An algorithm for tailoring pharmacotherapy for smoking cessation: results from a Delphi panel of international experts

Abstract

Background: Evidence-based smoking cessation guidelines recommend nicotine replacement therapy (NRT), bupropion SR and varenicline as first-line therapy in combination with behavioural interventions. However, there are limited data to guide clinicians in recommending one form over another, using combinations, or matching individual smokers to particular forms. Objective: To develop decision rules for clinicians to guide differential prescribing practices and tailoring of pharmacotherapy for smoking cessation. Methods: A Delphi approach was used to build consensus among a panel of 37 international experts from various health disciplines. Through an iterative process, panellists responded to three rounds of questionnaires. Participants identified and ranked ''best practices'' used by them to tailor pharmacotherapy to aid smoking cessation. An independent panel of 10 experts provided cross-validation of findings.Results: There was a 100% response rate to all three rounds. A high level of consensus was achieved in determining the most important priorities: (1) factors to consider in prescribing pharmacotherapy: evidence, patient preference, patient experience; (2) combinations based on: failed attempt with monotherapy, patients with breakthrough cravings, level of tobacco dependence; (3) specific combinations, main categories: (a) two or more forms of NRT, (b) bupropion + form of NRT; (4) specific combinations, subcategories: (1a) patch + gum, (1b) patch + inhaler, (1c) patch + lozenge; (2a) bupropion + patch, (2b) bupropion + gum; (5) impact of comorbidities on selection of pharmacotherapy: contraindications, specific pharmacotherapy useful for certain comorbidities, dual purpose medications; (6) frequency of monitoring determined by patient needs and type of pharmacotherapy. Conclusion: An algorithm and guide were developed to assist clinicians in prescribing pharmacotherapy for smoking cessation. There appears to be good justification for ''off-label'' use such as higher doses of NRT or combination therapy in certain circumstances. This practical tool reflects best evidence to date of experts in tobacco cessation.

An updated algorithm for choosing among smoking cessation treatments

“…Since the author's prior algorithm, two new algorithms have been published (Bader et al, 2009;LeFoll & George, 2007). The major differences in content between the current algorithm versus the author's prior algorithm and the other more recent algorithms are that the current algorithm (a) endorses both gradual and abrupt cessation, (b) does not consider single NRT a first line treatment, and (c) endorses Internet-based treatments.…”

“…One major limitation of the current algorithm is that is that it is based solely on one author's interpretation of the literature. In contrast, one of the other two algorithms was based on a structured Delphi process involving multiple experts from several countries (Bader et al, 2009). …”

“…The current algorithm attempts to integrate recent research findings and conclusions of guidelines, meta-analyses, reviews, and treatment manuals that have been published since 2008 (Bader, McDonald, & Selby, 2009;Fiore, 2008;Hatsukami, Stead, & Gupta, 2008;Lai, Cahill, Qin, & Tang, 2011;LeFoll & George, 2007;Raw, Regan, Rigotti, & McNeill, 2009) (www.treatobacco.net, www.nice.org.uk). The author has presented a similar algorithm but focused only on medication treatments among smokers actively trying to quit (www.ipap.org).…”

A Retrospective Review of Pilot Outcomes from an Out-patient Tobacco Treatment Programme Within Cardiology Services

“…Combinations of these products are frequently utilised. A medication protocol was established for the SCC programme based on existing treatment algorithms for the use of pharmacotherapy in clinics and outpatient settings (Bader, McDonald, & Selby, 2009). Decisions regarding the amount and type of pharmacotherapy used were guided by several factors determined at initial assessment.…”

Refining compliance surveys to measure the smokefree status of jurisdictions using the Delphi method

“…[18][19][20][21][22] However, this technique has not been used in tobacco control or specifically in smokefree compliance surveys. Compliance surveys for assessing smokefree status may be direct observational studies that are purely quantitative or semi-qualitative studies if subjective measures, such as the smell of tobacco, are introduced.…”