4.10.5 Cigarette smoking

ChoiceDrugDosage
1st choicesBehavioural support + nicotine replacement therapy (long-acting) patch 5mg, 10mg, 15mg or 25mg over 16 hours, 7mg, 14mg or 21mg over 24 hours Dose:
See BNF or product SmPC
Or
Behavioural support + nicotine replacement therapy (short-acting) gum, lozenge, sublingual tablet, mouth spray, nasal spray, inhalator, orodispersible film; nicotine chewing gum 2mg, 4mg,6mg; nicotine lozenges 1mg, 1.5mg, 2mg, 4mg; sublingual nicotine tablets 2mg, nicotine mouth spray 1mg/spray; nicotine nasal spray 500micrograms/spray; nicotine inhalator 15mg/cartridge; nicotine 2.5mg orodispersible film; Dose:
See BNF or product SmPC
2nd choiceVarenicline▼ f/c tablets 500 micrograms, 1mgDose:
Start usually1-2 weeks before target stop date, initially 500 micrograms once daily for 3 days, increased to 500 micrograms twice daily for 4 days, then 1mg twice daily for 11 weeks (reduce to 500 micrograms twice daily if not tolerated); 12 week course can be repeated in abstinent individuals to reduce risk of relapse
3rd choice Bupropion hydrochloride 150mg m/r, f/c tabletsDose:
Start 1-2 weeks before target stop date, initially 150mg daily for 6 days then 150mg twice daily (max single dose 150mg, max daily dose 300mg; minimum 8 hours between doses); period of treatment 7-9 weeks; discontinue if abstinence not achieved at 7 weeks; consider max 150mg daily in patients with risk factors for seizures and the elderly

Prescribing Notes

General Notes

  • Refer to NICE NG92 Stop smoking interventions and services, March 2018.
  • Prescribing of NRT should be combined with one to one or group behavioural support.
  • It should not commence until the patient has decided on a ‘target stop date’.
  • Initial prescriptions should be issued weekly. Further prescriptions should only be issued if the quit attempt is continued at review and normally not for more than 2 weeks treatment on each occasion. NRT must not be added to repeat prescribing systems.
  • Symptom control of nicotine withdrawal in hospital in-patients, is the only exception to a ‘target stop date’ being set prior to prescribing NRT.
  • The use of NRT preparations in an individual who is already accustomed to nicotine introduces few new risks and is widely accepted that there are no circumstances in which it is safer to smoke than to use NRT.
  • Patients wishing to use a cut down to quit approach should be advised to purchase NRT for this purpose. Refer to NICE PH45 Tobacco: harm-reduction approaches to smoking.
  • The choice of product should be based on patient preference, patient history, discussion of potential side-effects, consideration of co-morbidities, potential drug interactions and cost.
  • Professional judgement should be used to consider if a repeat course should be initiated within 6 months of an unsuccessful quit attempt.
  • Stopping smoking may result in slower metabolism and a consequent rise in blood levels of drug catalysed by CYP1A2 (and possibly CYP1A1). This is because the inhalation of induction agents such as polycyclic aromatic hydrocarbons has stopped. There are a few drugs for which this is clinically significant, e.g. warfarin, theophylline and clozapine.
  • NRT may be prescribed to adolescents (12-18 years) and ideally there should be a referral to a specialist stop smoking service for young people for provision of suitable support.

Nicotine Replacement Therapy (NRT)

  • If the first cigarette of the day is taken less than 30 minutes after waking, then initiate with a patch providing nicotine over 24 hours, reducing over 8–12 weeks as per product information. If the first cigarette of the day is taken more than 30 minutes after waking, then initiate with a patch providing nicotine over 16 hours, reducing over 8–12 weeks as per product information.
  • There is no evidence that any particular form of NRT is superior in achieving cessation. Patches provide more stable serum levels and are simple to use. While 24 hour patches may be best for those who experience cravings on first waking, the 16 hour patch can be useful if vivid dreams and insomnia become a problem on the longer-acting patch.
  • Short-acting NRT preparations are more useful than patches at suppressing acute nicotine cravings. Short-acting NRT preparations allow individuals to more closely control the dose of nicotine delivered and personalise this according to their need.
  • Side-effects such as hiccups or GI symptoms are more of a problem with buccal administration. Acidic drinks such as coffee, carbonated or fruit drinks should be avoided for at least 15 minutes before gum or lozenges are taken as they can interfere with absorption.
  • In patients with stable cardiovascular disease, NRT is a lesser risk than continuing to smoke and is therefore recommended.
  • 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.
  • Nicotine releases catecholamines which can affect carbohydrate metabolism. Smokers with diabetes should be advised to monitor the blood sugar levels more closely than usual when attempting to quit smoking (with or without NRT).
  • Moderate to severe hepatic impairment and/or severe renal impairment decreases the clearance of nicotine or its metabolites and NRT should be used with caution.
  • NRT should not be used in combination with varenicline or bupropion.

Varenicline

  • Varenicline must be prescribed on the recommendation of specialist smoking cessation services involving suitably trained healthcare professionals.
  • It should only be prescribed as a component of a smoking cessation support programme in combination with one to one or group behavioural support.
  • All individuals using varenicline must be regularly reviewed by a trained healthcare professional.
  • Varenicline should be prescribed for 2 weeks initially and then normally for no more than 2 weeks’ supply on each occasion for a total of 12 weeks. It is licensed for a further 12 weeks to maintain abstinence.
  • Varenicline should not be used in patients under 18 years old or in those that are pregnant or breastfeeding.
  • Patients should be advised to discontinue treatment and seek prompt medical advice if they develop agitation, depression or suicidal thoughts. Refer to MHRA/CSM advice. Those with a history of psychiatric illness should be monitored closely.
  • Varenicline should be used cautiously in patients with a history of seizures or other conditions that potentially lower the seizure threshold.
  • Varenicline may also increase the risk of cardiovascular adverse events in patients with cardiovascular disease. Patients should be instructed to notify their doctor of new or worsening cardiovascular symptoms and to seek immediate medical attention if they experience signs and symptoms of MI or stroke.
  • Varenicline should not be used in combination with NRT or bupropion.

Bupropion

  • Bupropion must be prescribed on the recommendation of specialist smoking cessation services involving suitably trained healthcare professionals.
  • It should only be prescribed as a component of a smoking cessation support programme in combination with one to one or group behavioural support.
  • All individuals using bupropion must be regularly reviewed by a trained healthcare professional.
  • Bupropion should be prescribed for 2 weeks initially and then normally for no more than 2 weeks treatment on each occasion for a total of 7-9 weeks only.
  • Although it works in a different way to NRT there is no evidence that using a combination of NRT plus bupropion will give better quit rates than either measure alone, so is not recommended. If the combination is used blood pressure should be monitored weekly.
  • Bupropion is contra-indicated in patients with a current or previous seizure disorder, diagnosis of bulimia or anorexia nervosa, severe hepatic cirrhosis, history of bipolar disorder, pregnancy, breast feeding, and caution advised in heavy alcohol intake.
  • Drug interactions are a significant problem with bupropion; see BNF.
  • Bupropion should not be used in combination with varenicline.