The preferred management is referral to an intensive support service, such as the NHS Stop Smoking Services.

• For women who do not want referral:
• Offer practical advice and follow up to help them stop smoking.
• Advise stopping without using any drug treatment for women who feel confident they can manage without.
• For women able to stop smoking but who are likely to relapse without treatment, offer nicotine replacement therapy.

In depth

Advise women 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.
• 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

• Nicotine replacement therapy is recommended for pregnant and breastfeeding women who are unable or unlikely to stop smoking without drug treatment.
• Bupropion and varenicline are not recommended for use in women who are pregnant or breastfeeding.

In depth

• For women stopping smoking without nicotine replacement therapy (NRT), review within 7 days of the stop date and offer NRT to those who have not stopped smoking or who are having difficulty not smoking.
• For women stopping smoking completely with NRT, review 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. Treat for up to 12 weeks after stopping smoking.
• For those with adverse effects from treatment, consider reducing their dose, or changing the formulation.
• For those with significant nicotine withdrawal symptoms on treatment, consider increasing the dose of NRT (up to the maximum licensed dose that is tolerated).
• For women 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