20th February 2024

Smoking cessation

Patients should be screened for smoking and should receive advice for smoking cessation. History around the patient’s smoking habits, amount smoked and any previous attempts to stop smoking. Clinicians also can explore other co-existing issues, including mental health issues and substance use. 

Psychosocial and pharmacological interventions should be considered in patients ready to stop smoking. Nicotine replacement therapies and advice regarding cutting down can be offered to those not ready to stop smoking.  

Psychosocial interventions 

Patients advised to stop smoking should receive ” very brief advice” from clinicians when they express interest in it. This includes counselling on the harm of smoking, withdrawal symptoms and triggers for relapses and management of these symptoms. Clinicians can also use the opportunity to discuss the importance of abrupt cessation and the barriers to change. 

This can be supported with referrals to smoking cessation services such as the NHS Stop Smoking services. These services can offer behavioural support and advice about treatments to stop smoking. 

Pharmacological interventions 

Nicotine replacement therapy (NRT) is recommended with behavioural therapies for smoking cessation. A combination of short-acting and long-acting NRT is more successful than individual treatments. NRT aims to reduce nicotine withdrawal symptoms without exposure towards tobacco and cigarette smoke. Examples of long-acting NRT treatment include patches, while short-acting NRT comes in lozenges, gum, inhalators or nasal sprays. Treatment with NRT is usually for 8-12 weeks before a gradual reduction in the dose. 

E-cigarettes do not have long-term evidence to support their use, but patients should be informed that they carry less risk than ongoing smoking. Caution should be taken when using NRT in pregnancy, adolescent patients and patients with unstable cardiac arrhythmias or ischemia. 

Varenicline acts as a partial α4β2 nicotinic receptor, preventing nicotine binding onto the receptor. This reduces the symptoms of nicotine withdrawal and cravings. It is usually associated with altered sleep and vivid dreams. Varenicline has been associated with cardiovascular and neuropsychiatric adverse events, but current research has not substantiated this. Despite this, caution should be taken when using varenicline in patients with psychiatric or cardiovascular history.

Bupropion acts on the central adrenergic and dopaminergic reuptake inhibitor. It appears to act on the pathways associated with addiction and withdrawal, but its precise mechanism of action is unknown. Its use is contraindicated in patients with seizures, severe hepatic cirrhosis and CNS tumours. Common side effects include insomnia, agitation, dry mouth and headaches. 

It is important to note that smoking affects the metabolism of several medications, and smoking cessation may increase the plasma concentration of several medications. This is due to the impact of smoking on the CYP1A2 enzyme. Common medications that will be affected include warfarin, olanzapine, clozapine, chlorpromazine and theophylline. Monitoring for side effects following smoking cessation is advised, and dose reduction as needed should be performed. 

References

• Park, E. (2020 Sept 30). Behavioural approaches to smoking cessation. Accessed on 2022 Mar 25. Available from: https://www.uptodate.com/contents/behavioral-approaches-to-smoking-cessation?topicRef=16634&source=see_link. 
• Rigotti, N. (2021 Dec 14). Pharmacotherapy for smoking cessation in adults. Accessed on 2022 Mar 25. Available from: https://www.uptodate.com/contents/pharmacotherapy-for-smoking-cessation-in-adults?topicRef=6920&source=see_link. 
• Rigotti, N. (2021 Nov 29). Overview of smoking cessation management in adults. Accessed on 2022 Mar 25. Available from: https://www.uptodate.com/contents/overview-of-smoking-cessation-management-in-adults?topicRef=16635&source=see_link. 
• National Institute for Health and Care Excellence. (2018). Tobacco: preventing uptake, promoting quitting and treating dependence. Accessed on 2022 Mar 25. Available from: https://www.nice.org.uk/guidance/ng209/resources/tobacco-preventing-uptake-promoting-quitting-and-treating-dependence-pdf-66143723132869. 
• National Institute for Health and Care Excellence Clinical Knowledge Summary. (2021 ). Smoking Cessation. Accessed on 2022 Mar 25. Available from: https://cks.nice.org.uk/topics/smoking-cessation/.