Stop-smoking aids

Smoking in enclosed public places (for example, offices, factories, pubs, and bars) was banned in England from 1 July, 2007; smoking in enclosed public places is already banned in other parts of the UK and in the Irish Republic.

The National Health Service offers advice and support to those who want give up smoking (www.gosmokefree.co.uk (external link)). To find your local NHS Stop Smoking Service call 0800 169 0 169 or text "give up" and your postcode to 88088. Information can also be obtained from:

• Cancer Research UK (external link)
• the charity QUIT (external link) or 0800 00 22 00
• the British Heart Foundation (external link)
• ASH (external link)

Several treatments are available to help people give up smoking, some of which are available only on prescription and some over the counter. It is important to always read the enclosed leaflet. A healthcare professional such as a GP may help someone decide the best treatment and can offer support, including information about a local stop-smoking clinic. Before starting to use a stop-smoking aid, it is important to set a date to aim to stop smoking.

Varenicline
Varenicline (Champix) is a new prescription-only medicine that was launched in the UK in December 2006 as a stop-smoking aid for adults. Varenicline tablets act on a specific nicotinic receptor and may reduce the craving and reward of smoking and may also decrease withdrawal symptoms when trying to quit. Immediately after treatment, risk of relapse is increased and some patients experience irritability, depression, or insomnia. Thus, a gradual reduction in dose may be prescribed for some high-risk patients.

Varenicline should not be prescribed to pregnant women or those who are breastfeeding. Varenicline may cause dizziness and drowsiness and may affect the ability to drive or use machines: patients should avoid potentially hazardous activities until they know how varenicline may affect them.

From studies of varenicline done before licensing, the most common side-effects include: increased appetite; abnormal dreams; insomnia; headache; drowsiness; dizziness; distorted taste; feeling sick; vomiting; constipation; diarrhoea; stomach discomfort; indigestion; flatulence; dry mouth; and fatigue.

Because varenicline is a new drug and information about its use in the population is limited, it will be monitored closely by the MHRA and will carry a black triangle symbol next to its name (for more information about black-triangle drugs see the New drugs and vaccines under intensive surveillance section). Healthcare professionals and patients are encouraged to report any side-effects thought to be associated with varenicline use via the Yellow Card scheme.

Bupropion
Bupropion (Zyban) is a prescription-only medicine to aid giving up smoking in combination with motivational support. Bupropion tablets block nicotinic receptors in the body and thus interrupt addiction to smoking.

Bupropion should be used with caution in elderly people, in those at risk of having seizures, and in those with impaired function of the liver and kidneys. Bupropion should not be prescribed to patients with a history of bipolar disorder, or to women who are pregnant or breastfeeding; it is not recommended for children or adolescents. Blood pressure should be monitored closely before and during treatment.

The Commission on Human Medicines has advised that bupropion should not be prescribed to people with: a history of seizures; a history of eating disorders; a tumour of the central nervous system; or symptoms of withdrawal from alcohol or benzodiazepine. People with risk factors associated with seizure (eg, those who take drugs such as antidepressants, treatment to protect against malaria, antipsychotics, some antihistamines, and corticosteroids; misusers of alcohol; users of stimulants, and those with a history of head injury or of diabetes) should be prescribed bupropion only if the benefits outweigh the risks.

Bupropion may affect the ability to do some skilled tasks such as driving. Other side-effects of bupropion treatment are: dry mouth; digestive-system disturbances; disturbed taste; insomnia (which can be minimised by not taking the drug at night); tremor; impaired concentration; headache; dizziness; depression; agitation and anxiety; and fever, rash, and sweating. Less commonly, it is associated with: chest pain; abnormal heart rhythm; high blood pressure; flushes; confusion; noise in the ears (tinnitus); lack of energy; and disturbed vision. Rarely, it is associated with: jaundice; hepatitis; palpitations; low blood pressure on standing; hallucinations; a loss of sense of self (depersonalisation); seizures; some movement and muscle disorders; abnormal dreams; impaired memory; disturbed blood sugar levels; urinary disorders; and some skin disorders. Very rarely, it has been associated with delusions and aggression.

Nicotine replacement therapy
Nicotine replacement therapy (NRT) can help people who smoke more than ten cigarettes a day give up.

There are many types of NRT products available, including: microtabs placed under the tongue; chewing gum; lozenges; skin patches; nasal sprays; and inhalator mouthpieces. Chewing gum or inhalator mouthpieces can be used to help reduce smoking, with the eventual aim of stopping completely. Although there are many types of NRT available, people may prefer or tolerate a certain product better than others. Treatment should be reviewed if it has no effect by the time recommended in the product information.
 
NRT products should be used with caution and under medical supervision in people with severe or unstable heart disease (eg, after a recent heart attack or stroke) or in those with diabetes. NRT should also be used with caution in people with: an uncontrolled overactive thyroid gland; a phaeochromocytoma (a non-cancerous growth in the adrenal gland); and with impaired function of the liver or kidneys.

Oral NRT products should be used with caution in patients with digestive-system disorders such as inflammation of the stomach or gullet, or presence of stomach ulcers. NRT products placed onto the skin should be used with caution in people with skin disorders; patches should not be placed on broken skin.

Some people who use NRT may have side-effects, which include: feeling sick; vomiting; indigestion; headache; dizziness; flu-like symptoms; dry mouth; rash; and, more rarely, palpitations and effects on the heart.

Nasal spray NRT products may cause sneezing, nose bleeds, watering eyes, and sensations in the ear; lozenges may cause thirst, sensations in the mouth, and disturbed taste; and skin patches may cause skin reactions and should be stopped if severe. Patches and lozenges used together may disturb sleep and cause chest pain; and gum and lozenges used together may cause mouth ulcers and increased salivation.

In December 2005, an expert working group of the Commission on Human Medicines recommended that pregnant or breastfeeding women, patients with heart disease, patients with kidney or liver problems, patients with diabetes, and adolescents could use NRT. The Commission considered that for these people the risks associated with smoking outweighed the risks of NRT.
› New advice on use of nicotine replacement therapy (NRT): wider access in at-risk populations

Summary
There many 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 with the product to ensure it is used safely.