Smoking cessation

NICE released guidance in 2008 on the management of smoking cessation. General points include:

• patients should be offered nicotine replacement therapy (NRT), varenicline or bupropion - NICE state that clinicians should not favour one medication over another
• NRT, varenicline or bupropion should normally be prescribed as part of a commitment to stop smoking on or before a particular date (target stop date)
• prescription of NRT, varenicline or bupropion should be sufficient to last only until 2 weeks after the target stop date. Normally, this will be after 2 weeks of NRT therapy, and 3-4 weeks for varenicline and bupropion, to allow for the different methods of administration and mode of action. Further prescriptions should be given only to people who have demonstrated that their quit attempt is continuing
• if unsuccessful using NRT, varenicline or bupropion, do not offer a repeat prescription within 6 months unless special circumstances have intervened
• do not offer NRT, varenicline or bupropion in any combination

Nicotine replacement therapy

• adverse effects include nausea & vomiting, headaches and flu-like symptoms
• NICE recommend offering a combination of nicotine patches and another form of NRT (such as gum, inhalator, lozenge or nasal spray) to people who show a high level of dependence on nicotine or who have found single forms of NRT inadequate in the past

Varenicline

• a nicotinic receptor partial agonist
• should be started 1 week before the patients target date to stop
• the recommended course of treatment is 12 weeks (but patients should be monitored regularly and treatment only continued if not smoking)
• has been shown in studies to be more effective than bupropion
• nausea is the most common adverse effect. Other common problems include headache, insomnia, abnormal dreams
• varenicline should be used with caution in patients with a history of depression or self-harm. There are ongoing studies looking at the risk of suicidal behaviour in patients taking varenicline
• contraindicated in pregnancy and breastfeeding

Bupropion

• a norepinephrine-dopamine reuptake inhibitor and nicotinic antagonist
  • unlike many antidepressants it has a minimal effect on serotonin