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Smoking cessation

Dr Rajesh Varma

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

  1. Drug treatment (varenicline or combination NRT) plus behavioural support, represent the most effective strategy for quitting smoking

  2. Pregnant women can use NRT (if non-drug treatment options have been unsuccessful)

  3. Patients with mental health diagnoses are slightly less likely to succeed in quitting smoking and may therefore need more support and initial monitoring

  4. 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:

  1. Smokers who wish to stop smoking should be referred to their local NHS Stop Smoking Services

  2. Set a QUIT DATE and commit to it.

  3. Stopping in one step on/before the quit date (abrupt quitting) offers the best chance of lasting success.

  4. The most effective approach is DRUG TREATMENT (Varenicline or combination NRT) plus BEHAVIOURAL SUPPORT (individual counselling or group meetings)

Follow up:

  1. Pre-quit appointment

  2. After 2 weeks of nicotine replacement therapy (NRT)

  3. After 3-4 weeks of treatment with varenicline or bupropion.

  4. Measure the carbon monoxide level 4 weeks after quitting: CO level<10 ppm equates non-smoker

  5. 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

  1. Prescribe NRT by brand name, as dosage instructions vary between brands of NRT

  2. NRT is licensed from the age of 12 (single or in combination)

  3. Start on the quit date and prescribe NRT for 8-12w

  4. 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

  1. Provide information and support for smoking cessation

  2. Advise to stop abruptly

  3. Offer drug treatment to reduce withdrawal symptoms.

  4. Consider a harm reduction approach +/-NRT

  5. Reviewed 2 weeks after stopping smoking, and the CO level measured at 4 weeks

E-cigarettes

  1. E-cigarettes deliver nicotine without the toxins found in tobacco smoke.

  2. E-cigarettes are the most popular method used in a smoking quit attempt in the UK

  3. Evidence suggests that e-cigarettes are 5% of the risk of tobacco smoking, but long-term effects are still largely unknown.

  4. E-cigarettes cannot be prescribed or supplied by smoking cessation services.

  5. E-cigarettes are NOT licensed drugs, they are regulated by the Tobacco and Related Products Regulations 2016.

  6. In the UK, sale of e-cigarettes is prohibited in children under 18 years of age

  7. 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

  1. Pregnant and breastfeeding women should be advised to stop smoking completely.

  2. NRT should only be used in pregnant females if non-drug treatment options have failed

  3. NRT intermittent therapy is preferred, but patches may be necessary

  4. NHS Pregnancy Smoking Helpline for further information (Tel: 0800 169 9169)

  5. 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