Mental Health Practice Guidelines
The below guidelines are meant for mental health professionals to use in their clinical practices. Please be aware that there are various authoring organizations. The NGC has summarized these guidelines. Links are provided to the original source within the guideline documents.
Guideline Title
Smoking cessation.
Bibliographic Source(s)
Singapore Ministry of Health. Smoking cessation. Singapore: Singapore Ministry of Health; 2002 Apr. 33 p. [82 references]
Guideline Status
This is the current release of the guideline.
Disease/Condition(s)
Tobacco dependence
Guideline Category
CounselingManagementTreatment
Clinical Specialty
DentistryFamily PracticeInternal MedicineNursingPharmacologyPreventive MedicinePsychiatry
Intended Users
Advanced Practice NursesDentistsHealth Care ProvidersHospitalsNursesPharmacistsPhysician AssistantsPhysiciansPsychologists/Non-physician Behavioral Health Clinicians
Guideline Objective(s)
To provide recommendations for smoking abstinence
Target Population
Smokers in Singapore
Interventions and Practices Considered
General Interventions The 5 As approach to smoking cessation: Ask Advise Assess Assist Arrange Pharmacological Management Nicotine replacement therapy (NRT), including nicotine patch (available as 24-hour and 16-hour patches) or nicotine inhaler Bupropion hydrochloride slow release (SR) Other drugs, such as clonidine and nortriptyline, as second-line therapy Non-pharmacological Management (counseling and behavior therapy used in conjunction with pharmacotherapy) Individualised counseling and skill-based training Social support as part of treatment Social support outside of treatment
Major Outcomes Considered
Health risks of smoking (e.g., lung cancer, heart disease, stroke, other lung disease, other cancers, impotence) Prevalence of smoking and smoking-related disease in Singapore Health benefits of smoking cessation Costs of smoking cessation interventions
Methods Used to Collect/Select Evidence
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
Not stated
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Levels of Evidence Ia Evidence obtained from meta-analysis of randomised controlled trials. Ib Evidence obtained from at least one randomised controlled trial. IIa Evidence obtained from at least one well-designed controlled study without randomisation. IIb Evidence obtained from at least one other type of well-designed quasi-experimental study. III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies. IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities.
Methods Used to Analyze the Evidence
Review of Published Meta-AnalysesSystematic Review
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations
Grades of Recommendation Grade A (evidence levels Ia, Ib) Requires at least one randomised controlled trial as part of the body of literature of overall good quality and consistency addressing the specific recommendation. Grade B (evidence levels IIa, IIb, III) Requires availability of well conducted clinical studies but no randomised clinical trials on the topic of recommendation. Grade C (evidence level IV) Requires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates absence of directly applicable clinical studies of good quality. GPP (good practice points) Recommended best practice based on the clinical experience of the guideline development group.
Cost Analysis
Cost-Effectiveness of Smoking Interventions Cost-effectiveness analyses have shown that smoking cessation treatments ranging from brief clinician advice to specialist-delivered intensive programmes, including pharmacotherapy, compare favourably with other medical interventions such as the treatment of hypertension and preventive screening interventions such as cervical pap smear screening or mammography. Studies in the United States showed that smoking cessation interventions cost less than US$1,000 per year of life saved. For comparison, cost estimates for the treatment of moderate hypertension is approximately US$10,000 per year of life saved.
Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation
Not stated
Major Recommendations
Each recommendation is rated based on the levels of the evidence and the grades of recommendation. Definitions of the grades of the recommendations (A, B, C, Good Practice Points) and levels of the evidence (Level I - Level IV) are presented at the end of the Major Recommendations field. A - All patients should be asked if they use tobacco and should have their tobacco use status documented on a regular basis. Clinicians and health care delivery systems should institutionalise the consistent identification, documentation, and treatment of every tobacco user seen in a health care setting (Chang, Zimmerman & Beck, 1995; National Cancer Institute, 1994; Ockene, 1987; Pederson, Baskersville & Wanklin, 1982; Robinson, Laurent & Little, 1995; Yarnall et al., 1998). (Grade A, Level Ia, Ib) A - All clinicians should strongly advise every patient who smokes to quit (American Psychiatric Association, 1996; Orleans, 1993; US Department of Health and Human Services, 1988). (Grade A, Level Ia) A - Tobacco dependence is a chronic condition that often requires repeated intervention. Effective treatments that can produce long-term or even permanent abstinence exist. (Grade A, Level Ib) A - Treatment for tobacco dependence is clinically effective and cost-effective relative to other medical and disease prevention interventions. (Grade A, Level Ia) A - Brief tobacco dependence treatment is effective and every patient who uses tobacco should be offered at least brief treatment. (Grade A, Level IIa) A - There is a strong dose-response relation between the session length of person-to-person contact and successful treatment outcomes. Intensive interventions are more effective than less intensive interventions and should be used whenever possible. (Grade A, Levels Ia, Ib, IIa) A - Nicotine replacement therapy (NRT) is effective and safe for smoking cessation (Abelin et al., 1989; Bohadana et al., 2000; Dale et al., 1995; Hjalmarson et al., 1997; Hurt et al., 1994; Lewis et al., 1998; Silagy et al., 1994; Silagy et al., 2000; Tonnesen et al., 1993). (Grade A, Level Ia) A - There is no difference in efficacy between various forms of nicotine replacement (Gourlay et al., 1995; Hjalmarson et al., 1997; Hurt et al., 1994; Sachs, Sawe & Leischow, 1993; Silagy et al., 2000). (Grade A, Level Ib) A - There is currently no evidence that nicotine replacement therapy increases cardiovascular risk. (Grade A, Level Ib) A - Bupropion Slow-Release (SR) is safe and effective for smoking cessation. (Grade A, Level Ib) C - Once a tobacco user is identified and advised to quit, the healthcare practitioner should assess the patient's willingness to quit at this time: Patients willing to try to quit tobacco use should be provided treatments identified as effective in this set of guidelines. Patients unwilling to try to quit tobacco use should be provided a brief intervention designed to increase their motivation to quit as described in this set of guidelines. (Grade C, Level IV) Definitions: Grades of Recommendation Grade A (evidence levels Ia, Ib) Requires at least one randomised controlled trial as part of the body of literature of overall good quality and consistency addressing the specific recommendation. Grade B (evidence levels IIa, IIb, III) Requires availability of well conducted clinical studies but no randomised clinical trials on the topic of recommendation. Grade C (evidence level IV) Requires evidence obtained from expert committee reports of opinions and/or clinical experiences of respected authorities. Indicates absence of directly applicable clinical studies of good quality. GPP (good practice points) Recommended best practice based on the clinical experience of the guideline development group. Levels of Evidence Ia Evidence obtained from meta-analysis of randomised controlled trials. Ib Evidence obtained from at least one randomised controlled trial. IIa Evidence obtained from at least one well-designed controlled study without randomisation. IIb Evidence obtained from at least one other type of well-designed quasi-experimental study. III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies. IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities.
Clinical Algorithm(s)
The original guideline contains a clinical algorithm for the 5 As approach to smoking cessation intervention.
References Supporting the Recommendations
Abelin T, Buehler A, Muller P, Vesanen K, Imhof PR. Controlled trial of transdermal nicotine patch in tobacco withdrawal. Lancet 1989 Jan 7;1(8628):7-10. PubMedBohadana A, Nilsson F, Rasmussen T, Martinet Y. Nicotine inhaler and nicotine patch as a combination therapy for smoking cessation: a randomized, double-blind, placebo-controlled trial. Arch Intern Med 2000 Nov 13;160(20):3128-34.Chang HC, Zimmerman LH, Beck JM. Impact of chart reminders on smoking cessation practices of pulmonary physicians. Am J Respir Crit Care Med 1995 Sep;152(3):984-7. PubMedDale LC, Hurt RD, Offord KP, Lawson GM, Croghan IT, Schroeder DR. High-dose nicotine patch therapy. Percentage of replacement and smoking cessation. JAMA 1995 Nov 1;274(17):1353-8. PubMedGourlay SG, Forbes A, Marriner T, Pethica D, McNeil JJ. Double blind trial of repeated treatment with transdermal nicotine for relapsed smokers. BMJ 1995 Aug 5;311(7001):363-6. PubMedHjalmarson A, Nilsson F, Sjostrom L, Wiklund O. The nicotine inhaler in smoking cessation. Arch Intern Med 1997 Aug 11-25;157(15):1721-8. PubMedHurt RD, Dale LC, Fredrickson PA, Caldwell CC, Lee GA, Offord KP, Lauger GG, Marusic Z, Neese LW, Lundberg TG. Nicotine patch therapy for smoking cessation combined with physician advice and nurse follow-up. One-year outcome and percentage of nicotine replacement. JAMA 1994 Feb 23;271(8):595-600. PubMedLewis SF, Piasecki TM, Fiore MC, Anderson JE, Baker TB. Transdermal nicotine replacement for hospitalized patients: a randomized clinical trial. Prev Med 1998 Mar-Apr;27(2):296-303. PubMedNational Cancer Institute. Tobacco and the clinician: interventions for medical and dental practice [NIH Publication No. 94-3693]. 5. Bethesda (MD): National Cancer Institute; 1994. 1-12 p. Ockene JK. Smoking intervention: the expanding role of the physician. Am J Public Health 1987 Jul;77(7):782-3. PubMedOrleans CT. Treating nicotine dependence in medical settings: a stepped care model. In: Orleans CT, Slade J, editor(s). Nicotine addiction: principles and management. New York (NY): Oxford University Press; 1993. Pederson LL, Baskerville JC, Wanklin JM. Multivariate statistical models for predicting change in smoking behavior following physician advice to quit smoking. Prev Med 1982 Sep;11(5):536-49. PubMedPractice guideline for the treatment of patients with nicotine dependence. American Psychiatric Association (APA). Am J Psychiatry 1996 Oct;153(10 Suppl):1-31. [219 references] PubMedRobinson MD, Laurent SL, Little JM Jr. Including smoking status as a new vital sign: it works. J Fam Pract 1995 Jun;40(6):556-61. PubMedSachs DP, Sawe U, Leischow SJ. Effectiveness of a 16-hour transdermal nicotine patch in a medical practice setting, without intensive group counseling. Arch Intern Med 1993 Aug 23;153(16):1881-90. PubMedSilagy C, Mant D, Fowler G, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2000;(3):CD000146. [131 references]Silagy C, Mant D, Fowler G, Lodge M. Meta-analysis on efficacy of nicotine replacement therapies in smoking cessation. Lancet 1994 Jan 15;343(8890):139-42. PubMedTonnesen P, Norregaard J, Mikkelsen K, Jorgensen S, Nilsson F. A double-blind trial of a nicotine inhaler for smoking cessation. JAMA 1993 Mar 10;269(10):1268-71. PubMedUS Department of Health and Human Servies. The health consequences of smoking: nicotine addiction. A report of the Surgeon General [DHHS Publication No. 88-8406]. Atlanta (GA): US Department of Health and Human Services. Public Health Service, Centres for Disease Control, Centre for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health; 1988. Yarnall KS, Rimer BK, Hynes D, Watson G, Lyna PR, Woods-Powell CT, Terrenoire J, Barber LT. Computerized prompts for cancer screening in a community health center. J Am Board Fam Pract 1998 Mar-Apr;11(2):96-104. PubMed
Type of Evidence supporting the Recommendations
The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").
Potential Benefits
It is beneficial to stop smoking at any age as it has major and immediate health benefits even for smokers who have smoked for many years. Within two days of quitting, the sensations of smell and taste are enhanced. Within two weeks to three months of quitting, circulation improves and lung function increases by up to 30%. The excess risk of heart disease is reduced by half within one year of stopping smoking. Within five years, the risk of heart disease reduces to the level of non-smokers. In those with existing heart disease, smoking cessation reduces the risk of recurrent infarction or death by half. The risk of lung cancer is reduced by 50-70% after 10 years of abstinence from smoking and continues to decline thereafter. Women who stop smoking before or during the first trimester of pregnancy reduce the risk to their baby to a level comparable to that of women who have never smoked. The incidence of babies born with low birth weight could potentially be reduced by 25% if pregnant women do not smoke during pregnancy.
Potential Harms
Nicotine Patch Skin irritation such as itch and rash caused by direct contact is the most common. Other side effects include nausea, vomiting, headache, insomnia and nightmares. Nicotine Inhaler Main side effects are irritation in the mouth and throat, and coughing. Other uncommon side effects listed in the product insert include nausea, vomiting, heartburn, nasal congestion, sinusitis, headache and dizziness. Bupropion Hydrochloride Slow-Release Adverse drug reactions reported to the Canadian Adverse Drug Reaction Monitoring Program (CADRMP) included myocardial infarction, seizures, hypoglycaemia, allergic reactions, nausea, anxiety, insomnia and dizziness.
Contraindications
The Canadian Adverse Drug Reaction Monitoring Program reported higher risk of hypoglycaemia with bupropion SR (slow-release) if there was concomitant use of insulin. It is contraindicated in patients at risk for seizures. The product insert warns of a higher risk of seizures in patients using either oral hypoglycaemic agents or insulin together with Bupropion Slow-Release.
Qualifying Statements
These guidelines are not intended to serve as a standard of medical care. Standards of medical care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge advances and patterns of care evolve. The contents of this publication are guidelines to clinical practice, based on the best available evidence at the time of development. Adherence to these guidelines may not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care. Each physician is ultimately responsible for the management of his/her unique patient in the light of the clinical data presented by the patient and the diagnostic and treatment options available.
Description of Implementation Strategy
Recommendation for Evaluation/Clinical Audit The most useful modality of evaluating the success of these guidelines is the National Survey of Smoking Prevalence which is conducted by the Ministry of Health every few years. This is part of the government's effort to bring down national smoking rates via public education and other means. It is also important to recognise that every health care practitioner has a duty to every patient to attempt to help identify and help that patient quit smoking.
Implementation Tools
Clinical AlgorithmFor information about availability, see the "Availability of Companion Documents" and "Patient Resources" fields below.
IOM Care Need
Staying Healthy
IOM Domain
EffectivenessPatient-centeredness
Bibliographic Source(s)
Singapore Ministry of Health. Smoking cessation. Singapore: Singapore Ministry of Health; 2002 Apr. 33 p. [82 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Date Released
2002 Apr
Guideline Developer(s)
Singapore Ministry of Health - National Government Agency [Non-U.S.]
Source(s) of Funding
Singapore Ministry of Health (MOH)
Guideline Committee
Workgroup on Smoking Cessation
Composition of Group that Authored the Guideline
Workgroup Members: Clinical Assoc Prof Philip Eng (Chairman); Maj (Dr) Gregory Chan; Dr Loo Chian Min; Dr Low Lip Pin; Dr Alfred Loh; Dr Swah Teck Sin; Dr Audrey Tan; Dr Veronica Tay; Dr Munidasa Winslow; Assoc Prof Wong Mee Lian; Ms Clare Yeo
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
Guideline Availability
Electronic copies: Available in Portable Document Format (PDF) from the Singapore Ministry of Health Web site. Print copies: Available from the Singapore Ministry of Health, College of Medicine Building, Mezzanine Floor 16 College Rd, Singapore 169854.
Availability of Companion Documents
None available
Patient Resources
None available
NGC STATUS
This NGC summary was completed by ECRI on May 20, 2003. The information was verified by the guideline developer on June 3, 2003.
COPYRIGHT STATEMENT
This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Please contact the Ministry of Health, Singapore by e-mail at MOH_INFO@MOH.GOV.SG.
NGC Disclaimer
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