Key Facts

Smoking remains the leading preventable cause of morbidity and mortality in the UK. Primary care is the most common setting for smoking cessation interventions. A combination of behavioural support and pharmacotherapy offers the best chance of success.

Epidemiology

• Approximately 6.4 million adults smoke in the UK (13% prevalence)
• Smoking-related diseases cause approximately 78,000 deaths/year
• Smoking is the leading cause of health inequalities: prevalence 25% in most deprived quintile vs 8% in least deprived
• Smoking causes approximately 15% of all cancer deaths and 25% of all CVD deaths

Health Effects

• Cancer: lung (15× risk), oesophageal, bladder, pancreatic, head and neck, kidney, stomach, cervical
• Cardiovascular: coronary heart disease (2-4× risk), stroke (2× risk), peripheral vascular disease, aortic aneurysm
• Respiratory: COPD (85% attributable to smoking), pneumonia, lung function decline
• Other: type 2 diabetes (30-40% increased risk), macular degeneration, osteoporosis, peptic ulcer, impaired fertility, pregnancy complications
• Passive smoking: increased risk of SIDS, childhood asthma, lung cancer in non-smokers

Addiction Pathophysiology

• Nicotine binds to nicotinic acetylcholine receptors (nAChRs) in the ventral tegmental area
• Stimulates dopamine release in the nucleus accumbens (reward pathway)
• Rapid tolerance develops; withdrawal symptoms (craving, irritability, anxiety, poor concentration) drive continued use
• Physical dependence develops within weeks; psychological and behavioural dependence reinforced by habit and social context

Assessment

• Smoking status: current, ex-smoker, never smoked
• Pack-year history (packs/day × years smoked)
• Fagerström Test for Nicotine Dependence: score ≥6 indicates high dependence
• Time to first cigarette (≤30 minutes indicates higher dependence)
• Previous quit attempts and methods used
• Readiness to quit (motivational assessment)
• Triggers for smoking
• Co-existing conditions affected by smoking (COPD, CVD, diabetes)

Withdrawal Symptoms

• Onset: within 24 hours of cessation
• Peak: 2-3 days
• Duration: most resolve within 2-4 weeks
• Symptoms: craving, irritability, restlessness, poor concentration, increased appetite, insomnia, depressed mood

Red Flags

• Persistent cough, haemoptysis, weight loss in smoker >40 — 2-week-wait lung cancer referral
• Exertional breathlessness, productive cough — investigate COPD
• Chest pain, claudication — investigate CVD/PAD
• Severe depression/suicidal ideation during cessation attempt — psychiatric assessment

Bedside

• Smoking history and pack-year calculation
• Fagerström Test for Nicotine Dependence
• CO breath test (exhaled carbon monoxide): confirms smoking status and monitors cessation (level should fall to <10 ppm after cessation)
• Blood pressure and BMI

Bloods

• Not routinely required specifically for cessation
• Consider as part of CVD risk assessment: lipids, HbA1c
• FBC: polycythaemia may be present in heavy smokers
• Cotinine levels: rarely used clinically; useful for research/insurance purposes

Other

• Spirometry: if COPD suspected
• CXR: if respiratory symptoms or lung cancer concern
• QRISK3: cardiovascular risk assessment

Non-pharmacological

• Very Brief Advice (VBA): Ask about smoking → Advise on best method of quitting → Act (prescribe, refer to stop smoking service, or provide self-help)
• Referral to NHS Stop Smoking Service: behavioural support (individual or group) — increases quit rates 3-fold
• Cognitive behavioural therapy: addresses psychological dependence
• Motivational interviewing: for those not yet ready to quit
• Brief interventions: even 30 seconds of advice increases quit rates by 1-3%

Pharmacological

Nicotine Replacement Therapy (NRT):

• Combination NRT (patch + fast-acting form) is most effective:
  • Nicotine patch (21mg/24h or 25mg/16h) + nicotine inhalator/gum/lozenge/nasal spray for breakthrough cravings
  • Duration: 8-12 weeks, tapering
  • Can be started 1-2 weeks before quit date or on quit date
  • Safe in cardiovascular disease, pregnancy (if unable to quit unaided)

Varenicline (Champix):

• Partial agonist at α4β2 nicotinic receptors (reduces craving and reward from smoking)
• Dose: 0.5mg OD for 3 days → 0.5mg BD for 4 days → 1mg BD for 11 weeks (total 12 weeks)
• Most effective single agent: OR 2.88 vs placebo; quit rate approximately 25-30% at 12 months
• EAGLES trial: no increased neuropsychiatric risk vs NRT or placebo
• Side effects: nausea (30%), vivid dreams, headache
• Note: supply issues have affected availability; check current stock

Bupropion (Zyban):

• Noradrenaline-dopamine reuptake inhibitor
• Dose: 150mg OD for 6 days → 150mg BD for 7-9 weeks (start 1-2 weeks before quit date)
• Contraindicated: seizure disorder, eating disorder, bipolar disorder, concurrent MAOIs
• Seizure risk: approximately 1 in 1,000

E-cigarettes:

• Not a licensed medicine but widely used for cessation
• NICE NG209 acknowledges role in tobacco harm reduction
• Significantly less harmful than combustible tobacco (estimated 95% less harmful by PHE)
• Encourage switching completely from tobacco to e-cigarette as interim step

Referral Criteria

• All smokers wanting to quit: offer referral to NHS Stop Smoking Service
• Complex patients (pregnancy, severe COPD, psychiatric comorbidity): specialist smoking cessation support
• Suspected smoking-related cancer: 2-week-wait referral as appropriate

• Unaided quit attempts: success rate 3-5% at 12 months
• Behavioural support + NRT: 15-20% at 12 months
• Behavioural support + varenicline: 25-30% at 12 months
• Benefits of quitting: CVD risk halves within 1 year; stroke risk equals non-smoker within 5-15 years; lung cancer risk halves within 10 years
• COPD: quitting slows FEV1 decline to age-related rate (most important intervention in COPD management)
• Life expectancy: stopping at age 30 gains almost 10 years; at 40 gains 9 years; at 50 gains 6 years; at 60 gains 3 years

Fagerström Test for Nicotine Dependence (Key Questions)

Smoking Cessation Pharmacotherapy Comparison