Saudi Guideline for Tobacco Cessation Services 2018 - 1439

Objectives

The guideline frames tobacco dependence as a chronic, relapsing condition and seeks to reduce tobacco-related disease, premature death and preventable harm by achieving complete abstinence from all tobacco products wherever possible.[1][2][3]It promotes timely, evidence-based cessation support for cigarette smokers and users of smokeless tobacco, cigars, pipes, water pipes and other tobacco products.[1][4][5]

• Identify tobacco users systematically, provide cessation advice regardless of readiness to quit, assess dependence and motivation, and arrange repeated support because multiple quit attempts may be needed.[6][2][7]
• Increase long-term abstinence by combining behavioural counselling, practical skills training, social support, telephone support and pharmacotherapy where appropriate.[6][2][8]
• Prevent relapse by supporting recent quitters, managing withdrawal, cravings, conditioned cues, stress, weight concerns and high-risk situations.[9][10][11]
• Promote cessation among population groups requiring tailored support, including adolescents, pregnant and breastfeeding women, people with mental illness or substance use disorders, hospitalised patients, people in prison, older people and those with chronic disease.[12][13][14][15][4]
• Protect non-smokers, especially children and pregnant women, from secondhand smoke, while communicating that non-cigarette and smokeless tobacco products are harmful rather than safe alternatives.[13][16][17]
• Address electronic cigarettes cautiously because their safety and effectiveness for cessation are not established in the cited guidance.[18]

Implementation

The delivery model centres on routine, person-centred clinical care: identify and document tobacco use, advise cessation, assess willingness and dependence, assist with behavioural and pharmacological treatment, and arrange follow-up.[7]Care should be adapted to clinical circumstances, patient preferences, contraindications, prior quit attempts, dependence severity and readiness to change.[19][20][21]

• Embed tobacco-use status in routine assessments, including at every clinical visit and hospital admission, through vital-sign documentation, prompts, problem lists and discharge diagnoses.[7][15]
• Apply the five A's model: ask about tobacco use, advise cessation, assess willingness to quit, assist treatment, and arrange follow-up.[7]Use motivational interviewing and the five Rs, relevance, risks, rewards, roadblocks and repetition, for people not ready to quit.[22][23]
• Provide brief advice to all smokers and offer more intensive individual, group, telephone or multi-session counselling where feasible.[19][10][24]Counselling should address problem-solving, coping skills, social support, stress, negative mood, tobacco cues and relapse prevention.[25][11]
• Set a quit date, preferably within two weeks, encourage removal of tobacco products and smoke-free environments, prepare patients for withdrawal, and support family and social disclosure where helpful.[25]Follow up promptly after the quit date, preferably in the first week and again within the first month, with further contacts according to need.[22]
• Offer first-line medicines, subject to clinical suitability, including nicotine replacement therapy, bupropion sustained release and varenicline; consider clonidine and nortriptyline as second-line options.[25][8]Select treatment according to dependence, anticipated difficulty quitting, adverse effects, interactions, cost, convenience and patient preference.[20]
• Consider combination nicotine replacement therapy, such as a patch with a faster-acting nicotine product, where appropriate.[20][21]Monitor medicine-related adverse effects and interactions, including changes in drug metabolism after smoking cessation and psychiatric symptoms where relevant.[21][3][26]
• Use specialised assessment where needed, including the Fagerström Test for Cigarette Dependence, carbon monoxide verification and, when appropriate, cotinine testing.[27][28]Carbon monoxide measurement can provide a baseline before quitting and validation at four weeks, and its verification rate is identified as a quality marker.[28]
• Tailor services for adolescents through counselling and confidentiality-sensitive care, for pregnant smokers through psychosocial support beginning at the first antenatal visit, and for parents through advice that reduces children’s exposure to tobacco smoke.[13][29]Use medication cautiously where evidence is insufficient, including for pregnant women, adolescents, light smokers and smokeless-tobacco users.[25][30]
• Integrate cessation into hospital care and chronic-disease management, provide counselling and withdrawal treatment during admission, and maintain post-discharge contact for at least one month.[15][4]
• Support access through healthcare systems, insurers and trained clinicians, including physicians, nurses, dentists, pharmacists and cessation practitioners.[6][19][31]Effective counselling and medication should be covered through public and private health benefit plans, as coverage is associated with increased treatment use, quit attempts and successful cessation.[31][10]
• Use low-cost reach-enhancing options, including quit-lines, tailored self-help resources, web-based support and mobile-phone messaging, while recognising that self-help materials alone have limited long-term effects.[24][32]

Monitoring & Evaluation

The guidance frames monitoring principally as a clinical quality process for identifying tobacco use, assessing dependence and readiness to quit, delivering treatment, verifying abstinence, and maintaining follow-up to prevent relapse. It does not establish a unified programme-level indicator framework, reporting schedule, surveillance platform, audit process, or named independent accountability body.[7][28][22][15]

• Record tobacco-use status systematically at every clinical encounter, including through vital-sign documentation, chart reminders or electronic prompts; for hospital admissions, record current use in the problem list and discharge diagnosis.[7][15]
• Assess readiness to quit, nicotine dependence, withdrawal risks, prior quit attempts and clinical circumstances to tailor counselling, medication and the intensity of support.[19][27][31]
• Apply the five A’s model by asking about tobacco use, advising cessation, assessing willingness, assisting treatment and arranging follow-up.[7]
• Measure treatment progress through quit attempts, abstinence duration, withdrawal symptoms, medication use and adverse effects, smoking behaviour, lapses, relapse and carbon monoxide readings where appropriate.[22][9][31][21]
• Verify adult smoking abstinence with carbon monoxide measurement, including a pre-quit baseline and four-week post-quit reading; the specified non-smoker threshold is 10 parts per million or below, and 6 parts per million for pregnant women.[28]
• Use urinary, blood or salivary cotinine testing when more specific confirmation is needed, while recognising that laboratory processing prevents immediate feedback and nicotine-replacement therapy can compromise its use as an abstinence indicator.[28]
• Schedule follow-up preferably within the first week after quitting, again within the first month, and further according to need; assess abstinence at the end of treatment and provide at least one month of follow-up after hospital discharge.[22][15]
• Monitor psychiatric symptoms, mood or behavioural changes, psychotropic-drug interactions and medication-related adverse effects among people with mental illness, substance-use disorders or complex treatment needs.[14][26]
• Track gradual reduction against interim goals of at least 50% reduction within six weeks and complete cessation within six months when this pathway is used.[33]
• Use the cited strength-of-evidence grades, including A, B and C, to support clinical recommendations, rather than as a formal service-performance or accountability system.[2][10][34]

Costing & Financing

Financing is addressed mainly through the case for covering tobacco-dependence treatment: behavioural counselling, pharmacotherapy and quit-line support are characterised as effective or cost-effective, while inadequate insurance coverage and institutional support are identified as barriers to access. No monetary budget, expenditure plan, reimbursement rate, funding allocation, funding gap, resource-mobilisation target or quantified economic model is specified.[35][2][31][10]

• Include effective counselling and tobacco-dependence medication as paid or covered benefits in public and private health-insurance plans, as coverage is associated with greater treatment use, more quit attempts and higher cessation rates.[2][31][10]
• Support health-system capacity for routine assessment and treatment, addressing limited clinician knowledge, training, institutional support, consultation time and insurance coverage.[35]
• Recognise counselling and medication as highly cost-effective relative to other reimbursed treatments, without a quantified cost-effectiveness ratio or financial threshold.[31][10]
• Use telephone cessation services as a cost-effective means of reaching large populations, particularly where face-to-face counselling is limited.[24]
• Consider carbon monoxide testing cost-effective as a cessation-verification and behavioural-support tool, although no unit cost or procurement requirement is supplied.[28]
• Consider online cessation interventions low cost and capable of reaching many smokers, while noting that no costed digital-delivery plan is provided.[32]
• Take account of cost and convenience when selecting pharmacotherapy; nicotine-replacement therapy and combination nicotine-replacement therapy are described as cost-effective.[20][21]
• Recognise that the source provides no separate financing arrangements for priority groups, including adolescents, pregnant or breastfeeding women, people with mental illness, hospitalised patients, people in prison, or users of smokeless tobacco.[13][14][15][16]