'Stop smoking' treatments

Several treatments are available to help people give up smoking, some available only on prescription and some over the counter. Always read the enclosed leaflet that comes with your treatment. A healthcare professional such as a GP could help you decide the best treatment and can offer support, including information about a local stop-smoking clinic. Before starting any treatment, set a date on which you aim to stop smoking.

Sources of information
There are many sources of information that are useful in helping people give up. These include:

• The National Health Service offers advice and support (www.gosmokefree.co.uk (external link))
• Cancer Research UK (external link)
• the charity QUIT (external link) or 0800 00 22 00
• the British Heart Foundation (external link)
• ASH (external link)

In addition, NHS Stop Smoking Services, with professional advice and support, are available in many parts of the country. To find your local NHS Stop Smoking Service call 0800 169 0 169 or text "give up" and your postcode to 88088.

Over-the-counter treatments to help people stop smoking
Nicotine replacement therapy (NRT)
Use of nicotine replacement therapy (NRT) is one way of helping people to quit smoking, particularly if they smoke ten or more cigarettes per day. NRT gets nicotine into the bloodstream, therefore helping to stop or reduce withdrawal symptoms without all the dangerous disease-causing chemicals in tobacco smoke. In those determined to stop, NRT roughly doubles the chances of successfully quitting and this is likely to be further increased when used in conjunction with counselling or support. The risk of continuing to smoke greatly outweighs any risks there may be with NRT. 

Overall, there is not much difference in how well the various types of NRT work, so the choice mainly depends on personal preference. Individual NRT products include:

• Chewing gum
• Patches  
• Tablets and lozenges
• Inhalators     
• Nasal spray

Most of these products are available from non-pharmacy retail outlets such as supermarkets, but others require the smoker to speak to a pharmacist. Always read the leaflet provided with an NRT product which will contain advice and detailed instructions on their use.

Circumstances under which I should talk to my doctor before using NRT
Speak to your doctor before starting to use NRT if you are:

• Pregnant.  Ideally a pregnant woman should stop smoking without NRT. However, if NRT is required, it is better to use oral forms of NRT which provide nicotine intermittently/every now and then, rather than patches because of their continuous release of nicotine. If a woman cannot tolerate oral forms of NRT, a patch that is removed at night is preferable so the developing baby is not exposed to nicotine throughout the 24-hour period.
• Breast-feeding.  Use of NRT products intermittently/every now and then (such as gums, sprays and other oral forms) is appropriate so that feeding can occur when the mother’s nicotine levels are low and the minimum amount reaches the baby.   
• A patient with heart disease. Patients with serious heart disease should try to stop smoking without NRT. However, if this is not possible, speak to your doctor, as NRT may be considered under medical supervision.
• An adolescent (aged 12 to 18 years). NRT can be used in this age-group, but if it is needed for longer than 12 weeks this should be discussed with a healthcare professional (e.g. a doctor, pharmacist or nurse).

The best option for quitting smoking is to stop abruptly. However, some smokers cannot do this; for these people NRT products can increase their chances of stopping smoking altogether. NRT can also help smokers to manage their cravings in places where smoking should be avoided, such as: places where second-hand smoke may damage others (especially children), e.g., in closed spaces such as vehicles or in the home; before surgery; on a flight or during hospital stay.

As with all medicines, side effects can occur with NRT use. Common side effects associated with different NRT products include:

• Lozenges and gums: irritation of the throat, increased salivation, indigestion, heartburn
• Patches: redness, itching, swelling or a burning sensation at the application site
• Nasal sprays and inhalators: nasal irritation such as sneezing or runny nose, watery eye, dizziness, headache, cough.

For a complete list of side effects associated with NRT use, along with useful information, please read the patient information leaflets which accompany NRT products:
› http://emc.medicines.org.uk/medicine/21472/PIL/Nicorette+Freshmint+4mg+Gum/ (external link)
› http://emc.medicines.org.uk/medicine/19957/XPIL/Nicopatch/ (external link)
› http://emc.medicines.org.uk/medicine/20475/XPIL/Nicopass+1.5mg+Liquorice+Mint+Lozenge/ (external link)

Prescription-only treatments to help people stop smoking
Several medicines are available on prescription from your doctor to help people give up smoking. It is important to always read the enclosed leaflet and to speak to a healthcare professional such as your GP about your treatment.

Bupropion
Bupropion (Zyban) is a prescription-only medicine to aid giving up smoking in combination with motivational support. It is NOT a form of nicotine replacement therapy.

Circumstances under which I should talk to my doctor before using buproprion
Speak to your doctor before starting to use buproprion if you are:

• An epilepsy or seizure sufferer
• A heavy drinker
• Suffering from a head injury
• A diabetic treated with insulin
• Suffering from a liver or kidney disease, or a psychiatric illness
• Breast feeding
• Pregnant
• Under 18 years old
• Elderly
• Taking other medicines

The Commission on Human Medicines has advised that bupropion should not be prescribed to people with: a history of seizures, depression or suicidal thoughts; a tumour of the central nervous system; or symptoms of withdrawal from alcohol or benzodiazepine. Using bupropion may also affect your ability to perform skilled tasks such as driving, so caution must be exercised. Talk to a healthcare professional if you have any concerns about the treatment you are taking to stop smoking.

As with all medicines, side effects can occur with buproprion use. Common side effects include:

• Fever
• Dry mouth
• Constipation
• Nausea
• Insomnia

For a complete list of side effects associated with buproprion use, along with useful information, please read the accompanying patient information leaflet:
› http://emc.medicines.org.uk/medicine/3957/PIL/Zyban+150+mg+prolonged+release+film-coated+tablets/ (external link)

Varenicline
Varenicline (Champix▼) is a prescription-only medicine that was launched in the UK in December 2006 as a stop-smoking aid for adults. Varenicline tablets may reduce the craving and reward of smoking and may also decrease nicotine withdrawal symptoms when trying to quit. Immediately after stopping treatment, the risk of relapse (ie, starting smoking again) is increased and some patients experience irritability, depression or insomnia. For these reasons, a gradual reduction in dose may be prescribed for some patients.

Circumstances under which I should talk to my doctor before using varenicline
You must not use varenicline without speaking to your doctor if you:

• Are pregnant
• Are breast feeding
• Have a history of depression or other serious psychiatric condition such as schizophrenia or bipolar disorder.

It is important to note that stopping smoking (with or without the use of smoking cessation aids) may cause symptoms of depression, irritability, anger, insomnia, anxiety, difficulty concentrating, restlessness and weight gain. Therefore, if a person experiences any of these symptoms whilst quitting smoking with the help of medication it is important to remember that they may not have been caused by that particular medicine – they may relate to other factors such as nicotine withdrawal from stopping smoking, other illnesses, or other medications taken at the same time.

Other common side effects associated with varenicline use include:

• Nausea
• Headache
• Abnormal dreams
• Insomnia
• Dizziness
• Drowsiness
• Fatigue
• Increased appetite
• Disturbed taste

Whilst these side-effects are generally not serious, there have been reports of more serious suspected side effects associated with the use of varenicline.

Psychiatric disorders
Changes in behaviour or thinking, anxiety, psychosis, mood swings, aggressive behaviour, depression, suicidal thoughts, suicide attempts and completed suicides have been reported in patients attempting to quit smoking with varenicline. Some of the patients had no known pre-existing psychiatric condition and some continued to smoke.

People who are taking varenicline who develop suicidal thoughts, agitation, depressed mood, or display any changes in behaviour or thinking that are of concern for the doctor, patient, family, or caregiver should stop varenicline and contact their doctor immediately.

Care should be taken if varenicline is prescribed to patients with a history of psychiatric illness.

For the most recent MHRA advice regarding varenicline and suicide-related events please refer to the November 2008 issue of our monthly bulletin Drug Safety Update.

Other potentially serious reactions that have been reported for varenicline

• hallucinations
• allergic reactions, including swelling of the face and throat
• serious skin conditions including erythema multiforme and Stevens Johnson syndrome (where the mucous membranes and skin start to blister and peel)

Varenicline may also affect the ability to drive or use machines: patients should not drive or operate complex machinery, or take part in potentially hazardous activities until they know how varenicline affects them

For a complete list of side effects associated with varenicline use, along with useful information, please read the accompanying patient information leaflet:

Electronic Medicines Compendium - CHAMPIX 0.5 mg film-coated tablets; CHAMPIX 1 mg film-coated tablets (external link)

Reporting of side effects
Varenicline is a relatively new drug and information about its use in the general population is limited. Therefore, it is monitored closely by the MHRA via the black triangle scheme. Healthcare professionals and patients are encouraged to report any side effects thought to be associated with varenicline use via the Yellow Card scheme.

Summary
There are various types of treatment available to help people stop smoking. A healthcare professional can help someone decide which treatment is best for them. It is important to commit to a date to aim to stop smoking, and to consider enrolling at a stop-smoking clinic to help maintain motivation to quit. Always read the leaflet accompanying any product to ensure that it is used safely, and if you have any questions, speak to a doctor, nurse or pharmacist.

Other information
The effectiveness and safety of a product called Nicobrevin, which is marketed as an 'anti-smoking preparation', has been analysed by the MHRA. The analysis found that neither Nicobrevin nor any of its active ingredients are effective in helping people to quit smoking. In addition, there are serious safety concerns with this product, and the risks outweigh the benefits. Therefore, Nicobrevin has been withdrawn from the UK market. A Public Assessment Report summarising the findings of the analysis is available below.

Nicobrevin: withdrawn from UK market as risks outweigh benefits (183Kb)