances or patientsor societal values2BWeakRecommendationModerate QualityEvidence2CWeakRecommendationLow QualityEvidenceBenefits closelybalanced with risksand burdens, someuncertainly in theestimates of benefits,risks and burdensUncertainty in theestimates of benefits,risks, and burdens;benefits may beclosely balanced withrisks and burdensEvidence from randomized, controlledtrials with important limitations(inconsistent results, methodologic flaws,indirect or imprecise), or very strongevidence of some other research design.Further research (if performed) is likely tohave an impact on our confidence in theestimate of benefit and risk and maychange the estimate.Evidence from observational studies,unsystematic clinical experience, or fromrandomized, controlled trials with seriousflaws. Any estimate of effect is uncertain.Weak recommendation,alternative approaches likelyto be better for some patientsunder some circumstancesVery weak recommendation;other alternatives may beequally reasonable.* GR- Grade of Recommendation, LOE – Level of Evidence** Adapted from: UpToDate. Grading guide. No date. Available from: http://www.uptodate.com/home/about/policies/grade.html; andGuyatt G, Gutterman D, Baumann MH, Addrizzo-Harris D, Hylek EM, Phillips B, Raskob G, Lewis SZ, Schünemann H. Gradingstrength of recommendations and quality of evidence in clinical guidelines: Report from an American College of Chest Physicia nstask force. Chest. 2006 Jan;129(1):174-81, originally adapted from the GRADE Working Group.APPENDICES 43

CANADIAN SMOKING CESSATION GUIDELINEAPPENDIX C – Clinical Practice Guidelines Identified in November 2006National Advisory Committee on Health and Disability (National Health Committee). (2002, May).Guidelines for smoking cessation. Retrieved October 24, 2007 from:http://www.nzgg.org.nz/guidelines/0025/Smoking_Cessation_full.pdfInstitute for Clinical Systems Improvement (ICSI). (2004, June). Health care guideline: Tobacco useprevention and cessation for adults and mature adolescents. Retrieved October 24, 2007 from:http://www.icsi.org/tobacco_use_prevention_and_cessation_for_adults/tobacco_use_prevention_and_cessation_for_adults_and_mature_adolescents_2510.htmlInstitute for Clinical Systems Improvement (ICSI). (2004, June). Tobacco use prevention and cessation forinfants, children and adolescents. Retrieved October 24, 2007 from:http://www.icsi.org/tobacco_use_prevention_and_cessation_for_children/tobacco_use_prevention_and_cessation_for_infants__children_and_adolescentsn_and_adolescents__full_version_.htmlRegistered Nurses Association of Ontario (RNAO). (2003, October). Integrating smoking cessation intodaily nursing practice. Retrieved October 24, 2007 from:http://www.rnao.org/bestpractices/PDF/BPG_smoking_cessation.pdfManagement of Tobacco Use Working Group. (2004, June). VA/DoD clinical practice guideline for themanagement of tobacco use. Version 2.0a. Washington (DC): Department of Veteran Affairs, Departmentof Defense. Retrieved October 24, 2007 from: http://www.oqp.med.va.gov/cpg/TUC3/G/TUC-2004.pdfNational Institute for Health and Clinical Excellence (NICE). (2006, March). Brief interventions andreferral for smoking cessation in primary care and other settings. Public Health Intervention GuidanceNo 1. Retrieved October 24, 2007 from: http://www.nice.org.uk/download.aspx?o=299608Le Foll, B., Melihan-Cheinin, P., Rostoker, G., & Lagrue, G. for the working group of AFSSAPS. (2005).Smoking cessation guidelines: Evidence-based recommendations of the French Health Products SafetyAgency. European Psychiatry: the Journal of the Association of European Psychiatrists, 20(5-6), 431-441.Smoking cessation guidelines for Australian general practice. (2004). Retrieved October 24, 2007 from:http://www.health.gov.au/internet/wcms/publishing.nsf/content/health-pubhlthpublicat-document-smoking_cessation-cnt.htm/$FILE/smoking_cessation.pdfEBM Guidelines. (2006, December). Smoking cessation.APPENDICES 44

CANADIAN SMOKING CESSATION GUIDELINEAPPENDIX D – Clinical Practice Guidelines Identified in December 2008U.S. Department of Health and Human Services Public Health Service. (2008, May). Clinical practiceguideline: Treating tobacco use and dependence: 2008 update.Reichert, J., de Araújo, A.J., Gonçalves, C.M., Godoy, I., Chatkin, J.M., Sales, Mda P., et al. (2008,October). Smoking cessation guidelines: 2008. Jornal Brasileiro de Pneumologia, 34(10), 845-880.Ministry of Health. (2007, August). New Zealand smoking cessation guidelines. Wellington: Ministry ofHealth.Registered Nurses Association of Ontario (RNAO). (2007, March). Integrating smoking cessation intodaily nursing practice.Tønnesen, P., Carrozzi, L., Fagerstro, K.O., Gratziou, C., Jimenez-Ruiz, C., Nardinie, S., et al. (2007).Smoking cessation in patients with respiratory diseases: a high priority, integral component of therapy.European Respiratory Society Task Force. European Respiratory Journal, 29, 390-417.APPENDICES 45

CANADIAN SMOKING CESSATION GUIDELINEAPPENDIX E – Clinical Practice Guidelines Used as Evidence Base forGuideline DevelopmentInstitute for Clinical Systems Improvement (ICSI). (2004, June). Health care guideline: Tobacco useprevention and cessation for adults and mature adolescents.Institute for Clinical Systems Improvement. (ICSI). (2004, June). Tobacco use prevention and cessation forinfants, children and adolescents.New Zealand Ministry of Health. (2007, August). New Zealand smoking cessation guidelines.Registered Nurses Association of Ontario (RNAO). (2003, October). Integrating smoking cessation intodaily nursing practice.Registered Nurses Association of Ontario (RNAO). (2007, March). Integrating smoking cessation intodaily nursing practice.U.S. Department of Health and Human Services Public Health Service. (2008, May). Clinical practiceguideline: Treating tobacco use and dependence: 2008 update.APPENDICES 46

CANADIAN SMOKING CESSATION GUIDELINEAPPENDIX F – Strength of Evidence Classification Tables for Clinical PracticeGuidelines Used as Evidence Base for CAN-ADAPTT’s Guideline DevelopmentThe following strength of evidence classification tables are for each of the existing CPGs used as the evidencebase for CAN-ADAPTT’s guideline development. Note that the grade of recommendation/strength of evidencetable for CAN-ADAPTT’s summary statements can be found in Appendix B.U.S. Department of Health and Human Services Public Health Service (2008)STRENGTH-OF-EVIDENCECLASSIFICATIONStrength of Evidence = AStrength of Evidence = BStrength of Evidence = CCRITERIAMultiple well-designed randomized clinical trials, directlyrelevant to the recommendation, yielded a consistentpattern of findings.Some evidence from randomized clinical trials supportedthe recommendation, but the scientific support was notoptimal. For instance, few randomized trials existed, thetrials that did exist were somewhat inconsistent, or thetrials were not directly relevant to the recommendation.Reserved for important clinical situations in which thePanel achieved consensus on the recommendation in theabsence of relevant randomized controlled trials.Registered Nurses Association of Ontario (RNAO) (2007)STRENGTH-OF-EVIDENCECLASSIFICATIONStrength of Evidence = AStrength of Evidence = BStrength of Evidence = CCRITERIARequires at least two randomized controlled trials as partof the body of literature of overall quality and consistencyaddressing the specific recommendations.Requires availability of well conducted clinical studies,but no randomized controlled trials on the topic ofrecommendations.Requires evidence from expert committee reports oropinions and/or clinical experience of respectedauthorities. Indicates absence of directly applicablestudies of good quality.APPENDICES 47

CANADIAN SMOKING CESSATION GUIDELINENew Zealand Ministry of Health (2007)GRADES OFRECOMMENDATIONSGrade of Recommendation = AGrade of Recommendation = BGrade of Recommendation = CGrade of Recommendation = IGrade of Recommendation =CRITERIAThe recommendation is supported by GOOD (strong)evidence.The recommendation is supported by FAIR (reasonable)evidence, but there may be minimal inconsistency oruncertainty.The recommendation is supported by EXPERT opinion(published) only.There is INSUFFICIENT evidence to make arecommendation.GOOD PRACTICE POINT (in the opinion of the guidelinedevelopment group).Institute for Clinical Systems Improvement (ICSI) (2004)EVIDENCE GRADING SYSTEMClasses of Research ReportsA. PRIMARY REPORTS OF NEW DATA COLLECTION:CLASS ACLASS BCLASS CCLASS DRandomized, controlled trialCohort studyNon-randomized trial with concurrent or historical controlsCase-control studyStudy of sensitivity and specificity of a diagnostic testPopulation-based descriptive studyCross-sectional studyCase seriesCase reportB. REPORTS THAT SYNTHESIZE OR REFLECT UPON COLLECTIONS OF PRIMARY REPORTS:CLASS MCLASS RCLASS XMeta-analysisSystematic reviewDecision analysisCost-effectiveness analysisConsensus statementConsensus reportNarrative reviewMedical opinionAPPENDICES 48

CANADIAN SMOKING CESSATION GUIDELINEAPPENDIX G – List of CommitteesExecutive CommitteeThe Executive Committee was responsible for overseeing the execution of the CAN-ADAPTT Project whichincluded providing direction to the Coordinating Centre staff with respect to methodology, work plan andobjectives for the development of the guideline, recruitment and management of the CAN-ADAPTT Network andthe Evaluation Framework.Peter Selby, MBBS, CCFP, FCFP, MHSc, Dip ABAMTupper Bean, MBA, MHScCharl Els, MBChB, FCPsych, MMedPsych (cum laude), ABAM, MROCCRoberta Ferrence, PhDJohn Garcia, PhDPaul McDonald, PhD, FRSPHCameron Norman, PhDMichele Tremblay, MDLaurie Zawertailo, PhDEvaluation CommitteeThe Evaluation of CAN-ADAPTT was subcontracted to an independent group, Ontario Tobacco Research Unit(OTRU). The Evaluation Committee provided opportunity for OTRU to gain valuable input into the Evaluationframework and methodology of CAN-ADAPTT which included understanding the value, quality and usability ofthe CAN-ADAPTT clinical practice guideline.Peter Selby, MBBS, CCFP, FCFP, MHSc, Dip ABAMAlexey Babayan, PhDRosa Dragonetti, MScJohn Garcia, PhDKatie Hunter, MScCameron Norman, PhDJess Rogers, BARobert Schwartz, PhDEmily Taylor, BSc, MAAPPENDICES 49

CANADIAN SMOKING CESSATION GUIDELINEAPPENDIX H – References1. Health Canada. Canadian Tobacco Use Monitoring Survey (CTUMS) 2010. http://www.hc-sc.gc.ca/hcps/tobac-tabac/research-recherche/stat/_ctums-esutc_2010/ann_summary-sommaire-eng.php.AccessedNovember 21, 2011.2. Health Canada. Canadian Tobacco Use Monitoring Survey (CTUMS) 2010. http://www.hc-sc.gc.ca/hcps/tobac-tabac/research-recherche/stat/_ctums-esutc_2010/ann-eng.php- t6. Accessed November 21,2011.3. Prochaska JO, Velicer WF, Fava JL, Ruggiero L, Laforge RG, Rossi JS, Johnson SS, Lee PA. Counselor andstimulus control enhancements of a stage-matched expert system intervention for smokers in a managedcare setting. Prev Med. 2001 Jan;32(1):23-32.4. Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review ofrigorous evaluations. Lancet. 1993 Nov 27;342(8883):1317-22.5. World Health Organization. Framework Convention for Tobacco Control. 2003 updated reprint 2004,2005: Geneva, Switzerland.6. AGREE Collaboration. http://www.agreetrust.org7. Smoking Cessation in Canada: Practice-informed Research Agenda. The Canadian Action Network forthe Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment (CAN-ADAPTT). April 19, 2011 http://www.can-adaptt.net/English/Pages/Research/Research-Agenda.aspx8. Harrison MB, Légaré F, Graham ID, Fervers B. Adapting clinical practice guidelines to local context andassessing barriers to their use. CMAJ. 2010 Feb 9;182(2):E78-84.9. GRADE working group. http://www.gradeworkinggroup.org/10. UpToDate. Grading guide. No date. Available from:http://www.uptodate.com/home/about/policies/grade.html; and Guyatt G, Gutterman D, BaumannMH, Addrizzo‐ Harris D, Hylek EM, Phillips B, Raskob G, Lewis SZ, Schünemann H. Grading strength ofrecommendations and quality of evidence in clinical guidelines: Report from an American College ofChest Physicians task force. Chest. 2006 Jan;129(1):174-81, originally adapted from the GRADE WorkingGroup.11. Grimshaw J, Eccles M, Tetroe J. Implementing clinical guidelines: current evidence and futureimplications. J Contin Educ Health Prof. 2004 Fall;24 Suppl 1:S31-7. Review.12. Graham ID, Beardall S, Carter AO, Tetroe J, Davies B. The state of the science and art of practiceguidelines development, dissemination and evaluation in Canada. J Eval Clin Pract. 2003 May;9(2):195-202.13. U.S. Department of Health and Human Services Public Health Service. (2008, May). Clinical practiceguideline: Treating tobacco use and dependence: 2008 update.14. Ministry of Health. (2007, August). New Zealand smoking cessation guidelines. Wellington: Ministry ofHealth.15. Institute for Clinical Systems Improvement (ICSI). (2004, June). Health care guideline: Tobacco useprevention and cessation for adults and mature adolescents. Retrieved October 24, 2007 from:http://www.icsi.org/tobacco_use_prevention_and_cessation_for_adults/tobacco_use_prevention_and_cessation_for_adults_and_mature_adolescents_2510.html. Accessed October 24, 2007.16. Registered Nurses Association of Ontario (RNAO). (2007, March). Integrating smoking cessation intodaily nursing practice. http://www.rnao.org/bestpractices/PDF/BPG_smoking_cessation.pdf. AccessedOctober 26, 2007.17. Hayward LM, Campbell HS, Sutherland-Brown C. Aboriginal users of Canadian quitlines: an exploratoryanalysis. Tob Control. 2007 Dec;16 Suppl 1:i60-4.18. Tønnesen H, Nielsen PR, Lauritzen JB, Møller AM. Smoking and alcohol intervention before surgery:evidence for best practice. Br J Anaesth. 2009 Mar;102(3):297-306. Review.APPENDICES 50

CANADIAN SMOKING CESSATION GUIDELINE19. Rigotti NA, Munafo MR, Stead LF. Smoking cessation interventions for hospitalized smokers: asystematic review. Arch Intern Med. 2008 Oct 13;168(18):1950-60. Review.20. Reid RD, Mullen KA, Slovinec D'Angelo ME, Aitken DA, Papadakis S, Haley PM,McLaughlin CA, PipeAL. Smoking cessation for hospitalized smokers: an evaluation of the "Ottawa Model". Nicotine Tob Res.2010 Jan;12(1):11-8.21. University of Ottawa Heart Institute. Ottawa Model for Smoking Cessation.http://ottawamodel.ca/en_about.php. Accessed November 16, 2010.22. Ziedonis D, Hitsman B, Beckham JC, Zvolensky M, Adler LE, Audrain-McGovern J, Breslau N, BrownRA, George TP, Williams J, Calhoun PS, Riley WT. Tobacco use and cessation in psychiatric disorders:National Institute of Mental Health report. Nicotine Tob Res. 2008 Dec;10(12):1691-715.23. Lasser K, Boyd JW, Woolhandler S, Himmelstein DU, McCormick D, Bor DH. Smoking and mentalillness: A population-based prevalence study. JAMA. 2000 Nov 22-29;284(20):2606-10.24. Canadian Tobacco Use Monitoring Survey (CTUMS). 2010. Annual Results. http://www.hc-sc.gc.ca/hcps/tobac-tabac/research-recherche/stat/_ctums-esutc_2010/ann_summary-sommaire-eng.php.AccessedNovember 21, 2011.25. Kalman D, Morissette SB, George TP. Co-morbidity of smoking in patients with psychiatric and substanceuse disorders. Am J Addict. 2005 Mar-Apr;14(2):106-23. Review.26. Action on Smoking and Health (2001). Mental health patients are victims of tobacco.http://www.ash.org/. Accessed August 25, 2011.27. Colton CW, Manderscheid RW. Congruencies in increased mortality rates, years of potential life lost, andcauses of death among public mental health clients in eight states. Prev Chronic Dis. 2006 Apr;3(2):A42.28. Le Strat Y, Ramoz N, Gorwood P. In alcohol-dependent drinkers, what does the presence of nicotinedependence tell us about psychiatric and addictive disorders comorbidity? Alcohol Alcohol. 2010 Mar-Apr;45(2):167-72.29. Farnam CR. Zyban: a new aid to smoking cessation treatment--will it work for psychiatric patients? JPsychosoc Nurs Ment Health Serv. 1999 Feb;37(2):36-42;quiz 43-4.30. Johnson JL, et al. Tobacco Reduction in the Context of Mental Illness and Addictions: A Review of theEvidence. Prepared for Dr. J. Millar and L. Drasic of the Provincial Health Services Authority by theCentre for Addiction Research of British Columbia. May 1, 2006.http://www.calgaryhealthregion.ca/programs/tobacco/pdf/evidence_review.pdf. Accessed November19, 2010.31. Steinberg ML, Williams JM, Ziedonis DM. Financial implications of cigarette smoking among individualswith schizophrenia. Tob Control. 2004 Jun;13(2):206.32. Baker A, Richmond R, Haile M, Lewin TJ, Carr VJ, Taylor RL, Jansons S, Wilhelm K. A randomizedcontrolled trial of a smoking cessation intervention among people with a psychotic disorder. Am JPsychiatry. 2006 Nov;163(11):1934-42.33. Lopes FL, Nascimento I, Zin WA, Valença AM, Mezzasalma MA, Figueira I, Nardi AE. Smoking andpsychiatric disorders: a comorbidity survey. Braz J Med Biol Res. 2002 Aug;35(8):961-7.34. Williams JM, Ziedonis D. Addressing tobacco among individuals with a mental illness or an addiction.Addict Behav. 2004 Aug;29(6):1067-83. Review.35. Prochaska JJ, Rossi JS, Redding CA, Rosen AB, Tsoh JY, Humfleet GL, Eisendrath SJ, Meisner MR, HallSM. Depressed smokers and stage of change: implications for treatment interventions. Drug AlcoholDepend. 2004 Nov 11;76(2):143-51.36. George TP, Vessicchio JC, Sacco KA, Weinberger AH, Dudas MM, Allen TM, et al. A placebo-controlledtrial of bupropion combined with nicotine patch for smoking cessation in schizophrenia. Biol Psychiatry.2008:63(11); 1092 – 1096.37. Marketed Health Products Directorate, Health Products and Food Branch. Important drug safetyinformation for WELLBUTRIN SR and ZYBAN (bupropion HCI): warning for SSRIs and other newer antidepressantsregarding the potential for behavioural and emotional changes, including risk of self-harm—APPENDICES 51

CANADIAN SMOKING CESSATION GUIDELINEBiovail Pharmaceuticals Canada. Ottawa, ON: Health Canada; 2010. www.hc-sc.gc.ca/dhpmps/medeff/advisories-avis/prof/_2004/wellbutrin_zyban_hpc-cps-eng.php.Accessed August 11, 2011.38. Marketed Health Products Directorate, Health Products and Food Branch. Champix (vareniclinetartrate)—changes to the Canadian product monograph. Ottawa, ON: Health Canada; 2010.http://www.hc-sc.gc.ca/dhp-mps/medeff/advisories-avis/public/_2010/champix_2_pc-cp-eng.php.Accessed August 11, 2011.39. Briggs GG, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation, 7th edition. Philadelphia:Lippincott Williams & Wilkins, 200540. Institute for Clinical Systems Improvement (ICSI). (2004, June). Tobacco use prevention and cessation forinfants, children and adolescents.http://www.icsi.org/tobacco_use_prevention_and_cessation_for_children/tobacco_use_prevention_and_cessation_for_infants__children_and_adolescentsn_and_adolescents__full_version_.html. AccessedOctober 24, 2007.41. Karp I, Paradis G, Lambert M, Dugas E, O'Loughlin J. A prognostic tool to identify adolescents at highrisk of becoming daily smokers. BMC Pediatr. 2011 Aug 11;11:70.42. Gervais A, O'Loughlin J, Dugas E, Eisenberg MJ, Wellman RJ, DiFranza JR: “A systematic review ofrandomized controlled trials of youth smoking cessation interventions”. Drogues, santé et société 2007, 6(Supplement II): ii1-ii2643. Priest N, Roseby R, Waters E, Polnay A, Campbell R, Spencer N, Webster P, Ferguson-Thorne G. Familyand carer smoking control programmes for reducing children's exposure to environmental tobaccosmoke. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD001746. DOI:10.1002/14651858.CD001746.pub2APPENDICES 52

Canadian Action Network for the Advancement,Dissemination and Adoption of Practice-informedTobacco TreatmentCentre for Addiction and Mental Health175 College StreetToronto, Ontario, M5T 1P7For more information or to join the network, please visit:www.can-adaptt.netOr write to us:can_adaptt@camh.net