Guidelines
Smoking Cessation Interventions
Available interventions:
| Category | Specific intervention |
|---|---|
| Behavioural interventions |
|
| Medicinally licensed products |
|
| Nicotine-containing e-cigarettes | n/a |
| Allen Carr’s Easyway in-person group seminar | n/a |
Advice on nicotine-containing e-cigarettes:
- E-cigarettes are not licensed medicines but are regulated by the Tobacco and Related Products Regulations (2016)
- Not enough evidence to know whether there are long-term harms from e-cigarette use
- Use of e-cigarettes is less likely to be substantially less harmful than smoking
- Any smoking is harmful, so people who use e-cigarettes should stop smoking tobacco completely
Prescribing Information
NICE do not recommend any specific medications as 1st line, instead advises that the decision should be guided by 1) contraindications and adverse effects, 2) patient’s preference, 3) previous experience with smoking cessation drugs.
| Drug | MoA | Contraindications | Adverse effects |
|---|---|---|---|
| Nicotine replacement therapy | Exogenous nicotine | No specific contraindications |
|
| Bupropion | Noradrenaline-dopamine reuptake inhibitor |
|
|
| Varenicline | Nicotinic acetylcholine receptor partial agonist |
|
|
| Cytisinicline | Nicotinic acetylcholine receptor partial agonist |
|
|
| Drug | Initiation timing | Duration of treatment |
|---|---|---|
| Nicotine replacement therapy | Start on quit date | 8-12 weeks |
| Bupropion | Start 1-2 weeks before quit date (i.e. start when the patient is still smoking) | 7-9 weeks |
| Varenicline | Start 1-2 weeks before quit date (i.e. start when the patient is still smoking) | 12 weeks |
| Cytisinicline | Start 5 days before quit date (i.e. start when the patient is still smoking) | 25 days |
Follow Up
Measure carbon monoxide level 4 weeks after quitting
- ≤10 suggests the person is not smoking
Smoking Cessation Interventions in Pregnancy
Testing
Routine carbon monoxide testing (to assess the person’s exposure to tobacco smoke) should be offered to ALL pregnant women at:
- First antenatal appointment, and
- 36-week appointment
Carbon monoxide testing should be offered at ALL antenatal appointments if the patient:
- Smokes, or
- Are quitting, or
- Used to smoke, or
- Carbon monoxide ≥4 ppm at first antenatal appointment
Apart from smoking, there are other causes of elevated carbon monoxide levels:
- 3-10 ppm = check for other sources of carbon monoxide (e.g. passive smoking, heating appliances, traffic emissions)
- >10 ppm = possible carbon monoxide poisoning (contact Gas Emergency Line for gas safety advice) or the patient smokes (explore sensitively using a non-judgmental approach)
Referral
Referral to stop-smoking support during pregnancy is indicated if ANY of the following:
- Carbon monoxide level ≥4 ppm
- The patient smokes or stopped in the past 2 weeks
Management
1st line: refer to the local smoking cessation service for behavioural support
2nd line: nicotine replacement therapy
- Advise that it is safe in pregnancy
- Combination nicotine replacement therapy is most effective (e.g. a patch + a short-acting preparation)
- Intermittent dose forms (e.g. gum and lozenges) are generally preferred over continuous dose forms (i.e. patches)
Do not offer varenicline / bupropion / cytisinicline during pregnancy / breastfeeding
Explain that it is the tar and carbon monoxide in tobacco smoke that cause the most harm to the baby (not nicotine), and that these are not present in NRT.
NICE also recommends monitoring smoking status regularly (to encourage patients to quit and as a way to provide positive feedback once an attempt has been made)
- Carbon monoxide tests
- Urine / saliva cotinine test (more accurate than carbon monoxide, as they can detect exposure over the past few days rather than hours)
References
NICE guideline Tobacco: preventing uptake, promoting quitting and treating dependence