Overview
General recommendations
- Patients should be offered nicotine replacement therapy (NRT), varenicline, or bupropion to those who plan to stop smoking
- Pharmacological therapy should be given as part of a treatment plan in which the patient commits to stop smoking on or before a particular target stop date
- The prescription of any pharmacological therapy should only last until 2 weeks after the target stop date:
- This is generally after 2 weeks of NRT or 3-4 weeks of varenicline/bupropion (due to their differences in the mechanism of action)
- Subsequent prescriptions should only be given to people who have demonstrated that their quit attempt is continuing
- If treatment is unsuccessful, do not offer a repeat within 6 months unless special circumstances have contributed to treatment failure
- Do not offer NRT, varenicline, or bupropion in any combination
Nicotine Replacement Therapy (NRT)
Overview
NRT is most effective with behavioural interventions and reduces withdrawal symptoms. Options are gum, patches, inhalation cartridges, lozenges, and nasal sprays.
Cautions
- Cardiovascular disease and peripheral arterial disease
- Diabetes mellitus
- Hyperthyroidism
- Renal/hepatic impairment
- Peptic ulcers
Contraindications
- Severe cardiovascular disease (e.g. arrhythmia, post-myocardial infarction, recent stroke or TIA)
Adverse effects
- Dizziness
- Nausea
- Myalgia and flu-like symptoms
- Palpitations
- Dyspepsia
Varenicline
Overview
Varenicline is an alpha-4 beta-2 nicotinic acetylcholine receptor partial agonist. It blocks and stimulates the receptor leading to reduced craving. It also inhibits the pleasure derived from smoking.
Cautions
- History of psychiatric illness – can increase risk of suicidal thoughts/behaviour
- Breastfeeding
- Severe renal impairment
- Withdrawal symptoms on stopping – gradual withdrawal may need to be considered
Contraindications
- Pregnancy
- <18 years
Adverse effects
- Nausea
- Headaches
- Insomnia
- Abnormal dreams
Bupropion
Overview
Bupropion is an atypical antidepressant that has been demonstrated in trials to be effective in smoking cessation. It is a noradrenaline and dopamine reuptake inhibitor and nicotinic antagonist.
Cautions
- There is a risk of seizures (1 in 1000)
- Hepatic cirrhosis
- Renal impairment
- Blood pressure
Contraindications
- Patients with a history of seizures
- Pregnancy
- Bipolar disorder
- <18 years
Adverse effects
- Seizures (1 in 1000)
- Insomnia
- Dry mouth
Smoking and Pregnancy
Management
- Pregnant people should be offered carbon monoxide testing at all antenatal appointments to assess exposure to tobacco smoke – this is because it can be difficult to disclose smoking during pregnancy due to the stigma surrounding it
- 1st-line: refer to stop-smoking support (e.g. NHS Stop Smoking)
- Consider NRT
- Varenicline and bupropion are contraindicated
