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Smoking cessation - Management
What drug treatment should I prescribe to help someone over 18 years of age to help them stop smoking?
- It is strongly recommended that people who want to stop smoking quit abruptly, supported by drug treatment whenever possible.
- For people who are willing and feel able to quit abruptly, reduce the risk of relapse by prescribing nicotine replacement therapy, bupropion, or varenicline. The choice of treatment should be made on an individual basis, taking into account:
- The individual's previous experience of smoking cessation drugs and their preference for treatment.
- Contraindications, cautions, and risk of adverse effects (see Table 1).
- For people who want to quit but are clearly unwilling or unable to quit abruptly, some experts recommend offering nicotine replacement therapy to help them to reduce the amount they smoke before quitting. However the National Institute for Health and Clinical Excellence does not recommend this approach. Instead it states that this strategy should only be used as part of a properly designed and conducted research study of people who have repeatedly tried and failed to quit and those who are adamant that they do not want to quit abruptly. This approach is therefore not recommended as part of routine clinical practice.
Clarification / Additional information
Table 1. Comparison of drug treatments for smoking cessation.
| Nicotine replacement therapy | Bupropion | Varenicline |
|---|
Clinically significant adverse effects | — | Increased risk of seizures | None noted, but still under intensive surveillance by Commission on Human Medicines (black triangle). Post-marketing cases of myocardial infarction have been reported in people taking varenicline. |
Contraindications | — | Current seizure disorder (e.g. epilepsy), an increased risk of seizures, or any history of seizures. Bipolar disorder. | — |
Clinically significant drug interactions | — | Any drug known to lower the seizure threshold (e.g. antipsychotics, some antidepressants, tramadol, quinolones). Monoamine oxidase inhibitors. | — |
Available form | Patch, gum, inhalator, nasal spray, lozenge, sublingual tablet | Tablet | Tablet |
Efficacy affected by previous use | No | Yes | Not known |
Use in pregnancy | Yes | Not recommended | Not recommended |
Minimum licensed age | 12 years | 18 years | 18 years |
Use in people with cardiovascular disease | Yes | Yes | Yes |
Approximate cost of one course of treatment | £110* | £65–84† | £164–328‡ |
MAOI = monoamine oxidase inhibitor. * Based on a 12-week course of Nicorette® patches. † Based on 7–9 weeks of treatment at 150 mg twice a day. ‡ Based on 12–24 weeks of treatment at 1 mg twice a day. |
|
Basis for recommendation
Basis for the recommendation to stop abruptly, supported by drug treatment:
- There is good evidence summarized by National Institute for Health and Clinical Excellence, to support the use of nicotine replacement therapy (NRT), bupropion, and varenicline for people who are trying to stop smoking [NICE, 2002; NICE, 2007]. This evidence shows that drug treatment increases a person's chances of stopping smoking and of staying stopped after 6–12 months compared with not using drug treatment.
- Nicotine replacement therapy (NRT):
- Good evidence indicates that NRT is significantly more effective than placebo at maintaining continuous abstinence from smoking after at least 6 months [NICE, 2002; Stead et al, 2008]. Evidence suggests that bupropion and NRT do not significantly differ in efficacy [NICE, 2002; Hughes et al, 2007].
- NRT has been in use for many years and has a very good safety profile. For these reasons, many regard it as the pharmacological treatment of choice in smoking cessation [BNF 54, 2007].
- Bupropion:
- Good evidence indicates that bupropion is significantly more effective than placebo at maintaining continuous abstinence from smoking after at least 6 months [NICE, 2002; Hughes et al, 2007]. Evidence suggests bupropion and NRT do not differ in efficacy [NICE, 2002; Hughes et al, 2007].
- Bupropion has been in use in the UK as an aid to smoking cessation since June 2000. Bupropion is associated with a dose-dependent risk of seizure, with an estimated risk of approximately 0.1% (1 in 1000) [CSM, 2001a; CSM, 2001b].
- Varenicline
- Good evidence indicates that varenicline is significantly more effective than placebo at maintaining continuous abstinence from smoking after at least 6 months [Cahill et al, 2007]. Evidence suggests that varenicline has greater efficacy in maintaining continuous abstinence than bupropion [Cahill et al, 2007; Hughes et al, 2007]. CKS found no published studies comparing varenicline with NRT.
- Varenicline has been in use in the UK since December 2006. It is still under intensive surveillance for adverse effects (black triangle).
Basis for using NRT to reduce the amount smoked before quitting:
- There is difference of opinion among experts as to the value of nicotine-assisted reduction to stop.
- Evidence from a systematic review found that compared to placebo [Wang et al, 2008]:
- For people who declare an unwillingness or inability to quit smoking in the short term, NRT is effective in reducing their smoking.
- A small but statistically significant proportion of people treated with NRT quit smoking completely even though they had declared no interest in quitting.
- In this population of recalcitrant smokers, NRT generates abstinence success rates less than half of those reported for smokers willing to attempt an abrupt quit with NRT.
- The National Institute for Health and Clinical Excellence (NICE) recommends that until further evidence becomes available nicotine-assisted reduction to stop only be used in properly designed and conducted research studies [NICE, 2008]. NICE recommend further research is required to establish:
- How to make nicotine-assisted reduction to stop available without deterring people who want to stop from attempting to quit abruptly.
- Which health care professionals can best support this strategy.
- How this strategy would fit in with existing services.
- Other experts support the use of nicotine-assisted reduction to stop, based upon this evidence [McEwen et al, 2006].
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