Partnering with patients to help them quit smoking

In this issue of CMAJ, the Canadian Task Force on Preventive Health Care presents its new guideline on interventions for tobacco smoking cessation.¹ Every time clinicians encounter a person who smokes tobacco, they have an important opportunity to act by advising their patient to quit smoking. In the guideline, the authors emphasize that doing so confers a small but significant increase in the likelihood that a patient will quit. I discuss why this guideline is relevant reading for all clinicians and provides them with the best tools available to empower their patients to quit smoking, with a long menu of effective interventions to choose from.

The guideline includes strong recommendations in favour of behavioural interventions (e.g., counselling), pharmacotherapies, or both together. Recommended pharmacotherapies include prescription medications (varenicline and bupropion), nicotine replacement therapy (various forms), and cytisine (a natural health product for which varenicline is a synthetic analogue). Although the task force considered only whether individual interventions had evidence of efficacy, a large body of evidence exists for efficacy of interventions used in combination or compared with one another. Among the above therapies, the largest effects on smoking cessation success have been observed with varenicline, cytisine, or combination nicotine replacement therapy (a slow-release patch together with a rapid-acting formulation).²

Laudably, the guideline authors make a conditional recommendation against electronic cigarettes (e-cigarettes) for smoking cessation for most patients. An updated systematic review by the authors did show that nicotine-containing e-cigarettes increase smoking cessation compared with non-nicotine e-cigarettes or usual care,¹ which is unsurprising, as such e-cigarettes are a form of nicotine replacement therapy. However, a key difference between e-cigarettes and other nicotine replacement modalities is that they deliver many of the same toxins and carcinogens found in tobacco smoke directly into patients’ lungs, albeit usually at lower concentrations than with regular cigarette smoking.³ How the long-term risks of e-cigarette vaping compare with the risks of smoking is not yet known. E-cigarettes comprise a vast array of poorly standardized and inconsistently formulated products. Only a handful of devices, many not currently marketed in Canada, have been studied in smoking cessation trials, and their observed benefits and harms cannot be generalized to all other e-cigarettes. Approval from Health Canada has neither been sought nor granted for the indication of smoking cessation. All these factors make recommending e-cigarettes to patients difficult for clinicians, especially given the availability of other effective, safer interventions that should be the first-line choice for smoking cessation therapy.

Successful smoking cessation requires a patient who is ready to make a quit attempt. Therefore, placing patients at the centre of clinical decisions about smoking cessation — while always important — is crucial when it comes to smoking cessation. The authors of the guideline acknowledge this explicitly by framing the recommendations as a menu of options from which patients can choose in consultation, either with their health care provider or, in some cases, on their own. However, the options that people currently choose do not align well with evidence. The most recent Canadian Tobacco and Nicotine Survey showed that in 2022, nearly two-thirds of people attempting to quit smoking did not use any intervention to increase quitting success and, among those who did, e-cigarettes were chosen slightly more frequently than conventional nicotine replacement therapy.⁴ These findings suggest that patients face substantial barriers to accessing recommended smoking cessation therapies, which may be related to health care access, cost, mistrust, or misinformation. Therefore, clinicians have a critical role in ensuring that patient choices are informed in this context.

Although governments need to do more to make the smoking cessation interventions recommended in the guideline equitably and universally available to people across Canada,⁵ people who smoke should be made aware of the existing supports available to them. All provincial and territorial formularies cover some or all of varenicline, bupropion, and nicotine replacement therapy. For people without public drug coverage, most provinces and territories have government or community agencies that provide free or subsidized access to smoking cessation pharmacotherapies. Behavioural supports are offered though free smoking cessation helplines operated by each province and territory, as well as by Health Canada.

Health care institutions also play a critical role in smoking cessation, given the important contribution of smoking to a great many diseases that consume health care resources. People who smoke are more likely to engage successfully in smoking cessation when they are identified and an offer to help quit is made as a routine part of care. For example, many hospitals across Canada and internationally have introduced the Ottawa Model for Smoking Cessation, a multicomponent process of care intervention combined with a program of evidence-based behavioural therapy and pharmacotherapy that has demonstrated a significant long-term increase in smoking cessation and reduction in mortality at 1 year.⁶

Although Canada has succeeded in substantially reducing the prevalence and incidence of smoking over the last half century, more work remains to help people who continue to smoke. Using this new guideline, clinicians will be better equipped to partner with their patients to enable them to free themselves from Canada’s leading preventable cause of death and disease.

See related article at www.cmaj.ca/lookup/doi/10.1503/cmaj.241584