Smoking cessation

Smoking cessation

NICE released updated guidance (NG209) on the management of smoking cessation (latest review Feb 2025). General points include:

• adults who smoke should be offered behavioural support alongside pharmacotherapy
• first-line pharmacological options include nicotine replacement therapy (NRT), varenicline, bupropion or cytisinicline
• clinicians should take patient preference, contraindications and previous response into account rather than favouring one medication universally
• pharmacotherapy should usually be started before or on a planned target stop date
• treatment should be reviewed shortly before the end of the initial prescription and continued only if the quit attempt is ongoing
• combination NRT (long-acting patch plus short-acting form) is recommended where appropriate

Nicotine replacement therapy

• adverse effects include nausea, vomiting, headache and local skin irritation
• NICE recommend offering combination NRT (nicotine patch plus a faster-acting product such as gum, lozenge, inhalator or spray), particularly for people with higher nicotine dependence or previous failure with single-agent NRT
• NRT can be used in combination with behavioural support

Varenicline

• a nicotinic acetylcholine receptor partial agonist
• should be started 1 to 2 weeks before the target stop date
• standard course is 12 weeks, with review before continuation
• more effective than bupropion and single-agent NRT
• common adverse effects include nausea, headache, insomnia and abnormal dreams
• use with caution in patients with significant psychiatric history, with monitoring
• contraindicated in pregnancy and breastfeeding

Bupropion

• a norepinephrine–dopamine reuptake inhibitor and nicotinic antagonist
  Bupropion is a norepinephrine-dopamine reuptake inhibitor and nicotinic antagonist
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  Importance: 63
  • minimal effect on serotonin compared with many antidepressants
• should be started 1 to 2 weeks before the target stop date
• small risk of seizures (approximately 1 in 1,000)
  Bupropion should not be used in a patient with epilepsy as it reduces seizure threshold
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  Importance: 50
• contraindicated in epilepsy
  Bupropion should not be used in a patient with epilepsy as it reduces seizure threshold
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  Importance: 50
  , pregnancy and breastfeeding
• eating disorders are a contraindication

Cytisinicline

• a plant-derived nicotinic acetylcholine receptor partial agonist
• similar mechanism of action to varenicline
• typically started before the target stop date, with a shorter treatment course than varenicline
• may be offered as an alternative where other pharmacological options are unsuitable or not tolerated
• common adverse effects include nausea and gastrointestinal upset
• contraindicated in pregnancy and breastfeeding

Pregnant women

NICE recommend routine carbon monoxide (CO) testing in pregnancy (e.g. at booking and later in pregnancy). Women who smoke, have recently stopped, or have a raised CO reading (≥4 ppm) should be offered referral to NHS Stop Smoking Services.

Interventions

• first-line interventions in pregnancy are behavioural support, including cognitive behavioural therapy, motivational interviewing and structured support from NHS Stop Smoking Services
• NRT
  NRT
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  may be considered if behavioural interventions alone are unsuccessful; it is preferable to smoking and there is no evidence of adverse effects on birthweight
• nicotine patches should be removed at night
• varenicline, bupropion and cytisinicline are contraindicated

+PassMedicine Notes

NICE released updated guidance (NG209) on the management of smoking cessation (latest review Feb 2025). General points include:

• adults who smoke should be offered behavioural support alongside pharmacotherapy
• first-line pharmacological options include nicotine replacement therapy (NRT), varenicline, bupropion or cytisinicline
• clinicians should take patient preference, contraindications and previous response into account rather than favouring one medication universally
• pharmacotherapy should usually be started before or on a planned target stop date
• treatment should be reviewed shortly before the end of the initial prescription and continued only if the quit attempt is ongoing
• combination NRT (long-acting patch plus short-acting form) is recommended where appropriate

Nicotine replacement therapy

• adverse effects include nausea, vomiting, headache and local skin irritation
• NICE recommend offering combination NRT (nicotine patch plus a faster-acting product such as gum, lozenge, inhalator or spray), particularly for people with higher nicotine dependence or previous failure with single-agent NRT
• NRT can be used in combination with behavioural support

Varenicline

• a nicotinic acetylcholine receptor partial agonist
• should be started 1 to 2 weeks before the target stop date
• standard course is 12 weeks, with review before continuation
• more effective than bupropion and single-agent NRT
• common adverse effects include nausea, headache, insomnia and abnormal dreams
• use with caution in patients with significant psychiatric history, with monitoring
• contraindicated in pregnancy and breastfeeding

Bupropion

• a norepinephrine–dopamine reuptake inhibitor and nicotinic antagonist
• minimal effect on serotonin compared with many antidepressants
• should be started 1 to 2 weeks before the target stop date
• small risk of seizures (approximately 1 in 1,000)
• contraindicated in epilepsy, pregnancy and breastfeeding
• eating disorders are a contraindication

Cytisinicline

• a plant-derived nicotinic acetylcholine receptor partial agonist
• similar mechanism of action to varenicline
• typically started before the target stop date, with a shorter treatment course than varenicline
• may be offered as an alternative where other pharmacological options are unsuitable or not tolerated
• common adverse effects include nausea and gastrointestinal upset
• contraindicated in pregnancy and breastfeeding

Pregnant women

NICE recommend routine carbon monoxide (CO) testing in pregnancy (e.g. at booking and later in pregnancy). Women who smoke, have recently stopped, or have a raised CO reading (≥4 ppm) should be offered referral to NHS Stop Smoking Services.

Interventions

• first-line interventions in pregnancy are behavioural support, including cognitive behavioural therapy, motivational interviewing and structured support from NHS Stop Smoking Services
• NRT may be considered if behavioural interventions alone are unsuccessful; it is preferable to smoking and there is no evidence of adverse effects on birthweight
• nicotine patches should be removed at night
• varenicline, bupropion and cytisinicline are contraindicated