While approximately 17% of Canadians are current smokers1, a large proportion have been shown to be willing to make a quit attempt2. Health care providers have an important role to play in assisting individuals to quit smoking. Moreover, even brief interventions by providers are known to be effective in increasing the likelihood of a quit attempt by a person who smokes3. Clinical practice guidelines are known to be an important and effective provider tool to close the gap between recommended care and actual care provided4.
The need for national clinical practice guidelines has also been identified by the World Health Organization’s Framework Convention for Tobacco Control (FCTC), which states that parties to the treaty “…shall develop and disseminate appropriate, comprehensive and integrated guidelines based on scientific evidence and best practice, taking into account national circumstances and priorities, and shall take effective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence”5.
BACKGROUND OF CAN-ADAPTT
In May 2007, the Tobacco Control Program of Health Canada assembled selected members of the tobacco control community for a roundtable discussion pertaining to tobacco cessation guidelines. This roundtable of experts highlighted several issues and needs, including:
· Traditional methods of guideline development have relied on a narrow field of evidence, focusing mainly on randomized controlled trials (that typically fail to account for conditions and factors that influence treatment)
· Need to approach guideline/guidance development with inter-professional collaboration that significantly contributes both clinically practical and population level perspectives
· Need to engage stakeholders in guideline development and implementation processes
· Need for effective vehicles of communication and knowledge translation between the different audiences and stakeholders
To address these needs, the Canadian Action Network for the Advancement, Dissemination, and Adoption of Practice-informed Tobacco Treatment (CAN-ADAPTT) was established in 2008, with funding from the Drugs and Tobacco Initiatives Program of Health Canada.
CAN-ADAPTT’s vision is to encourage a Canada where health care providers have access to the tools needed to deliver up to date evidence-based smoking cessation interventions to reduce the prevalence of tobacco use and dependence. Its overall goal is to establish a national PBRN to facilitate research and knowledge exchange to inform the development of a dynamic cessation guideline for use in clinical practice and population-based strategies within Canada.
CAN-ADAPTT is committed to facilitating smoking cessation research and knowledge exchange among health care providers, researchers, and policy/ decision makers. CAN-ADAPTT aims to close the gap between research and practice by meeting the following objectives:
· Create a practice-based research network (PBRN) to inform smoking cessation research and practice across Canada
· Develop a practice-informed research agenda that bridges the gaps between clinical practice, research and theoretical frameworks
· Translate research evidence into a dynamic set of evidence-based guidelines
· Disseminate findings and engage stakeholders to promote the adoption of the guidelines
· Collaborate with others involved in tobacco use and dependence
· Evaluate the system and population impacts of the PBRN
From 2008-2011, CAN-ADAPTT worked with stakeholders to develop a practice informed clinical practice guideline (CPG) for smoking cessation in Canada. CAN‐ADAPTT’s guideline development process reflects a dynamic opportunity to ensure that its guideline is practice-informed and addresses issues of applicability in the Canadian context.
CAN-ADAPTT, while building from recognized standards for guideline development (outlined in the AGREE Instrument6), also integrated unique approaches to guideline development, including:
1. Building from existing guidelines
CAN-ADAPTT subcontracted the Guidelines Advisory Committee (GAC) to independently identify and evaluate existing CPGs using the AGREE Instrument by family physicians. The recommendations contained in the high quality guidelines (determined by AGREE scores) were used as the evidence base for the CAN-ADAPTT guideline development process.
2. Using a practice-informed approach and dynamic process
CAN-ADAPTT engaged stakeholders, health care provider from diverse practice settings, policy makers and health care managers and a broad range of researchers to provide input into the development of the guideline.
SCOPE AND PURPOSE
This guideline is intended for use by Canadian health care providers in diverse clinical or treatment settings. This guideline is also intended for researchers and decision makers with an interest in understanding the key elements to a comprehensive smoking cessation system in Canada. The guideline contains sections on both clinical and population level approaches to smoking cessation interventions for persons who smoke or use tobacco. Sections of the guideline were also developed to address some of the questions regarding specific populations such as Aboriginal Peoples and Hospital Based Populations (see below for a complete list of topics).
This guideline is not intended to be prescriptive. It is designed to support rather than replace the clinical judgment of health care providers. Information contained in this guideline may be less applicable in certain situations or with specific populations. This guideline is intended to provide a foundation from which health care providers, researchers and decision makers (including health care managers) in Canada can adapt and tailor the information and recommendations to meet their own needs and settings.
FORMAT OF GUIDELINE
The guideline is organized into the following sections:
· Counselling & Psychosocial Approaches
· Pharmacotherapy (in progress using a different guideline development methodology)
· Aboriginal Peoples
· Hospital Based Populations
· Mental Health and/or Other Addiction(s)
· Pregnant & Breastfeeding Women
· Youth (Children & Adolescents)
Population Level Approaches (in progress).
Each section of the guideline is divided into the following sub-sections:
1. Overview of Evidence includes the recommendations and supporting evidence extracted from relevant pre-existing high quality CPGs, which have contributed to the CAN-ADAPTT summary statements.
2. Summary Statements are based on the best evidence identified, and are the important messages for health care providers to consider implementing in practice. Each Summary Statement includes the Grade of Recommendation and Level of Evidence supporting the Statement.
3. Clinical Considerations is information supporting the Summary Statements, such as how to best implement the Statements, important implications for specific practice settings and key considerations. Clinical Considerations were informed by the input of the Guideline Development Group and CAN-ADAPTT Network Members. It was not informed by a systematic review of the literature.
4. Tools and Resources provides a list of resources that health care providers can use to help implement the Summary Statements. The lists are not intended to be comprehensive; they are a starting point informed by the Guideline Development Group and CAN-ADAPTT Network Members.
5. Research Gaps describes any gaps in the evidence and recommendations for future research in the area. See the CAN-ADAPTT Research Agenda for more information7.
CLARIFICATION AND LIMITATIONS
In this document, the term “tobacco” refers to manufactured, commercial tobacco products including, but not limited to, cigarettes, smokeless tobacco such as snuff, snus, and chewing tobacco, and cigars. Tobacco misuse does not refer to tobacco use for traditional or ceremonial purposes by Aboriginal Peoples.
Most research in the area of smoking cessation has examined cigarette use; it is important to note this limitation when using this guideline with smokeless tobacco users. More research is needed on smokeless tobacco products and the people who use smokeless tobacco to understand the impact of smoking cessation interventions.
The term patient/client is used throughout this guideline to reflect the diverse clinical settings where smoking cessation treatment is provided. The term health care provider is used throughout and is intended to reflect a broad range of providers in a range of different settings, including hospital, clinic, home care, acute, community, primary and long term care.