• Scenario: Smoking cessation - adults: covers the management of people aged 18 years and older who express a wish to stop smoking.
• Scenario: Smoking cessation - pregnant or breastfeeding: covers the management of women who are pregnant or breastfeeding who express a wish to stop smoking.
• Scenario: Smoking cessation - 12-17 years: covers the management of children between 12 and 17 years of age who express a wish to stop smoking.

• 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

• 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

• Pregnancy and breastfeeding: varenicline should not be used during pregnancy or breastfeeding.
• Children and adolescents: varenicline is not licensed for use in smokers younger than 18 years of age.
• Epilepsy: there is no clinical experience of varenicline in people with epilepsy.
• Renal impairment:
• Mild-to-moderate renal impairment: no dosage adjustment necessary.
• Severe renal impairment (estimated creatinine clearance < 30 mL/min): the recommended dose is varenicline 1 mg once daily. Start treatment with a dose of 500 micrograms once a day for the first 3 days, then increase to 1 mg once a day.
• Varenicline is not recommended for people who have end-stage renal disease.

In depth

• The recommended treatment dose is 1 mg varenicline twice daily following a 1-week titration as follows:
• Days 1–3: 500 micrograms once a day.
• Days 4–7: 500 micrograms twice a day.
• Day 8 onwards: 1 mg twice a day.
• For people who cannot tolerate the adverse effects of higher doses (1 mg twice daily) of varenicline, the dose may be reduced to 0.5 mg twice a day.
• Advise the person to stop smoking 7–14 days after starting varenicline.
• The recommended course of treatment is 12 weeks.
• For people who have successfully stopped smoking at the end of 12 weeks, an additional course of 12 weeks' treatment with varenicline at 1 mg twice daily may be considered to help maintain abstinence.
• Varenicline may be stopped without tapering the dose. However, immediately after stopping treatment with varenicline, up to 3% of people experience an increase in irritability, urge to smoke, depression, or insomnia. Inform the person accordingly and discuss or consider the need for dose tapering.

In depth

• The most common adverse effect is mild-to-moderate nausea, which usually occurs early in the treatment period.
• Other common adverse effects include headache, insomnia, abnormal dreams, increased appetite, somnolence, dizziness, vomiting, constipation, diarrhoea, abdominal distension and discomfort, dyspepsia, flatulence, dry mouth, and fatigue.
• Varenicline may cause dizziness and somnolence, and therefore may influence the ability to drive and use machines. Advise the person not to drive, operate complex machinery, or engage in other potentially hazardous activities until it is known whether varenicline affects their ability to perform these activities.
• There have been reports of depression and suicidal ideation associated with the use of varenicline. Prescribers are advised that:
• Patients should be told to stop treatment and contact their doctor immediately if they develop suicidal thoughts or behaviour.
• Varenicline should be stopped immediately if agitation, depressed mood, or changes in behaviour are observed that are of concern to the patient, family, or caregivers.
• The safety and efficacy of varenicline in people with serious psychiatric illness have not been established. Patients who have a history of psychiatric illness should be monitored closely while taking varenicline.

In depth

• Pregnancy and breastfeeding: bupropion should not be used during pregnancy or breastfeeding.
• Children and adolescents: bupropion should not be used in smokers younger than 18 years of age.
• Epilepsy (or increased risk of seizures): bupropion is associated with a dose-related risk of seizure:
• Bupropion is contraindicated in people with:
• A current seizure disorder or any history of seizures.
• A current or previous diagnosis of bulimia or anorexia nervosa.
• A central nervous system tumour.
• Abrupt withdrawal from alcohol or benzodiazepines.
• Severe hepatic cirrhosis.
• Bipolar disorder.
• Only prescribe bupropion to people with other risk factors for seizures if there is compelling clinical justification. If bupropion is prescribed for these people, use a lower dose of 150 mg daily throughout the entire treatment period. Risk factors for seizures include:
• Concomitant use of any drug known to lower the seizure threshold (including antipsychotics; antidepressants; some antimalarials, such as mefloquine; theophylline; systemic corticosteroids; tramadol; quinolones; and sedating antihistamines).
• Alcohol abuse.
• A history of head trauma.
• Diabetes treated with hypoglycaemic drugs or insulin.
• Use of stimulants or anorectic products.
• Stop bupropion if an individual has a seizure while taking it.

In depth

• Do not give bupropion with other drugs that lower the seizure threshold (e.g. antipsychotics; antidepressants; some antimalarials, such as mefloquine; theophylline; systemic corticosteroids; tramadol; quinolones; and sedating antihistamines).
• Do not give bupropion within 2 weeks of stopping a monoamine oxidase inhibitor (MAOI). For moclobemide (a reversible MAOI), this can be reduced to 2–3 days.

In depth

• The recommended treatment dose is 150 mg once a day for 6 days, increasing to 150 mg twice a day (doses at least 8 hours apart).
• Continue the lower dose of 150 mg once a day if the person:
• Is older than 65 years of age.
• Has hepatic impairment (mild to moderate).
• Has renal impairment (glomerular filtration rate < 50 mL/min).
• Advise the person to stop smoking 7–14 days after starting bupropion.
• The recommended course of treatment is 7–9 weeks.
• After a usual course of 7–9 weeks, bupropion can be stopped without tapering the dose. If the course of bupropion has been longer than 6 months, consider a tapering period.

In depth

• The most common adverse effects of bupropion include dry mouth, gastrointestinal disturbances, insomnia (which can be reduced by not giving the last dose at bedtime), headache, impaired concentration, and dizziness.
• Seizures occur rarely in people taking bupropion (incidence of seizures is approximately 0.1%):
• Do not prescribe for people at increased risk of seizures (see Contraindications to bupropion).
• To minimize the risk, do not exceed the recommended daily dose.
• Stop bupropion if an individual has a seizure while taking it.
• Reports of seizures as an adverse effect of prescribed medication do not automatically imply that such events will be considered by the DVLA as provoked. The person may, therefore, be disallowed from driving a car or motorcycle for 1 year, or an LGV or PCV for 5 years.

In depth

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

• 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