Smoking Cessation

Introduction

Smoking remains the largest single cause of preventable death and illness in the UK, responsible for around 64,000 deaths a year and implicated in cancer, cardiovascular disease, respiratory disease, poor wound healing, infertility and adverse pregnancy outcomes.¹ It is also one of the clearest examples in medicine of an intervention that is simultaneously high-impact, low-cost and frequently under-delivered.

Supporting a quit attempt is one of the most cost-effective things a clinician can do - more so than most drug treatments for established disease - because it addresses the underlying cause of so much of that disease burden at once. It is examined heavily because it combines pharmacology, behavioural science and communication skills in a single, high-yield topic.

Smoking prevalence is strongly patterned by deprivation, and quitting is harder, not easier, in more deprived groups because of higher nicotine dependence, more smokers in the household, and greater life stress - a fact worth knowing for both clinical and public health exam questions.

Very Brief Advice

Very Brief Advice (VBA), sometimes taught as Ask, Advise, Act, is the minimum standard every clinician should deliver opportunistically, and takes under 30 seconds.²

Assessing dependence and motivation

Before selecting pharmacotherapy, establish nicotine dependence and readiness to change.

• Cigarettes per day and time to first cigarette after waking - lighting up within 30 minutes of waking indicates higher dependence and predicts a harder quit, informing the choice and dose of pharmacotherapy
• Previous quit attempts: what was tried, what worked, what triggered relapse - previous partial success with a method is informative
• Motivation and readiness: open questions about reasons to quit and confidence in succeeding, rather than assuming readiness or pushing a reluctant patient
• Household and social context: other smokers at home substantially reduce success rates
• Comorbidities relevant to drug choice: psychiatric history, cardiovascular disease, pregnancy

Scoring dependence: the Fagerström test

The Fagerström Test for Nicotine Dependence is a brief, validated tool combining cigarettes per day and time to first cigarette after waking (its two most heavily weighted items) with several other questions, producing a score that predicts withdrawal severity and helps guide the intensity of pharmacotherapy needed.

In practice, even without the formal tool, these two questions alone give a rapid, useful estimate of dependence severity and inform decisions such as whether to start with combination NRT or a single form, and how much initial support to offer.

Pharmacotherapy

Three licensed options exist in the UK: nicotine replacement therapy (NRT), varenicline, and bupropion. All roughly double quit rates compared with placebo when combined with behavioural support; the choice depends on patient preference, comorbidities and prior experience.³

Nicotine replacement therapy

NRT relieves withdrawal by providing nicotine without the thousands of other combustion products in tobacco smoke. Combination NRT - a patch for steady background levels plus a fast-acting form (gum, lozenge, mouth spray, inhalator) for breakthrough cravings - outperforms any single product used alone and is now the recommended default.³

Varenicline

Varenicline is a partial agonist at the α4β2 nicotinic acetylcholine receptor: it relieves craving and withdrawal (agonist effect) while blunting the reward from any cigarette smoked during a lapse (antagonist effect, by blocking nicotine binding). Trial and meta-analysis evidence consistently shows it is the single most effective monotherapy, more effective than either NRT alone or bupropion.⁴ It is started 1-2 weeks before the quit date and continued for 12 weeks. Nausea is the commonest side effect; earlier concerns about neuropsychiatric adverse effects have not been confirmed by large post-marketing studies, but a psychiatric history still warrants closer monitoring.

Bupropion

An atypical antidepressant that reduces craving by an incompletely understood dopaminergic and noradrenergic mechanism. It is an alternative where varenicline is unsuitable, but lowers the seizure threshold and is contraindicated in epilepsy, eating disorders and during acute alcohol or benzodiazepine withdrawal.

E-cigarettes

NICE and the Office for Health Improvement and Disparities support e-cigarettes as a quit aid for adult smokers who want to use them, with evidence that they are substantially less harmful than combustible tobacco and at least as effective as NRT for quitting.⁵ They are not licensed as a medicine, so cannot be prescribed on the NHS, but stop smoking services can advise on their use and supply devices in some local schemes. Counsel that vaping is not risk-free and is not recommended for people who have never smoked, particularly children and young people.

Behavioural support

NHS Stop Smoking Services combine pharmacotherapy with structured behavioural support - typically weekly contact around the quit date - and achieve substantially higher success rates than pharmacotherapy or willpower alone. Core behavioural elements include:

• Setting a quit date, usually within 2-4 weeks, giving time to prepare and start pharmacotherapy without losing motivation
• Identifying triggers (situations, moods, other smokers) and planning specific coping strategies for each
• Carbon monoxide monitoring at follow-up, which gives immediate, objective, motivating feedback on abstinence
• Planning for high-risk moments, particularly the first 2 weeks, when most relapse occurs
• Removing cues: disposing of cigarettes, lighters and ashtrays before the quit date

Special populations

Pregnancy

Smoking in pregnancy is associated with miscarriage, low birth weight, preterm birth and stillbirth. Behavioural support is first line; NRT can be used if this alone is insufficient, ideally intermittent (gum, lozenge) rather than patch to avoid continuous fetal nicotine exposure, though patches are used if intermittent forms fail. Varenicline and bupropion are not recommended in pregnancy or breastfeeding. Carbon monoxide screening is offered at booking as a routine part of antenatal care.

Mental illness

Smoking prevalence is markedly higher in people with severe mental illness, and quitting is often assumed - wrongly - to be too destabilising to attempt. In fact combined pharmacotherapy and behavioural support is effective and does not worsen psychiatric symptoms; smoking cessation is associated with improved mood and reduced anxiety over time. Closer monitoring is still sensible, and stopping smoking increases plasma levels of some drugs metabolised via CYP1A2 (for example clozapine, olanzapine), so doses may need adjusting after a quit.

Cardiovascular and respiratory disease

Smoking cessation is one of the highest-yield interventions in ischaemic heart disease, COPD and peripheral arterial disease - more effective at reducing further events than most drug therapy. NRT does not meaningfully increase cardiovascular risk compared with continued smoking and should not be withheld after a recent cardiac event.

Practical prescribing and follow-up

Pharmacotherapy works best when it is started before the quit date, dosed adequately, and continued for a full course rather than stopped as soon as the initial cravings settle - under-dosing and premature discontinuation are two of the commonest reasons a quit attempt supported by medication still fails.

Arrange follow-up at around 4 weeks after the quit date, which is the standard point at which quit outcomes are measured in NHS services, ideally with carbon monoxide validation. Reassess side effects, adequacy of the dose (persistent strong cravings often mean the NRT dose is too low rather than that NRT 'does not work' for that patient), and any emerging triggers, adjusting rather than abandoning the plan.

Relapse and re-attempt

Most successful long-term quitters have made several unsuccessful attempts before succeeding - relapse is a normal part of the process, not evidence that quitting is impossible for that patient. Framing a lapse as useful information (what triggered it, what would help next time) rather than personal failure preserves motivation for a further attempt.

Complications of continued smoking

• Cardiovascular: ischaemic heart disease, stroke, peripheral arterial disease, abdominal aortic aneurysm
• Respiratory: COPD, increased risk and severity of respiratory infection, worsened asthma control
• Malignancy: lung, head and neck, bladder, pancreatic and cervical cancer among others
• Reproductive: reduced fertility, miscarriage, preterm birth, low birth weight
• Surgical: impaired wound healing and higher rates of surgical site infection and anaesthetic complications

Red flags

Prognosis

The health benefits of quitting begin within hours and accumulate for years: carbon monoxide and nicotine clear within 24-48 hours, cardiovascular risk falls substantially within 1 year, and by 10-15 years post-cessation excess risk of most smoking-related disease approaches that of a lifelong non-smoker, though some risk (particularly lung cancer) never returns fully to baseline.

Quitting before age 40 avoids most of the excess lifetime mortality risk associated with smoking, which is why cessation advice should be offered with urgency regardless of a patient's age or how long they have smoked.