SMOKING CESSATION

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First quit attempt pathway

First to fifth consultations

First consultation

NRT is the usual choice for a first quit attempt – see below for further information.

  • Assess motivation, offer behavioural advice and encouragement.
  • Discuss strategies including choice of drug/formulation and contra-indications.
  • Advise that smoking cessation, with or without pharmacological support, may cause symptoms of depression and affect the metabolism of some medicines. In particular the dose of theophylline, cinacalcet, ropinirole and some antipsychotics (including clozapine, olanzapine, chlorpromazine and haloperidol), may need to be reduced. Monitor for adverse effects.
  • People with a high level of nicotine dependence, or who have failed with NRT previously, may benefit from the addition of a second NRT preparation to achieve abstinence, eg combination of a patch and one of the immediate-release preparations.
  • Agree a quit date, (7 to 9 days following appointment) prescribe/arrange NRT in patient’s choice of formulation (usually 4 weeks supply, endorsing the prescription ‘Dispense weekly’ to minimise waste) and arrange follow-up, usually within a week. Advise to contact prescriber if adverse effects.
  • Advise patient that normal course of NRT is an approximately 12-week period.
  • At each visit measure carbon monoxide levels if possible and offer advice on diet and exercise.

Second consultation

Discuss progress and any issues and encourage and reassure. Alter NRT if necessary. If still smoking, offer advice about risks and set new quit date. Studies have shown very poor quit rates if still smoking after first week.  Ask again about motivation, suggest alternative smoking cessation strategies and arrange a follow-up appointment.

Third consultation

If not smoking, congratulate and prescribe/arrange 1 month’s NRT supply, stepping down if appropriate. Set new follow-up appointment. Submit the 1 month Client Information Return.  If still smoking, offer advice on risks. Only prescribe/arrange further NRT supplies (as per first consultation) if new quit date set.

Fourth consultation

If still not smoking congratulate and prescribe/arrange final month’s supply of NRT (lowest dose) and offer advice on NRT withdrawal and dose tapering.

Fifth consultation (face to face, by telephone or by letter)

If still not smoking, congratulate.

The aim of NRT is to reduce usage over 8 to 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.

It may be necessary to prescribe NRT for longer than 12 weeks. Patients must meet the following criteria if continuing treatment for more than 12 weeks:

  • significant indication that to discontinue treatment would result in relapse due to withdrawal symptoms
  • patient is prepared to commit and adhere to reduction plan resulting in discontinuing product within the next six weeks
  • patient is completely abstinent.
Subsequent quit attempt

Patient re-presents requesting support to stop smoking.

For further information on the use of NRT in specific patient groups and advice on selection of formulations, refer to the BNF.

 

First choice - Nicotine replacement therapy (NRT)

There is no evidence that one particular type of NRT is more effective than another. The choice of formulation is down to personal preference.

For full details on doses, adverse effects, cautions and contra-indications of individual products refer to the BNF.

Product

Advantages

Disadvantages

Patch: 12 week course

16-hour patch

use one range of patches and do not interchange

apply new patch once daily to a non-hairy area of skin. Take off before bedtime.

24-hour patch

new patch once daily, keeping patch on all day and night, changing next morning.

easy to use

discreet

breaks habits

supplies nicotine continuously throughout the day.

with 16-hour patch patient may have early morning craving

no oral satisfaction

possible skin reaction – rotate the site of the patch to prevent irritation developing

24-hour patch can cause sleep disturbance.

Lozenges

withdraw gradually after 6 to 12 weeks

Nicotinell® not licensed for under-18s.

discreet, flexible and offers good dose control

easy to use.

nicotine destroyed in stomach if product not used properly, leading to heartburn or stomach irritation

stinging in mouth, hiccups and localised irritation can occur.

 

Microtabs – sublingual: reduce dose after 3 months

the small tablet dissolves under the tongue

discreet, flexible and offers good dose control

easy to use

side-effects minimal.

the tablet must not be sucked, chewed or swallowed as this will reduce the amount of nicotine absorbed

stomach upset, stinging mouth, hiccups and localised irritation can occur.

Inhalator: 12-week course

good for those who miss the behavioural habit of smoking

easy to use.

some may feel self-conscious using inhalator.

Nasal spray: reduce dose after 8 weeks

fast-acting for heavy smokers

easy control of dose.

side-effects – nasal irritation, eyes watering, coughing, sneezing etc.

most addictive of the NRT products.

Gum: reduce dose after 3 months

use ‘chew/park/chew’ technique

do not use liquorice-flavoured gum in pregnancy.

easy to use

discreet

side-effects minimal

oral satisfaction

available in a variety of flavours.

nicotine destroyed in stomach if product not used properly

over-chewing can cause hiccups

can taste slightly peppery at first

can irritate the mouth and throat, increase salivation and aggravate stomach ulcers

not recommended in denture wearers.

Oral spray

if using the oral spray for the first time, or if unit not used for 2 or more days, prime the unit before administration.

fast-acting for heavy smokers

immediate effect

easy control of dose.

hiccups

nausea and dyspepsia

local irritation.

Oral film (dissolvable)

DO NOT EAT OR DRINK WHILE NICOTINE FILM IS IN THE MOUTH.

suitable for smokers who have their first cigarette of the day more than 30 minutes after waking.

possible sleeplessness

nausea and dyspepsia

hiccups

headache and dizziness.