Smoking cessation
Useful Resources
Stop smoking interventions and services. March 2018. NICE guideline 92.
National Centre for Smoking Cessation and Training NCSCT
CKS Smoking cessation CKS/NICE
Drug treatment (varenicline or combination NRT) plus behavioural support, represent the most effective strategy for quitting smoking
Pregnant women can use NRT (if non-drug treatment options have been unsuccessful)
Patients with mental health diagnoses are slightly less likely to succeed in quitting smoking and may therefore need more support and initial monitoring
Overall quit smoking programme is around 5 appointments over 8-12 weeks
Introduction
Smoking tobacco is the main cause of preventable illness and premature death in the UK.
Smoking causes:
cancer (primarily lung cancer)
chronic obstructive pulmonary disease (COPD)
ischaemic heart disease (IHD)
complications during pregnancy
Withdrawal symptoms of smoking cessation
Smoking cessation in an individual with nicotine dependency may lead to short-term withdrawal symptom:
nicotine cravings
irritability
depression
restlessness
poor concentration
light-headedness
sleep disturbances
increased appetite
weight gain (less likely if drug treatment is used to aid smoking cessation)
Generic management of smoking cessation
All people who smoke should be advised to quit.
If the person does smoke, very brief advice (VBA) for smoking cessation should be provided.
VBA (30 seconds)
Establish and record smoking status
Explain that the best way to stop is with medication and behavioural support
Offer help and signpost the patient to their NHS Stop Smoking Service (or GP practice nurse)
In general, the following plan is recommended:
Smokers who wish to stop smoking should be referred to their local NHS Stop Smoking Services
Set a QUIT DATE and commit to it.
Stopping in one step on/before the quit date (abrupt quitting) offers the best chance of lasting success.
The most effective approach is DRUG TREATMENT (Varenicline or combination NRT) plus BEHAVIOURAL SUPPORT (individual counselling or group meetings)
Follow up:
Pre-quit appointment
After 2 weeks of nicotine replacement therapy (NRT)
After 3-4 weeks of treatment with varenicline or bupropion.
Measure the carbon monoxide level 4 weeks after quitting: CO level<10 ppm equates non-smoker
Overall quit smoking programme is around 5 appointments over 8-12 weeks
To produce one non-smoker,
NNT 51 for VBA
NNT 23 for NRT + behavioural support
NNT 22 for bupropion + behavioural support
NNT 11 for varenicline + behavioural support
Drug treatment for smoking cessation
The prescription should last till the QUIT DATE + 2 weeks later.
Three drug treatment modalities; these are prescribed as individual treatment modalities and NOT in combination.
1.Nicotine replacement therapy (NRT) used to prevent relapse/nicotine withdrawal symptoms
Long-acting transdermal patch NRT
16hr patch on/8hr patch off
24hr patch if strong nicotine cravings upon waking)
Short-acting NRT
Lozenges, mini lozenges, gum, sublingual tablets, inhalator, nasal spray, oral spray, oral strips
Combination NRT
Short-acting PLUS long-acting NRT
Combination of NRT is more effective than using a single type of NRT
General notes on NRT
Prescribe NRT by brand name, as dosage instructions vary between brands of NRT
NRT is licensed from the age of 12 (single or in combination)
Start on the quit date and prescribe NRT for 8-12w
NRT can be stopped abruptly or tapered gradually
Offer NRT as part of a 'harm reduction approach', which could manifest as:
stopping smoking whilst using NRT to prevent relapse
smoking reduction/temporary abstinence +/- NRT
as NRT usage will reduce how much they smoke (in total) and improve their chance of stopping smoking in the long-term.
2.Varenicline
Partial nicotinic receptor agonist
Acts to reduce nicotine craving, withdrawal, rewarding effects of smoking
Quit smoking 7-14 days AFTER starting varenicline (i.e. started 7-14 days BEFORE the quit date)
Dosage 1st week (500mcg OD, 500mcg BD), thereafter, 1mg BD
Treatment course is 12w (but is licensed up to 24 weeks)
Reduce dose to 1mg OD if severe renal impairment eGFR<30 mL/min
Varenicline may be stopped without tapering the dose.
Contraindications:
Age<18
End-stage renal disease
Pregnancy and breastfeeding
3.Bupropion
Selective dopamine and noradrenaline re-uptake inhibitor
Acts on brain addiction pathways
Quit smoking 7-14 days AFTER starting bupropion (i.e. started 7-14 days BEFORE the quit date)
Dosage: 150 mg OD 6d, then 150 mg BD
Treatment course is 7–9 weeks
Discontinue if no effect after 7w
Use 150 mg OD if elderly, mild to moderate hepatic impairment or renal impairment (eGFR < 50 mL/min).
Bupropion can be stopped without tapering the dose
Contraindications:
Age<18
Seizure disorder or factors which reduce seizure threshold (e.g. SSRIs, antipsychotic drugs, alcohol abuse, head trauma)
CNS tumour
History of bulimia or anorexia nervosa
History of bipolar disorder
Severe hepatic cirrhosis
Pregnancy or breastfeeding
Smokers who are unwilling or not ready to stop smoking or decline referral to the NHS Stop Smoking Service
Provide information and support for smoking cessation
Advise to stop abruptly
Offer drug treatment to reduce withdrawal symptoms.
Consider a harm reduction approach +/-NRT
Reviewed 2 weeks after stopping smoking, and the CO level measured at 4 weeks
E-cigarettes
E-cigarettes deliver nicotine without the toxins found in tobacco smoke.
E-cigarettes are the most popular method used in a smoking quit attempt in the UK
Evidence suggests that e-cigarettes are 5% of the risk of tobacco smoking, but long-term effects are still largely unknown.
E-cigarettes cannot be prescribed or supplied by smoking cessation services.
E-cigarettes are NOT licensed drugs, they are regulated by the Tobacco and Related Products Regulations 2016.
In the UK, sale of e-cigarettes is prohibited in children under 18 years of age
If the person wishes to use e-cigarettes, they should be advised that
Drug treatment (varenicline or combination NRT or bupropion) is the most effective way to stop and is preferred method
If the person prefers to use e-cigarettes, they should be given information about these, alongside behavioural support
Stop Smoking Services will support those who choose e-cigatettes
Pregnancy and breastfeeding
Pregnant and breastfeeding women should be advised to stop smoking completely.
NRT should only be used in pregnant females if non-drug treatment options have failed
NRT intermittent therapy is preferred, but patches may be necessary
NHS Pregnancy Smoking Helpline for further information (Tel: 0800 169 9169)
Varenicline or bupropion should not be prescribed to pregnant or breastfeeding women
At risk groups recommended for referral to NHS Stop Smoking Service
Pregnant women (including pregnant women who have stopped smoking in the past 2 weeks or who have a carbon monoxide reading of 7ppm or more)
Mothers of young children, especially breastfeeding women
Young people aged 12-17
Smoking interferes with the therapeutic efficacy of concomitant drugs
Polycyclic aromatic hydrocarbons found in tobacco smoke increase the metabolism of some drugs by inducing hepatic enzymes, often requiring an increase in dose.
Hence, bioavailability of some psychiatric medications increases on stopping smoking and therefore dose reductions of 25-50% may be necessary