• The preferred management is referral to an intensive support service, such as the NHS Stop Smoking Services.
• For people who do not want referral:
• Offer practical advice and follow up to help them stop smoking.
• Advise stopping smoking completely with nicotine replacement therapy.

In depth

• For children over the age of 12 years, offer nicotine replacement therapy to reduce the risk of relapse.
• Limit treatment to 12 weeks where possible.

In depth

Advise people who want to stop smoking to:

• Prepare mentally to stop by:
• Making a list of reasons why they want to stop.
• Explaining that most of the pleasure of smoking comes from the relief of nicotine withdrawal symptoms.
• Expecting stopping to be difficult but progressively easier after the third or fourth day. Modest weight gain may occur but is less likely while using drug treatments to help stop smoking.
• Involving family and friends by telling people about their intention to stop and, if possible, stopping with someone else.
• Set a date to stop smoking when they feel well and under the least amount of stress possible. Advise people to stop immediately if they are motivated to do so.
• Avoid relapses by:
• Using nicotine replacement therapy to relieve the symptoms of nicotine withdrawal.
• Avoiding situations associated with smoking until they can comfortably resist the impulse to smoke.
• Replacing smoking with other activities, such as chewing gum, drinking water or tea, or taking glucose tablets relieve nicotine cravings.
• Setting targets for remaining smoke free and rewarding themselves for reaching these targets.
• Try again if they relapse. Most people who successfully stop smoking long term need several attempts before they finally stop completely.

In depth

• Review young people using nicotine replacement therapy (NRT) within 2 weeks of their stop date:
• For those who continue to smoke, reassess their readiness to quit by asking them whether they would like help to continue with their quit attempt. Continue treatment if they demonstrate a continuing attempt to stop. Treatment should not usually exceed 12 weeks.
• For those with adverse effects from treatment, consider reducing the dose or changing the formulation.
• For those with significant nicotine withdrawal symptoms on treatment, the options include:
• Increasing the dose (up to the maximum licensed dose that is tolerated).
• For people using NRT patches, consider combining with a rapid-release NRT product to relieve breakthrough symptoms.
• Changing formulation of NRT e.g. people who experience withdrawal symptoms first thing in the morning after removing NRT at night could consider using a 24-hour patch.
• For those remaining smoke free and managing well, review each month and prescribe further NRT for up to 12 weeks.

In depth

• There is no difference in efficacy between different formulations of nicotine replacement therapy.
• Points to discuss with the smoker when choosing a product include:
• The number of cigarettes smoked per day.
• The time to the first cigarette of the day.
• Speed of nicotine delivery.
• Ease of use.
• Local irritant effects.
• Amount of behavioural replacement provided.
• Ability for the smoker to adjust and titrate the nicotine dose as required.
• Use of intermittent formulations as required to relieve cravings.

In depth

• Smokers must use sufficient nicotine replacement therapy (NRT) in order to achieve good success rates. To ensure a sufficient dose, several expert reviewers advise regular use of intermittent (non-patch) formulations of NRT, topping up as needed.
• NRT patches are available in two preparations (16-hour and 24-hour), each with three strengths prescribed in a programme of reducing dose, usually over 8–12 weeks:
• 16-hour patch: 15 mg, 10 mg, 5 mg (Nicorette^®).
• 24-hour patch: 21 mg, 14 mg, 7 mg (Nicotinell^®, NiQuitin^®).
• NRT gum is available in two strengths — 2 mg and 4 mg:
• People who smoke more than 20 cigarettes per day: start with the 4 mg gum.
• NRT lozenges are available in four strengths — 1 mg, 1.5 mg, 2 mg, and 4 mg:
• Nicotinell^®:
• People who smoke less than 20 cigarettes per day: start with 1 mg lozenges.
• People who smoke 20 to 30 cigarettes per day: start with 1 mg or 2 mg lozenges, depending on the person's characteristics and preference.
• People who smoke more than 30 cigarettes per day: start with 2 mg lozenges.
• Niquitin^®:
• People who have their first cigarette of the day more than 30 minutes after waking up: start with 2 mg lozenges.
• People who have their first cigarette of the day within 30 minutes of waking up: start with 4 mg lozenges.
• Nicopass^® 1.5 mg lozenges are not suitable for smokers who are heavily dependent on nicotine.
• NRT sublingual tablets — 2 mg:
• 20 cigarettes or more per day: start taking two tablets (4 mg) sublingually each hour.
• Fewer than 20 cigarettes per day: start taking one tablet (2 mg) sublingually each hour (increase to two tablets each hour if the person fails to stop smoking or has significant withdrawal symptoms).
• NRT nasal spray and inhalator — one strength only:
• All smokers: use when required, to relieve the urge to smoke.
• Duration of NRT in people maintaining abstinence from cigarettes is usually 8–12 weeks (depending on which form of NRT is used and which dose is initiated), followed by a gradual reduction in dose.
• Some people, in particular those who are more dependent on nicotine, may need higher doses of NRT for a longer duration to reduce the risk of relapse.

In depth

• Nicotine replacement products may be combined to gain better control of withdrawal symptoms.
• This is usually done by providing a steady delivery of nicotine using a patch, with an intermittent formulation to provide relief from breakthrough cravings.

In depth

• The most common adverse effects include local reactions (e.g. skin irritation with patches; irritation of the nose, throat, and eyes with nasal spray), sleep disturbances (e.g. vivid dreams), gastrointestinal disturbances, dizziness, and headache. If these are problematic, try a different formulation.
• In addition to the adverse effects above, the nasal spray can cause sneezing and watering eyes for a short time after use; advise people not to use it while they are driving.

In depth