(i) cigarette smoking

First Choice:
cessation support by specialist stop smoking services* and community pharmacies
AND

combination nicotine replacement therapy (long-acting + short-acting)

OR
varenicline
Formulations/Dose

Refer to product information for details

  • nicotine patch 10mg, 15mg, 25mg over 16 hours (Nicorette® Invisi); 7mg, 14mg, or 21mg over 24 hours (Nicotinell® TTS)
  • nicotine chewing gum 2mg, 4mg (Nicorette®)
  • nicotine lozenges 1.5mg, 4mg (Niquitin® minis), 2mg (Nicotinell®)
  • varenicline tablets, 500 micrograms, 1mg; initally 500micrograms once daily for 3 days, inreased to 500micrograms twice daily for 4 days, then 1mg twice daily for 11 weeks.
Prescribing Notes

General notes

  • Prescribing of NRT or varenicline should not commence until the patient has decided on a ‘quit date’. Initial prescriptions should be sufficient to last two weeks after this date. Further prescriptions should only be issued if the quit attempt is continued at review.
  • Symptom control of nicotine withdrawal in hospital in-patients is the only exception to a 'quit-day' being set.
  • NRT or varenicline must not be added to repeat prescribing systems.
  • Stopping smoking may result in slower metabolism and a consequent rise in blood levels of drug catalysed by CYP1A2 (and possibly CYP1A1). This is because the inhalation of induction agents such as polycyclic aromatic hydrocarbons has stopped. There are a few drugs for which this is clinically significant, e.g. warfarin, theophylline and clozapine.
  • Nicotine releases catecholamines which can affect carbohydrate metabolism.  Smokers with diabetes should be advised to monitor the blood sugar levels more closely than usual when attempting to quit smoking (with or without treatment).

Nicotine Replacement Therapy (NRT)

  • NRT may be prescribed to adolescents (12-18years), these patients should be referred to a specialist stop smoking service for young people for provision of suitable support.
  • For use of NRT in pregnancy, please refer to specialist stop smoking service.
  • The aim of NRT is to reduce usage over 12 weeks as per product information.  If patients require support beyond 12 weeks they should be referred to specialist stop smoking services for further support and advice.
  • Moderate to severe hepatic impairment and/or severe renal impairment decreases the clearance of nicotine or its metabolites and NRT should be used with caution.
  • Nicotine inhalator may be a useful option for patients within a hospital setting.

Varenicline

  • Prescribers should be aware of the cautions and side-effect profile of varenicline both during treatment and on treatment cessation.
  • The efficacy and safety of varenicline in patients with significant co-morbidity is unclear. It should be prescribed for a maximum of 12 weeks only.
  • Varenicline should not be used in patients under 18 years old, or in those that are pregnant or breastfeeding, women planning a pregnancy or those who are in end stage renal disease.
  • Patients prescribed varenicline should be advised of the MHRA/CHM advice regarding suicidal behaviour. Those with a history of psychiatric illness should be monitored closely as varenicline may exacerbate underlying illness, including depression.
  • All patients should be advised to discontinue treatment and seek prompt medical advice if they develop agitation, depression or suicidal thoughts.
  • Abnormal semen and sexual dysfunction have been reported with varenicline (uncommon).  However no hazard for human fertility is evident when taking varenicline.  As such there is no advice regarding the need to stop varenicline prior to conception.  It should be borne in mind that smoking is known to have a detrimental effect on male fertility, causing sexual impotence, decreased sperm counts and increased proportions of abnormal sperm.