To optimise the results from smoking cessation programmes it is advised that patients access motivational support from specialist services.

Refer all people who smoke to a smoking cessation service for behavioural support and pharmacotherapy. Some local community pharmacies and GP practices may offer a level 2 service. Level 3 services can be accessed via:

• Devon – Stop For Life Devon
• Plymouth – One You Plymouth
• Torbay - Your Health Torbay

Most smoking-related health problems are caused by other components in tobacco smoke, not by the nicotine. Any risks from using NRT are much lower than those of smoking. Nicotine levels in NRT are much lower than in tobacco, and the way these products deliver nicotine makes them considerably less addictive than smoking.

Agree a quit date (unless the person is adopting a harm reduction approach) and ensure the person has NRT ready to start the day before the quit date. In most cases NRT may be provided for up to 12 weeks, however there may be circumstances in which an individual would benefit from extended use e.g. pregnant women, people using a harm reduction method, or those who are very close to achieving a quit and whose attempt might be threatened by withdrawal of NRT. Appropriate intervals for prescribing will depend on the individual’s circumstances but are likely to be every two weeks during the first month; this may be extended to 4-weekly supplies for the rest of the quit attempt.

The person may be supported with ongoing NRT and behavioural support by a stop smoking advisor if accessing smoking cessation services.

Alternatives to long-term NRT provision include consideration of nicotine-containing e-cigarettes or vapes. At the time of writing, these products are not prescribable on the NHS but can be purchased, and may be available from some specialist smoking cessation services. Specialist smoking cessation services may be able to provide individual advice and support.

MHRA Drug Safety Update (November 2023): E-cigarette use or vaping: reminder to remain vigilant for suspected adverse reactions and safety concerns and report them to the Yellow Card scheme:

• Document use of e-cigarette products (’vapes’ or ‘vaping’) in the medical records for all patients when taking a medical history. Refer to the safety update for information to record.
• Advise patients to be vigilant about suspected adverse reactions that occur after the use of e-cigarettes and e-liquids, and to purchase and use legally compliant (‘notified’) e-cigarette and e-liquid products. Refer to the safety update for advice to give to patients on checking whether products are legally compliant.
• Report suspected adverse reactions or safety concerns to the Yellow Card Scheme.

Long-acting NRT

Advise people that use of a combination of short-acting and long-acting NRT alongside behavioural support, are more likely to result in them successfully stopping smoking.

Patches should be applied to dry non-hairy skin. The site of application should be rotated, avoiding the same area for several days.

16-hour transdermal patches

The 16-hour patches may help avoid vivid dreams and sleep disturbance, which may be associated with the 24-hour patches. They are also the preferred option for pregnant women.

Nicorette Invisipatch

(16-hour transdermal patch)

• Clear 10mg/16hours (£11.43 = 7 patches), 15mg/16hours (£11.43 = 7 patches), 25mg/16hours (£11.43 = 7 patches, £18.72 = 14 patches)

Dose

• Apply one patch each morning for 16 hours and remove the patch before going to bed. A new patch is applied to a different site the following morning.

24-hour transdermal patches

Pregnant women who are using nicotine patches should remove them before going to bed; 16-hour patches (above) are therefore preferred for these women.

The 24-hour patches may be more suitable for those who experience cravings within the first 30 minutes of waking.

Nicotinell TTS (transdermal therapeutic system)

(24-hour transdermal patch)

• TTS 10 (7mg/24hours, £10.49 = 7 patches), TTS 20 (14mg/24hours, £10.82 = 7 patches), TTS 30 (21mg/24hours, £11.48 = 7 patches / £28.20 = 21 patches)

Dose

• Apply one patch each morning and remove after 24 hours. A new patch is applied to a different site the following morning.

NiQuitin Patch

(24-hour transdermal patch)

• Clear 7mg/24hours (£11.48 = 7 patches), 14mg/24hours (£11.48 = 7 patches, £18.79 = 14 patches), 21mg/24hours (£11.48 = 7 patches, £18.79 = 14 patches)
• Beige 7mg/24hours (£11.48 = 7 patches), 14mg/24hours (£11.48 = 7 patches), 21mg/24hours (£11.48 = 7 patches)

Dose

• Apply one patch each morning and remove after 24 hours. A new patch is applied to a different site the following morning.

Short-acting NRT

Advise people that use of a combination of short-acting and long-acting NRT alongside behavioural support, are more likely to result in them successfully stopping smoking.

Short acting NRT should be used when required (up to the maximum) when the urge to smoke occurs, or to prevent cravings.

Medicated chewing gum

Nicorette Gum

(Medicated chewing gum SF)

• Original 2mg (£11.89 = 105 pieces, £19.34 = 210 pieces), 4mg (£14.55 = 105 pieces, £23.93 = 210 pieces)
• Freshmint 2mg (£11.89 = 105 pieces, £19.34 = 210 pieces), 4mg (£14.55 = 105 pieces, £23.93 = 210 pieces)
• Fruitfusion 2mg (£11.89 = 105 pieces), 4mg (£14.55 = 105 pieces)
• Icy White 2mg (£11.89 = 105 pieces, £19.34 = 210 pieces), 4mg (£14.55 = 105 pieces)

Dose

• One piece of gum should be chewed slowly until the taste becomes strong. Rest the gum between the gum and cheek until the taste subsides after which it should be re-chewed. The gum will become exhausted after about 30 minutes.
  • Maximum of 15 pieces of gum per day

Nicotinell Gum

(Medicated chewing gum SF)

• Fruit 2mg (£10.93 = 96 pieces, £18.00 = 204 pieces), 4mg (£13.57 = 96 pieces)
• Mint 2mg (£10.93 = 96 pieces, £18.00 = 204 pieces), 4mg (£13.57 = 96 pieces)

Dose

• One piece of gum should be chewed slowly until the taste becomes strong. Rest the gum between the gum and cheek until the taste subsides after which it should be re-chewed. The gum will become exhausted after about 30 minutes.
  • Maximum of 24 pieces of 2mg gum per day
  • Maximum of 15 pieces of 4mg gum per day

Lozenges

NiQuitin Lozenge

(Lozenges SF)

• Mint 2mg, 4mg (£7.40 = 72 lozenges)

Dose

• One lozenge should be placed in the mouth and allowed to dissolve fully. Periodically, the lozenge should be moved from one side of the mouth to the other until the lozenge is completely dissolved. The lozenge should not be chewed or swallowed.
  • Maximum of 15 lozenges per day.

Nicotinell Lozenge

(Lozenges SF)

• Mint 1mg (£12.06 = 96 lozenges, £15.19 = 144 lozenges, £16.89 = 204 lozenges), 2mg (£14.02 = 96 lozenges, £17.86 = 144 lozenges, £19.76 = 204 lozenges)

Dose

• One lozenge should be sucked until the taste becomes strong. The lozenge should then be lodged between the gum and cheek. When the taste fades, sucking of the lozenge should commence again. The lozenge should not be chewed or swallowed.
  • Maximum of 24 x 1mg lozenges per day
  • Maximum of 15 x 2mg lozenges per day

Nicorette Lozenge

(Lozenges SF)

• Fruit 2mg (£12.05 = 80 lozenges)
• Icy mint (“Cools”) 2mg (£12.05 = 80 lozenges), 4mg (£12.17 = 80 lozenges)

Dose

• One lozenge should be placed in the mouth and allowed to dissolve fully. Periodically, the lozenge should be moved from one side of the mouth to the other, and repeated, until the lozenge is completely dissolved. The lozenge should not be chewed or swallowed.
  • Maximum of 15 lozenges per day.

NiQuitin Minis Lozenge

(Mini lozenges SF)

• Mint 2mg, 4mg (£12.56 = 60 lozenges, £17.74 = 100 lozenges)

Dose

• One lozenge should be placed in the mouth and allowed to dissolve fully. Periodically, the lozenge should be moved from one side of the mouth to the other until the lozenge is completely dissolved. The lozenge should not be chewed or swallowed.
  • Maximum of 15 lozenges per day.

Sublingual tablets

Nicorette Microtab

(Sublingual tablets SF)

• Original 2mg (£19.14 = 100 tablets)

Dose

• One or two tablets should be placed under the tongue until dissolved. The tablet will dissolve completely after 30 minutes. Most smokers require 8 to 12 or 16 to 24 tablets per day.
  • Maximum 40 tablets per day

Inhalator

Nicorette Inhalator

(Inhalator for oromucosal use)

• Inhalation cartridge with device 15mg (£22.64 = 20 cartridges, £35.56 = 36 cartridges)

Dose

• Insert one cartridge into the device and draw air into the mouth through the mouthpiece when the urge to smoke occurs. A single 15mg cartridge lasts for approximately 40 minutes of intense use.
  • Maximum 6 cartridges per day

Notes

1. Patients with obstructive lung disease may find use of the inhalator difficult. An alternative formulation of NRT may be preferred in such cases.
2. The inhalator should be used with caution in patients with chronic throat disease or bronchospastic disease.

Nasal Spray

Nicorette Nasal Spray

(Nasal spray solution)

• Nasal spray 500 micrograms/spray dose (£21.05 = 10ml)

Dose

• One spray in each nostril, up to a maximum of two sprays in each nostril per hour for 16 hours daily.
  • Maximum 64 sprays per day

Notes

1. Use of the nasal spray in patients with hyper-reactive airways is not recommended as cases of exacerbation of bronchospasm have been reported in patients with bronchial asthma.
2. Each 10ml bottle provides approximately 175 metered sprays / 100 doses.

Oromucosal spray

Nicorette QuickMist

(Oromucosal spray)

• Freshmint mouth spray 1mg/spray dose (£14.97 = 13.2ml, £23.29 = 26.4ml)
• Cool berry mouth spray 1mg/spray dose (£14.97 = 13.2ml, £23.29 = 26.4ml)

Dose

• One or two sprays in the mouth. Do not exceed 2 sprays per episode (up to 4 sprays every hour).
  • Maximum 64 sprays per day

Notes

1. Each 13.2ml bottle contains at least 150 sprays.

To optimise the results from smoking cessation programmes it is advised that patients access motivational support from specialist services.

Refer all people who smoke to a smoking cessation service for behavioural support and pharmacotherapy. Some local community pharmacies and GP practices may offer a level 2 service. Level 3 services can be accessed via:

• Devon – Stop For Life Devon
• Plymouth – One You Plymouth
• Torbay - Your Health Torbay

Do not offer cytisine (cytisinicline), varenicline or bupropion to pregnant or breastfeeding women.

Cytisine (Cytisinicline)

• Tablets 1.5mg (£115.00 = 100 tablets)

Indications

• Smoking cessation in adults, as part of a programme of behavioural support

Dose

• Adults aged 18-65 years:
  • Cytisine is taken in a reducing regimen over 25 days (see table below); the NCSCT has produced a helpful dosing guide. Smoking should be stopped no later than on the 5th day of treatment.
  • Not recommended in patients with any degree of renal or hepatic impairment due to lack of clinical experience.

Notes

1. Do not offer cytisine to pregnant or breastfeeding women, people under 18 or over 65 years of age, or those with unstable angina, history of recent myocardial infarction, clinically significant arrhythmias or who have had a recent stroke (refer to SmPC for additional information).
2. Women of childbearing potential must use highly effective contraception during treatment; women using systemically acting hormonal contraceptives should add a second barrier method (see note b)
   1. Specialist smoking cessation services should ensure that highly effective contraception is in place and that the GP is informed of this when recommending cytisine.
   2. The effect of cytisine on hormonal contraception is unknown. Additional barrier methods should be used when women are using systemically acting hormonal contraceptives, including combined hormonal methods (i.e. combined oral contraceptive pills, vaginal ring, and patch), progestogen-only pills (POP), depot medroxyprogesterone acetate injection, and contraceptive progestogen implants.
3. Interactions: Cytisine should not be used with anti-tuberculosis drugs.
4. Smoking (or use of other products containing nicotine) should not be continued during treatment as this may aggravate adverse reactions. In case of treatment failure, the treatment should be discontinued and may be resumed after 2 to 3 months.
5. Cytisine should normally be prescribed only as part of a programme of behavioural support.

Varenicline

• Tablets 500micrograms, 1mg (£23.21= 28 tablets)

Indications

• Smoking cessation in adults, as part of a programme of behavioural support

Dose

• Initially 500micrograms once daily for 3 days, increased to 500micrograms twice daily for 4 days, then 1mg twice daily for 11 weeks.
  • Dose may be reduced if not tolerated to 500micrograms twice daily.
  • Usually started 1–2 weeks before target stop date but can be started up to a maximum of 5 weeks before target stop date (see also note 2).
  • 12-week course can be repeated in abstinent individuals to reduce risk of relapse.
• Hepatic impairment: No dosage adjustment necessary
• Renal Impairment:
  • Mild or moderate impairment (CrCl ≥30 to ≤80mL/min): No dosage adjustment necessary
  • Severe impairment (CrCl <30mL/minute): initial dose 500micrograms once daily, increased after 3 days to 1 mg once daily

Notes

1. Do not offer varenicline to pregnant or breastfeeding women, or to people under 18 years of age.
2. A gradual approach to quitting smoking with varenicline may be considered for patients who are not able or willing to quit abruptly. Patients should reduce smoking during the first 12 weeks of treatment and quit by the end of that treatment period. Patients should then continue taking varenicline for an additional 12 weeks for a total of 24 weeks of treatment.
3. NICE TA123: Varenicline is recommended within its licensed indications as an option for smokers who have expressed a desire to quit smoking (July 2007).
   1. Varenicline should normally be prescribed only as part of a programme of behavioural support.

Bupropion

• Modified-release tablets 150mg (£41.76 = 60 tablets)

Indications

• An aid to smoking cessation in combination with motivational support in nicotine-dependent patients

Dose

• Start 1–2 weeks before target stop date, initially 150mg daily for 6 days then 150mg twice daily; period of treatment 7–9 weeks; discontinue if abstinence not achieved at 7 weeks; consider maximum 150mg daily in patients with risk factors for seizures and the elderly

Notes

1. Do not offer bupropion to pregnant or breastfeeding women, or people under 18.
2. Bupropion has been associated with seizures (see note 5 below), which occur in around 1 in 1,000 patients treated (0.1%).
3. Insomnia is a very common adverse event which can be reduced by avoiding bedtime doses of bupropion (provided there is at least 8 hours between doses).
4. Patients should exercise caution before driving until they know whether bupropion affects their ability to drive.
5. Bupropion is contra-indicated in patients with a history of seizures or of eating disorders, a history of bipolar disorder, a CNS tumour, or who are experiencing acute symptoms of alcohol or benzodiazepine withdrawal. Bupropion should not be prescribed to patients with other risk factors for seizures unless the potential benefit of smoking cessation clearly outweighs the risk. Factors that increase the risk of seizures include concomitant administration of drugs that can lower the seizure threshold (e.g. antidepressants, antimalarials (such as mefloquine and chloroquine), antipsychotics, quinolones, sedating antihistamines, systemic corticosteroids, theophylline, and tramadol), alcohol abuse, history of head trauma, diabetes, and use of stimulants and anorectics.
6. MHRA Drug Safety Update (November 2020): Bupropion (Zyban): risk of serotonin syndrome with use with other serotonergic drugs
   1. Cases of serotonin syndrome have been reported in association with bupropion and co-administration with serotonergic drugs, for example
      1. selective serotonin reuptake inhibitors (SSRIs)
      2.  serotonin norepinephrine re-uptake inhibitors (SNRIs).
   2. If concomitant prescribing with other serotonergic drugs is clinically warranted:
      1. do not exceed the recommended dose
      2. remind patients of the milder symptoms of serotonin syndrome at initiation of treatment and at any change of dose and the importance of seeking medical advice if they occur
      3. if serotonin syndrome is suspected, either decrease the dose of bupropion or withdraw therapy depending on the severity of the symptoms.
   3. Advice to give to patients:
      1. if you are told you may be at risk of serotonin syndrome, be aware of symptoms, including mild signs such as nausea, vomiting, and diarrhoea or increased heart rate and agitation (see Drug Safety Update for full list) and talk to your prescriber if you experience these
      2. never exceed the prescribed dose of bupropion.