The UK has experienced a dramatic reduction in smoking prevalence of about 75% over the last 60 years (Royal College of Physicians (RCP), 2021). However, if the recent, rather slow, rate of reduction continues, it is predicted that the UK will still be a long way from eradicating smoking by 2050, a plan that was advocated in the 1962 UK White Paper ‘Smoking and Health’ (RCP, 1962). Despite the reduction in smoking prevalence in the UK, smoking remains the most important avoidable cause of premature death and disability in the UK, and the biggest preventable cause of cancer. The latest figures show that 14.1% of people aged 18 years or older smoke cigarettes, which equates to around 6.9 million individuals (Cancer Research UK, 2022). Worryingly, a new study found that the number of 18–34-year-olds in England who smoke, increased by 25% during the first lockdown, meaning that there are over 652 000 more young adults who smoke than before the pandemic (Jackson et al, 2022).
The overall reduction in smoking prevalence has been largely because of government initiatives regarding environmental and retail policy, regulation and guidance (gov.uk, 2021). As of yet, the integration of evidence-based treatment for tobacco dependence has not been broadly put into standard protocols in secondary, and more importantly, primary care (Pipe et al, 2022), as this is where the majority of smokers first contact the healthcare system. Smokers can be found in primary care waiting rooms, presenting with early signs of chronic obstructive pulmonary disease, heart disease or cancer. Successful implementation of recent National Institute for Health and Care Excellence (NICE) guidelines could be a good opportunity to get such patients smoke-free for the first time in their adult lives (Ross, 2022).
NICE guidelines
The revised NICE (2021) guidelines (NG209): Tobacco: preventing uptake, promoting quitting and treating dependence, recommended greater flexibility and clearer guidance in the use of nicotine replacement therapy (NRT), and the use of nicotine-containing e-cigarettes as a first line quit aid. The guidance includes advice on using incentives to stop smoking, particularly in pregnant women, clearer recommendations on stopping the use of smokeless tobacco, particularly by the Asian community, and the role of harm reduction for those who are not yet ready to quit (NICE, 2021). The quickest and easiest way to initiate smoking cessation is with very brief advice (VBA).
VBA is a 30-second intervention that can be delivered by all healthcare professionals in almost every consultation with patients who smoke (Papadakis et al, 2020). This involves providing empathetic support and understanding, which encourages smokers to consider quitting. When providing VBA, a healthcare professional should ask patients about their smoking status, advising them on the best methods of stopping smoking, offering information and interventions and helping them to access stop-smoking support.
Although it seems straightforward, the guidelines recommend that all frontline healthcare staff undergo brief training in the best approaches to deliver VBA (NCSCT, 2022). This includes the three elements of establishing and recording smoking status (ASK); advising on how to stop (ADVISE) and offering help (ACT). The guidelines also offer recommendations on the best way to ask important questions. For example, ‘are you ready to stop smoking?’ can raise anxiety and cause defensiveness (McEwen and Locker, 2022). This simple and effective approach will be more successful if used correctly (NCSCT, 2022). For those who are reluctant to consider quitting, motivational interviewing may be beneficial, as this is a directive patient-centred style of counselling may be beneficial (Lindson et al, 2019a)
Pharmaceutical aids to quitting
Pharmacotherapy is indicated for all smokers who are motivated to quit and are nicotine dependent. Their degree of dependency can be assessed using the Heaviness of Smoking Index (Table 1). The sooner a patient smokes after waking and the more cigarettes smoked daily, the more benefit they can expect from pharmacotherapy (Shiffman et al, 2013).
Table 1. Heaviness of Smoking Index for assessing nicotine dependence
| Criterion | Scoring |
|---|---|
| Average cigarettes per day | 1–10 = 0 points |
| 11–20 = 1 point | |
| 21–30 = 2 points | |
| ≥31 = 3 points | |
| Time to first cigarettes (minutes) | |
| 61+ = 0 points | |
| 31–60 = 1 point | |
| 5–30 = 2 points |
Nicotine dependence level: total score 0–2 low, 3–4 moderate, 5–6 high (Mendelsohn, 2022)
The efficacy of the different forms of NRT and other pharmaceutical aids are shown with comparisons to control interventions or placebo (Table 2) (Mendelsohn, 2022). A high proportion of people purchase their NRT over-the-counter (OTC), but this is not advised, as all treatments are significantly more effective with behavioural support (Stead and Lancaster, 2012). The key to long-term success is to keep trying to quit at every opportunity. For the best health outcomes, the most effective treatment should be used as soon as possible. If a previous pharmacotherapy was effective and well tolerated, it is generally best to use the same drug again. Other factors guiding the choice of therapy include effectiveness, personal preferences, contraindications, drug interactions and cost (Mendelsohn, 2022).
Table 2. Efficacy of pharmacotherapy for smoking cessation
| Efficacy of pharmacotherapy for smoking cessation at 6–12 months | ||
|---|---|---|
| Drug | Effect size* | Quality of the evidence (grade) |
| Comparison to control or placebo | ||
| Varenicline** | 15% | High |
| Combination nicotine replacement therapy | 11% | High |
| Bupropion | 7% | High |
| Single nicotine replacement therapy | 6% | High |
| Comparison to nicotine replacement therapy | ||
| Vaping nicotine | 3% | Moderate |
| Varenicline | 4.8% | Moderate |
Currently not available in the UK
Nicotine replacement is the most widely used first-line treatment. It is approved for use by people from the age of 12 years, and temporarily replaces the nicotine from smoking, achieving approximately half of the usual blood concentrations, thus helping to reduce cravings and withdrawal symptoms (Hukkanen et al, 2005). Two types of NRT are available: the nicotine patch, which is long release, whereby nicotine is steadily released into the bloodstream throughout the day and relieves background cravings, and oral preparations, which are quick release, sometimes within a minute, but are shorter acting, such as gum, lozenge and inhalator. These are best used regularly, say hourly or even after 20 minutes, before a ‘withdrawal trigger’ is anticipated. Possible triggers include just before or after eating, drinking alcohol or while driving.
It is important to optimise the type and doses to increase the chance of success. Combining the nicotine patch with an oral form of NRT relieves both background and breakthrough cravings. This is more effective than using a single formulation. Combination therapy should be considered for all smokers, especially those who are more nicotine dependent or when nicotine replacement monotherapy has not worked (Mendelsohn, 2022).
Another consideration is that misinformation about safety concerns is a major cause of poor NRT adherence (Ferguson et al, 2012). Therefore, patients should be reassured about the safety, stating that nicotine does not cause cancer or lung disease, that NRT has very low addictive potential, and that it is always safer than smoking. It is also important to give clear instructions on how to use oral products and to review the technique regularly, as most patients use them incorrectly (Mendelsohn, 2022). For example, explain the ‘chew and park’ technique for using gum, and the importance of shallow, frequent puffs from the inhalator. Lozenges should be dissolved slowly in the mouth over about 20 minutes, and the mouth spray should be used under the tongue, delaying swallowing for as long as possible. However, such oral preparations are not without side effects, particularly on oral health, and users should be advised to see their dentist regularly (Sivaramakrishnan et al, 2023).
Most patients do not use enough nicotine, often because of misconceptions about safety. The dose should be sufficient to control withdrawal symptoms and cravings with frequent review to titrate the dose accordingly. More heavily dependent smokers should use combination NRT, taking 4 mg gum or lozenges instead of 2 mg and they may need two patches. Too much nicotine causes nausea, but the risk of toxicity is very low.
Starting the nicotine patch two weeks before the day the patient intends to stop smoking increases quit rates by 25% compared to starting on the quit day (Lindson et al, 2019b). A course of at least 10 weeks is recommended. At the end of the course abrupt cessation of NRT is generally advised as the evidence does not support tapering (Mendlesohn, 2022). Extending the course for 12–18 months may help prevent relapse.
Minor adverse effects are common with NRT. They vary with the method of delivery (Table 3). NRT is safe in stable cardiovascular disease and approved in pregnancy with informed consent (especially if behavioural treatment has not been successful). Larger doses are needed as nicotine clearance is accelerated in pregnancy. It can also be used while breastfeeding, and there are no relevant drug interactions with NRT.
Table 3. Adverse effects of nicotine-containing products
| Product | Adverse effects | Management |
|---|---|---|
| Nicotine patch | Skin irritation, redness, itch | 1% hydrocortisone, rotate application site daily |
| Insomnia and vivid dreams (24-hour patch) | Use 16-hour patch or remove the 24-hour patch at bedtime | |
| Gum, inhalator, lozenge | Dyspepsia, nausea and throat irritation | Avoid swallowing excessively |
| Mouth spray | Throat irritation, hiccups | Delay swallowing |
| Nicotine-containing vaping | Cough, dry throat, nausea, headache | Sips of water for dry throat |
Other pharmaceutical aids
Varenicline (Champix) (Table 2) has been shown to be the most effective monotherapy for smoking cessation, by blocking nicotine receptors in the brain and relieving cravings and withdrawal symptoms. Unfortunately, this product is currently unavailable in the UK because of detected impurities (NHS Medicines, 2022).
Bupropion (Zyban) is an alternative. It is an antidepressant that is also an effective aid for quitting smoking (Hughes et al, 2014). It is taken as an eight-week course with quitting in the second week. Adverse effects include insomnia, dry mouth and nausea. The main risk from bupropion is a one-in-a-thousand incidence of seizures. Consequently, bupropion is contraindicated in patients with a raised seizure risk and should be used with caution in people taking drugs that can lower seizure threshold, such as antidepressants (Davidson, 1989). Pregnancy is also a contraindication.
Electronic cigarettes
Electronic cigarettes or vapes that contain nicotine are now recommended as a second-line option for smokers who have been unable to quit with other methods (NICE, 2021). Vaping provides the nicotine that smokers crave as well as the rituals and sensations of smoking, but without most of the toxins and carcinogens from burning tobacco. Another advantage is the cost, as vaping costs are around 10% of the costs of smoking. Vaping can be used as a short-term quitting aid, with a cessation date advisable. E-cigarettes can also have a long-term role in tobacco-harm reduction in those smokers unwilling to quit nicotine altogether (Notley et al, 2018). Randomised controlled trials have found that vaping nicotine was about 50% more effective than NRT (Hartmann-Boyce, et al, 2021). However, vaping is not risk-free, as it contains low doses of some toxic chemicals such as heavy metals, carbonyls and volatile organic compounds, but it is considerably less harmful than smoking. While the long-term risk of vaping nicotine is unknown, it is unlikely to be more than 5% of the risk of smoking (RCP, 2016). Concurrent use of vaping and smoking tobacco (dual use) should be discouraged. One other factor to be considered is that users should be strongly advised to dispose of their devices and other paraphernalia correctly, as there are serious concerns about discards being an environmental hazard (Pourchez et al, 2022).
Conclusion
Smoking remains a serious public health issue. Smokers should be advised about quitting at every opportunity, using VBA as a quick and reliable method. Providing empathetic support and understanding encourages smokers to consider quitting. NRT, particularly combining different methods, should be the first step in the use of pharmaceutical aids. Ideally, heavily dependent smokers should be prescribed varenicline, but as this is currently unavailable in the UK, then bupropion should be considered although this is less effective and has more side effects. Vaping should also be suggested as a cessation aid, and also as a harm-reduction tool, especially in those people who are not ready to quit.