STATEMENT #4 (cont'd) f) Two types of counselling and behavioural therapies yield significantly higher abstinence rates and should be included in smoking cessation treatment: 1) providing practical counselling on problem solving skills or skill training and 2) providing support as a part of treatment.#
i  PREFACE

# NOTE TO USERS
This guideline has been developed by the Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment (CAN-ADAPTT). CAN-ADAPTT's Guideline for Smoking Cessation is intended to guide practice and is not intended to serve as a comprehensive overview of smoking cessation management. This guideline is intended to inform provision of evidence based smoking cessation care in Canada.
CAN-ADAPTT has been made possible through a financial contribution from the Drugs and Tobacco Initiatives Program, Health Canada. This guideline is editorially independent of funding sources. The views expressed herein do not necessarily represent the views of Health Canada.

# REPRODUCTION OF THE GUIDELINE
Reproduction of the CAN-ADAPTT Smoking Cessation Guideline is permitted for educational and non-commercial purposes, in any form, including electronic form, without requiring the consent or permission of the authors and/or the CAN-ADAPTT project, provided that the following is noted on all electronic or print versions:  CAN-ADAPTT/CAMH 2012 CITATION CAN-ADAPTT. (2011). Canadian Smoking Cessation Clinical Practice Guideline. Toronto, Canada: Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment, Centre for Addiction and Mental Health.
The guideline is available in its entirety or by individual section online at www.can-adaptt.net.
Sections including the information icon above, indicate links to contribute to the guideline via CAN-ADAPTT's website (www.can-adaptt.net).

# Sections include:
Clinical Considerations Tools/Resources Research Gaps
In addition to the work of the CAN-ADAPTT Guideline Development Group, CAN-ADAPTT wishes to acknowledge the Executive Committee and Evaluation Committee of CAN-ADAPTT for their contribution to the development of the Canadian Guideline for Smoking Cessation and the support of the CAN-ADAPTT Project as a whole. A complete list of these Committees and a brief description of their roles can be found in Appendix G.
The development of this guideline would not have been possible without the efforts, knowledge and expertise of the CAN-ADAPTT Network. The Network provided valuable input into the guideline through contributions on the discussion board, through attendance at CAN-ADAPTT's Annual General Meetings and during partnership meetings/ workshops. CAN-ADAPTT would like to acknowledge and thank these individuals for their time and support.  Health care providers are encouraged to provide counselling that supports abstinence from tobacco and/or cessation to youth (children and adolescents) that use tobacco.

# GRADE: 2C
SUMMARY STATEMENT #3
Health care providers in pediatric health care settings should counsel parents/guardians about the potential harmful effects of secondhand smoke on the health of their children. a large proportion have been shown to be willing to make a quit attempt 2. Health care providers have an important role to play in assisting individuals to quit smoking. Moreover, even brief interventions by providers are known to be effective in increasing the likelihood of a quit attempt by a person who smokes
. Clinical practice guidelines are known to be an important and effective provider tool to close the gap between recommended care and actual care provided 4.
The need for national clinical practice guidelines has also been identified by the World Health Organization's Framework Convention for Tobacco Control (FCTC), which states that parties to the treaty "...shall develop and disseminate appropriate, comprehensive and integrated guidelines based on scientific evidence and best practice, taking into account national circumstances and priorities, and shall take effective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence"

# BACKGROUND OF CAN-ADAPTT
In May 2007, the Tobacco Control Program of Health Canada assembled selected members of the tobacco control community for a roundtable discussion pertaining to tobacco cessation guidelines. This roundtable of experts highlighted several issues and needs, including:
Traditional methods of guideline development have relied on a narrow field of evidence, focusing mainly on randomized controlled trials (that typically fail to account for conditions and factors that influence treatment) Need to approach guideline/guidance development with inter-professional collaboration that significantly contributes both clinically practical and population level perspectives Need to engage stakeholders in guideline development and implementation processes Need for effective vehicles of communication and knowledge translation between the different audiences and stakeholders, also integrated unique approaches to guideline development, including:
- Building from existing guidelines CAN-ADAPTT subcontracted the Guidelines Advisory Committee (GAC) to independently identify and evaluate existing CPGs using the AGREE Instrument. The recommendations contained in the high quality guidelines (determined by AGREE scores) were used as the evidence base for the CAN-ADAPTT guideline development process.
- Using a practice-informed approach and dynamic process CAN-ADAPTT engaged stakeholders, health care providers from diverse practice settings, policy makers, health care managers and a broad range of researchers to provide input into the development of the guideline.

# SCOPE AND PURPOSE
This guideline is intended for use by Canadian health care providers in diverse clinical or treatment settings. This guideline is also intended for researchers and decision makers with an interest in understanding the key elements to a comprehensive smoking cessation system in Canada. The guideline contains sections on both clinical and population level approaches to smoking cessation interventions for persons who smoke or use tobacco. Sections of the guideline were also developed to address some of the questions regarding specific populations such as Aboriginal Peoples and Hospital Based Populations (see below for a complete list of topics).
This guideline is not intended to be prescriptive. It is designed to support rather than replace the clinical judgment of health care providers. Information contained in this guideline may be less applicable in certain situations or with specific populations. This guideline is intended to provide a foundation from which health care providers, researchers and decision makers (including health care managers) in Canada can adapt and tailor the information and recommendations to meet their own needs and settings.
The guideline is available in full text on the CAN-ADAPTT website (www.can-adaptt.net) in both English and French.

# INTRODUCTION 3

# FORMAT OF GUIDELINE
The guideline is organized into the following sections:

# CLARIFICATION AND LIMITATIONS
In this document, the term "tobacco" refers to manufactured, commercial tobacco products including, but not limited to, cigarettes, smokeless tobacco such as snuff, snus, and chewing tobacco, and cigars. Tobacco misuse does not refer to tobacco use for traditional or ceremonial purposes by Aboriginal Peoples.
Most research in the area of smoking cessation has examined cigarette use; it is important to note this limitation when using this guideline with smokeless tobacco users. More research is needed on smokeless tobacco products and the people who use smokeless tobacco to understand the impact of smoking cessation interventions.
The term patient/client is used throughout this guideline to reflect the diverse clinical settings where smoking cessation treatment is provided. The term health care provider is used throughout and is intended to reflect a broad range of providers in a range of different settings, including hospital, clinic, home care, acute, community, primary and long term care.

#  METHODS

# Guideline Development Group (GDG)
The Guideline Development Group (GDG) was formed in 2009 by the CAN-ADAPTT Coordinating Team and the GDG Chair, Dr. Peter Selby. There are seven members of the GDG ranging from family physician to public health researcher to physician specialists (see page ii for a list of GDG members). Each GDG member was a Section Lead for one of the sections listed on page 3. GDG Members were identified by the Chair to include experts in each topic area while ensuring a multi-disciplinary and nationally representative committee. Each GDG member was contracted through CAMH for their participation on the GDG, which included a modest honorarium to support their attendance at meetings and compensation for travel and accommodation for in-person meetings. Each GDG member confirmed that they had not received funds from the Tobacco Industry. No conflicts of interest were identified by members of the GDG that could have compromised the summary statements contained within this document. The GDG recognizes that representation from all potential guideline target end users was not possible. The intent was to leverage the CAN-ADAPTT Network members that represented a greater number of professional groups involved in smoking cessation throughout the guideline development process to provide critical input into the drafting of the guideline.

# IDENTIFYING AND EVALUATING THE EVIDENCE

# IDENTIFYING EXISTING CLINICAL PRACTICE GUIDELINES
Prior to being engaged in the CAN-ADAPTT Project, the Guidelines Advisory Committee had conducted, in November 2006, a full review of CPGs in the area of smoking cessation published in the English language. At that time, nine guidelines met the basic predetermined quality criteria: they contained recommendations linked to the evidence, and included some indication that a systematic search of the literature had been conducted. Six guidelines met our criteria and were selected for use in developing the dynamic CAN-ADAPTT CPG.
This process has been developed and was recommended by the Guidelines Advisory Committee (GAC).
CAN-ADAPTT extracted key recommendations from the highest scoring guidelines, and used these as the formal evidence base to inform the development of its guideline.
NOTE: CAN-ADAPTT did not review the primary literature to inform the development of its Summary Statements unless emerging evidence was identified by the Guideline Development Group.

# SUMMARY STATEMENTS AND CLINICAL CONSIDERATIONS DEVELOPMENT AND APPROVAL: A Practice-Informed Approach
The CAN-ADAPTT process of guideline development was informed by the ADAPTE process
. This methodology was unique in that evidence was extracted from existing high quality guidelines to develop summary statements. Evidence tables were created for each of the guideline sections (as listed on page 3). The existing CPGs identified for inclusion were reviewed and relevant recommendations extracted for each section along with the level of evidence/grade of recommendation attributed to it by the original guideline developer. The CAN-ADAPTT Coordinating Team developed draft summary statements from the existing recommendations for each theme and included it in the evidence tables. The Chair of the GDG reviewed the evidence tables and approved for distribution to the GDG.
The entire GDG reviewed the evidence tables and suggested revisions independently. The CAN-ADAPTT Coordinating Team collated the revisions into one document and re-circulated revisions to each section to the respective GDG lead for review. The updated evidence tables were then prepared for the Annual General Meeting (AGM) of the CAN-ADAPTT Network held in Ottawa 2009. At the AGM, the GDG Section Leads were responsible for leading small group breakout sessions with Network members to review the evidence tables and invite input on the Summary Statements and Clinical Considerations for the CAN-ADAPTT Guideline. The feedback was captured by designated recorders in each group as well as in participant workbooks that were collected at the end of the day. Following the AGM, all of the feedback was collated by the CAN-ADAPTT Coordinating Team and re-circulated to the GDG Section Lead for review and presentation to the other GDG members at the next GDG meeting.
During this GDG meeting, each GDG Section Lead was charged with facilitating discussion and eliciting feedback from the other GDG members for their respective section including revision to the Summary Statements, identification of relevant evidence to include in the background section, articulation of key clinical considerations and in assigning a level of evidence/grade of recommendation to each Summary Statement. The GDG Section Leads were supported by the CAN-ADAPTT Coordinating Team who assisted in drafting the content for review and confirmation by the GDG Section Leads. Final revision and approval of all Summary Statements and the level of evidence/ grade of recommendation was accomplished at an inperson GDG meeting where members were required to discuss and vote on final summary statements. Overall, there were seven GDG Meetings from 2009 to 2010.

# GRADES OF RECOMMENDATION AND LEVELS OF EVIDENCE
Summary Statements were assigned Grades of Recommendation (GR) and Levels of Evidence (LoE) using a modified GRADE approach 9. Given that this process built from existing clinical practice guidelines, traditional GRADE evidence tables were not used. The GDG utilized the Grading guide table, compiled by UptoDate 10 to help consider the level of evidence and grade of recommendation for its Summary Statements. The Guideline Development Group Members reviewed each Summary Statement and weighed the clarity of risk and benefit, quality of the supporting evidence, and implications of the Summary Statement and assigned a GR and LoE for each. Members of the Guideline Development Group voted on the wording of the Summary Statement and each GR and LoE.

# Grades of Recommendation and Levels of Evidence can be found in Appendix B.

# CAN-ADAPTT NETWORK PARTICIPATION

# Composition of Network
The example of the AGM, as described above, demonstrates how the CAN-ADAPTT methodology also included engagement of the target end users; researchers, health care providers and manager/ decision makers in its process of guideline development. The feedback approach was iterative allowing for ongoing participation and reflection from the target end users. The impact or effectiveness of clinical practice guidelines is often limited by the lack of consideration given to implementation or the applicability of the CPGs to local context and provider needs
. It was the aim of CAN-ADAPTT to explore the value and contribute to emerging guideline methods integrating implementation considerations into guideline development
CAN-ADAPTT targeted a variety of groups and key stakeholders for membership in the Network and participation in the guideline development process though a number of strategies. These included connecting with professional associations/ organizations representing various related disciplines and practices, presenting and displaying at conferences, sending out email blasts, conducting workshops, and publishing articles in professional journals and newsletters, as well as other promotional materials. Recruiting health providers committed to smoking cessation was considered particularly important, as they are in a unique position to engage in the delivery of smoking cessation interventions and thus are likely to use a revised, up-to-date, evidencebased guideline on smoking cessation practices. Network members were recruited from across Canada, and almost all Canadian provinces and territories had participants. Between 2008 and March 2011, more than 800 individuals have joined CAN-ADAPTT's Network, and were invited to participate in the development of these guidelines. The most significant and successful forum for soliciting members' comments, suggestions and recommendations regarding the guideline was at the Annual General Meetings.

# Methods of Participation

# GUIDELINE UPDATES
An update of this guideline was not scheduled or required by our funder, Health Canada. Funding support of CAN-ADAPTT continues until March 2012. Dr. Peter Selby will seek funding opportunities to continue the work of CAN-ADAPTT including an update to the guideline.

# DISSEMINATION AND IMPLEMENTATION
Four regional coordinators representing Western Canada, Ontario, Quebec and Atlantic Canada provided information on the CAN-ADAPTT initiative, and collaborated with regional providers, researchers, policy makers and other stakeholders on guideline dissemination strategies. The guideline was disseminated to regional provider networks, at conferences and workshops, integrated into existing educational efforts, and summary articles were published in newsletters and journals.
CAN-ADAPTT members were encouraged to disseminate the guideline by e-mail, and to discuss the guideline with colleagues. Members have also been incorporating the guideline into training or educational sessions.
National and professional organizations have been promoting the guideline primarily through passive dissemination such as publishing articles in newsletters, and providing links to the CAN-ADAPTT Guideline on their websites.
The CAN-ADAPTT website provides a virtual networking space where CAN-ADAPTT members are invited to comment on the guideline, suggest smoking cessation tools and resources and identify additional research gaps. Any member can post to an existing subject thread or create a new discussion topic.

#  COUNSELLING AND PSYCHOSOCIAL APPROACHES
CAN-ADAPTT's Clinical Practice Guideline Development Group; Section Lead: Gerry Brosky, MD, CCFP

# OVERVIEW OF EVIDENCE

# The following recommendations, and supporting evidence, have been extracted from existing clinical practice guidelines to inform the development of the CAN-ADAPTT Summary Statements.
CAN-ADAPTT worked with the Guidelines Advisory Committee (GAC) to conduct a literature search (years: 2002-2009) to identify existing clinical practice guidelines (CPGs). Five existing clinical practice guidelines were identified as meeting the high quality criteria set out in the AGREE Instrument. The recommendations contained in these high-quality CPGs have been used as the evidence base for the CAN-ADAPTT guideline development process.
The strength of evidence classification for each of these existing CPGs can be found in Appendix F. Note that the grade of recommendation/strength of evidence summary table for CAN-ADAPTT's summary statements can be found in Appendix B.

# U.S. Department of Health and Human Services Public Health Service (2008) 13
All patients should be asked if they use tobacco and New Zealand Ministry of Health (2007) 14 Ask about and document smoking status for all patients. For people who smoke or have recently stopped smoking, the smoking status should be checked and updated on a regular basis. Systems should be in place in all health care settings (medical centres, clinics, hospitals, etc.) to ensure that smoking status is accurately documented on a regular basis.

# Institute for Clinical Systems Improvement (ICSI) (2004) 15
Adults who have not used tobacco for at least 12 months and who have an easily visible mark on their chart to that effect should be asked about their tobacco use status yearly until abstinent for five years. Everyone without a tobacco use mark on the chart or those with a mark indicating use within the past six months should be asked at nearly The first 12 months after quitting (especially the first two weeks) is when one is at the highest risk for relapse. Follow-up options include a face-to-face, telephone, or mailed (postal or electronic) expression of support and willingness to help.

# (Class = M)
A pre-contemplator (a user not ready to consider quitting within the next six months) benefits from non-confrontational messages about the importance of quitting and the awareness that provider help is available when ready.

# (No Class)
A contemplator (who will consider quitting within the next 1-6 months) is accepting of supportive urging to quit and encouragement of a plan. (Class = C, R)

# Registered Nurses Association of Ontario (RNAO) (2007) 16
Nurses implement minimal tobacco use intervention using the "Ask, Advise, Assist, Arrange" protocol with all clients.
Comprehensive online quit smoking service with access to counselling, selfassessments, medication guide, international community, and forums

# Centre for Addiction and Mental Health (CAMH) Nicotine Dependence Clinic
This clinic offers service to smokers and tobacco users who want to quit or reduce their tobacco use. It also provides specialized treatment services for smokers who are pregnant and for people with other substance use issues, chronic mental illness and serious health concerns.

# Cost of smoking calculator (Canadian Cancer Society)
Online tool to calculate the cost of smoking.

# Decisional Balance Sheet
A tool designed to facilitate a discussion between care providers and patients/clients about the pros and cons of substance use.

# Fagerstrom Test for Nicotine Dependence
A validated tool for assessing initial dosing of NRT patches.

# Motivational Interviewing Website
These pages provide background information on the practice of Motivational Interviewing.

# On the Road to Quitting: Guide to becoming a nonsmoker
This guide will help individuals prepare and take action to successfully stop smoking.

# One Step at a time Series (Canadian Cancer Society)
For smokers who want to quit (English / French)
For smokers who don't want to quit (English / French)
If you want to help a smoker quit (English / French)

# Ontario Tobacco Research Unit Online Course -Cessation Module
Free online course Cessation module deals with the complexities of quitting smoking, the roles that nicotine addiction and motivation play in the quitting process, and best practices for smoking cessation.

# Partnership to Assist with Cessation of Tobacco (PACT)
Smoking cessation workshops provided free of charge to groups, facilities and health regions with funding from Saskatchewan Health.

# Program Training and Consultation Centre (PTCC)
Online information and training on brief tobacco interventions for health professionals Variety of minimal contact tobacco trainings available. Free of charge.

# Q.U.I.T.: Quit Using and Inhaling Tobacco
Canadian Pharmacists Association resource.
QU.I.T. is a continuing education program, available in both live and online formats, that trains pharmacists to expand their role in patient care and offer smoking cessation services in their pharmacy.

# RESOURCE DETAILS Smokers' Helpline Online

# Smoking Diary
A tool for tracking ongoing smoking when patients/clients are attempting to reduce or quit smoking. The tool is intended to enhance patients' awareness of their smoking behaviour.

# Stages of Change Diagram

# Training program for health care professionals on tobacco cessation interventions

# TRaC (Tobacco Reduction & Cessation) Training
Training to help build capacity of health professionals in providing smoking cessation treatment

# RESEARCH GAPS
When should the topic of smoking be raised if a patient/client is dealing with multiple stressors? When is the optimal time to advise someone to quit and how does a professional recognize this "optimal time"? Social network research and how this can be used in practice

# OVERVIEW OF EVIDENCE

# The following recommendations, and supporting evidence, have been extracted from existing clinical practice guidelines to inform the development of the CAN-ADAPTT Summary Statements.
CAN-ADAPTT worked with the Guidelines Advisory Committee (GAC) to conduct a literature search (years: 2002-2009) to identify existing clinical practice guidelines (CPGs). Five existing clinical practice guidelines were identified as meeting the high quality criteria set out in the AGREE Instrument. The recommendations contained in these high quality CPGs have been used as the evidence base for the CAN-ADAPTT guideline development process.
The strength of evidence classification for each of these existing CPGs can be found in Appendix F. Note that the grade of recommendation/strength of evidence summary table for CAN-ADAPTT's summary statements can be found in Appendix B.

# New Zealand Ministry of Health (2007) 14
Offer Ma ori who smoke cessation support that incorporates known effective components (such as medication).
It should be recognized by healthcare providers that tobacco has played an important part in traditional and spiritual practices in many Aboriginal communities. Traditionally tobacco was used by many First Nations for ceremonial and medicinal purposes and is still practiced across many First Nations.
However, it is well documented that mis-use/abuse of tobacco is of growing concern not only to the general Canadian population, but as well as to First Nations. For example, studies have demonstrated that smoking rates amongst First Nations peoples are more than double that of the general Canadian population. Furthermore, it has been documented that within First Nations populations, there are instances of smoking beginning as early as 6-8 years with an increase in uptake between the ages of 10-12, and peaking at 16 years of age. The relevance of targeting children/youth within this population is therefore evident.
Not only are rates of smoking higher in this population, but the poorer health status of First Nations people in Canada has also been well documented in the literature which together points to significantly higher rates of smoking related illnesses in this population.
There is limited evidence available demonstrating effective strategies for smoking cessation within Aboriginal populations. It should be noted that this does not suggest weak evidence of effective strategies within this population, but rather, a limited amount of research available (see Research Gaps section). However, generally those strategies which are effective for the general Canadian population should be considered effective within Aboriginal peoples. One recent Canadian study provides evidence that quitlines are an effective option for Aboriginal populations
Cultural adaptations should also be considered to tailor interventions for this population. Similarly, all interventions must consider the spiritual and traditional role within the culture and acknowledge other barriers to smoking cessation with the First Nations population such as the concurrent high rates of drug use and alcohol consumption.

# CAN-ADAPTT SUMMARY STATEMENTS
CAN-ADAPTT's development process reflects a dynamic opportunity to ensure that its guideline is practice informed and addresses issues of applicability in the Canadian context. It has built from the evidence and recommendations contained in existing guidelines. It did not review the primary literature to inform the development of its Summary Statements unless emerging evidence was identified by the Guideline Development Group. The CAN-ADAPTT Guideline Development Group has provided the below Summary Statements for Aboriginal Peoples.

# SUMMARY STATEMENT #1
Tobacco misuse  status should be updated for all Aboriginal peoples by all health care providers on a regular basis.

# OVERVIEW OF EVIDENCE

# The following recommendations, and supporting evidence, have been extracted from existing clinical practice guidelines to inform the development of the CAN-ADAPTT Summary Statements.
CAN-ADAPTT worked with the Guidelines Advisory Committee (GAC) to conduct a literature search (years: 2002-2009) to identify existing clinical practice guidelines (CPGs). Five existing clinical practice guidelines were identified as meeting the high quality criteria set out in the AGREE Instrument. The recommendations contained in these high-quality CPGs have been used as the evidence base for the CAN-ADAPTT guideline development process.
The strength of evidence classification for each of these existing CPGs can be found in Appendix F. Note that the grade of recommendation/strength of evidence summary table for CAN-ADAPTT's summary statements can be found in Appendix B.

# U.S. Department of Health and Human Services Public Health Service (2008) 13
The interventions found to be effective in this Guideline have been shown to be effective in a variety of populations. In addition, many of the studies supporting these interventions comprised diverse samples of tobacco users. Therefore, interventions identified as effective in this Guideline are recommended for all individuals who use tobacco, except when medication use is contraindicated or with specific populations in which medication has not been shown to be effective (pregnant women, smokeless tobacco users, light smokers, and adolescents).
Smoking is known to have a significant negative impact on risks associated with hospitalization; quitting smoking prior to admission has been shown to be beneficial for postoperative complication rates
Hospitalization provides an ideal window of opportunity to deliver smoking cessation services and supports for patients. Moreover, patients admitted for a smoking-related reason may be more receptive to smoking cessation interventions
. A recent Cochrane review has demonstrated that smoking cessation interventions, which begin during hospitalization and continue for at least one month post-discharge are effective
. Furthermore, with the prevalence of hospital smokefree policies on the rise, the provision of nicotine withdrawal treatment and availability of smoking cessation services to patients is becoming increasingly vital.
A model of systematic hospital interventions for smoking cessation, The Ottawa model, has been shown to be effective in increasing abstinence rates for patients 20 and has been implemented in nearly 70 sites across Canada to date 21.

# CAN-ADAPTT SUMMARY STATEMENTS
CAN-ADAPTT's development process reflects a dynamic opportunity to ensure that its guideline is practice informed and addresses issues of applicability in the Canadian context. It has built from the evidence and recommendations contained in existing guidelines. It did not review the primary literature to inform the development of its Summary Statements unless emerging evidence was identified by the Guideline Development Group. The CAN-ADAPTT Guideline Development Group has provided the below Summary Statements for Hospital-Based Populations.

# SUMMARY STATEMENT #1
All patients should be made aware of hospital smoke-free policies.

# GRADE: 1C

# SUMMARY STATEMENT #2
All elective patients who smoke should be directed to resources to assist them to quit smoking prior to hospital admission or surgery, where possible.  however, continuous follow-up is preferable. Efforts should be made to link patients to their primary healthcare provider upon discharge to ensure continuation of treatment and follow-up.
It should be recognized that pharmacotherapy can be provided to treat withdrawal during hospitalization as well as to promote long term cessation attempts.

# HOSPITAL POLICIES

# OVERVIEW OF EVIDENCE

# The following recommendations and supporting evidence have been extracted from existing clinical practice guidelines to inform the development of the CAN-ADAPTT Summary Statements.
CAN-ADAPTT worked with the Guidelines Advisory Committee (GAC) to conduct a literature search (years: 2002-2009) to identify existing clinical practice guidelines (CPGs). Five existing clinical practice guidelines were identified as meeting the high quality criteria set out in the AGREE Instrument. The recommendations contained in these high-quality CPGs have been used as the evidence base for the CAN-ADAPTT guideline development process..
Prevalence of smoking among those diagnosed with mental disorders has been well documented. Smoking rates, differing by diagnoses, vary between 40 to 90%, compared to 17% in the general Canadian population
Studies have shown smoking rates amongst people suffering from the following disorders: bipolar disorder 51 to 70%; major depressive disorder 40 to 60%; anxiety disorders 8 to 66% 25 Smoking prevalence for persons with schizophrenia has been found to be considerably high, ranging from 45 to 88%
. The burden in morbidity and mortality due to high smoking rates among the mentally ill and addicted clients is alarming; this population suffers disproportionately from smoking related disabilities and this causes great financial burden to the heath care system. It appears that the mentally ill and addicted population are more likely to suffer from various physical problems such as cardiovascular, lung diseases, and diabetes
, and tend to die much earlier than the general population 27.
Similarly, smoking prevalence within substance abuse/addicted populations is also high; people reporting substance abuse problems have higher smoking prevalence than the general population, with nearly 50% having nicotine dependence
. Rates ranging from 11 to 48% have been found for those who abuse alcohol, cannabis, cocaine, amphetamines and opioids
There are various factors contributing to higher smoking rates among people with mental illness and/or addictions including social, environmental and biological factors. Self medication theory, shared genetic vulnerability and pathophysiological mechanisms may provide some explanations for high rates of comorbidity. Nicotine triggers release of various neurotransmitters involved in some psychiatric disorders and are associated with the reinforcement effects of some addictive substances
. Consequently, people with mental illness may smoke for various reasons including to self medicate the effects of their illness
. The high smoking rates among those with mental illness and/or other addictions translate into more widespread health consequences and deaths due to smoking among this group
. People with mental health and addictive disorders who smoke also face enormous economic and social challenges. Studies have also shown that up to 27% of their disability income budget may be spent on tobacco products

# NEED FOR EFFECTIVE AND SPECIALIZED TREATMENT
Smokers experience negative nicotine withdrawal symptoms when they stop smoking. These withdrawal symptoms are more pronounced in smokers who suffer from mental illness or have other addictions when they stop smoking. Some studies, for example, have found that nicotine withdrawal can mimic or worsen psychiatric disorders, although other studies have not confirmed this
. Smoking cessation may also aggravate medication side-effects
. This means that clients on some psychotropic medications must be reviewed by health care professionals when quitting smoking, as they may need adjustment in their medication dosages in order to avoid drug toxicities due to increased drug levels in the blood
Thus close monitoring of the amount smoked, cessation treatment, medication side effects and psychiatric symptoms becomes important when addressing tobacco dependence treatment in populations with psychiatric disorders.
Historically, the culture of tobacco use has been ingrained in the mental health and addictions fields with cigarettes having been used as reinforcement for compliant behaviour and enhancing social activity among individuals with mental illness
. This common practice in most mental health institutions and residential programs poses great challenges in addressing tobacco use problems in such settings. However, studies have shown that mentally ill clients are interested in quitting smoking
, and are able to quit with successful rates
. This means that tobacco use interventions should be an integral part of the comprehensive mental health care delivery system.

# CAN-ADAPTT SUMMARY STATEMENTS
CAN-ADAPTT's development process reflects a dynamic opportunity to ensure that its guideline is practice informed and addresses issues of applicability in the Canadian context. It has built from the evidence and recommendations contained in existing guidelines. It did not review the primary literature to inform the development of its Summary Statements unless emerging evidence was identified by the Guideline Development Group. The CAN-ADAPTT Guideline Development Group has provided the below Summary Statements for Mental Health and/or Other Addiction(s).

# SUMMARY STATEMENT #1
Health care providers should screen persons with mental illness and/or addictions for tobacco use. CLINICAL CONSIDERATIONS
An equally accurate term for 'screening' may be 'case finding' given the prevalence of tobacco use among persons with mental health diagnosis and/or addiction(s). The term 'addictions' refers to those addicted to substances other than nicotine.
Asking about tobacco use should be an integral part of a routine medical, mental health and addiction screening in both ambulatory and inpatient settings. Due to the high prevalence of concurrent mental illness and addiction, all patients/clients should be screened for underlying, non-debilitating, undiagnosed mental health challenges. Conducting regular, brief screenings for mood changes is encouraged since it may affect quitting and can be part of withdrawal, grief over loss of identity as a smoker, or emergence of a depressive disorder.

# OFFER PHARMACOTHERAPY/COUNSELLING
It should be noted that no pharmacotherapy has been contraindicated in persons with mental illness unless medically contraindicated.
Pharmacotherapy and counselling approaches yield greater success rates than providing either pharmacotherapy or counselling approach alone. Recently there have been advisories from Health Canada regarding the need for vigilance for neuropsychiatric side effects when quitting smoking especially when assisted by bupropion SR 37 or varenicline
. Recognize that involuntary abstinence from tobacco that occurs when smoker patients are admitted to smoke free facilities requires management with an agonist at sufficient doses. The withdrawal/anxiety experienced by persons abstaining from smoking should be recognized and addressed, especially in acute care facilities. Health care providers who work with patients with mental health and/or addiction should not promote smoking, provide cigarettes or smoke with clients.
Employers of health care professionals who smoke should offer smoking cessation treatment to their employees.
Consider that persons with mental illness and/or addiction(s) who smoke might need higher doses of nicotine replacement therapy. Pharmacotherapy use may be required for a longer duration for persons with mental illness and/ or addiction(s). Flexibility in the quit date can be tailored to individual needs. Assess for interactions with medications used for treating comorbid conditions. Since caffeine levels can rise significantly when quitting smoking, caffeine intake needs to be monitored. Dose adjustments usually downwards may be needed if client is on psychotropics (especially clozapine and olanzepine) that are affected by smoking cessation. Clients' psychiatric symptoms throughout the quitting process should be monitored. Clients should be encouraged to live in smoke free settings in the community.
Clients should be followed by a health care provider during the quitting process. Referral to appropriate healthcare services (community, program referral, other team members) for management/treatment and follow-up can be considered when one is unable to offer the service. In-patient staff should be aware of community resources to support cessation and address nicotine dependence especially on discharge into community settings.

# RESOURCES FOR HEALTHCARE PROVIDERS
Treatment facilities staff should increase their understanding of mental health/addiction and nicotine dependence to effectively offer cessation and to address stigma attached to mental illness and/or addiction.

# ADDITIONAL CONSIDERATIONS
Given the culture of mental health and addictions treatment facilities where staff often smoked and thereby, clients' smoking behaviour was sustained, these facilities must address smoking in their policies. For example, by becoming smoke-free indoors and where possible on the facility's grounds. All healthcare providers and staff in a practice setting or treatment facilities should be offered smoking cessation treatment. Financial resources for this "longer and stronger" counselling and/or pharmacotherapy are necessary. Persons with mental illness and/or addictions, due to a likelihood of lower disposable income and proportionally higher spending on tobacco, may especially benefit from subsidized pharmacotherapy, in sufficient dose and duration. Limit out-of-pocket costs to smokers with mental illness and/or addictions to improve outcomes.

# TITLE DESCRIPTION Canadian Mental Health Association
Provides resources for various mental health conditions

# Canadian Psychiatry Association
This national professional association provides clinical practice guidelines on various mental health conditions and other resources.

# Nicotine Dependence Clinic (Centre for Addiction and Mental Health)
This clinic offers service to smokers and tobacco users who want to quit or reduce their tobacco use. It also provides specialized treatment services for smokers with other substance use issues, chronic mental illness and serious health concerns.
No referral is required

# TEACH Program
Tobacco Interventions for patients with mental health and/or addictive disorders Offers a specialized course about the detection and treatment of concurrent tobacco dependence and mental health and/or addictive disorders.

# Here to Help
A partnership of seven leading mental health and addictions non-profit agencies working to help people prevent and manage mental health and substance use problems.

# U.S. Department of Health and Human Services Public Health Service (2008) 13
Because of the serious risks of smoking to the pregnant smoker and the fetus, whenever possible pregnant smokers should be offered person-to-person psychosocial interventions that exceed minimal advice to quit. (Strength of Evidence = A) Although abstinence early in pregnancy will produce the greatest benefits to the fetus and expectant mother, quitting at any point in pregnancy can yield benefits. Therefore, clinicians should offer effective tobacco dependence interventions to pregnant smokers at the first prenatal visit as well as throughout the course of pregnancy.

# (Strength of Evidence = B)
New Zealand Ministry of Health (2007) 14 Offer all pregnant and breastfeeding women who smoke multi-session behavioural smoking cessation interventions from a specialist/dedicated cessation service.

# CLINICAL CONSIDERATIONS
There is limited evidence on harms associated with the use of NRT during pregnancy. Two prospective studies found no adverse maternal or fetal effects from the use of nicotine patch during pregnancy; however, one recent study demonstrated potential association between NRT and congenital defects. This data cannot support or exclude an association between first trimester NRT use and an increased risk of congenital defects due to several methodological issues. Therefore, until further information is available, the risks and benefits of smoking versus the use of NRT during pregnancy must be considered when counselling about smoking cessation options.
There is some evidence from RCTs that NRT may be efficacious in pregnancy in terms of decreasing tobacco use and improving pregnancy outcomes. No safety concerns were identified in these trials. Therefore, benefits of NRT seem to outweigh potential risks; NRT should be considered when counselling has been ineffective. Despite preliminary evidence that continued smoking and relapse are more likely among pregnant women who have a smoking partner, there is limited data regarding the benefits of partner involvement in smoking cessation interventions for pregnant smokers. Depression during pregnancy is a common occurrence and the use of Zyban (bupropion) may be appropriate to treat both smoking and depression. There is limited evidence on the effectiveness of bupropion for smoking cessation during pregnancy. In addition, there is no evidence of harm related to the use of bupropion during pregnancy and therefore, it may be considered for use as an alternative to NRT for a subpopulation of pregnant smokers (see Table 1
Including partners, friends, and/or family in a pregnant smoker's quit attempt is essential to increase the likelihood of successful smoking cessation interventions.
A smoke-free home environment should be encouraged for partners, friends, family members of pregnant and breastfeeding women to ensure safety from second-hand smoke/environmental tobacco smoke. This specialty course manual will allow clinicians to increase their knowledge about tobacco use, screening, assessment, and interventions with pregnant and postnatal women. The price of this manual reflects only the development and labor costs associated with its production.

# Course manual and in-person training
Connected to Sick Children's Hospital in Toronto, Motherisk provides online information on the risks of using substances (including tobacco) while pregnant. It also offers telephone counselling for women, and consultation for service providers. This booklet is based on fathers' experiences of reducing and quitting smoking. The quotes in the booklet are from expectant and new dads who smoke or have recently reduced or quit and offer their thoughts and ideas. This booklet is for men who identify with the challenges around being an expectant or new dad who smokes.

# Self-help booklet

# RESEARCH GAPS
Relationship between smoking and infertility Use of bupropion and varenicline as a smoking cessation aid -need more research on the effectiveness and safety Need more evidence of risk/benefit analysis of various smoking cessation aids
Youth have their own social network of individuals whom they trust and who exert influence over them. Healthcare practitioners may or may not be part of these networks. Cooperative efforts to provide nonsmoking messages between adults other than healthcare practitioners might increase effectiveness. Community mobilization in tobacco use prevention provides a model for shared efforts between parties.
Tobacco use habits among youth evolve during adolescence and the timing and trajectory of smoking and addiction differ between youth depending on factors such as access to tobacco, genetic predisposition, family and peer influence etc. There are no guidelines as to what constitutes "smoking" in youth so consensus is needed as to when a youth is considered to be a smoker (the recommendation is that first puff be viewed as a risk factor for continued smoking). three school-based programs and one in a clinic setting provided evidence of effectiveness. An intervention that combined NRT and behavioural counselling also showed promise.
There is little evidence to date on whether or not to recommend NRT to youth and this issue requires further research. As indicated in the UK and New Zealand guidelines, however, measures for treating smoking cessation in adults may be suitable for youth.

# CAN-ADAPTT SUMMARY STATEMENTS
CAN-ADAPTT's development process reflects a dynamic opportunity to ensure that its guideline is practice informed and addresses issues of applicability in the Canadian context. It has built from the evidence and recommendations contained in existing guidelines. It did not review the primary literature to inform the development of its Summary Statements unless emerging evidence was identified by the Guideline Development Group. The CAN-ADAPTT Guideline Development Group has provided the below Summary Statements for Youth (Children and Adolescents).

# SUMMARY STATEMENT #1
Health care providers, who work with youth (children and adolescents) should obtain information about tobacco use (cigarettes, cigarillos, waterpipe, etc.) on a regular basis.

# GRADE: 1A

# SUMMARY STATEMENT #2
Health care providers are encouraged to provide counselling that supports abstinence from tobacco and/or cessation to youth (children and adolescents) that use tobacco.

# GRADE: 2C

# SUMMARY STATEMENT #3
Health care providers in pediatric health care settings should counsel parents/guardians about the potential harmful effects of secondhand smoke on the health of their children.

# CLINICAL CONSIDERATIONS
Youth, unlike adults who are usually established in their pattern of tobacco use, are more likely to be in the process of acquiring the smoking habit with its concomitant nicotine dependence. In addition to not beginning to smoke, prevention of transition from intermittent to regular smoking may be key in helping youth stop smoking. The following recommendations are relevant to inquiry about youth smoking. Ask questions to ascertain use of tobacco products in multiple ways; use language and terminology that youth are familiar with.
To date, there is little empirical evidence that advising parents about the potential harmful effects of their smoking or of secondhand smoke on their child(ren), is effective. However, counselling parents in pediatric settings or "...during child hospitalizations may increase parents' interest in stopping smoking, parents' quit attempts and parents' quit rates..."

# TITLE DESCRIPTION RESOURCE BLAST program
BLAST (Building Leadership for Action in Schools Today) is a youth leadership tobacco prevention program developed by the Lung Association of Alberta & NWT. It challenges youth to think critically about the tobacco industry and its products, and the social and health effects from tobacco.

# Program to empower youth to become leaders and advocates in their schools and communities
Leave the Pack Behind LTPB delivers smoking cessation and prevention support to post-secondary students who smoke or are at risk of starting to smoke.
Resources for smokers, friends of smokers and health professionals.
A free, best-practices Web-based treatment program designed to help young smokeless tobacco users quit.

# Web-based treatment program Quit4Life
Health-Canada sponsored website with profiles and activities to support youth in smoking cessation.

# Interactive and personalized 4 week web program. Stupid.ca
An anti-tobacco movement created for youth, by youth, funded by Ontario's Ministry of Health Promotion.

# Educational resource for

# Talk with your children about smoking
A pamphlet suggesting how to approach the discussion about smoking with children
CAN-ADAPTT wishes to acknowledge the contribution to the Clinical Practice Guideline from Paul McDonald. Dr. McDonald was involved in the early Guideline Development Group meetings but was not involved in the final review and approval of the Clinical Practice Guideline.

# APPENDIX E -Clinical Practice Guidelines Used as Evidence Base for Guideline Development APPENDIX F -Strength of Evidence Classification Tables for Clinical Practice Guidelines Used as Evidence Base for CAN-ADAPTT's Guideline Development
The following strength of evidence classification tables are for each of the existing CPGs used as the evidence base for CAN-ADAPTT's guideline development. Note that the grade of recommendation/strength of evidence table for CAN-ADAPTT's summary statements can be found in Appendix B.

# U.S. Department of Health and Human Services Public Health Service (2008)

# STRENGTH-OF-EVIDENCE CLASSIFICATION CRITERIA

# Strength of Evidence = A
Multiple well-designed randomized clinical trials, directly relevant to the recommendation, yielded a consistent pattern of findings.

# Strength of Evidence = B
Some evidence from randomized clinical trials supported the recommendation, but the scientific support was not optimal. For instance, few randomized trials existed, the trials that did exist were somewhat inconsistent, or the trials were not directly relevant to the recommendation.

# Strength of Evidence = C
Reserved for important clinical situations in which the Panel achieved consensus on the recommendation in the absence of relevant randomized controlled trials.

# Registered Nurses Association of Ontario (RNAO) (2007)

# STRENGTH-OF-EVIDENCE CLASSIFICATION CRITERIA

# Strength of Evidence = A
Requires at least two randomized controlled trials as part of the body of literature of overall quality and consistency addressing the specific recommendations.

# Strength of Evidence = B
Requires availability of well conducted clinical studies, but no randomized controlled trials on the topic of recommendations.

# Strength of Evidence = C
Requires evidence from expert committee reports or opinions and/or clinical experience of respected authorities. Indicates absence of directly applicable studies of good quality.

# New Zealand Ministry of Health (2007)

# GRADES OF RECOMMENDATIONS CRITERIA

# Grade of Recommendation = A
The recommendation is supported by GOOD (strong) evidence.

# Grade of Recommendation = B
The recommendation is supported by FAIR (reasonable) evidence, but there may be minimal inconsistency or uncertainty.

# Grade of Recommendation = C
The recommendation is supported by EXPERT opinion (published) only.

# Grade of Recommendation = I
There is INSUFFICIENT evidence to make a recommendation.

# Grade of Recommendation =
GOOD PRACTICE POINT (in the opinion of the guideline development group).

# APPENDIX G -List of Committees

# Executive Committee
The Executive Committee was responsible for overseeing the execution of the CAN-ADAPTT Project which included providing direction to the Coordinating Centre staff with respect to methodology, work plan and objectives for the development of the guideline, recruitment and management of the CAN -ADAPTT Network and the Evaluation Framework.

# Evaluation Committee
The Evaluation of CAN-ADAPTT was subcontracted to an independent group, Ontario Tobacco Research Unit (OTRU). The Evaluation Committee provided opportunity for OTRU to gain valuable input into the Evaluation framework and methodology of CAN-ADAPTT which included understanding the value, quality and usability of the CAN-ADAPTT clinical practice guideline.