To provide updated clinical practice guidelines for tobacco and nicotine dependence treatment in military service members and veterans.
Approach:
Guideline Development: A multidisciplinary work group of 21 VA and DoD experts developed 19 key questions and conducted a systematic review of 952 articles, ultimately including 109 studies.
Evidence Assessment: The GRADE framework was used to evaluate evidence quality, benefits and harms, patient and clinician preferences, and feasibility.
Recommendations: The guideline includes 32 recommendations across 10 topic areas, emphasizing complete abstinence as the primary outcome.
Key Findings:
Strong recommendation for FDA-approved nicotine replacement therapy (NRT), bupropion, or varenicline for combustible tobacco cessation.
Varenicline monotherapy is preferred over bupropion or single-agent NRT based on high-certainty evidence from 20 randomized controlled trials.
Combination NRT is recommended over NRT monotherapy, with evidence showing improved abstinence rates from 16 trials involving more than 12,000 participants.
Weak recommendations for NRT or varenicline for patients not ready to quit within 30 days, based on evidence from 7 randomized controlled trials.
Weak recommendation for pharmacotherapy among patients with stable mental health conditions, supported by a randomized controlled trial of more than 8,000 participants.
Interpretation:
The guideline aims to enhance tobacco treatment approaches, including for those not ready to quit, while addressing various patient needs.
Limitations:
Evidence quality varied, with some recommendations based on limited studies.
Much evidence derived from civilian populations, requiring extrapolation to military contexts.
Limited evidence for newer nicotine products and specific populations.
Conclusion:
The guideline promotes evidence-based care while allowing for clinical judgment and patient preferences.
