Supporting patients to quit

Smoking cessation: supporting patients to quit

The UK prevalence of smoking in the over-18s is now around 15%, with slight variation within the four countries. At its peak in 1948, 82% of the male population and 41% of women smoked. This stayed about the same until the 1970s, and then fell – quickly at first, but more slowly later – to present figures (from 2017). However, smoking still caused 78,000 deaths in England in 2015. Smoking prevalence is higher among the socially deprived and those with mental health problems. At over 25%, the smoking rate among manual workers is two and a half times higher than for those in professional jobs.¹

There are about 7,000 different chemicals in tobacco smoke.² Around 250 are known to be harmful, including hydrogen cyanide, carbon monoxide and ammonia (added by manufacturers to increase the addictive effects of smoking).³ At least 69 of these are carcinogenic, including arsenic, benzene and cadmium.² It is the nicotine that causes the addiction, and the other chemicals that cause harm.

So, how do you get people to stop smoking? NICE/CKS issued updated guidance in March 2018.⁴

Hunt the smoker

Ask patients at every opportunity whether they smoke. If they do, try Very Brief Intervention (VBI). This should take no more than 30 seconds. Over 60% of current smokers say that they want to stop, and under 20% say they have no intention of ever stopping.6 About 40% of smokers try and stop at least once each year, but only about 5% are successful.5 For those who do not wish to stop smoking, give advice about harm reduction. NICE guidance on smoking harm reduction is available at: https://www.nice.org.uk/guidance/ng209.⁶

Very brief intervention for smoking

• Ask about current and past smoking behaviour.

• Provide verbal and written information on the risks of smoking and the benefits of stopping smoking.

• Advise on the options for quitting smoking including behavioural support, medication and e-cigarettes.

• Refer the person to their local Stop Smoking service (if they wish to stop smoking).

Assess the smoker

Is there evidence of nicotine addiction? About 43% of smokers are physically addicted to nicotine,¹ and rather more smokers fear to stop because they think they are addicted. It is plausible that the addicts will respond better to medications, and the non-addicts will respond better to behavioural support.

Checking for nicotine dependence

• Ask how many cigarettes the person smokes per day. Score 0 points for 10 or less, 1 point for 11-20, 2 points for 21-30, 3 points for 31 or more.

• Ask how soon after waking the person smokes their first cigarette. Score 3 points for within 5 minutes, 2 points for 6–30 minutes, 1 point for 31–60 minutes, 0 points for after 60 minutes.

The higher the score, the greater the level of nicotine dependence.

What have you tried so far?

Most smokers try to stop more than once before success: depending on how you do the research it takes between 6 and 142 attempts before success.⁷ There is no cause for despondency at this poor success rate. Multiple quit attempts will usually result in a reduction in the lifetime consumption of tobacco – even a failed attempt is better than nothing.

Ask about previous attempts to quit

• How successful were you?
• Did you try any drug treatment?
• Did you use any support, for example through a smoking cessation service?
• What were your experiences of withdrawal symptoms and cravings?

Any complicating factors?

Some smokers may also be (other) drug users, have mental health issues, or may already have a smoking-related disease (e.g. lung cancer). Others may have ongoing illness that is exacerbated by smoking (e.g. COPD, diabetes). Smoking alters the bioavailability of some drugs, so that the dosages may need adjusting when smoking has ceased (e.g. olanzapine, warfarin, metformin).

MEDICATION FOR SMOKING CESSATION

There are four main medications licensed in the UK which have proven efficacy in smoking cessation:

• Nicotine Replacement Therapy – NRT (patches, oral preparations such as gum or lozenges, nasal sprays, inhalators)
• Cytisinicline
• Varenicline
• Bupropion

Choice of medication should be guided by patient preference and also by any pre-existing illness or ongoing medication. All medications work best when used in conjunction with behavioural support.⁴

Referral to a specialised NHS Stop Smoking service is advised.⁴ Psychosocial support is available, and there will also be a mechanism for issuing smoking cessation medication. For smokers who cannot or will not go to the Stop Smoking service, but who still want to stop smoking, then the responsibility rests with primary care.

Some people want to try to stop smoking using e-cigarettes, but these cannot currently be prescribed (or supplied by smoking cessation services), so it recommended that they use one of the above licensed medications instead.⁴ Though e-cigarettes almost certainly carry fewer dangers than smoking real cigarettes, nevertheless it is not yet clear if they are safe long-term. E-cigarette use alone or in combination with licensed medication and behavioural support appears to be helpful in the short term but further research is needed to establish the role of e-cigarettes in smoking cessation.⁴

Nicotine Replacement Therapy (NRT)

NRT delivers nicotine at a lower concentration and more slowly than cigarettes, so it is plausible that the risks are lower. NRT may cause chest pain and palpitations, but it does not cause cardiac ischaemia.⁸

The patches are used for 16 hours and then taken off at night. If there is evidence of nicotine addiction (see earlier) then leave the patch on for 24 hours (16 hour and 24 hour patches are available). Branded products are recommended as the doses are different and bioavailability may vary.⁴ Each brand of patch is made in a number of doses, and it is usual to start on the highest dose.

Start use on the ‘quit day’ with a higher dose patch. This may be topped-up as needed with an oral preparation or a spray. There is good evidence to show that combination NRT is more effective than single product use,⁹ and this approach is recommended by NICE.

Treatment usually persists for 8 to 12 weeks, but longer durations and higher doses may be needed in the more dependent smokers. Since NRT is available without prescription, it is not unknown for patients to use patches and also smoke cigarettes – not an ideal situation, but it is to be hoped that at least the number of cigarettes used is reduced.

Usually the dose of NRT is tapered down to nothing, and the individual product instructions give advice on this. Whether you stop suddenly or gradually has little effect on the long-term outcome of the treatment.⁴

Advantages of NRT

• Can be used at all ages, including adolescence

• Can be used with caution in pregnancy and breastfeeding

• Can be used in unstable cardiovascular disease

• Available without prescription

• Variety of dosages and forms

• May use a long-term form (e.g. patch) with additional short-acting top-ups (e.g. nasal spray)

About 20% of patch users get irritation where the patch is applied, but rarely is this so bad that treatment has to be stopped.¹⁰ Other side effects include dizziness, headache, sleep disturbance, agitation, irritability, fatigue, gastro-intestinal upset, dry mouth, cough, muscle pain, joint pain, palpitations, tingling, tremor, anxiety, dyspnoea. The nasal spray can cause nosebleeds and runny eyes. Oral preparations can cause sore mouth and tongue, and hiccoughs.¹⁰

Cytisinicline

NICE has recently added cytisinicline to its recommended products to help patients to stop smoking because it has been found to be very effective, especially when combined with behavioural support. Cytisinicline is a plant alkaloid that resembles nicotine, and is a nicotine-receptor partial agonist. It works by attaching to the same neuronal receptors in the brain that nicotine does, to reduce cravings.

Cytisinicline is prescribed initially at a dose of 1.5mg every 2 hours, from day 1 to 3 (following the decision to stop smoking), then reducing gradually to 1.5–3mg a day by day 21. If treatment fails, it should be discontinued and a further attempt made after 2 to 3 months. Cytisinicline is contraindicated in people who had had a recent myocardial infarction, stroke or with unstable angina.

Common side effects (may affect 1 to 10 users in 100) include gastrointestinal symptoms, such as nausea, sleep disturbance, difficulty in concentration, slow heart rate, burning tongue, and malaise.

Varenicline

Oral varenicline is a partial nicotine receptor agonist that binds less effectively than nicotine.⁸

The tablet should be started 7 to 14 days before ‘quit day’, meaning that the tablets are started while the smoker is still smoking. The ‘quit day’ is the day when smoking stops – the ‘not a puff rule’ is advised, i.e. the ex-smoker should not have any tobacco, not even a single puff. The tablet regime is:

Day 1 to 3 – 500mcg once daily

Day 4 to 7 – 500mcg twice daily

Day 8 onwards – 1mg twice daily

(If the full dose can’t be tolerated, revert to 500mcg twice daily)

Varenicline is available in a ‘starter pack’ with the right doses to achieve this build-up of treatment.

The maximum tolerated dose is taken for 12 weeks, with an option to continue for another 12 weeks if required. The medication is then stopped, without tapering the dose. In 3% of cases there is a reaction to stopping – irritability, depression, insomnia, urge to smoke: if this happens then tapering the dose down is a better idea.⁴

Concerns about varenicline causing neuropsychiatric or cardiac events have not been confirmed by placebo-controlled trials.⁸ Adverse effects include: headache; abnormal dreams; insomnia; appetite change; weight gain; fatigue; toothache; dry mouth; cough.¹⁰ A Cochrane review found that nearly 10% of people stop varenicline because of side effects, but in the same trial 8% of the placebo group also stopped their tablets.¹¹

Advantages and disadvantages of varenicline

• Use only in adult smokers

• Can be used in chronic illness

• Not for use in childhood or pregnancy

• Caution in mental illness

• Reduce dose in severe renal impairment

• Nausea in 30% of users

• Few drug interactions

• Probably the most effective medication

Bupropion

Bupropion was developed as a possible treatment for depression: it is used for depression in some countries, but does not have a UK licence for this use. In smoking cessation it appears to work by blocking nicotine receptors – it is a nicotine receptor antagonist. In addition it mimics the actions of dopamine and noradrenaline, two mood chemicals. It acts by blocking the effects of nicotine withdrawal, and at the same time reducing any resulting mood depression.⁸

The tablets are to be started between 7 and 14 days before the ‘quit day’. The doses are 150mg OD for six days, and then 150mg BD for 7 to 9 weeks. If it has not worked after 7 weeks, then stop the drug.4 In the elderly, and those with hepatic or renal impairment (eGFR of less than 50 ml/min), then keep the dose at 150mg once daily. Treatment can be stopped suddenly or tapered down – it does not appear to matter.

A concern about bupropion is that it causes fits: it does, but in only around 0.1% of users.¹⁰ Another concern raised in post-marketing surveillance was that it causes possible psychiatric side effects, including behaviour changes, depression, hostility and attempted suicide. Formal trials have failed to confirm this fear.¹⁰ Nevertheless, guidance suggests that the use of bupropion is contraindicated in smokers under 18 years old; past or present seizures; brain tumour; current or previous eating disorder; bipolar disorder or severe liver cirrhosis.⁴

Caution should be exercised when using bupropion in smokers who have conditions that may reduce the epileptic threshold (alcohol abuse; past brain injury; diabetes; taking drugs, such as antipsychotics, that make seizures more likely; taking stimulants or slimming pills) or who have severe hepatic or renal impairment.

Patients taking bupropion should nevertheless be monitored for psychiatric side effects – overall the evidence suggests that there is not a problem, but this encompasses trials that do show a risk and trials that don’t so that evidence is conflicting. Between 30% and 40% of takers get insomnia, and 10% get a dry mouth. Between 7% and 12% of patients stop bupropion because of side effects.¹⁰

Advantages and disadvantages of bupropion

• Use only in adult smokers

• Safe in chronic illness

• May help where NRT has failed

• Oral preparation

• Contraindicated: current or past seizures; pregnancy; breast feeding; use of mono-amine oxidase inhibitors

• Caution with drugs that lower the seizure threshold e.g. alcohol

References

1. Action on Smoking and Health (ASH). Fact sheet no. 1: Smoking statistics. http://ash.org.uk/category/information-and-resources/fact-sheets/

2. ASH. Facts at a glance – key smoking statistics. http://ash.org.uk/category/information-and-resources/fact-sheets/

3. McKee M. The marketing push that surprised everyone. BMJ 2013;347:f5780.

4. NICE/CKS. Smoking cessation. https://cks.nice.org.uk/smoking-cessation

5. Zwar AN, Mendelsohn CP, Richmond RL. Supporting smoking cessation. BMJ 2014;348:f7535.

6. NICE NG209. Tobacco: preventing uptake, promoting quitting and treating dependence; February 2025 https://www.nice.org.uk/guidance/ng209

7. Chaiton M, Diemert L, Cohen JE et al. Estimating the number of quit attempts it takes to quit smoking successfully in a longitudinal cohort of smokers http://dx.doi.org/10.1136/bmjopen-2016-011045

8. Hartmann-Boyce J and Aveyard P. Drugs for smoking cessation. BMJ 2016;352:i571.

9. Avery P. Combination nicotine replacement therapy (NRT), 2012. National Centre for Smoking Cessation and Training (NCSCT). http://www.ncsct.co.uk/usr/pub/Briefing%203.pdf

10. Monthly Index of Medical Specialities (MIMS). https://www.mims.co.uk/

11. Cahill K, Stevens S, Perera R, et al. Pharmacological interventions for smoking cessarion: an overview and network meta-analysis. Cochrane Database Syst Rev 2013;5:CD009329.23728690