Smoking Cessation

Half of all smokers die prematurely of a smoking-related ailment. 90% of smokers aged 45-64 say that they would not smoke given their time again. 4 million smokers a year attempt to quit but only 3% of these succeed. Surveys reveal a “delusion gap” as 53% expect to stop within two years but only 6% manage it. The widespread disaffection with smoking plus the tendency to be deluded about how easy it is to stop justifies promoting chances to stop.¹ The ban on smoking in virtually all enclosed public places and workplaces in England from 1st July 2007 has offered a further window of opportunity.²

Smoking cessation interventions are a cost-effective way of reducing ill health. Quitting at any age provides both immediate and long-term health benefits. Smokers should be advised to stop and offered help and follow-up, with access to a smoking cessation clinic for behavioural support. NICE recommends focusing particularly on reducing the prevalence of smoking among people in manual groups, ethnic groups and disadvantaged communities. A reminder about the health benefits of smoking cessation and brief advice should be given at every opportunity in primary and secondary care. If appropriate, a referral should be made to the local NHS smoking cessation service.

Opportunities identified by NICE include patients referred for elective surgery and those recently discharged from hospital.

NICE recommendations (February 2008) are as follows:³

• Offer nicotine replacement therapy (NRT), varenicline or bupropion, as appropriate, to people who are planning to stop smoking.
• Pharmacological therapy should normally be prescribed as part of an abstinent-contingent treatment, in which the smoker makes a commitment to stop smoking on or before a particular date (target stop date).
• The prescription of NRT, varenicline or bupropion should be sufficient to last only until 2 weeks after the target stop date. Normally, this will be after 2 weeks of NRT therapy and 3-4 weeks for varenicline and bupropion, to allow for the different methods of administration and mode of action.
• Subsequent prescriptions should be given only to people who have demonstrated, on re-assessment, that their quit attempt is continuing.
• If a smoker's attempt to quit is unsuccessful using NRT, varenicline or bupropion, do not offer a repeat prescription within 6 months unless special circumstances have hampered the person's initial attempt.
• Varenicline or bupropion may be offered to people with unstable cardiovascular disorders, subject to clinical judgement.
• Consider offering a combination of nicotine patches and another form of NRT (such as gum, inhalator, lozenge or nasal spray) to people who show a high level of dependence on nicotine or who have found single forms of NRT inadequate in the past.
• Do not offer NRT, bupropion or varenicline in any combination.
• Do not favour one medication over another. The clinician and patient should choose the one that seems most likely to succeed.
• When deciding which therapies to use and in which order, discuss the options with the patient and take into account:
  • whether a first offer of referral to the NHS Stop Smoking Service has been made
  • contra-indications and the potential for adverse effects
  • the patient's personal preferences
  • the availability of appropriate counselling or support
  • the likelihood that the patient will follow the course of treatment
  • their previous experience of smoking cessation aids

Six NRT formulations are available on prescription and most can also be bought over-the-counter (OTC) at pharmacies and supermarkets. None of these formulations is more effective than any other. Higher dose gum and patches are more effective in those smoking more than 10 cigarettes a day. There has been some recent criticism of the effectiveness of the OTC strategy and more research is required.⁴

Combining products (e.g. patch and nasal spray or inhalator) is more effective than single agents.

• Patches 5, 10, 15 mg/16 hr (Nicorette®); 7, 14, 21 mg/24 hr (NiQuitin®)
• Gum (2 mg, 4 mg)
• Nasal spray (0.5 mg per puff)
• Inhalation cartridge (10 mg cartridge plus mouthpiece)
• Lozenges (1 mg, 2 mg, 4 mg)
• Sublingual tablets (2 mg)

NRT is most effective with behavioural interventions. NRT reduces but does not completely eliminate the symptoms of withdrawal because it takes a few seconds for nicotine from a cigarette to reach the brain but minutes for nasal spray, gum, inhalator, sublingual tablet, or lozenge and hours for transdermal patches.⁵

NRT can control the weight gain commonly experienced after cessation. NRT should be continued for eight weeks and can then be stopped immediately.

The risk of dependence on NRT is small. About 5% who quit continue to use nicotine regularly.

Nicotine from NRT is considerably safer than cigarettes, as the patient is not exposed to tar, carbon monoxide and other harmful products. Long-term use of NRT is not thought to be associated with any seriously harmful effects.

NICE advises explaining the risks and benefits of using NRT to young people aged from 12 to 17, pregnant or breastfeeding women and people who have unstable cardiovascular disorders.³ These groups should also be strongly encouraged to use behavioural support in their quit attempt.

Smokers should be advised not to smoke while using NRT products, although some gums are licenced for smoking reduction (see below).

Contra-indications

Severe cardiovascular disease (severe arrhythmias, post-infarction period); recent CVA (including transient ischaemic attacks).

Cautions

Cardiovascular disease; peripheral vascular disease; hyperthyroidism; diabetes mellitus; phaeochromocytoma, renal impairment, hepatic impairment, gastritis and peptic ulcers.

Side-effects

• Nausea
• Dizziness
• Flu-like symptoms
• Palpitations
• Dyspepsia
• Hiccups
• Insomnia
• Vivid dreams
• Myalgia

Bupropion (Zyban®) is only available on prescription. Bupropion was developed as an antidepressant but subsequently shown in trials to be effective in smoking cessation. Bupropion is an atypical antidepressant similar to diethylpropion, an appetite suppressant; it inhibits reuptake of dopamine, noradrenaline and serotonin in CNS and is a non-competitive nicotine receptor antagonist.

Contra-indications

Cautions

Hepatic cirrhosis, renal impairment; predisposition to seizures; raised BP (monitor weekly if used with nicotine products). May impair performance of skilled tasks (e.g. driving).

Side-effects

The most important side-effects are seizures (fits), which occur in about 1 in 1,000 patients. Insomnia and dry mouth commonly occur. About 0.1% of smokers suffer severe hypersensitivity reactions (e.g. angio-oedema, bronchospasm and anaphylactic shock) and 3% suffer milder reactions, such as rash, urticaria or pruritus.

Rare side-effects include: GI disturbances, tremor, anorexia, headache, dizziness, visual disturbance, anxiety, flushing, hallucinations, depersonalisation, seizures, paraesthesia, Stevens-Johnson syndrome, hepatitis, exacerbation of psoriasis.

See the BNF for full prescribing details.

Varenicline is only available on prescription. It is an α4β2 nicotinic acetylcholine receptor partial agonist. This means that it both blocks and stimulates the receptor it is attracted to. The α4β2 receptor is located in the nucleus accumbens area of the brain (the 'pleasure centre'). The stimulatory effect produces a weak nicotine-like effect which reduces the craving for nicotine itself, whilst the blocking effect inhibits the pleasurable effect derived from smoking.

Varenicline should be started 1-2 weeks before the target stop date. Ideally, weekly support from a health professional should be provided. The drug should be initiated at 500 mcg (one tablet) daily for 3 days, 500 mcg twice-daily for 4 days, then 1 mg twice-daily for 11 weeks. If the patient cannot tolerate the higher dose, it can be reduced to 500 mgc twice-daily. A further 12 weeks' course of 1 mg twice-daily can be considered for patients who have stopped smoking but feel they still need further pharmacological support.

Contra-indications

• Pregnancy
• Age under 18

Cautions

• Severe renal impairment
• Breastfeeding
• Up to 3% of individuals in the trials complained of irritability, an urge to smoke, depression and/or insomnia on stopping the drug. Patients should be advised of this and a gradual reduction in dosage towards the end of the course may need to be considered.

Side-effects

The commonest side effect noted in trials was nausea, which occurred in 30% of patients. This usually resolved spontaneously in a few days in patients who continued the drug. It is also helped by taking the tablet with water but a reduction in dosage to 500 mcg twice-daily was sometimes required. A wide range of other adverse effects was reported, of which the commonest were insomnia, abnormal dreams, headaches and flatulence. Both nausea and abnormal dreams can be reduced by taking the second pill at dinner time or supper time rather than at bedtime.

See the BNF for full prescribing details.

The following drugs have some effect on smoking cessation but are not licensed in the UK for this indication, nor are they recommended by NICE.
Nortriptyline, a tricyclic with noradrenergic properties and dopaminergic activity, is effective in cessation therapy, independent of the presence of depressive symptoms.

Clonidine is an alpha agonist that suppresses sympathetic activity and has increased smoking cessation in eight out of nine trials but has serious side-effects, including sedation and postural hypotension.

Acupuncture has not been shown to be effective in clinical trials.