There are about 10 million smokers in the UK. It is the biggest cause of premature death and preventable disease in the UK - more than the next six causes put together. It kills over 100,000 people in the UK a year; about half of all smokers will eventually die of a smoking-related illness.
Dr Hayley Willacy recently read the latest Office for National Statistics figures that record the largest decline in smoking prevalence of around 6 percentage points in 18- to 24-year-olds since 2010. This may reassure those concerned that vaping may be introducing more young people to tobacco. However, this still remains the second most likely age group to smoke, at 19.3%. In 2016, 15.8% of the UK population smoked, equating to around 7.6 million people. The figures show that the proportion of smokers who have quit continues to increase.
Smoking is implicated as a risk factor for many health problems, including:
- Premature death: cigarette smoking is the single most important cause of premature death in the UK. Most premature deaths caused by smoking are due to lung cancer, chronic obstructive pulmonary disease and coronary heart disease.
- Cancers of the upper respiratory tract, oesophagus, bladder, kidney, stomach, and pancreas; myeloid leukaemia.
- Cerebrovascular disease, aortic aneurysm, and heart failure caused by coronary heart disease.
- Peptic ulceration (gastric and duodenal).
- Angina, peripheral arterial disease (including Buerger's disease), macular degeneration, impotence, infertility, skin wrinkling, osteoporosis.
- Increased severity of asthma, respiratory tract infections and diabetic retinopathy.
- Passive smoking: exposure to environmental tobacco smoke causes an increased risk of smoking-related diseases, especially lung cancer and heart disease.
- Children exposed to environmental tobacco smoke are at increased risk of sudden infant death syndrome, asthma, otitis media and chest infections in the first years of life.
- Fetal exposure to maternal smoking increases the risk of miscarriage, premature birth, low birth weight and stillbirth. Smoking in pregnancy may also affect the child's physical growth and academic attainment may be reduced.
Smoking cessation interventions are a cost-effective way of reducing ill health. Quitting at any age provides both immediate and long-term health benefits.
Smokers should be advised to stop and be offered help and follow-up, with access to a smoking cessation clinic for behavioural support. The National Institute for Health and Care Excellence (NICE) recommends focusing particularly on reducing the prevalence of smoking among people in manual groups, ethnic groups and disadvantaged communities. A reminder about the health benefits of smoking cessation and brief advice should be given at every opportunity in primary and secondary care. If appropriate, a referral should be made to the local NHS Stop Smoking Service.
Opportunities identified by NICE include patients referred for elective surgery and those recently discharged from hospital.
NICE recommendations (February 2008) are as follows:
- Offer nicotine replacement therapy (NRT), varenicline or bupropion, as appropriate, to people who are planning to stop smoking.
- Pharmacological therapy should normally be prescribed as part of an abstinent-contingent treatment, in which the smoker makes a commitment to stop smoking on or before a particular date (target stop date).
- The prescription of NRT, varenicline or bupropion should be sufficient to last only until two weeks after the target stop date. Normally, this will be after two weeks of NRT therapy and 3-4 weeks for varenicline and bupropion, to allow for the different methods of administration and mode of action.
- Subsequent prescriptions should be given only to people who have demonstrated, on re-assessment, that their quit attempt is continuing.
- If a smoker's attempt to quit is unsuccessful using NRT, varenicline or bupropion, do not offer a repeat prescription within six months unless special circumstances have hampered the person's initial attempt.
- Varenicline or bupropion may be offered to people with unstable cardiovascular disorders, subject to clinical judgement.
- Consider 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.
- Do not offer NRT, bupropion or varenicline in any combination.
- Do not favour one medication over another. The clinician and patient should choose the one that seems most likely to succeed.
- When deciding which therapies to use and in which order, discuss the options with the patient and take the following into account:
- Whether a first offer of referral to the NHS Stop Smoking Service has been made.
- Contra-indications and the potential for adverse effects.
- The patient's personal preferences.
- The availability of appropriate counselling or support.
- The likelihood that the patient will follow the course of treatment.
- Their previous experience of smoking cessation aids.
NICE has also issued guidance on smoking cessation activities in schools.
Clinical Editor's note
January 2018 - Dr Hayley Willacy read the recent UK paper that shows smoking just one cigarette a day has a much higher risk of developing coronary heart disease and stroke than expected. The research found that men who smoked one cigarette per day had 46% of the excess risk of heart disease and 41% of the excess risk of stroke associated with smoking 20 cigarettes per day (much higher than the expected 5%). For women, those who smoked one cigarette per day had 31% of the excess risk of heart disease and 34% of the excess risk of stroke associated with smoking 20 cigarettes per day.
Nicotine replacement therapy
Seven NRT formulations are available on prescription and most can also be bought over the counter (OTC) at pharmacies and supermarkets. None of these formulations is more effective than any other. Higher-dose gum and patches are more effective in those smoking more than 10 cigarettes a day. There has been some recent criticism of the effectiveness of the OTC strategy and more research is required.
Available methods of NRT include:
- Nasal spray
- Mouth spray
- Inhalation cartridge
- Sublingual tablets
NRT is most effective with behavioural interventions. NRT reduces but does not completely eliminate the symptoms of withdrawal because it takes a few seconds for nicotine from a cigarette to reach the brain, one minute for the mouth spray, several minutes for the nasal spray, gum, inhalator, sublingual tablet and lozenge and hours for transdermal patches.
NRT can control the weight gain commonly experienced after cessation. NRT should be continued for eight weeks and can then be stopped immediately.
The risk of dependence on NRT is small. About 5% who quit continue to use nicotine regularly. Nicotine from NRT is considerably safer than cigarettes, as the patient is not exposed to tar, carbon monoxide and other harmful products. However, the safety of the long-term use of NRT is currently being investigated.
NICE advises explaining the risks and benefits of using NRT to young people aged from 12 to 17, pregnant or breastfeeding women and people who have unstable cardiovascular disorders[5, 12]. These groups should also be strongly encouraged to use behavioural support in their quit attempt. NRT is licensed for use in children from the age of 12. Nicotinell® lozenges have the added rider that they should only be prescribed for children under the age of 18 on the recommendations of a doctor.
Smokers should be advised not to smoke while using NRT products, although some gums are licensed for smoking reduction (see 'Chewing gum', below).
Severe cardiovascular disease (severe arrhythmias, post-infarction period); recent cerebrovascular accident (including transient ischaemic attacks).
Cardiovascular disease; peripheral vascular disease; hyperthyroidism, diabetes mellitus, phaeochromocytoma, renal impairment, hepatic impairment, gastritis and peptic ulcers.
- Flu-like symptoms
- Vivid dreams
Patches - these are applied on waking, to dry, non-hairy skin and removed, usually when retiring to bed; the next patch should be sited on a different area. Nicorette® is a 16-hour patch, whereas Nicotinell® and NiQuitin® are 24-hour patches. As a general guide, people who smoke more than 10 cigarettes a day should apply a high-strength patch daily for 6-8 weeks, the medium-strength patch for two weeks and then the low-strength patch for the final two weeks. Lower-dose regimes are more appropriate for those who smoke 10 a day or fewer. Each brand has its own regime so the manufacturer's instructions should be followed in individual cases. The most common side-effect is skin irritation. Minor sleep disturbances can occur, in which case 16-hour patches are best.
Chewing gum (can be used when trying to reduce the number of cigarettes) - sugar-free, nicotine 2 mg and 4 mg. Available in fruit, liquorice and mint flavours (Nicotinell®). Chew slowly for 30 minutes, when the urge to smoke occurs. Maximum 60 mg daily. Withdraw gradually after three months. Individuals smoking more than 20 cigarettes daily may need the 4 mg strength.
Nasal spray - nicotine 500 micrograms/spray. One spray into each nostril to maximum twice an hour for 16 hours daily (maximum 64 sprays daily) for eight weeks; then reduce gradually over the next four weeks (reduce by half at the end of the first two weeks; stop altogether at the end of the next two weeks). Maximum treatment three months.
Oral spray - this is an oral alternative which can be used whenever the urge to smoke appears. The maximum is two sprays per episode (up to four sprays every hour), 64 sprays daily.
Nicorette® inhalator - this is now available as a 15 mg cartridge. It should be inhaled when the urge to smoke occurs. Up to 12 cartridges can be used daily for eight weeks; then they should be reduced by half over the next two weeks and then tailed off over two weeks. The 15 mg cartridge is replacing the 10 mg cartridge and lasts twice as long (40 minutes).
Electronic cigarettes, or e-cigarettes - are designed to look and feel like normal cigarettes. They have a heating element inside that vaporises a solution that may contain nicotine - this looks like smoke. They are substituted for normal cigarettes or cigars. There is some uncertainty whether this is better (or safer) than the other ways of stopping smoking.
Lozenges - one lozenge every 1-2 hours, when the urge to smoke occurs. Maximum 30 mg daily. Withdraw gradually after three months. The period of treatment should not usually exceed six months (eg, four hours for three weeks, then every eight hours for three weeks).
Sublingual tablets (2 mg) - one each hour (two may be needed for those on more than 20 cigarettes daily). Maximum 80 mg daily. Continue for three months, then gradually reduce. Treatment should not exceed six months.
Bupropion (Zyban®) is only available on prescription. Bupropion was developed as an antidepressant but subsequently shown in trials to be effective in smoking cessation. Bupropion is an atypical antidepressant similar to diethylpropion, an appetite suppressant; it inhibits reuptake of dopamine, noradrenaline (norepinephrine) and serotonin in the CNS and is a non-competitive nicotine receptor antagonist.
Bupropion is contra-indicated in pregnancy or whilst breast-feeding. It is also contra-indicated in patients with a history of bipolar illness. It should not be given to patients under the age of 18. NB: allow 14 days after stopping a monoamine-oxidase inhibitor (MAOI).
Hepatic cirrhosis, renal impairment; predisposition to seizures; raised blood pressure (monitor weekly if used with nicotine products). It may impair performance of skilled tasks (eg, driving).
The most important side-effects are seizures (fits), which occur in about 1 in 1,000 patients. Insomnia and dry mouth commonly occur. About 0.1% of smokers suffer severe hypersensitivity reactions (eg, angio-oedema, bronchospasm and anaphylactic shock) and 3% suffer milder reactions, such as rash, urticaria or pruritus.
Rare side-effects include gastrointestinal disturbances, tremor, anorexia, headache, dizziness, visual disturbance, anxiety, flushing, hallucinations, depersonalisation, seizures, paraesthesia, Stevens-Johnson syndrome, hepatitis and exacerbation of psoriasis.
See the British National Formulary (BNF) for full prescribing details.
Varenicline (Champix®) is only available on prescription. It is an alpha-4 beta-2 (α4β2) nicotinic acetylcholine receptor partial agonist. This means that it both blocks and stimulates the receptor to which it is attracted. The α4β2 receptor is located in the nucleus accumbens area of the brain (the 'pleasure centre'). The stimulatory effect produces a weak nicotine-like effect which reduces the craving for nicotine itself, whilst the blocking effect inhibits the pleasurable effect derived from smoking.
Varenicline should be started 1-2 weeks before the target stop date. NICE recommends that it should normally only be prescribed as part of a programme of behavioural support. The drug should be initiated at 500 micrograms (one tablet) daily for three days, 500 micrograms twice-daily for four days, then 1 mg twice-daily for 11 weeks. If the patient cannot tolerate the higher dose, it can be reduced to 500 micrograms twice-daily. A further 12-week course of 1 mg twice-daily can be considered for patients who have stopped smoking but feel they still need further pharmacological support.
- Age under 18
- Severe renal impairment.
- Up to 3% of individuals in the trials complained of irritability, an urge to smoke, depression and/or insomnia on stopping the drug. Patients should be advised of this and a gradual reduction in dosage towards the end of the course may need to be considered.
The most common side-effect noted in trials was nausea, which occurred in 30% of patients. This usually resolved spontaneously in a few days in patients who continued the drug. It is also helped by taking the tablet with water but a reduction in dosage to 500 micrograms twice-daily was sometimes required. A wide range of other adverse effects was reported, of which the most common were insomnia, abnormal dreams, headaches and flatulence. Both nausea and abnormal dreams can be reduced by taking the second pill at dinner time or supper time rather than at bedtime.
See the BNF for full prescribing details.
Other treatments for smoking cessation
The following treatments have some effect on smoking cessation but are neither licensed in the UK for this indication, nor recommended by NICE:
Nortriptyline, a tricyclic with noradrenergic properties and dopaminergic activity - is effective in cessation therapy, independent of the presence of depressive symptoms.
Clonidine, an alpha-agonist that suppresses sympathetic activity - has increased smoking cessation in eight out of nine trials; however, it has serious side-effects, including sedation and postural hypotension.
Further reading and references
Tobacco: harm-reduction approaches to smoking; NICE Public Health Guidance, June 2013
Smoking cessation in secondary care: acute, maternity and mental health services; NICE Public Health Guidance, November 2013
Cahill K, Stevens S, Perera R, et al; Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database Syst Rev. 2013 May 315:CD009329. doi: 10.1002/14651858.CD009329.pub2.
Smoking statistics; Action on Smoking and Health, January 2015
Adult smoking habits in the UK: 2016; Office for National Statistics (2017)
Smoking cessation; NICE CKS, October 2012 (UK access only)
Wu J, Sin DD; Improved patient outcome with smoking cessation: when is it too late? Int J Chron Obstruct Pulmon Dis. 20116:259-67. doi: 10.2147/COPD.S10771. Epub 2011 May 2.
Smoking Cessation Services; NICE Public Health Guidance, February 2008
School-based interventions to prevent smoking; NICE Public Health Guidance, February 2010
Hackshaw A, Morris JK, Boniface S, et al; Low cigarette consumption and risk of coronary heart disease and stroke: meta-analysis of 141 cohort studies in 55 study reports. BMJ. 2018 Jan 24360:j5855.
British National Formulary; 69th Edition (Mar 2015) British Medical Association and Royal Pharmaceutical Society of Great Britain, London
Dome P; Over-the-counter nicotine replacement therapy for everyone: Is it the best Med Hypotheses. 2011 Dec77(6):1048-50. Epub 2011 Sep 15.
How Addiction Causes Disease; Centers for Disease Control and Prevention, 2010
Shields PG; Long-term Nicotine Replacement Therapy: Cancer Risk in Context. Cancer Prev Res (Phila). 2011 Nov4(11):1719-23.
Smoking: stopping in pregnancy and after childbirth; NICE Public Health Guidance (June 2010)
McRobbie H, Bullen C, Hartmann-Boyce J, et al; Electronic cigarettes for smoking cessation and reduction. Cochrane Database Syst Rev. 201412:CD010216. doi: 10.1002/14651858.CD010216.pub2. Epub 2014 Dec 17.
British National Formulary (BNF); NICE Evidence Services (UK access only)
Varenicline: Guidance for health professionals on a new prescription-only stop smoking medication; Action on Smoking and Health, July 2007
Smoking cessation - varenicline; NICE Technology Appraisal Guidance, July 2007
Quaak M, van Schayck CP, Postma DS, et al; Genetic variants in the serotonin transporter influence the efficacy of bupropion Addiction. 2011 Jun 9. doi: 10.1111/j.1360-0443.2011.03534.x.
Gourlay SG, Stead LF, Benowitz NL; Clonidine for smoking cessation. Cochrane Database Syst Rev. 2004(3):CD000058.
White AR, Rampes H, Liu JP, et al; Acupuncture and related interventions for smoking cessation. Cochrane Database Syst Rev. 2014 Jan 231:CD000009. doi: 10.1002/14651858.CD000009.pub4.
Barnes J, Dong CY, McRobbie H, et al; Hypnotherapy for smoking cessation. Cochrane Database Syst Rev. 2010 Oct 6(10):CD001008.
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