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Smoking remains one of the biggestkillers in our society, causing prema-ture death in more than half of smokers.Smoking is the primary cause of prevent-able illness and premature death,accounting for 81 400 deaths in Englandin 2009.1

Smoking harms nearly every organ ofthe body and dramatically reduces bothquality of life and life expectancy. Itcauses lung cancer, respiratory diseaseand heart disease, as well as numerouscancers in other organs including lip,mouth, throat, bladder, kidney, stomach,liver and cervix. Adults with mental health problems

are at particular risk. This group smokes42 per cent of all tobacco in England2 anddie on average 16–25 years sooner thanthe general population, largely due tohigher rates of respiratory and cardiovas-cular illness and poor survival outcomesdue to smoking-related illnesses likeCOPD, which is largely undiagnosed anduntreated.3

Patients with schizophrenia, for exam-ple, have a 28 per cent five-year mortality

from COPD compared to a 12 per centfive-year mortality in an age-adjusted pop-ulation,4 and this is despite the fact thatover 50 per cent of patients with mentalhealth disorders want to stop smoking.5

Stop smoking support, across theboard, has been shown to be an effectiveand highly cost-effective long-term inter-vention for people with smoking-relatedlong-term disease.

Available strategiesStrategies for stopping smoking are out-lined in Table 1. Stopping smoking unas-sisted using neither behavioural supportnor medication has a poor success rate:only 4 per cent of people can quit suc-cessfully for at least one year going ‘coldturkey’.16 Over-the-counter (OTC) nicotinereplacement therapy (NRT) has the samesuccess rate as going unassisted (seeFigure 1). Getting stop smoking medication on

prescription alone can almost double thechances of quitting successfully com-pared to stopping unassisted or gettingOTC NRT.

Figure 1. Success rates achieved with available strategies for smoking cessation7

Providing support to patients who wish to quit smokingElizabeth Pang MSc and Myra Stern PhD, FRCP

Smoking cessation is themost cost-effective interven-tion for the prevention andtreatment of smoking-related disease. Here, theauthors discuss the availableproducts for aiding smokingcessation and how to sup-port patients wishing to quit.

NHS support andmedication

medication on prescription

nicotine OTC

unassisted

0 0.5 1 1.5 2 2.5 3 3.5 4Odds ratio (relative to no aid)

The chances double again using med-ication together with support from a stopsmoking specialist. NHS stop smoking services provide

guidance on the most appropriate stopsmoking pharmacotherapy as well asbehavioural support, advice and informa-tion about coping without a cigarette andmanaging withdrawal symptoms, makingit the most successful strategy for stop-ping smoking.

Stop smoking pharmacotherapyThe three stop smoking medicationsapproved by NICE are NRT, varenicline(Champix) and bupropion (Zyban).17

These are extremely cost-effective andall three medications should be offeredas first-line products to smokers whowant to stop smoking. None of thesemedications should be favoured overanother unless there are contraindica-tions.18

Although NRT can be bought OTC,varenicline and bupropion are prescrip-tion-only medications. All three medica-tions should only be prescribed as part ofan abstinent-contingent treatment inwhich the smoker sets a quit date andcommits to stopping smoking. Only two weeks of medication should

be prescribed and further prescriptionsshould only be given to people who haveshown on reassessment they haveremained abstinent or the clinician andpatient feels there is a high chance thatabstinence will be achieved. Abstinence can be validated either by

self-report or by measuring a person’scarbon monoxide level.

Nicotine replacement therapyNRT is available as a patch (16 hours and24 hours duration), mouth spray, chewinggum, lozenge and mini lozenge, inhalator,nasal spray and microtabs (see Table 2).They come in different strengths and aresafe and effective. There are very few contraindications

to NRT as it delivers nicotine in a safeform instead of in a cigarette where youwould get nicotine plus tar, carbonmonoxide and over 4000 toxic chemicals,many known to be carcinogenic. Risks and benefits of using NRT

should be discussed with pregnant and

breastfeeding women and children underthe age of 18 years old.The odds ratio (OR) of maintaining

long-term abstinence compared to aplacebo with NRT is 1.84.19 There is lit-tle significant difference between theeffectiveness of each NRT product. Theeffectiveness of each product is basedon individual preference; however, thereis good evidence that using a combina-tion of NRT, preferably a combination ofslow release (eg a patch) and fast act-ing (eg an inhalator or mouth spray), ismore effective than using just singleNRT.19

The most common reason for poorefficacy and relapse is that an inade-quate amount of NRT has been used.NRT delivers approximately half theamount of nicotine that a cigarettewould deliver, therefore it is importantfor people to use the product frequently(on an hourly basis) and use the maxi-mum dose to maintain blood nicotinelevels to make their quit attempt morecomfortable and minimise withdrawalsymptoms. Withdrawal from nicotine can be pro-

foundly unpleasant, coming on two tothree hours after the last cigarette andpeaking two to three days later.Symptoms include an intense craving fornicotine, coupled with any or all of the fol-lowing: anxiety, depression, drowsinessor trouble sleeping, bad dreams andnightmares, feeling tense, restless or frus-trated, headaches, increased appetiteand weight gain, and problems concen-trating.Poor technique and incorrect usage

of NRT is another common reason forfailure. For example, with the gum, thetechnique is to chew the gum, then rest

it between the gum and cheek and thenchew again when the taste has faded.Resting the gum allows the nicotine tobe absorbed through the lining of themouth. If the gum is just continuously chewed

the nicotine is released too quickly and isthen just swallowed, providing only mini-mal therapeutic effect. It is therefore highly important for

people to seek advice and support withan NHS stop smoking service who canadvise them the best ways of maximisingthe use of their NRT. Providing smokerswith a choice of pharmacotherapy bydemonstrating the actual products avail-able facilitates better uptake of treat-ment by empowering smokers to decidewhat would work best for them (seeFigure 2).NRTs were originally only licensed

for abrupt quitting from smoking andhave also now been granted a furtherlicence indication called ‘cut down toquit’. This is aimed at smokers whoexpress unwillingness to or inability tostop smoking in the short term butenabling them to gradually cut downover an extended period while sup-ported by NRT.20

VareniclineVarenicline is a nicotine receptor partialagonist that helps people to stop smokingby binding the alpha4beta2 subtype ofnicotinic acetylcholine receptors, blockingthe ability of nicotine to bind (reducingsmoking satisfaction) and stimulating themesolimbic dopamine system (maintain-ing moderate levels of dopamine to coun-teract withdrawal symptoms). Varenicline is indicated for smoking

cessation in adults over 18 years old who

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Table 1. Strategies used for stopping smoking

1. Self-managed quitting or reduction, eg:• cold turkey, ie an unassisted immediate quit • nicotine replacement therapy bought over the counter • self-help literature • e-cigarettes.

2. Health professional-assisted evidence-based interventions using stop smokingmedication provided on prescription and an NHS stop smoking service.

3. Alternative strategies such as acupuncture, hypnosis, homeopathy, herbal reme-dies or reflexology, which can be useful for some smokers but are not evidence-based strategies.

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Table 2. Types of NRT and their properties

Product What it does Who should What to Pros Cons Contra- Side-effectsuse prescribe indications

Patch steady flow of any daily smoker up to 25mg per easy to use, does not offer skin problems possible slightnicotine into the 16hr widely tolerated, replacement (eg eczema), skin marking/blood stream steady blood activity for excessive irritation

levels of smoking sweating,nicotine previous allergic

reaction

Gum nicotine any smoker 4mg nicotine can titrate to poor dentition, can causeabsorbed (need good gum prn, up to nicotine needs, peptic ulcer indigestionthrough the natural teeth) 15 daily offers disease especially if notlining of the replacement for used correctlymouth when smokinggum ‘parked’after chewing

Lozenge nicotine any smoker 4mg nicotine can titrate to peptic ulcer can causeabsorbed lozenge prn, nicotine needs, disease indigestionthrough lining up to 15 daily offersof the mouth replacementwhen parked for smoking‘in cheekand allowedto dissolve

Microtabs nicotine smokers wanting 2mg nicotine discrete, can tastes peptic ulcer indigestionabsorbed discrete oral microtab prn, titrate to needs unpleasant diseasethrough lining product up to 40 dailyof the mouth/tongue

Nasal nicotine long-term, high 10ml nasal spray very strong, quick, difficult to use nasal irritationspray absorbed dependent prn, up to 64 can titrate to at start,

through the smokers; gives sprays daily nicotine needs sneezing, eyeslining of the rapid increase watering,nose in blood levels temporary nasal

closest to irritationcigarette effect

Inhalator nicotine any smoker as 15mg cartridge offers very useful sore throat,absorbed a secondary prn, up to replacement especially if notdirectly through product to any 12 cartridges activity for used correctlythe mouth of the others or daily smoking; can

as a main titrate toproduct for nicotine needsoccasionalsmokers

Varenicline partial agonist long-term/highly 2mg daily very effective not for under 18s, nausea, sickness,to nicotine dependent maintenance treatment when pregnant or abdominalreceptors smokers dose for 3 combined with lactating bloating,

months counselling/ women, non- flatulence,support; can daily smokers, suicidal ideationsmoke for first end-stage renal (rare butweek disease described)

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are not pregnant and not in renal failure.It is unknown whether varenicline issecreted in human breast milk thereforecaution and clinical judgement needs tobe taken with pregnant and breastfeed-ing women. Every smoker who takesvarenicline should also receive behav-ioural support.The OR of achieving long-term absti-

nence (six months or longer) using vareni-cline compared to a placebo is 2.88.19

This is comparable to using combinationNRT but more effective than using a sin-gle NRT agent.The most common side-effect

reported from the use of varenicline isnausea (28 per cent). In the majority ofcases nausea is mild to moderate inseverity and subsides over time.21

There have been media reports tosuggest that varenicline can increasethe risk of cardiovascular events and ofsuicide and is, therefore, unsafe to beused in people with mental health prob-lems. These reports have, however,been refuted in a recent meta-analysisthat demonstrates that there is no evi-dence of an increased risk of suicidalbehaviour in patients prescribedvarenicline compared to those pre-scribed NRT.22

Bupropion Bupropion has antidepressant propertiesand is indicated as a stop smoking med-ication in combination with behaviouralsupport. The OR of bupropion achievinglong-term abstinence compared to aplacebo is 1.82.19 It is comparable withusing single NRT but has been shown tobe less effective when compared to usingvarenicline.Bupropion is contraindicated in peo-

ple with seizure disorder, CNS tumour,under 18 years old, pregnant or breast-feeding, previous diagnosis of bulimiaor anorexia nervosa, severe hepatic cir-rhosis, bipolar disorder and for peopleusing MAOIs.Side-effects of bupropion can include

a rash, seizures (0.1 per cent) andincreased anxiety and depression. It alsohas a number of drug interactions andinteractions with clinical conditions andtherefore caution should be taken beforerecommending to a smoker.

E-cigarettesThe e-cigarette is a battery-powered elec-tronic nicotine delivery device designedfor the purpose of providing inhaleddoses of nicotine by way of a vaporisedsolution to the respiratory system.They provide a flavour and physical

sensation similar to that of inhaledtobacco smoke, with no smoke or com-bustion actually involved, although somevapour is released into the air when thesmoker exhales. Propylene glycol is typi-cally used to produce the nicotine-carry-ing vapour. E-cigarettes may be used:23–25

• to help quit smoking or avoid relapsing• to reduce cigarette consumption• to relieve tobacco withdrawal symp-toms in places where there are smokingrestrictions• in order not to disturb other people withsmoke• to continue having a ‘smoking’ experi-ence with reduced health risks• because it is cheaper than smoking.Benefits include the positive effects

of abstinence from smoking (less cough-ing, improved breathing, better physicalfitness), enjoyment of the flavour and thesensation of inhalation. Side-effectsinclude dryness of the mouth andthroat.24

Evidence on the safety of e-cigarettesis limited, and there is no evidenceregarding the health effects of long-termuse. While it is unlikely that long-term useof e-cigarettes is as harmful as smoking,inconsistencies in product contents andlabelling are of concern,26 and thus, atthis stage, e-cigarettes are not licensedas a quit treatment.The WHO reported that there is con-

cern that nicotine delivery to the lungmight result in stronger toxicological,physiological and addictive effects,27 andmore evidence is needed about the safetyof long-term use and about their effective-ness as cessation devices. Thus, while e-cigarettes are poten-

tially a powerful force for public health,they need to be better regulated if theyare to deliver. In June 2013 theMedicines and Healthcare productsRegulatory Agency announced its inten-tion to regulate e-cigarettes as medicines.The revised Directive is expected to be

adopted in 2014 and to come into effectin 2016. Until that time, NHS stop smoking

advisers have been advised not to rec-ommend that smokers wishing to quitshould use e-cigarettes in favour of NHS-approved smoking cessation treatmentsto have the best chances to quit suc-cessfully. For those smokers who have success-

fully switched to e-cigarettes, however, thepriority should be staying off conventionalcigarettes, rather than quitting e-ciga-rettes.28

ConclusionSmoking cessation is the most cost-effec-tive intervention for the prevention ofsmoking-related disease and treatmentfor smokers who have smoking-relateddisease(s). A range of evidence-basedtreatments exist to support smokers facing the difficulty of behaviour changeand breaking nicotine addiction.Supporting smokers to quit, knowing andusing these interventions, is every clini-cian’s business.

References1. Department of Health. Healthy lives, healthypeople: a tobacco control plan for England.2011.2. Department of Health. No health withoutmental health: a cross-government mental

Figure 2. Example of a patient choice box to assistsmokers to make a choice of pharmacotherapy thatwould best suit them. The box is filled with dummy stopsmoking products and a guideline for prescribing is in-cluded at the bottom of the box. Smokers can look atand assess which of the available evidence-based prod-ucts would be most likely to suit them

health outcomes strategy for people of allages. 2011. 3. Health Development Agency. Smoking andpatients with mental health problems. 2004.4. Jones DR, et al. Psychiatric Services2004;55:1250–7.5. Jochelson K, et al. Clearing the air – debat-ing smoke free policies in psychiatric units.Kings Fund, 2006.6. Critchley JA, et al. J Clin Epidemiol 2003;56:583–90.

7. Hoogendern M, et al. Thorax 2010;65(8):711–8.8. IMPRESS. Guide to the relative value ofinterventions for people with COPD. 2012.9. Au DH, et al. J Gen Int Med 2009;24:457.10. Kawachi I, et al. JAMA 1993;269:232–6.11. Critchley JA, et al. Cochrane Database ofSystemic Reviews, 2003, Issue 4. Art. No.:CD003041. DOI: 10.1002/14651858.CD003041.pub2.12. Suskin NS, et al. J Am Coll Cardiology

2001;37(6):1677.13. Nyhäll-Wålin BM, et al. Rheumatology2009;48(4):416–20.14. Quick CRG, et al. B J Surgery 2005;69(S6):24–6.15. Dogar O, et al. The Lancet RespiratoryMedicine 2013;1(5):e23–4.16. Hughes JR, et al. Addiction2004;99:29–38.17. West R, et al. Smoking and smoking ces-sation in England 2011. London. April 2012.www.smokinginengland.info. 18. NICE. Smoking cessation services. PH10.February 2008.19. Cahill K, et al. Cochrane Database ofSystematic Reviews 2013, Issue 5.Art.No.:CD009329.DOI: 10.1002/14651858.CD009329.pub2.20. Wang D, et al. Health Technol Assess2008;12:iii-iv, ix-xi, 1–135.21. Cahill K, et al. Cochrane Database ofSystematic Reviews 2011(2):CD006103.22. Thomas KH, et al. BMJ 2013;347:f5704.23. Etter JF, et al. Addiction 2011;106(11):2017–28. 24. Caponnetto P, et al. Expert Rev Respir Med2012;6(1):63–74.25. Etter JF. BMC Public Health 2010;10:23.26. ASH Scotland. E-cigarettes. August 2010.http://bit.ly/OvQTWt.27. WHO. WHO study group on tobacco prod-uct regulation report on the scientific basis oftobacco product regulation. WHO TechnicalReport Series 955. March 2010. http://bit.ly/1qTvvJA. 28. Foulds J, et al. Int J Clin Pract 2011;65(10):1037–42.

Declaration of interestsNone to declare.

Elizabeth Pang is stop smoking specialist and Myra Stern is an inte-grated consultant respiratory physician,Whittington Health, London

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• NHS Smokefree is a free resource for advice to help people stop smoking. Youcan call and talk to a stop smoking adviser over the phone or chat to an adviseronline. They also have useful tools you can access from their website such aswidgets, stop smoking mobile app and a cost calculator. www.smokefree.nhs.ukor 0800 0224332

• QUIT is a charity that provides practical help, advice and support by trained coun-sellors to all smokers who want to stop. You can speak to a trained counsellor on0800 002200 or visit their website www.quit.org.uk

• Shared Decision Making. A patient decision aid to help patients make aninformed choice about the best route to stop smoking for them. http://sdm.right-care.nhs.uk/pda/smoking-cessation

• Action on Smoking and Health (ASH) is a campaigning public health charity thatworks to eliminate the harm caused by tobacco. They have useful resources forboth patients who want to stop smoking or health professionals wanting to helppeople stop smoking. www.ash.org.uk

• The National Centre for Smoking Cessation and Training (NCSCT) has usefulresources for healthcare professionals wanting to help people stop smoking. TheNCSCT has developed a range of training, assessment and certification pro-grammes to enable people to become more skilled stop smoking practitioners.www.ncsct.co.uk

• NICE has produced a Quality Standard (QS43) on Smoking cessation: supportingpeople to stop smoking. http://publications.nice.org.uk/smoking-cessation-sup-porting-people-to-stop-smoking-qs43

Table 3. Available support and resources for clinicians and smokers

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