eBulletin Newsletter

NCCN Flash Updates: NCCN Guidelines Updated for Smoking Cessation

NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®), and the NCCN Drugs & Biologics Compendium (NCCN Compendium®) for Smoking Cessation. These NCCN Guidelines® are currently available as Version 1.2025.

Link directly to the Updates section of the NCCN Guidelines: Smoking Cessation

Global

  • Bupropion long-acting revised: Bupropion long acting.

INTRO-1

  • First paragraph, new bullet added: Recognition that there is a continuum of harm for nicotine-containing products.
  • New paragraph added: Non-combustible nicotine-containing products such as e-cigarettes or nicotine pouches are used by people who smoke to quit smoking. These alternative nicotine products are not FDA approved for smoking cessation. The primary goal for providers should be that their patients achieve complete and sustained abstinence from cigarette smoking.
  • Second paragraph, last sentence revised: ...Therefore, the NCCN Guidelines for Smoking Cessation are directly applicable to not only combustible tobacco products (eg, cigarettes, pipes, cigars, hookah, cigarillos) but also electronic cigarettes (e-cigarettes)/vaping and smokeless tobacco products (eg, nicotine pouches).

INTRO-2

  • Clinical Recommendations:
    • First bullet, second sub-bullet revised: Behavior therapy with multiple counseling sessions is most effective. At a minimum, brief counseling advice is needed. . .
    • Fifth bullet revised: E-cigarettes are not FDA-approved for the treatment of smoking. Patients should be counseled toward the use of evidence-based smoking treatment approaches. For patients who choose to use e-cigarettes exclusively for smoking cessation, despite recommendations to use evidence-based pharmacotherapies, encourage behavioral counseling and abstinence from smoking There is a continuum of harm from most harmful (cigarettes and other combustible tobacco products) to less harmful non-combustible nicotine-containing products (eg, e-cigarettes, heat-not-burn products, snus, and nicotine pouches). There is growing evidence from randomized clinical trials and meta-analyses that e-cigarettes are effective tools for smoking cessation. However, e-cigarettes are addictive, and they contain and produce harmful chemicals. Providers should strongly support the use of evidence-based pharmacotherapies for smoking cessation. However, for patients who choose to use alternative nicotine products (non-combustible) for smoking cessation, the principal focus is to support complete abstinence from cigarette smoking. Some alternative tobacco products are designated by the Center for Tobacco Products as Modified Risk Tobacco Products (MRTPs), but this is not the same as the FDA approval for the treatment of smoking.
  • Footnote a revised: Combination NRT = Long-acting NRT (nicotine patch) + short-acting NRT (ie, lozenge, gum, inhaler, nasal spray). (Also page SC-5)

SC-1

  • Initial Evaluation, third bullet revised: Have you ever or do you currently use other tobacco products (eg, pipes, cigars, hookah, cigarillos, e-cigarettes/vaping, smokeless tobacco, nicotine pouches)?
  • Footnotes revised:
    • Footnote c: ...Patients with cancer should be encouraged to achieve and maintain abstinence from all combustible tobacco products (eg, cigarettes, pipes, cigars, hookah, cigarillos), e-cigarettes/vaping, and smokeless tobacco alternative nicotine products. For information about e-cigarettes and other non-combustible nicotine-containing products, see Principles of Alternative Approaches to Treatment of Smoking (SC-A).
    • Footnote f: Smoking status of all tobacco products, including e-cigarettes and other non-combustible nicotine-containing products, should be documented in the patient health record and assessment should be repeated at every visit.

SC-2

  • Evaluation:
    • First bullet:
      • First sub-bullet revised: How much do you currently smoke or use tobacco products (eg, cigarettes, pipes, cigars, hookah, cigarillos, E-cigarettes/vaping, non-combustible nicotine-containing products, smokeless tobacco, nicotine pouches) per day?
      • Third sub-bullet revised: How soon do you smoke or use tobacco products after you wake up in the morning? (ie, within 30 minutes)
    • Second bullet, fourth sub-bullet:
      • Tertiary bullet removed: Unaided
      • Fifth tertiary bullet revised: E-cigarettes Non-combustible nicotine-containing products.
      • New tertiary bullet added: Nicotine pouches.
    • Last bullet revised: Tobacco use of individuals within household and other shared spaces.
  • Footnote l revised: Smoking by other household members is an important predictor for not remaining abstinent and exposes the patient to secondhand smoke. To benefit the patient, individuals in the household and other shared spaces should be encouraged to abstain from smoking; resources may be provided.

SC-4

  • Last column, top option revised: Provide Aassessment of individuals who currently smoke (SC-2).

SC-A (1 of 2)

  • New header added: General
  • New section added: Harm Reduction
    • New bullets added:
      • There area wide variety of products on the market that may be used as alternative nicotine products such as non-combustible tobacco products (smokeless tobacco in the form of snus) and nicotine-containing products without tobacco (nicotine pouches).
      • Some of these products have been determined by the FDA’s Center for Tobacco Products to be MRTPs. MRTPs have been determined to be less harmful than cigarette smoking. The current list of MRTPs is found at: https://www.fda.gov/tobaccoproducts/advertising-and-promotion/modified-risk-granted-orders. MRTPs are not approved for smoking cessation by the FDA’s Center for Drug Evaluation and Research (CDER).
      • The long-term health effects of MRTPs remain unknown, but complete transition from cigarette smoking to MRTPs may reduce smoking-related cancer and disease.
      • Dual use of cigarette smoking and alternative tobacco products may be more harmful than smoking alone and should be actively discouraged.
      • For patients who choose to use non-combustible alternative products for smoking cessation, the provider’s main focus should be to support complete long-term smoking abstinence.

SC-A (2 of 2)

  • E-Cigarettes (Vaping):
    • New bullets added:
      • E-cigarettes are non-combustible tobacco products that deliver nicotine through heated aerosols for inhalation. The use of e-cigarettes is often referred to as vaping.
      • There is accumulating evidence from randomized clinical trials and systematic reviews that e-cigarettes are effective for smoking cessation.
      • E-cigarettes are addictive and they contain and produce harmful chemicals.
      • If a patient has already quit cigarette smoking through the use of vaping, providers should support continued smoking abstinence. As the patient becomes more confident about maintaining long-term smoking abstinence, the provider can encourage cessation of e-cigarettes, but not at the risk of relapse back to cigarette smoking.
      • The long-term health effects of vaping are unknown. However, e-cigarette aerosols contain substantially lower concentrations of harmful toxicants than combustible cigarette smoke.
      • Optimal methods for vaping cessation are currently unknown. Because of this, providers are encouraged to follow guidelines for smoking cessation in the treatment of e-cigarette use including behavioral counseling and pharmacotherapy.
      • Resources are available to aid in vaping cessation (SC-C).
    • Bullets revised:
      • Second bullet: The FDA may authorize the sale of select electronic nicotine delivery system (ENDS) products as modified risk tobacco products. Currently, none of these products are FDA-approved for the treatment of smoking some e-cigarettes, but no e-cigarette has been approved as a smoking cessation device.
      • Last bullet: Vaping products contaminated with vitamin E acetate are associated with EVALI (e-cigarette or vaping product use-associated lung injury) has occurred in patients who have vaped products contaminated with vitamin E acetate added with illicit drug use to e-liquids. Investigations are ongoing and health care professionals should be aware of the latest recommendations from the Centers for Disease Control and Prevention (https://www.cdc.gov/tobacco/basic_information/e-cigarettes/index.html). Educate patients on the unknown risks of using e-cigarettes in lieu of evidence-based methods. Continue to provide support during any quit attempts These were not commercial products, for example, as approved for marketing by the FDA. Vitamin E acetate has been largely eliminated from vaping products in the United States.

SC-A (2 of 2) (continued)

  • Bullets removed:
    • The use of e-cigarettes is often referred to as vaping.
    • The most effective use of e-cigarettes is unknown, particularly when considering factors such as real-world use and the addition of behavior therapy. Efficacy of e-cigarette use in patients with cancer is also unknown. Thus, patients should be counseled toward the use of evidence-based smoking treatment approaches.
    • For patients who choose to use e-cigarettes exclusively for smoking cessation, despite recommendations to use evidence-based pharmacotherapies, encourage abstinence from smoking and incorporate behavioral counseling.
      • For patients who use both e-cigarettes and combustible tobacco, dual use is strongly discouraged as it continues to pose a risk of cancer and other smoking-related diseases. Complete smoking abstinence is recommended.
      • If an individual has already quit using combustible tobacco and is solely using e-cigarettes, support continued non-smoking. If long-term abstinence with e-cigarettes is maintained, continue counseling and redirect to evidence-based methods in the event of relapse. As the patient becomes more confident about quitting combustible tobacco, encourage cessation of e-cigarettes, but not at the risk of relapse to smoking combustible products.
  • Other Alternative Methods, bullet removed: There are multiple nicotine-mimicking and nicotine-containing products that are not FDA approved for smoking treatment.

SC-B (1 of 3)

  • Second bullet, last sub-bullet revised: To benefit the patient, individuals in the household and other shared spaces should be encouraged to abstain from smoking; resources may be provided.

SC-C (1 of 3)

SC-C (2 of 3)

  • New page added: Smoking Cessation and Treatment Resources for Patients, General Resources for Patients for E-Cigarette/Vaping Cessation and Treatment.

SC-C (3 of 3)

  • Cancer-Related Resources for Health Professionals, new resource added: Commission on Cancer (Just/Beyond ASK)
  • General Resources for Health Professionals:
    • American Academy of Family Physicians (AAFP), bullet revised: Ask and Act Smoking Tobacco Cessation Program
    • American College of Chest Physicians (ACCP) (CHEST)
    • U.S. Department of Health and Human Services, bullet revised: Surgeon General Reports Tobacco Reports and Publications. . .

SC-D

  • First bullet:
    • First sub-bullet, second tiertiary bullet revised: . . .Smoking treatment should happen as soon as possible; ideally, the patient should be abstinent for ≥4 weeks or more, but this recommendation should not cause a delay in surgery.
    • Second sub-bullet revised: NRT use is not a contraindication to surgery...
  • Fifth bullet revised: There is insufficient evidence to support delaying a quit attempt at any time prior to surgery. For patients who need surgery, quitting smoking is recommended as soon as possible. It is not recommended to wait until after surgery.

SC-E (1 of 3)

  • Bullets revised:
    • First bullet: ...Brief counseling advice is better than no counseling.
    • Second bullet, first sub-bullet: ...(Note: Most nicotine withdrawal symptoms manifest in the first 1–2 days, peak within the first week, and subside within 2–4 weeks of quitting. Increased appetite, weight gain, and cravings may persist for several months. It is important to parse out perceived withdrawal symptoms from treatment side effects.).
    • Sixth bullet: Smoking by other household members is an important predictor for not remaining abstinent and exposes the patient to secondhand smoke. To benefit the patient, individuals in the household and other shared spaces should be encouraged to abstain from smoking; resources may be provided.
    • Seventh bullet, first sub-bullet: Increased relapse risk among patients living with HIV, psychiatric disorders, or other substance use disorders, those experiencing homelessness or incarceration, or those who identify as lesbian, gay, bisexual, transgender, queer, and additional sexual orientation and gender identities (LGBTQ+).

SC-E (2 of 3)

  • Behavior Therapy/Counseling Recommendations, second bullet, second sub-bullet revised: Refer to evidence-based resources for quitting, such as a smoking cessation quitline, in addition to providing brief counseling advice from a health care professional, if face-to-face or group intervention is not available...

SC-E (3 of 3)

  • New references added:
    • Reference 13: Streck JM, Rigotti NA, Livingstone-Banks J, et al.Interventions for smoking cessation in hospitalised patients. Cochrane Database Syst Rev. 2024;5:CD001837.
    • Reference16: U.S. National Cancer Institute. Treating smoking in cancer patients: An essential component of cancer care. National Cancer Institute Tobacco Control Monograph 23. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute; 2022. National Cancer Institute website. Available at:https://cancercontrol.cancer.gov/sites/ default/files/2022-07/MON23_ExecSumm_Final_071422.pdf. Accessed: April 30, 2025.
  • References revised:

SC-F (1 of 4)

  • Second bullet, fourth sub-bullet revised: Pharmacotherapy dose adjustments, including increasing the dosages of NRT and varenicline (but not bupropion), may be considered as clinically indicated.
  • Pharmacotherapy Options, Preferred Regimens, Combination NRT revised: Long-acting NRT (nicotine patch) + short-acting NRT (lozenge/gum/inhaler/nasal spray).

SC-F (2 of 4):

  • Standard Dose/Administration:
    • Combination NRT (preferred), new bullet added: Initiate dosing 1–2 weeks prior to agreed upon quit date, while patient is actively cutting down cigarettes per day
    • Varenicline (preferred), first bullet revised: Initiate dosing 1–5 wks prior to quitting 1–2 weeks prior to agreed upon quit date, while patient is actively cutting down cigarettes per day.
    • Bupropion, first bullet revised: Initiate dosing 1–2 wks prior to quitting agreed upon quit date, while patient is actively cutting down cigarettes.

SC-F (3 of 4)

  • Adverse Effects and Contraindications:
    • Varenicline, new bullet added: For patients experiencing nicotine withdrawal while on varenicline, NRT may be considered.
    • Bupropion, fourth bullet revised: ...Dose Use bupropion with caution when used with drugs that lower seizure threshold. Caution should be used for bupropion for patients treated with tamoxifen. Central nervous system (CNS) toxicity can occur when bupropion is used concomitantly with dopaminergic drugs.

SC-F (4 of 4)

  • New reference 1 added: Hawk LW Jr, Ashare RL, Rhodes JD, et al. Does extended pre quit bupropion aid in extinguishing smoking behavior? Nicotine Tob Res 2015;17:1377-1384.
  • References revised:
    • Reference 6: Cahill K, Stevens S, Perera R, Lancaster T. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database Syst Rev 2013;2013:CD009329. Lindson N, Theodoulou A, Ordóñez-Mena JM, et al. Pharmacological and electronic cigarette interventions for smoking cessation in adults: component network meta-analyses. Cochrane Database Syst Rev 2023;9:CD015226.
    • Reference 7: Howes S, Hartmann-Boyce J, Livingstone-Banks J, et al. Antidepressants for smoking cessation. Cochrane Database Syst Rev 2020;4:CD000031. Hajizadeh A, Howes S, Theodoulou A, et al. Antidepressants for smoking cessation. Cochrane Database Syst Rev 2023;5:CD000031.

 

For the complete updated versions of the NCCN Guidelines, NCCN Guidelines with NCCN Evidence Blocks™, the NCCN Drugs & Biologics Compendium (NCCN Compendium®), the NCCN Biomarkers Compendium®, the NCCN Chemotherapy Order Templates (NCCN Templates®), the NCCN Radiation Therapy Compendium™, and the NCCN Imaging Appropriate Use Criteria (NCCN Imaging AUC™), please visit NCCN.org.

To view the NCCN Guidelines for Patients®, please visit NCCN.org/patientguidelines.

Free NCCN Guidelines apps for iPhone, iPad, and Android devices are now available! Visit NCCN.org/apps.

About NCCN Flash Updates™

NCCN Flash Updates™ is a subscription service from NCCN that provides timely notification of updated and new information appearing in the NCCN Guidelines, the NCCN Compendium®, and other NCCN Content.

Subscribe to NCCN Flash Updates™

Third Party Content: The NCCN Content may contain content (such as figures, tables or illustrations) that NCCN licenses from third parties as displayed on NCCN Third Party Content site: private.filesanywhere.com/fs/v.aspx?v=8a6d65cfa19ea4bda0a3&C=6241. Licensee shall be solely responsible for obtaining permissions from each such third party to use any such Third Party Content in the Permitted Works. 

Access information on permissions and licensing of NCCN Content

Users may unsubscribe from Flash Updates at any time by contacting us. NOTE: The subscription fee for NCCN Flash Updates™ is non-refundable.

3025 Chemical Road, Suite 100, Plymouth Meeting, PA 19462
Phone: 215-690-0300
Fax: 215-690-0280
Copyright © National Comprehensive Cancer Network, All Rights Reserved.

No portion of this Site or any NCCN Content may be copied, transferred, reproduced, modified, or otherwise used for any purpose without NCCN’s express written permission.
See Legal Notices Section for additional notices and terms governing your use of this Site.