Sage Journals: Discover world-class research

Abstract

Objective:

To review the quality of current smoking cessation guidelines that include recommendations for people with severe mental illness.

Methods:

A systematic search of scientific databases, central government health authority websites, psychiatry peak bodies, guideline clearing houses and Google was undertaken for relevant smoking cessation guidelines. Three reviewers independently assessed guideline quality using the AGREE II (Appraisal of Guidelines for REsearch and Evaluation II) instrument. Two reviewers extracted recommendations specific to smokers with severe mental illness.

Results:

Thirteen guidelines met the inclusion criteria. Seven guidelines scored ⩾60% in at least four domains. Median scores for ‘Editorial independence’, ‘Rigour of development’, ‘Stakeholder Involvement’ and ‘Applicability’ were less than 60%. The highest median scores were for ‘Scope and purpose’ (87%, 69–96%) and ‘Clarity of presentation’ (87%, 56–98%). ‘Editorial independence’ (33.3%, 0–86%) and ‘Rigour of development’ (54%, 11–92%) had the lowest median domain scores. The guidelines varied greatly in their recommendations but the majority recommended nicotine replacement therapy, bupropion or varenicline as first-line pharmacotherapy, along with behavioural support.

Conclusion:

Many guidelines did not adequately report their methods or the competing interests of the authors. Future guidelines development may benefit from more specifically addressing AGREE II criteria and the needs of smokers with severe mental illness.

Keywords

Mental health disorders smoking cessation AGREE II practice guideline harm reduction

Introduction

Smoking prevalence among people with severe mental illnesses (SMI), such as schizophrenia, bipolar disorder and major depression, is 3–5 times higher than for the remainder of the population (Lawrence et al., 2009). Smoking-related morbidities such as cardiovascular and respiratory diseases contribute substantially to the 10–15 years lower life expectancy of people with SMI compared to the general population (Galletly et al., 2016; Lawrence et al., 2013). Reducing smoking is critical to improving the physical health of people with SMI (Galletly et al., 2016). However, the combination of heavy dependence on nicotine, lingering pro-smoking culture in many mental health institutions, socio-economic disadvantage experienced by many people with SMI and insufficient smoking cessation support provided by mental health practitioners pose substantial barriers to people with SMI quitting smoking (Sharma et al., 2016a).

The evidence-base to inform smoking cessation interventions in this population is limited (Peckham et al., 2017). However, the available research shows that most smoking cessation interventions that are effective for smokers without SMI are also effective for smokers with SMI (Peckham et al., 2017). Behavioural interventions (e.g. brief advice and motivational interviewing) and pharmacotherapy (e.g. nicotine replacement therapy [NRT], bupropion and varenicline) are currently the mainstays of smoking cessation treatment for people with and without SMI (Peckham et al., 2017). However, smokers with SMI have lower quit success rates than general population smokers, even when assisted with cessation aids (Ferron et al., 2011). Non-abstinence or harm-reduction strategies such as switching to NRT or e-cigarettes for longer term use (i.e. >6 months) have also been recommended for those who have tried and failed to quit smoking using traditional smoking cessation methods (Gartner and Hall, 2015).

Practice guidelines for smoking cessation help translate research into clinical practice. Hence, it is vital that guidelines reflect best practice, are kept up to date and cover areas of need. We assessed the quality of smoking cessation clinical practice guidelines which include recommendations for smoking cessation among people with SMI.

Methods

Search strategy

We used the National Library of Medicine’s (NLM) Medical Subjects Heading (MeSH) definition of practice guidelines to identify relevant documents for inclusion in this study. This definition states that practice guidelines are a

set of directions or principles to assist the healthcare practitioner with patient care decisions about appropriate diagnostic, therapeutic, or other clinical procedures for specific clinical circumstances [that are] developed by government agencies at any level, institutions, organizations such as professional societies or governing boards, or by the convening of expert panels.

We searched medical databases (PubMed, CINAHL, EMBASE and PsycINFO), central government health authority websites, psychiatry peak bodies and guideline clearing houses of Australia, New Zealand, Canada, the United States and the United Kingdom for guidelines on smoking cessation or tobacco harm reduction that were specific or explicitly relevant to smokers with SMI (Supplemental Table 1). This was supplemented by a general Internet search using the Google search engine. The search terms used were ‘guidelines’, ‘guidance’, ‘mental illness’, ‘smoking’, ‘tobacco cessation’ and ‘tobacco harm reduction’. Where multiple versions of a guideline were found, the most recent guideline was reviewed. Guidelines were included if they

Explicitly stated that they were designed for smoking cessation among people with mental illness or included a dedicated section for addressing smoking cessation/harm reduction among people with mental illness;

Were endorsed or funded by central government bodies, national health departments or medical professional bodies. State, regional or provincial guidelines were excluded;

Used English as the reporting language.

The search strategy is given in Figure 1 .

Figure 1.

Search strategy.

Evaluation

The guidelines were appraised for their methodological rigour and quality of reporting using the AGREE II (Appraisal of Guidelines for REsearch and Evaluation II) online instrument. This instrument has been developed by the AGREE Next Steps Research Consortium, an international group of guideline developers and researchers (Brouwers et al., 2010). It is a validated and widely accepted tool to assess the quality of practice guidelines.

The AGREE II instrument evaluates the process of practice guideline development and reporting quality, using 23 items which represent 6 quality domains (see Table 1). Each item is given a score on a scale, ranging from 1 (strongly disagree) to 7 (strongly agree).

Table 1.

AGREE II instrument.

1. Scope and purpose – three items
The items in this domain determine whether the overall objective, health question and the target populations (patients, public, etc.) were specifically described.

2. Stakeholder involvement – three items
The items in this domain evaluate whether the guideline development group included individuals from all relevant professional groups, whether the views and preferences of the target population were taken into consideration and whether the targeted users (health professionals) were clearly defined.

3. Rigour of development – eight items
This domain consists of maximum number of items. They cover issues such as use of systematic methods to review literature, criteria for selecting evidence, description of strengths and limitations of the body of evidence, description of methods for formulating the evidence, consideration of health benefits, risks and side-effects, evidence of explicit links between recommendations and supporting evidence, external review by experts and provision of procedure for updating the guidelines.

4. Clarity of presentation – three items
The items evaluate if the recommendations are specific and unambiguous, options for management are clearly presented and key recommendations are easily identifiable.

5. Applicability – four items
Items in this domain evaluate the description of facilitators and barriers to its application, provision of tools on how to put recommendations into practice, resource implications of the recommendations and presentation of monitoring or/and auditing criteria.

6. Editorial independence – two items
The items judge whether the funding bodies have influenced the content of guideline and whether the competing interests of guideline development group have been recorded and addressed.
An additional domain called ‘overall guideline assessment’ is judged using two additional items – overall guideline assessment 1(overall quality of the guideline) and overall guideline assessment 2 (if the evaluator would recommend the use of the guideline).

Apart from the domain score, AGREE II methodology provides two subjective measures of overall assessment, not calculated from the domain scores:

Overall assessment 1. The overall quality of each guideline is rated on a seven-point scale (lowest possible quality to highest possible quality) and expressed as a percentage, similar to the domain scores.

Overall assessment 2. Each assessor provides a recommendation on whether to use the guideline in practice or not (recommendation for use: ‘yes’, ‘yes with modifications’ or ‘no’).

Three researchers (R.S., D.P. and K.A.) independently appraised the guidelines using the online AGREE II platform. Prior to starting the evaluation, all assessors read the AGREE II instruction manual, watched the tutorial videos and completed a practice guideline evaluation available from the AGREE II website.

Additionally, R.S. and D.P. extracted content on the specific interventions discussed in each guideline. Data were extracted according to a pre-determined template of interventions, designed in consultation with C.G. and C.M., who are experienced researchers in the field of tobacco cessation and mental health. Content pertaining to the endorsement or disendorsement of interventions and qualifying details were extracted from guidelines.

Analysis

The analysis followed the AGREE II methodology (Brouwers et al., 2010). For each guideline, the points given by all evaluators for the items relating to each quality domain were added together to give the domain total for that guideline. The domain scores of each guideline were then calculated as follows: (domain total − minimum possible score)/(maximum possible score − minimum possible score). The maximum possible score was calculated as: (number of questions) × (number of reviewers) × 7. The minimum possible score was calculated as: (number of questions) × (number of reviewers) × 1. The domain scores were expressed as a percentage, where 0% is the worst possible score and 100% is the best possible score. A similar method was used to calculate the overall assessment 1. Frequencies were calculated for each item of overall assessment 2. Medians and ranges were calculated for the domain scores for all guidelines. We also calculated the medians for the six domain scores of each guideline.

The AGREE II manual does not make any suggestions about a minimum domain score which can be considered acceptable for a guideline. Hence, we followed the examples of other published studies which deem a score of 60% or greater in the quality domains as acceptable (Armstrong et al., 2016). Intra-class correlation coefficients (ICCs) were calculated for each domain to assess the inter-rater reliability.

The extracted recommendations were tabulated (see Table 2), appraised and summarised for their relevance to smoking cessation and harm reduction for smokers with SMI by three of the authors (R.S., C.G. and C.M.).

Table 2.

Extracted guideline recommendations.

	EPA guidelines	NICE-PH48	AHRQguidelines	RACGPguidelines	New Zealand guidelines	CAN-ADAPTT guidelines	NICE-PH45	Tobacco-Free Toolkit	NCSCT guidelines	NHS Scotland guidelines	RCGP guidelines	Guidance for frontline staff	APA guidelines
Structured approach	4A approach: (1) Ask, (2) Advise, (3) Assist and (4) Arrange	–	5As	5As	ABC: asking, brief advice and cessation support	5As	–	5As and 5Rs	AIMS approach: Ask, Inform, Medication and Support	–	–	Yes; ask, advise and act	–
Nicotine replacement therapy (NRT)	First-line therapy for all smokers, longer use (for at least 8 weeks) is recommended	Recommend and offer licensed nicotine-containing products	Yes; first line	Yes; NRT is safe and effective for people with a mental illness	Yes	Yes; higher doses may be needed	Yes; offer nicotine products as a replacement for smoking and preventing relapse	Yes	Yes; combination NRT	No details in the guideline document. Referred to external information sources	Yes; combination of sustained release and faster acting forms	Yes; combined with behavioural support	First-line treatment
Varenicline	First-line therapy – assurance about effectiveness, need for more studies	With caution	Warning against neuropsychiatric adverse events, advises monitoring and maintenance up to 6 months	Advised with close monitoring	Yes; with caution despite lack of evidence about neuropsychiatric events due to varenicline	Vigilance for neuropsychiatric side-effects	–	Yes; varenicline can improve success rates over those achieved with NRT as it may impact cravings more effectively, at least in the short term. No advice about neuropsychiatric events	Yes; with caution and close monitoring for neuropsychiatric symptoms. Links for list of contraindications and cautions for smoking cessation pharmacotherapy in people with mental illness provided	No details in the guideline document. Referred to external information sources	With caution; indicated for depression but contraindicated for schizophrenia	Yes; with caution. Better than bupropion and NRT. There has been no suggestion in the published studies or case reports that smokers with pre-existing mental health problems are more vulnerable to neuropsychiatric side-effects than other patients	No mention of varenicline. However included in subsequent update supplements with adverse effects warning.
Bupropion	First-line therapy	With caution	Warning against neuropsychiatric adverse events	Advised with caution; contraindications given	Yes	Vigilance for neuropsychiatric side-effects	–	More effective in smokers with depression. Not advised in bipolar disorder	Yes; especially for people with schizophrenia but contraindicated in those with depression, suicidal ideation and at risk for seizures	No details in the guideline document. Referred to external information sources	With caution; indicated for schizophrenia but contraindicated for bipolar disorder and with drugs which increase risk of seizures such as tricyclic antidepressants, monoamine oxidase inhibitors (MAOIs) and some antipsychotics	With caution; bupropion is not recommended for smokers with a current or past history of seizures, current or previous diagnosis of bulimia or anorexia nervosa, or a history of bipolar disorder. There is the potential for interactions between bupropion and psychotropic medicines (such as some antipsychotics and antidepressants)	First-line therapy; caution when prescribing to individuals with history of seizures and eating disorders
Behavioural support	Individual therapy, group therapy, telephone coaching and motivational interviewing	Offer and provide intensive behavioural support	Yes	Group or individual counselling	Yes; intensive	Yes; intensive	Yes; intensive	Yes; more intensive. Healthcare providers should ask whether group or individual intervention is preferred. Mindfulness, cognitive behavioural therapy (CBT), group therapy and peer support	Yes; includes individual and group support, family/couple support and drop in support; telephone and online support	Yes, tailored advice	Yes; individual, group, Internet and multiple call back telephonebased intervention. Motivational interviewing, contingency payment	Yes; 6–12 sessions of behavioural support with pharmacotherapy	Yes; social support, brief therapies, behavioural therapies and CBT
Combined counselling and pharmacotherapy	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Self-help resources, e.g. web-based resources, printed material and books	Yes	–	Yes; tailored material both print and web-based	Can be used as an adjunct: text messages, mobile phone support and web-based resources. Online resources are low cost, interactive and tailored	Telephone, text messages and online help for behavioural support	Yes	Yes; written and electronic	Available via quitline	Yes; web-based and text-based telephone support	Tailored treatment	Not clear; Internet, telephone but multisession intensive behavioural support is better than self-help	–	Community support groups; telephone counselling; written manuals; videos; and computer-generated, tailored, self-help materials and exercise programmes
Therapeutic drug monitoring and dose adjustment	Yes; list of drugs to be monitored not provided (except clozapine)	Yes; list of drugs to be monitored limited (clozapine, olanzapine, theophylline and warfarin)	Yes; no exhaustive list	Yes; list provided with the guideline	Yes; list of drugs provided	Yes; list of drugs not provided	–	Yes; several medications suspected to have their levels affected by smoking and smoking cessation listed in detail	Yes; small list of recommended drugs affected by stopping smoking provided	Care should be taken when prescribing smoking cessation pharmacotherapy to check for possible interactions with ongoing courses of medication; no details provided	Yes; percentage of dose reduction of a few drugs mentioned.	Yes; list of drugs given	Names of some drugs mentioned without details
More intensive smoking cessation therapy	Several counselling session should be conducted; combination therapy; prolonging the treatment period	Provide intensive support for people using acute and mental health services	Yes	Yes; intensive smoking cessation counselling and close follow up are important in this group	Yes, multisession support with stop-smoking medication	Yes; longer term and more intensive counselling and pharmacotherapy	–	Yes: individuals with health conditions may need more intensive therapy to assist with social supports and development of coping skills, particularly early on in a quit attempt	More intensive pharmacological and non-pharmacological interventions	Yes; with fast tracking	Yes	Yes	Yes
Using higher doses of NRT (e.g. double patches)	Yes	–	–	Higher doses for more addicted smokers	Yes; higher doses are more effective for highly dependent smokers	Yes	Sufficiently high dose to control craving	–	As for more dependent smokers in the general population, the amount of NRT required by heavy smokers with mental disorder is likely to be higher than that required by the rest of the population	–	Yes	Due to higher levels of nicotine dependence, the amount of NRT required by smokers with mental illness is likely to be higher than the rest of the population	Further treatment studies are needed to determine whether high-dose patches are effective for heavier and more dependent smokers
Long-term substitution of cigarettes with NRT	No	For anyone who does not want, is not ready or is unable to stop completely, encourage the use of licensed nicotine-containing products to help them abstain and provide intensive behavioural support to maintain abstinence from smoking while in secondary care	–	Yes; regular use of NRT beyond 12 months is not generally recommended. However, long-term use of some forms of NRT has been reported and has not caused ill health effects – it may help some people remain abstinent and it is much safer than smoking	Yes	Yes	Yes	Yes; long-term abstinence from tobacco may require treatments that are extended in nature and designed to address a chronic disease model rather than a short-term acute illness, particularly for individuals dependent on tobacco	Yes	No reference to SMI in addendum about harm reduction	Yes	Yes	Long-term use is debatable, some individuals may require long-term NRT (>6 months), and patient preference should be considered
Electronic cigarettes/nicotine vaporisers	–	Likely to be less harmful than smoking. Encourage people who are already using electronic cigarettes to switch to a licensed product such as NRT	–	Categorised as unproven approach for smoking cessation	Classified under ‘other interventions’; not approved. Links to detailed information about e-cigarettes for health workers.^a	Classified as tobacco product	Does not recommend but states that unlicensed nicotine products (such as e-cigarettes) are likely to be less harmful than cigarettes	Information about e-cigarettes in a negative light	Listed as unlicensed	No reference to SMI in addendum about harm reduction	Electronic cigarettes are likely to be less harmful than tobacco, although people using them should be encouraged to switch to a licensed product	–	–
Unassisted quitting or cold turkey quitting	–	–	–	Low likelihood of success	–	–	–	–	–	–	–	Smokers are more likely to quit with local stop-smoking services than unaided	–
Smoking reduction	Reduce to quit	Yes	Yes	Smoking reduction encouraged for people with mental illness	Yes; reduce to quit with NRT	Reduction implied	Yes	Smoking reduction encouraged	Cutting down to quit	Information about harm reduction in addendum but no mention about its use in SMI	Yes	Long-term nicotine	Not mentioned explicitly

Information available at http://www.health.govt.nz/our-work/preventative-health-wellness/tobacco-control/e-cigarettes

Results

In total, 13 guidelines met the study’s inclusion criteria (see Table 3).

Table 3.

Characteristics of included guidelines.

Name of guideline	Referred to in text as	Region of origin	Year	Publishing body
EPA guidance on tobacco dependence and strategies for smoking cessation in people with mental illness	EPA guidelines	Europe	2014	European Psychiatric Association
PH48 Smoking: acute, maternity andmental health services	PH48	United Kingdom	2013	National Institute for Health and Care Excellence
PH45 Smoking: harm reduction	PH45	United Kingdom	2013	National Institute for Health and Care Excellence
Local Stop Smoking Services: Service and delivery guidance 2014	NCSCT guidelines	United Kingdom	2014	National Centre for Smoking Cessation and Training
Smoking Cessation and Mental Health: a briefing for frontline staff	Guidance for frontline staff	United Kingdom	2014	National Centre for Smoking Cessation and Training
Primary Care Guidance on Smoking and Mental Disorders	RCGP guidelines	United Kingdom	2014	Royal College of General Practitioners and Royal College of Psychiatrists, NHS England, Public Health England
A guide to smoking cessation in Scotland 2010: planning and providing specialist smoking cessation services	NHS Scotland guidelines	United Kingdom	2010	NHS Health Scotland
Treating Tobacco Use and Dependence: 2008 Update	AHRQ guidelines	United States	2008	Agency for healthcare research and quality: Department of Health and Human Services
DIMENSIONS: Tobacco-Free Toolkit for Healthcare Providers	Tobacco-free toolkit guidelines	United States	2013	University of Colorado Anschutz Medical Campus, School of Medicine, Behavioral Health and Wellness Program
Canadian smoking cessation clinical practice guideline	CAN-ADAPTT guidelines	Canada	2012	Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment (CAN-ADAPTT)
RACGP: Supporting smoking cessation – a guide for health professionals	RACGP guidelines	Australia	2014	Royal Australian College of General Practitioners
Background and Recommendations of the New Zealand Guidelines for Helping People to Stop Smoking	New Zealand guidelines	New Zealand	2014	Ministry of Health, Wellington
Practice Guideline for the Treatment of Patients With Substance Use Disorders- Second Edition	APA guidelines	United States	2006	American Psychiatric Association

AGREE evaluation

The ICC (inter-rater reliability) ranged from 0.7 to 0.9 (good to excellent). The domain scores for all the guidelines are presented in Table 4. The highest median domain score was achieved by the AHRQ guidelines (89%, range = 98.1–66.7%), while the Guidance for frontline staff (31.5%, range = 0–83.3%) scored the lowest. Seven guidelines scored ⩾60% in at least four quality domains.

Table 4.

Domain scores of each guideline.

	D1 scoreScope and purpose	D2 scoreStakeholder involvement	D3 scoreRigour of development	D4 scoreClarity of presentation	D5 scoreApplicability	D6 scoreEditorial independence	Domains scoring more than 60%	Median of domain score for each guidelineMedian (minimum−maximum), %	Overall assessment 1 score (%)
EPA guidelines	90.7	46.3	54.2	83.3	38.9	66.7	3	60.4 (38.9–90.7)	66.7
NICE-PH48 guidelines	94.4	88.9	91.7	87.0	83.3	8.3	5	87.9 (8.3–94.4)	88.9
AHRQ guidelines	96.3	88.9	89.6	98.1	75.0	66.7	6	89.2 (66.7–98.1)	94.4
RACGP guidelines	92.6	59.3	64.6	94.4	54.2	72.2	4	68.4 (54.2–92.6)	88.9
New Zealand guidelines	74.1	51.9	52.8	87.0	58.3	33.3	2	55.6 (33.3–87.0)	61.1
CAN-ADAPTT guidelines	83.3	81.5	76.4	88.9	50.0	86.1	5	82.5 (50.0–88.9)	88.9
NICE-PH45 guidelines	96.3	87.0	86.1	96.3	84.7	25.0	5	86.6 (25.0–96.3)	88.9
Tobacco-free toolkit guidelines	75.9	35.2	18.1	55.6	33.3	27.8	1	34.3 (18.1–75.9)	33.3
NCSCT guidelines	75.9	33.3	50.0	68.5	66.7	0.0	3	58.3 (0.0–75.9)	55.6
NHS Scotland guidelines	87.0	68.5	47.9	83.3	73.6	47.2	4	71.1 (47.2–87)	66.7
RCGP guidelines	68.5	42.6	28.5	75.9	22.2	8.3	2	35.5 (8.3–75.9)	44.4
Guidance for frontline staff	83.3	24.1	11.1	57.4	38.9	0.0	1	31.5 (0.0–83.3)	38.9
APA Guidelines	88.9	59.3	88.2	92.6	59.7	83.3	4	85.8 (59.3–92.6)	94.4
Median (minimum–maximum) for each domain (%)	87.0 (68.5−96.3)	59.3 (24.1−88.9)	54.2 (11.1−91.7)	87.0 (55.6−98.1)	58.3 (22.2−84.7)	33.3 (0−86.1)
No. of guidelines with more than 60% in individual domains	13	5	6	11	5	5

Scope and purpose

All 13 guidelines scored more than 60% in this domain with the AHRQ guidelines (96.3%) and NICE-PH45 guidelines (96.3%) scoring the highest. The median score for ‘Scope and purpose’ was 87% (range = 68.5–96.3%).

Stakeholder involvement

Five out of 13 guidelines obtained a score of 60% or more on this criterion. The median score for this domain was 59.3% (range = 24.1–88.9%). The maximum scores were achieved by the NICE-PH48 guidelines (88.9%) and AHRQ guidelines (88.9%). Guidance for frontline staff scored the lowest (24.1%).

Rigour of development

Six out of 13 guidelines scored more than 60% with NICE-PH48 guidelines (91.7%) scoring the maximum and Guidance for frontline staff (11.1%) scoring the lowest. The median score for rigour of development was 54.2% (range = 11.1–91.7%).

Clarity of presentation

Most guidelines’ recommendations were explicit and easily identifiable with 11 guidelines achieving scores greater than 60% in this domain. The median score was 87% (range = 55.6–98.1%). AHRQ guidelines (98.1%) scored the maximum, while Tobacco-Free Toolkit (55.6%) scored the lowest in this domain.

Applicability

Five out of 13 guidelines scored more than 60% for applicability with an overall median of 58.3% (range = 22.2–84.7%). Maximum domain scores were achieved by the NICE-PH45 guidelines (84.7%) while RCGP guidelines (22.2%) scored the lowest.

Editorial independence

Five out of 13 guidelines scored more than 60% in this domain. Most guidelines performed poorly with a median domain score of 33.3% (range = 0–86.1%). The maximum domain score was obtained by CAN-ADAPTT guidelines (86.1%) and the minimum by the Guidance for frontline staff (0%) and NCSCT guidelines (0%).

Overall guideline assessment

Six out of 13 guidelines were scored as ‘recommended’ (CAN-ADAPTT, 2011; Fiore et al., 2008; Kleber et al., 2006; NICE, 2013a, 2013b; RACGP, 2011) and ‘recommended with modifications’ (Campion et al., 2014; Friend et al., 2010; Ministry of Health, 2014; Morris et al., 2013; Ruther et al., 2014; NCSCT, 2014), respectively, by at least two of the three reviewers. Of these, two guidelines were scored as recommended by all reviewers (APA guidelines and AHRQ guidelines) (Kleber et al., 2006; Tobacco Use and Dependence Guideline Panel, 2008). The AHRQ guidelines received the highest median domain score (89.2% [66.7–98.1%]), while the highest overall assessment 1 score was obtained by AHRQ guidelines (94.4%) and APA guidelines (94.4%).

Guideline recommendations

Key guideline recommendations have been summarised in Table 5.

Table 5.

Summary of key smoking cessation guideline recommendations.

1. Use structured approach such as the 5As to provide a comprehensive smoking cessation intervention. The 5As are as follows: (a) Ask your clients if they smoke; (b) Assess their nicotine dependence and readiness to quit; (c) Advise them to consider quitting or reducing their smoking; (d) Assist by providing information, behavioural support, pharmacotherapy and harm-reduction options; (e) Arrange follow up to assess progress and provide motivation.

2. Intensive behavioural support should be offered in the form of group/individual counselling or telephone helpline (quitline) counselling.

3. Behavioural support should always be offered along with pharmacotherapy.

4. First-line pharmacotherapies include: (a) Combination nicotine replacement therapy (patches + a fast acting variant). Higher doses of NRT should be considered for more dependent smokers. (b) Varenicline: latest evidence shows that varenicline is not more likely to cause neuropsychiatric adverse events in users with SMI than those without or when using other methods of quitting smoking. However, it is best that patients be closely monitored while on varenicline. (c) Bupropion: especially effective for those with schizophrenia and depression. Contraindicated in smokers who have eating disorder, bipolar disorder or are at risk of seizures.

5. Self-help resources (such as web-based resources, text messaging, telephone helpline and printed material) should be offered as an adjunct to counselling and pharmacotherapy.

6. Tobacco harm-reduction options are as follows: (a) Long-term maintenance on NRT should be encouraged for smokers who are unable or unwilling to quit nicotine completely. (b) Smoking reduction or cutting down the number of cigarettes smoked per day (preferably in conjunction with pharmacotherapy and behavioural support) should be encouraged, as it can be an important step towards complete quitting. (c) There are currently no nicotine vaporisers or e-cigarettes that are marketed as approved smoking cessation aids. Although unlicensed and of variable quality, safety and effectiveness, these products are expected to be less harmful than smoking.

7. Monitor and re-evaluate the dosage of certain psychiatric drugs on reducing or stopping smoking.

Discussion

AGREE evaluation

This systematic guideline review is the first to assess the methodological rigour and quality of smoking cessation guidelines aimed at smokers with SMI. The guidelines included in our assessment varied considerably in their quality, and only two guidelines were recommended by all the reviewers. Most of the guidelines were from the United Kingdom, where a dedicated health authority (NICE: National Institute for Health and Care Excellence) provides national guidelines on health and social care, in addition to those produced by professional bodies and national health departments. Unlike some other guideline evaluations in other fields, where more recent guidelines were of better quality than older ones, we found an even spread of scores over the years (Polus et al., 2012).

In keeping with guidelines for other topics, the ‘Scope and purpose’ domain consistently received high scores (⩾60%), followed by ‘Clarity of presentation’ where all but two guidelines scored high (Polus et al., 2012; Sabharwal et al., 2014; Xie et al., 2016). Many of the assessed guidelines presented their recommendations using flow charts, boxes, tables and bold fonts as required by the AGREE II scoring criteria.

By contrast, ‘Rigour of development’ was not adequately reported in the assessed guidelines. This could have resulted from the fact that not all guidelines conducted their own independent and extensive literature reviews to formulate the recommendations. For example, some UK guidelines borrowed recommendations from NICE guidelines (Friend et al., 2010; NCSCT, 2014), while those from New Zealand were based on a systematic review done for a previous version of the guideline. Thus, guidelines such as these were unable to fully report on methods of the literature review or criteria for inclusion of evidence with consequent low scores.

Only a minority of guidelines (CAN-ADAPTT, 2011; Kleber et al., 2006; RACGP, 2011; Ruther et al., 2014; Tobacco Use and Dependence Guideline Panel, 2008) satisfactorily fulfilled the criteria for ‘Editorial independence’. According to AGREE II criteria, this involves listing and addressing the potential conflicts of interest of the guideline developers, and explicitly confirming to the reader that funding bodies did not influence the recommendations of the guideline. Many published practice guidelines did not report or under-reported conflict of interests of guidelines’ panel members (Neuman et al., 2011; Papanikolaou et al., 2001). Establishing editorial independence is relevant to smoking cessation guidelines because funding from the pharmaceutical industry could present a conflict of interest in terms of recommendations that encourage the use of cessation pharmacotherapy (Etter et al., 2007). Declaring conflicts of interest is also an implementation issue because poor reporting may detract from the trustworthiness of the guidelines, reducing their uptake by health professionals.

Smoking cessation by people with SMI involves a concerted effort by health practitioners, smokers, caregivers and policymakers. For instance, consumer participation can improve the quality of services and the production of new or improved information sources (Crawford et al., 2002). However, the guidelines we reviewed scored low in stakeholder involvement, meaning that they did not provide sufficient evidence of stakeholder relevant input into their guideline’s development. Resulting guidelines may therefore be less successful (Cluzeau et al., 2012), given that smokers with SMI may have personal preferences for different smoking cessation approaches (Meurk et al., 2016).

As in other fields, most of the guidelines did not satisfactorily fulfil the criteria for ‘Applicability’ (Armstrong et al., 2016). ‘Applicability’ refers to the inclusion of practice tools (such as patient leaflets, algorithms and referral forms), monitoring criteria and the appropriate financial and human resources for implementation (Brouwers et al., 2010). The main reason for low scores in this domain was that very few guidelines addressed the human and financial implications of implementation that are specific to smokers with SMI, despite mentioning other resources such as links to telephone quit lines or support groups. The highest scoring guidelines were those formulated by NICE (2013a, 2013b), and included both detailed cost effectiveness analysis and economic modelling.

Smoking cessation guidelines for people with SMI also need to address practitioner barriers such as time and financial constraints and competing priorities in delivering smoking cessation (Sheals et al., 2016). Cost-effectiveness and affordability are particularly relevant for both practitioners and their patients, given that many smokers with SMI have limited incomes (Francke et al., 2008). Information about government subsidies for smoking cessation assistance, and about how to access this support, needs to be communicated to health practitioners via guidelines (RACGP, 2011).

Relevance of guidelines’ recommendations for smokers with SMI

Smoking cessation interventions effective in the general population are also effective for smokers with mental illness (Peckham et al., 2017). However, smokers with SMI may require more intensive counselling, closer monitoring for changes in psychiatric symptoms during a quit attempt, prolonged pharmacotherapy and titration of their psychotropic medication (Ruther et al., 2014). Recent guidelines for the management of schizophrenia and mood disorders published by the Royal Australian and New Zealand College of Psychiatrists recommend pharmacotherapy, peer-supported group therapy and adjustment of antipsychotic medication for those smokers who reduce or stop smoking (Galletly et al., 2016; Malhi et al., 2015; Mendelsohn et al., 2015). Tobacco harm-reduction techniques such as long-term maintenance on NRT and/or e-cigarettes may need to be considered for smokers with SMI who may be more dependent on nicotine and find it difficult to quit or do not want to quit nicotine (Gartner and Hall, 2015). Guidelines not tailored to smokers with SMI may be poorly implemented as mental health practitioners may consider them unsuitable for their patients, or because smokers with SMI may be unable to adhere to treatment due to logistic, including financial, constraints (Davis and Taylor-Vaisey, 1997).

Four out of the 13 guidelines (EPA guidelines, Guidance for frontline staff, RCGP guidelines and APA guidelines) were exclusively targeted at smokers with SMI, while the remaining nine were general smoking cessation guidelines with some consideration of smokers with SMI (Campion et al., 2014; Kleber et al., 2006; Robson and Potts, 2014; Ruther et al., 2014). These provided varying levels of detail on the required adaptations in practice to adequately meet the needs of smokers with SMI.

The majority of the guidelines recommended NRT, bupropion and varenicline as a first-line pharmacotherapy for nicotine dependence, with most warning about neuropsychiatric symptoms and recommending close monitoring, especially when prescribing varenicline to smokers with SMI. There is evidence that varenicline is more effective than either NRT or bupropion, and recent data suggest it is not more likely to cause adverse events in people with SMI compared to the general population or when compared to placebo or NRT (Anthenelli et al., 2016). In the light of this evidence, the US Food and Drug Administration (FDA) removed the requirement for boxed warning about neuropsychiatric side-effects for varenicline in 2016. Despite superior effectiveness, mental health practitioners can be reluctant to prescribe varenicline possibly due to fears about side-effects (Chen et al., 2016). This indicates the need to update smoking cessation guidelines regularly, as clinical guidelines can be a key vehicle for translating research into practice by informing the decisions of clinicians.

All guidelines mentioned that the dosage of certain psychotropic drugs may require monitoring and re-evaluation following smoking cessation although many did not provide a comprehensive list of relevant agents. Such a list might help non-specialists to decide whether and when it would be appropriate to refer the patient for medication review (Mendelsohn et al., 2015).

Four out of 13 guidelines did not recommend or expressed a sceptical view of using NRT for an extended period to prevent relapse, and none recommended the extended use of varenicline or bupropion. This is despite the fact that smokers with SMI are more likely to relapse and, thus, may require extended pharmacotherapy and counselling (Evins et al., 2017; Shahab et al., 2016).

No guideline recommended or endorsed e-cigarettes as a smoking cessation method. Three UK guidelines mentioned that e-cigarettes may be less harmful than cigarettes, in line with official support for tobacco harm reduction in the United Kingdom (Campion et al., 2014; NICE, 2013a, 2013b). E-cigarettes are battery-operated devices which heat a solution of nicotine and other additives to produce inhalable nicotine vapour. The use of these devices remains controversial because of uncertainty surrounding their role in smoking cessation, adverse effects, potential renormalisation of smoking and concerns about uptake by young non-smokers (Fairchild et al., 2014). However, there is early evidence to suggest that e-cigarettes may have similar efficacy to NRT in assisting smokers with mental illness to stop or reduce smoking (O’Brien et al., 2015). Surveys of health practitioners in the United States and Europe have shown that a significant proportion recommend e-cigarettes to their patients (Kandra et al., 2014; Moysidou et al., 2016). Research also shows that smokers with mental illness and their carers are interested in using e-cigarettes for smoking cessation and reduction, and may approach healthcare providers for information on using e-cigarettes as a smoking cessation method (Meurk et al., 2016; Sharma et al., 2016b). Given this, guidelines should include information about e-cigarettes to enable mental health clinicians to deliver accurate advice about e-cigarettes, including which products and nicotine concentration are the most appropriate and how to use and maintain these devices. As with conventional NRT, specific guidance is needed for health practitioners on the need to monitor or adjust the dosage of psychiatric medications when a patient switches from cigarettes to e-cigarettes (Sharma et al., 2016b).

Limitations

This study has several limitations. First, our sample was restricted to guidelines endorsed by central government or professional peak bodies of predominantly high-income countries. We chose this strategy to include guidelines from similar health systems. As a result, we are not able to comment on the quality of guidelines originating in low- and middle-income countries. Second, despite using several ways to supplement our search strategy, there is a possibility that we may not have captured all relevant guidelines, mainly due to there being no consolidated national or international database for smoking cessation guidelines. Third, our study was possibly limited by use of three assessors, instead of the preferred four. For adequate reliability, AGREE II instrument requires that a minimum of two and preferably four assessors appraise the guidelines; however, our high inter-rater agreement between the three assessors suggests a fourth assessor was not needed. Fourth, AGREE II scores may have underestimated the rigour of development of some guidelines that referenced other documents, such as research articles or older versions of the guideline, rather than providing explicit details of the methodology underlying guideline development within the guideline document itself. Finally, the AGREE II instrument evaluates the method of development of the guidelines but not the clinical appropriateness of their content resulting in possible dissonance between the scores and the clinical relevance of some guidelines. For example, RACGP and New Zealand guidelines received modest scores on AGREE II due to a lack of detailed reporting. However, recommendations made in these guidelines were judged as being up to date and clinically relevant for smokers with SMI. To overcome this limitation of the AGREE II instrument, another instrument called AGREE-REX (Recommendation EXcellence) is being developed by the AGREE consortium which will evaluate if the guidelines make clinically optimal and implementable recommendations (Makarski et al., 2014). As AGREE-REX is not yet available, we tried to address this limitation using a self-designed data extraction template to critique the clinical relevance and recency of guidelines’ recommendations.

Conclusion

Our evaluation indicates that there is substantial room for improvement of smoking cessation guidelines for smokers with mental illness. Guidelines that are evidence-based, detailed, comprehensible, address practical factors that affect implementation and account for the views of different stakeholders are highly desirable. Several good-quality smoking cessation guidelines do exist; however, they could be improved by careful and detailed reporting in accordance with the AGREE II guidelines. To optimally support the smoking cessation efforts of people with SMI, regular updates of existing guidelines are necessary to incorporate the latest evidence into smoking cessation practice. Guidelines also need to be tailored to jurisdictional regulatory, policy and financing frameworks.

Footnotes

Author contribution

All authors contributed to the idea and design of the study. R.S., K.A. and D.P. performed the AGREE II evaluation. R.S. and D.P. extracted the recommendations of the guidelines. R.S. did the data analysis and wrote the initial draft of the paper. All authors contributed to revising and finalising the manuscript.

Declaration of Conflicting Interests

R.S. and K.A. hold an Australian Government Research Training Scholarship. C.G. holds a National Health and Medical Research Council Career Development Fellowship (GNT#1061978). C.M. is funded by the National Health and Medical Research Council (NHMRC) Centre for Research Excellence in Mental Health Systems Improvement (GNT1041131).

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

Supplementary material

Supplementary material is available at: .

References

Anthenelli

Benowitz

West

et al . (2016) Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): A double-blind, randomised, placebo-controlled clinical trial. Lancet 387: 2507–2520.

Armstrong

Rodrigues

Wasiuta

et al . (2016) Quality assessment of osteoporosis clinical practice guidelines for physical activity and safe movement: An AGREE II appraisal. Arch Osteoporos 11: 6.

Brouwers

Kho

Browman

et al . (2010) AGREE II: Advancing guideline development, reporting and evaluation in health care. CMAJ 182: E839–842.

Campion

Shiers

Britton

et al . (2014) Primary care guidance on smoking and mental disorders. Available at: www.rcgp.org.uk/clinical-and-research/toolkits/~/media/E7087878A24547E795903F432738AD35.ashx (accessed 10 July 2017).

CAN-ADAPTT (2011) Canadian smoking cessation clinical practice guidelines. Available at: www.nicotinedependenceclinic.com/English/CANADAPTT/Documents/CAN-ADAPTT%20Canadian%20Smoking%20Cessation%20Guideline_website.pdf (accessed 11 July 2017).

Chen

Baker

Brownson

et al . (2016) Smoking cessation and electronic cigarettes in community mental health centers: Patient and provider perspectives. Community Mental Health Journal 1: 8.

Cluzeau

Wedzicha

Kelson

et al . (2012) Stakeholder involvement: How to do it right: Article 9 in Integrating and coordinating efforts in COPD guideline development. An official ATS/ERS workshop report. Proceedings of the American Thoracic Society 9: 269–273.

Crawford

Rutter

Manley

et al . (2002) Systematic review of involving patients in the planning and development of health care. BMJ 325: 1263.

Davis

Taylor-Vaisey

(1997) Translating guidelines into practice. A systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines. CMAJ 157: 408–416.

10.

Etter

Burri

Stapleton

(2007) The impact of pharmaceutical company funding on results of randomized trials of nicotine replacement therapy for smoking cessation: A meta-analysis. Addiction 102: 815–822.

11.

Evins

Hoeppner

Schoenfeld

et al . (2017) Maintenance pharmacotherapy normalizes the relapse curve in recently abstinent tobacco smokers with schizophrenia and bipolar disorder. Schizophrenia Research 183: 124–129.

12.

Fairchild

Bayer

Colgrove

(2014) The renormalization of smoking? E-cigarettes and the tobacco ‘endgame’. New England Journal of Medicine 370: 293–295.

13.

Ferron

Brunette

et al . (2011) Course of smoking and quit attempts among clients with co-occurring severe mental illness and substance use disorders. Psychiatric Services 62: 353–359.

14.

Fiore

Jaén

Baker

et al . (2008). Treating tobacco use and dependence: 2008 update. Available at: www.ahrq.gov/sites/default/files/wysiwyg/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/update/treating_tobacco_use08.pdf (accessed 11 July 2017).

15.

Francke

Smit

De Veer

et al . Factors influencing the implementation of clinical guidelines for health care professionals: A systematic meta-review. BMC Medical Informatics and Decision Making 8: 38.

16.

Friend

Bery

Grierson

et al . (2010) A guide to smoking cessation in Scotland 2010: Planning and providing specialist smoking cessation services.

17.

Galletly

Castle

Dark

et al . (2016) Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders. Australian and New Zealand Journal of Psychiatry 50: 410–472.

18.

Gartner

Hall

(2015) Tobacco harm reduction in people with serious mental illnesses. Lancet Psychiatry 2: 485–487.

19.

Kandra

Ranney

Lee

et al . (2014) Physicians’ attitudes and use of e-cigarettes as cessation devices, North Carolina, 2013. PLoS ONE 9: e103462.

20.

Kleber

Weiss

Anton

et al . (2006) Practice guidelines for the treatment of patients with substance use disorders (second edition). Available at: https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/substanceuse.pdf (accessed 11 August 2017).

21.

Lawrence

Hancock

Kisely

(2013) The gap in life expectancy from preventable physical illness in psychiatric patients in Western Australia: Retrospective analysis of population based registers. BMJ 346: f2539.

22.

Lawrence

Mitrou

Zubrick

(2009) Smoking and mental illness: Results from population surveys in Australia and the United States. BMC Public Health 9: 285.

23.

Makarski

Brouwers

Enterprise

(2014) The AGREE Enterprise: A decade of advancing clinical practice guidelines. Implement Sci 9: 103.

24.

Malhi

Bassett

Boyce

et al . (2015) Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Australian and New Zealand Journal of Psychiatry 49: 1087–1206.

25.

Mendelsohn

Kirby

Castle

(2015) Smoking and mental illness. An update for psychiatrists. Australasian Psychiatry 23: 37–43.

26.

Meurk

Ford

Sharma

et al . (2016) Views and preferences for nicotine products as an alternative to smoking: A focus group study of people living with mental disorders. International Journal of Environmental Research and Public Health 13: E1166.

27.

Ministry of Health (2014) Background and recommendations of the New Zealand guidelines for helping people to stop smoking. Available at: www.health.govt.nz/system/files/documents/publications/background-recommendations-new-zealand-guidelines-for-helping-stop-smoking-mar15-v2.pdf (accessed 10 August 2017).

28.

Morris

Martin

et al . (2013) Dimensions: Tobacco free toolkit for healthcare providers; SUPPLEMENT: Priority populations: Behavioral health. Available at: https://www.bhwellness.org/toolkits/Tobacco-Free-Toolkit.pdf and https://www.bhwellness.org/toolkits/TF-Toolkit-Supp-Behavioral-Health.pdf (accessed 11 August 2017).

29.

Moysidou

Farsalinos

Voudris

et al . (2016) Knowledge and perceptions about nicotine, nicotine replacement therapies and electronic cigarettes among healthcare professionals in Greece. International Journal of Environmental Research and Public Health 13: 514.

30.

NCSCT (2014) Local Stop Smoking Services: Service and Delivery Guidance 2014. Dorchester: National Centre for Smoking Cessation and Training.

31.

Neuman

Korenstein

Ross

et al . (2011) Prevalence of financial conflicts of interest among panel members producing clinical practice guidelines in Canada and United States: Cross sectional study. BMJ 343: d5621.

32.

NICE (2013a) PH45: Smoking: Harm reduction. Available at: www.nice.org.uk/guidance/ph45/chapter/Introduction-scope-and-purpose-of-this-guidance (accessed 12 July 2017).

33.

NICE (2013b) PH48: Smoking: Acute, maternity and mental health services. Available at: www.nice.org.uk/guidance/ph48 (accessed 12 July 2017).

34.

O’Brien

Knight-West

Walker

et al . (2015) E-cigarettes versus NRT for smoking reduction or cessation in people with mental illness: Secondary analysis of data from the ASCEND trial. Tobacco Induced Diseases 13: 5.

35.

Papanikolaou

Baltogianni

Contopoulos-Ioannidis

et al . (2001) Reporting of conflicts of interest in guidelines of preventive and therapeutic interventions. BMC Medical Research Methodology 1: 3.

36.

Peckham

Brabyn

Cook

et al . (2017) Smoking cessation in severe mental ill health: What works? An updated systematic review and meta-analysis. BMC Psychiatry 17: 252.

37.

Polus

Lerberg

Vogel

et al . (2012) Appraisal of WHO guidelines in maternal health using the AGREE II assessment tool. PLoS ONE 7: e38891.

38.

RACGP (2011) Supporting Smoking Cessation: A Guide for Health Professionals (2014 ed). East Melbourne, VIC, Australia: RACGP.

39.

Robson

Potts

(2014) Smoking cessation and mental health: A briefing for front-line staff. Available at: http://www.ncsct.co.uk/usr/pub/mental%20health%20briefing%20A4.pdf (accessed 11 August 2017).

40.

Ruther

Bobes

De Hert

et al . (2014) EPA guidance on tobacco dependence and strategies for smoking cessation in people with mental illness. European Psychiatry 29: 65–82.

41.

Sabharwal

Patel

Gauher

et al . (2014) High methodologic quality but poor applicability: Assessment of the AAOS guidelines using the AGREE II instrument. Clinical Orthopaedics and Related Research 472: 1982–1988.

42.

Shahab

Dobbie

Hiscock

et al . (2016) Prevalence and impact of long-term use of nicotine replacement therapy in UK stop-smoking services: Findings from the ELONS study. Nicotine & Tobacco Research. Epub ahead of print 24 September 2016. DOI: 10.1093/ntr/ntw258.

43.

Sharma

Gartner

Hall

(2016a) The challenge of reducing smoking in people with serious mental illness. Lancet Respiratory Medicine 4: 835–844.

44.

Sharma

Wigginton

Meurk

et al . (2016b) Motivations and limitations associated with vaping among people with mental illness: A qualitative analysis of Reddit discussions. International Journal of Environmental Research and Public Health 14: 7.

45.

Sheals

Tombor

McNeill

et al . (2016) A mixed-method systematic review and meta-analysis of mental health professionals’ attitudes toward smoking and smoking cessation among people with mental illnesses. Addiction 111: 1536–1553.

46.

Tobacco Use and Dependence Guideline Panel (2008) Treating Tobacco Use and Dependence: 2008 Update. Rockville, MD: US Department of Health and Human Services. Available at: https://www.ncbi.nlm.nih.gov/books/NBK63952/ (accessed 9 August 2017).

47.

Xie

Wang

Sun

et al . (2016) Appraisal of clinical practice guidelines on community-acquired pneumonia in children with AGREE II instrument. BMC Pediatrics 16: 119.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.02 MB

An appraisal of practice guidelines for smoking cessation in people with severe mental illness

Abstract

Objective:

Methods:

Results:

Conclusion:

Keywords

Introduction

Methods

Search strategy

Evaluation

Analysis

Results

AGREE evaluation

Scope and purpose

Stakeholder involvement

Rigour of development

Clarity of presentation

Applicability

Editorial independence

Overall guideline assessment

Guideline recommendations

Discussion

AGREE evaluation

Relevance of guidelines’ recommendations for smokers with SMI

Limitations

Conclusion

Footnotes

Author contribution

Declaration of Conflicting Interests

Funding

Supplementary material

References

Supplementary Material