QuestionSBA
QuestionChoice
The National Institute for Health and Care Excellence (NICE) recommends that nicotine replacement therapy (NRT) with varenicline OR bupropion, as appropriate, to people planning to stop smoking; however, these medications should not be used in combination. In addition, patients should be advised not to smoke whilst on NRT
32707
e
Offer nicotine replacement therapy (NRT) with varenicline AND bupropion
QuestionChoice
Some patients may find acupuncture beneficial; however, it has not been shown to be effective in clinical trials and therefore is not currently recommended
32706
d
Acupuncture
QuestionChoice
Some patients may find hypnotherapy beneficial; however, it has not been shown to be effective in clinical trials and, therefore, is not recommended
32705
c
Referral for hypnotherapy
QuestionChoice
Whilst behavioural therapy can be helpful in stopping smoking in identifying triggers and craving coping strategies, behavioural therapy alone has a lower success rate than when used in conjunction with NRT
32704
b
Cognitive behavioural therapy alone
QuestionChoice
The National Institute for Health and Care Excellence (NICE) recommends that nicotine replacement therapy (NRT) with varenicline or bupropion, as appropriate, to people planning to stop smoking. Patients should be advised not to smoke whilst on NRT
32703
a
Offer nicotine replacement therapy (NRT) with varenicline OR bupropion
Concept
Chapter
# Summary

Smoking is a major public health issue, leading to premature death and multiple health conditions including cancers, COPD and cardiovascular diseases. Encouraging smoking cessation is therefore an important aspect of health promotion. The main strategies include behavioural therapies and pharmacotherapies, which include nicotine replacement therapy (NRT), bupropion, and varenicline. E-cigarettes and vaping are popular aids to smoking cessation and may be offered alongside behavioural support.

# Epidemiology

Smoking is the single biggest cause of premature death in the UK. There are around 10 million active smokers and approximately 50% will eventually die from smoking related conditions (on average 10 years earlier than non-smokers).

Conditions associated with smoking include:

- Cancer - smoking is the commonest cause of lung cancer, and contributes to the development of many other tumour types
- COPD
- Cardiovascular disease - including stroke, ischaemic heart disease and peripheral vascular disease
- Peptic ulcers
- Pregnancy complications (e.g. stillbirth, birth defects, low birth weight)
- Infertility
- Osteoporosis
- Dementia
- Dental disease

Passive smoking (exposure to second-hand smoke) is also associated with increased risk of lung cancer and heart disease as well as asthma, chest infections and otitis media in children.

# Nicotine Withdrawal Symptoms

When attempting to stop smoking, people may experience a variety of unpleasant symptoms due to both physical and psychological dependence on smoking and nicotine. 

Most people find they improve within 2-3 weeks of stopping smoking although some may last longer.

Symptoms include:

- Mood changes (irritability, frustration, anger, anxiety, depression)
- Insomnia
- Poor concentration
- Increased appetite and weight gain
- Restlessness
- Cravings for cigarettes

# Management

- Patients should be asked if they smoke at every opportunity
- Those who do smoke should be offered Very Brief Advice (VBA), also known as the 3 As:
- **Ask** patients if they smoke
- **Advise** those who smoke that the best way to quit is with specialist support
- **Act** refer to smoking cessation services if they wish to quit
- Those who do not want to quit smoking should be offered advice about harm reduction and encouraged to seek support if they are considering quitting
- Harm reduction strategies include:
- Cutting down with or without NRT 
- Temporarily stopping smoking with or without NRT
- Using an e-cigarette

## Behavioural Advice

- Abrupt quitting is the most effective way to stop smoking
- Encourage patients to set a quit date
- After this date they should commit to not smoking at all ("not a puff" rule)
- Think about ways to avoid other people smoking and situations in which they would usually smoke
- Discuss individual barriers to stopping smoking
- Signpost to resources e.g. free helplines, phone apps
- Individual and group support services are also available 
- Offer follow up and ongoing support

## Medical Management

Only one of the following should be prescribed at any time.

- **Nicotine replacement therapy (NRT)**
	- Reduces cravings and nicotine withdrawal symptoms
	- Multiple formulations are available including patches, gums, sprays and lozenges
	- Should be started on the day of quitting
	- Common side-effects include nausea, dizziness, vivid dreams and palpitations
	- Combination NRT is the most effective - this involves using a patch for 'background' cravings and a short-acting preparation (e.g. a mouth spray) for 'breakthrough' cravings
- **Bupropion**
	- Acts by inhibiting reuptake of dopamine and noradrenaline
	- Tablet taken once a day for 6 days then twice a day for 7-9 weeks
	- Should be started 7-14 days before the quit date
	- Contraindicated in:
	- Epilepsy (decreases seizure threshold)
	- Eating disorders
	- Bipolar disorder
	- Brain tumours
	- Current benzodiazepine or alcohol withdrawal
	- Pregnancy and breast-feeding
	- Important side-effects include insomnia, hypersensitivity reactions and rarely seizures
- **Varenicline**
	- Works as a partial nicotinic receptor agonist
	- Taken as an oral medication which is uptitrated in dose over the first week
	- Start 7-14 days before the quit date, usually continued for 12 weeks
	- Contraindicated in pregnancy and end-stage renal disease
	- Important side-effects include psychiatric effects (e.g. suicidal thoughts, depression and hallucinations), nausea and headaches
- **E-cigarettes**
	- These are not licensed medications and are not available on the NHS currently but patients may wish to buy them 
	- Patients should be advised that there is not enough evidence to know whether there are long-term harms of vaping
	- However, available evidence suggests that vaping is significantly less harmful than smoking and can help people stop smoking
	- Advise patients using e-cigarettes to stop smoking tobacco completely

# Prognosis

Around half of people using NHS Stop Smoking services are successful in quitting at four weeks, with evidence suggesting that people who stop smoking for a month are five times more likely to quit long term. 

Stopping smoking before the age of 50 halves the risk of dying of smoking-related disease.


# NICE Guidelines

[NICE - Tobacco dependence](https://www.nice.org.uk/guidance/ng92)

[NICE CKS - Smoking Cessation](https://cks.nice.org.uk/topics/smoking-cessation/)

# References

[Action on Smoking and Health](https://ash.org.uk/)

[NHS advice on e-cigarettes](https://www.nhs.uk/live-well/quit-smoking/using-e-cigarettes-to-stop-smoking/)

[National Centre for Smoking Cessation and Training](https://www.ncsct.co.uk/)
1861
2660
Smoking Cessation
Topic
20
Respiratory Physiology
6541
A 45-year-old male presents to General Practice requesting help and advice on quitting smoking.

What is the most appropriate treatment?
a