(i) cigarette smoking

First Choice:
cessation support *
+combination nicotine replacement therapy (long-acting + short acting)
* by stop smoking services, including community pharmacies
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 (Niquitin®)
  • nicotine chewing gum 2mg, 4mg (Nicorette®)
  • nicotine minis lozenges 1.5mg, 4mg (Niquitin® minis)
  • nicotine inhalator 15mg/cartridge (Nicorette®)
Prescribing Notes

General notes

  • Young people, patients who are intermittent smokers, or have had a recent cardiovascular event or who are pregnant, should be offered cessation support (as above) and a short acting nicotine replacement therapy.

  • Prescribing of NRT should not commence until the patient has decided on a ‘target stop 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.
  • Advice on "Cutting down to quit" using NRT can be provided by specialist stop smoking services.  (This is not avilable from pharmacies.)
  • NRT must not be added to repeat prescribing systems.
  • Symptom control of nicotine withdrawal in hospital in-patients, is the only exception to a ‘target stop date’ being set prior to prescribing NRT.
  • 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.
  • NRT may be prescribed to adolescents (12-18 years), 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.
  • As new nicotine replacement products become available, some patients may request they are supplied. Only the products listed above are formulary products.

Nicotine Replacement Therapy (NRT)

  • The aim of NRT is to reduce usage over 8-12 weeks as per product information.  If patients require treatment beyond 12 weeks they should be referred to specialist stop smoking services for further support and advice.

  • Pharmacy services should refer any patients requiring NRT beyond 12 weeks to other specialist stop smoking services for further support and advice, or patients can be advised to purchase NRT over the counter.

  • Nicotine releases catecholamines which can effect 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 NRT).
  • 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.
  • Women with symptoms of nausea related to pregnancy, may find the nicotine strips a useful NRT preparation.

Varenicline

  • Varenicline should only be prescribed when NRT has failed, and on the recommendation of specialist smoking cessation services.

  • 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 or women who are planning a pregnancy.
  • Patients prescribed varenicline should be advised of the MHRA advice regarding suicidal thoughts and behaviour. Those with a history of psychiatric illness should be monitored closely.
  • 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.