Objective:

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.

Sources:

• Annals of Internal Medicine