WHO Clinical Guideline for Tobacco Cessation in Adults

Overview

This concise Guidelines summary covers World Health Organization (WHO) evidence-based recommendations for clinicians treating adult tobacco users, including behavioural and pharmacological interventions. 

For information on methods and evidence grading, system-level interventions and policies, and traditional, complementary, and alternative therapies, refer to the full guideline. 

Reflecting on Your Learnings

Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.

Behavioural Support 

• Brief advice (between 30 seconds and 3 minutes per encounter) should be consistently provided by healthcare providers as a routine practice to all tobacco users accessing any healthcare settings
• More-intensive behavioural support should be offered to all tobacco users interested in quitting. Options for behavioural support include individual face-to-face counselling, group face-to-face counselling, or telephone counselling; multiple behavioural-support options should be provided.

Intensive Behavioural Support Options 

• Individual face-to-face counselling may be more practical to implement, especially where there is an existing system for delivering counselling on other health issues (such as mental health). Increased frequency and duration of counselling sessions, at least up to five sessions of 10 minutes in duration, increases quit success rates, but fewer sessions are still helpful
• Group face-to-face counselling may increase efficiency and have added benefits (for example, enhanced cohesiveness) compared with individual counselling. However, groups may have challenges regarding availability, sustainability, logistics, and participation
• Telephone counselling can reach people without requiring them to come to a specific location, and can be centralised for efficiency and quality control.

Implementation Considerations 

• Making behavioural support (including of longer duration and intensity) available to tobacco users is especially important in settings where they have minimal or no access to pharmacotherapy
• Behavioural support should be provided by personnel who have received sufficient training in knowledge and skills to aid tobacco users who are attempting to quit. These personnel can be either hired and trained specifically to provide cessation support, or they can be existing staff who already provide counselling to people with other health conditions
• Counselling support that is culturally sensitive and available in the primary language of tobacco users is important. It is useful to have support materials and training available in local languages, and to include examples that are inclusive of smokeless tobacco and other products, such as waterpipes (hookah, shisha) and bidis, especially in areas of high prevalence.

Digital Tobacco-Cessation Interventions 

• Digital tobacco-cessation modalities (text messaging, smartphone apps, artificial intelligence [AI]-based interventions, or internet-based interventions), individually or combined, can be made available for tobacco users interested in quitting, as an adjunct to other tobacco-cessation support or as a self-management tool.

Implementation Considerations 

• Digital tobacco-cessation interventions have the potential to reach millions of tobacco users, and can serve as an entry point through which they can access other recommended tobacco-cessation interventions
• Digital tobacco-cessation interventions can be implemented as a standalone service to support people to stop using tobacco. When offered as a standalone service to support self-management, it is important to advise potential users on the full range of recommended and available tobacco-cessation interventions, including information on their effectiveness
• Digital tobacco-cessation interventions may also be implemented as an add-on support to other recommended tobacco-cessation interventions
• For tobacco users who are interested in using other recommended and available tobacco-cessation interventions, digital interventions may be used to complement, but not replace, those interventions
• Careful content design and ongoing monitoring and evaluation is required to develop and maintain new digital tobacco-cessation programmes
• Digital tobacco-cessation interventions with interactive content and responses tailored according to user replies are most likely to be effective.

Pharmacological Interventions 

• Varenicline, nicotine-replacement therapy (NRT), bupropion, and cytisine are recommended as pharmacological treatment options for tobacco users who smoke and are interested in quitting
• Varenicline, NRT, or bupropion are recommended as first-line options; combination NRT (a patch plus a short-acting form, such as gum or a lozenge) is an option for tobacco users interested in quitting who will use NRT
• Bupropion in combination with NRT or varenicline may be offered to tobacco users interested in quitting when there is inadequate response to first-line treatments.

Implementation Considerations 

• Because tobacco-cessation medications have different advantages and disadvantages, with potential impacts on adherence, individuals and clinicians may prefer one medication over another or a particular combination. When feasible, having multiple medications available is preferable to increase patient and clinician choice
• Varenicline and combination NRT both have greater effectiveness compared with NRT monotherapy and bupropion. Where resources allow, countries may make the following options, which have higher likelihoods of quit success associated with their use, and are available to all tobacco users:
  • single-agent varenicline or cytisine
  • combination NRT (a long-acting and a short-acting agent)
  • combination of any medication(s) and behavioural support
• Healthcare providers should consider recommending these more effective therapies routinely, without preconditions, but especially for selected patients, such as more dependent tobacco users (for example, those who smoke more than 10 cigarettes per day) and those who have not been able to quit despite multiple attempts
• Tobacco-cessation medications are effective in most adult tobacco users
• It is important to advise all users of cessation medications to seek concurrent behavioural support; to provide them with instructions and follow up to ensure proper use and adherence to the recommended duration of therapy; and to assist with the management of any side effects or withdrawal symptoms
• Encouraging the use of combination pharmacotherapies that have high effectiveness and providing instructions for the use of combination therapy (the potential additive side effects and relevant coping strategies) to patients and healthcare providers is an important clinical strategy.

Interventions for Smokeless Tobacco Use Cessation 

• Provide intensive behavioural-support interventions (individual face-to-face counselling, face-to-face group counselling, or telephone counselling) for smokeless tobacco users interested in quitting
• Varenicline or NRT are recommended as pharmacological options for smokeless tobacco users interested in quitting.

Implementation Considerations 

• Because the evidence for the effectiveness of medications is not as certain for smokeless tobacco products as for cigarettes, behavioural support remains the primary intervention that should be offered to smokeless tobacco users, with and without medication use
• Support materials and training to healthcare providers should be made available in local languages and include examples of smokeless tobacco use, especially in areas of high prevalence
• Dosing/duration and other tailoring considerations need to be developed for smokeless tobacco users.

Combination of Behavioural and Pharmacological Treatments 

• WHO recommends combining pharmacotherapy and behavioural interventions to support tobacco users interested in quitting.

Overarching Guideline Implementation Considerations 

• Individuals interested in quitting should be informed about which interventions can maximise their chance of success, taking into account individual preferences when relevant
• There are four treatments with a higher rate of quit success:
  • combining any medication with counselling
  • combining two medicines, such as two forms of NRT (longer-acting and shorter-acting), or bupropion in combination with NRT or varenicline
  • using partial agonists of α4β2 nicotinic receptors (varenicline and cytisine), and
  • increasing the intensity of counselling above a minimal level (benefits increase for with multisession counselling of up to five sessions, and for a duration of up to at least 10 minutes per session)
• Whenever feasible and acceptable, clinicians and tobacco users interested in quitting should be encouraged to use treatments associated with the highest success rates. However, the chances of quit success are increased by the use of any of the individual medications endorsed by this guideline
• Chances of success are increased by using any form of counselling, with similar effects
• Chances of success may be increased by using certain forms of digital support (text messaging, websites, apps, and AI-based software), but this may depend on the characteristics of the specific intervention, and the effect may be smaller than with medications or live counselling.