• 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.
• Offer drug treatment to reduce withdrawal symptoms.

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 drug treatments to relieve the symptoms of nicotine withdrawal (e.g. nicotine replacement therapy).
• Avoiding situations associated with smoking until they can comfortably resist the impulse to smoke. Remove smoking paraphernalia from the home and avoid alcohol in the early stages of stopping.
• 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

• Encourage people who want to stop smoking to 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 (NRT), 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.
• For people who are clearly unwilling or unable to quit abruptly, some experts recommend offering NRT to help them to reduce the amount they smoke before quitting. However the National Institute for Health and Clinical Excellence 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.

In depth

• For people quitting abruptly supported by drug treatment, review within 2 weeks of their stop date:
• For people who continue to smoke, reassess their readiness to quit. If they demonstrate a continuing attempt to quit:
• Encourage them to quit abruptly. If they can quit abruptly, continue treatment.
• For people who want to quit but are clearly unwilling or unable to quit abruptly, some experts recommend offering nicotine replacement therapy (NRT) to help them to reduce the amount they smoke before quitting. However NICE 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.
• For people with adverse effects from treatment, consider reducing the dose of current treatment, or trying an alternative treatment or formulation.
• For people with significant nicotine withdrawal symptoms on treatment, consider:
• Increasing the dose (up to the maximum licensed dose that is tolerated).
• Combining NRT patches with a rapid-release NRT product to relieve breakthrough symptoms.
• Changing formulation of NRT.
• For people remaining smoke free and managing well, review each month and prescribe further medication.
• For people using NRT to assist a reduction in smoking before quitting, review within 1 month of starting NRT and assess their level of smoking. The goal is to reduce smoking by at least 50% within a month of starting NRT and to have stopped smoking completely within 6 months.

In depth