Previous changes

May 2025 — minor update. QOF indicators updated in line with the NHS England Quality and Outcomes Framework guidance for 2025/26.

April 2025 — minor update. The recommendations on vaping in pregnancy have been clarified and detail added to the basis for information section. 

February 2025 — minor update. Added information on the potential use of cytisinicline as a stop smoking intervention to align with the updated NICE guideline NG209 Tobacco: preventing uptake, promoting quitting and treating dependence

August 2024 — minor update. Alopecia added as an adverse effect of bupropion, in line with the manufacturer's updated SPC.

May 2024 — minor update. Removed the information regarding the lack of provision of e-cigarettes from smoking cessation clinics. 

March 2024 — minor update. Added information about the risk of panic attacks with bupropion in line with an update of the manufacturer's SPC.

September 2023 — minor update. Change of wording in pregnancy follow-up to align with wording elsewhere in the topic regarding definition of non-smoker.

April 2023 — reviewed. A literature search was conducted in March to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. Minor changes to prescribing information in line with updated manufacturer guidance, and the British National Formulary. The carbon monoxide breath test result that should be used to identify women who require referral to NHS Stop Smoking Services has been changed from 7 ppm and above to 4 ppm and above.

March 2023 — minor update. Added information about the risk of bupropion unmasking Brugada syndrome in line with an update of the manufacturer's SPC. Caution is advised in at risk patients. 

December 2022 — minor update. Updated the quality standards in line with the publication of NICE, 2022 QS207 Tobacco: treating dependence. 

August 2022 — minor update. Added information relating to the Allen Carr Easyway seminar programme. Added information about the lack of availability of varenicline until further notice. 

September 2021 — minor update. History of epilepsy added to the cautions section for nicotine replacement therapy in line with updated manufacturer's SPC.

November 2020 — minor update. Risk of serotonin syndrome if selective serotonin reuptake inhibitors (SSRIs) and serotonin noradrenaline reuptake inhibitors are taken concurrently with bupropion has been added in line with updated manufacturer's SPC.

March 2018 — reviewed. A literature search was conducted in February to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. There have been minor structural changes to the topic and information on Very Brief Advice on smoking cessation for adults and pregnant women, and recommendations regarding e-cigarettes have been added.

September 2017 — QOF indicators were updated as per the 2017/18 QOF recommendations. 

December 2016 — minor update. Information on a possible drug interaction with bupropion and digoxin has been added to the drug interactions section of this topic, in line with the manufacturer's Summary of Product Characteristics ABPI, 2016.

August 2014 — minor update to the text to reflect an update to the Summary of Product Characteristics for NiQuitin® patches that the dose should be reduced or patches discontinued if there is a significant increase in cardiovascular or other effects attributable to nicotine.

April 2014 — minor update to the text to reflect an update to the Summary of Product Characteristics for NiQuitin® that seizures have been reported (frequency unknown).

February 2014 — minor update to the prescribing information for nicotine gum to reflect an update in the manufacturer's Summary of Product Characteristics about cardiovascular risks.

January 2014 — minor update. Formatting errors corrected.

June 2013 — minor update. The 2013 QOF options for local implementation have been added to this topic.

October 2012 — reviewed. A literature search was conducted in September 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic. Recommendations have been amended as a result of the extended indications for nicotine replacement therapy (NRT). In addition to being used to relieve and/or prevent craving and nicotine withdrawal symptoms in smokers wishing to quit abruptly, NRT can also be used to reduce the amount smoked prior to quitting, to assist smokers who want (or need) to abstain from smoking temporarily (for example during enforced abstinence [such as on a long flight or in hospital] or in the company of non-smokers), and as a safer alternative to smoking.

November 2016 — minor update. The basis for recommendation for adverse effects of varenicline has been updated with information from a randomised controlled trial, which found that varenicline did not significantly increase the risk of neuropsychiatric events in people with or without a history of psychiatric disorder, compared with nicotine patches or placebo. 

April 2012 — minor update. The 2012/2013 QOF indicators have been added to this topic. 

June 2011 — minor update. The 2011/2012 QOF indicators have been added to this topic. 

March 2011 — topic structure revised to ensure consistency across CKS topics — no changes to clinical recommendations have been made.

March 2011 — minor update. Missing QOF indicators added. 

October 2009 — minor update to include new information from the Medicines and Healthcare products Regulatory Agency (MHRA) regarding varenicline and suicidal thoughts and behaviour, and regarding drug interactions with smoking cessation. 

May 2009 — updated to include the indicators related to smoking cessation in the Quality and Outcomes Framework (QOF) of the General Medical Services (GMS) contract in the Goals and outcome measures section. 

February 2009 — minor typographical correction. 

August 2008 — minor update to include updated advice from the Medicines and Healthcare products Regulatory Agency (MHRA) regarding varenicline and suicidal thoughts and behaviour. 

November 2007 to April 2008 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence.

March 2008 — Correction to the title of one varenicline prescription. Change in text to read 500 mcg instead of 500 mg.

July 2007 — Minor update to text to include new advice from the NICE technology appraisal guidance on the use of varenicline for smoking cessation.

July 2007 — Minor update to text, incorporating MHRA (2005) advice, which states that nicotine replacement therapies may be used in combination.

July to September 2005 — reviewed. Validated in December 2005 and issued in February 2006.

May 2002 — reviewed. Validated in June 2002 and issued in July 2002.

April 2002 — updated to include Guidance on the use of nicotine replacement therapy and bupropion for smoking cessation, Technology Appraisal Guidance No. 39, issued by the National Institute for Health and Care Excellence.

April 2001 — updated to include the amendment of Schedule 10 to the NHS (General Medical Services) Regulations 1992 permitting the full range of nicotine replacement products to be prescribed on NHS prescriptions.

October 2000 — updated to include information and prescriptions for bupropion.

November 1998 — written. Validated in March 1999 and issued in May 1999.

New evidence

Evidence-based guidelines

• NICE guideline NG209 Tobacco: preventing uptake, promoting quitting and treating dependence NICE, 2025
• WHO (2025) WHO report on the global tobacco epidemic, 2025: warning about the dangers of tobacco. World Health Organisation. https://www.who.int [Free Full-text]

HTAs (Health Technology Assessments)

No new HTAs since 1 April 2023.

Economic appraisals

No new economic appraisals since 1 April 2023.

Systematic reviews and meta-analyses

• Theodoulou, A., Chepkin, S.C., Ye, W., et al. (2023) Different doses, durations and modes of delivery of nicotine replacement therapy for smoking cessation. Cochrane Library https://www.cochranelibrary.com/ [Free Full-text]
• Livingstone-Banks, J., Fanshawe, T.R., Thomas, K.H., et al. (2023) Nicotine receptor partial agonists for smoking cessation. Cochrane Library https://www.cochranelibrary.com/ [Free Full-text]
• RCP (2024) E-cigarettes and harm reduction: An evidence review. Royal College of Physicians. [Free Full-text]
• DBT (2024) Cytisine for smoking cessation. BMJ. https://dtb.bmj.com/ [Abstract]
• Khalifeh, M., Ginex, P., Boffetta, P. (2024) Reduction of head and neck cancer risk following smoking cessation: a systematic review and meta-analysis. BMJ Open. https://journals.bmj.com/home [Free Full-text]

Primary evidence

• Auer, R., Schoeni, A., Humair, J., et al. (2024) Electronic Nicotine-Delivery Systems for Smoking Cessation. NEJM. [Abstract]
• Cinciripini, P. M., Green, C. E., Shete, S., et al. (2024). Smoking Cessation After Initial Treatment Failure With Varenicline or Nicotine Replacement: A Randomized Clinical Trial. JAMA. [Abstract]
• Hopkinson, N. S., Vrinten, C., Parnham, J. C., et al. (2024). Association of time spent on social media with youth cigarette smoking and e-cigarette use in the UK: a national longitudinal study. Thorax. [Abstract]
• Tuisku, A., Rahkola, M., Nieminen, P. (2024). Electronic Cigarettes vs Varenicline for Smoking Cessation in Adults: A Randomized Clinical Trial. JAMA Internal Medicine. [Abstract]
• NHS Digital (2024) Smoking, drinking and drug use among young people in England. NHS Digital. [Abstract]
• Cinciripini, P.M., Kypriotakis, G., Blalock, J.A., et al. Survival Outcomes of an Early Intervention Smoking Cessation Treatment After a Cancer Diagnosis. JAMA Oncology. https://jamanetwork.com [Free Full-text]
• Rigotti, N. A., Benowitz, N. L., Prochaska, J., Leischow, S., Nides, M., Blumenstein, B., ... & Jacobs, C. (2023). Cytisinicline for smoking cessation: a randomized clinical trial. JAMA, 330(2), 152-160. [Abstract]
• WHO (2025) WHO global report on trends in prevalence of tobacco use 2000–2024 and projections 2025–2030. World Health Organisation https://www.who.int [Free Full-text]

New policies

No new policies since 1 April 2023.

New safety alerts

No new safety alerts since 1 April 2023.

Changes in product availability

• New product cytisine 1.5 mg tablets are indicated for Smoking cessation and reduction of nicotine cravings in smokers who are willing to stop smoking. See more here.

How should I identify smokers and deliver brief advice on smoking cessation?

• Ask people at every opportunity if they smoke, and advise them to stop smoking in a way that is sensitive to their needs and preferences.
• If the person smokes, deliver very brief advice (VBA).
  
  • Ask about current and past smoking behaviour. 
  • Provide verbal and written information on the risks of smoking and the benefits of stopping smoking.
  • Advise on the options for quitting smoking including behavioural support, medication, and e-cigarettes. The most successful approach to stopping smoking is a combination of smoking cessation therapies with specialist support.
  • Refer the person to their local stop smoking service (if they wish to stop smoking).
• For information on how to assess people who wish to stop smoking (and do not wish to attend a stop smoking service), see the section on Assessment. 
• For people who do not wish to stop smoking:
  • Advise them to think about doing so, and encourage them to return if they decide they would like to stop smoking in the future.
  • Ask them about adopting a harm reduction approach.
  • Record the person's smoking status and at every opportunity ask them about it again in a way that is sensitive to their preferences and needs. 

How should I assess a person who smokes?

• Assess the person's dependence on nicotine to help predict the severity of withdrawal symptoms they may experience.  
• Ask about the two most important indicators of dependence and score the person's nicotine dependence depending on their answers: 
  • How many cigarettes they smoke per day — 0 points for 10 or less, 1 point for 11-20, 2 points for 21-30, and 3 points for 31 or more.
  • How soon after waking they smoke their first cigarette — 3 points for within 5 minutes, 2 points for 6-30 minutes, 1 point for 31-60 minutes, and 0 points for after 60 minutes.
  • The higher the score, the greater the level of nicotine dependence.
• Ask about previous quit attempts:
  • How successful they were and if they tried any treatment.
  • Whether they used any support, for example, through a smoking cessation service.
  • The person's experiences of withdrawal symptoms and cravings.
• Ask about the person's medical history, and identify people in specific groups that may be at high risk of tobacco-related harm, including:
  • People with mental health problems.
  • People who misuse substances. 
  • People with a smoking-related illness (for example lung cancer).
  • People with medical conditions exacerbated by smoking:
    • Asthma.
    • Cardiovascular disease.
    • Chronic obstructive pulmonary disease.
    • Type one diabetes mellitus.
  • Women who are pregnant.
• Ask about current medication that may be affected by stopping smoking or starting smoking cessation treatment.
  • For more information see the section on Drugs affected by stopping smoking.
• If available, measure the amount of carbon monoxide (CO) in expired air to provide a baseline.
  • A person with a CO reading of 10 ppm or less is classed as a non-smoker. 

How do I manage adults over 18 who want to stop smoking?

• Advise all people who smoke to stop.
• Offer referral to a local smoking cessation service, or inform the person how to access local NHS stop smoking services. 
  • People who are more dependent on nicotine should be especially encouraged to attend a smoking cessation service, as they are likely to need higher levels of support, a higher dose of medication, and several attempts at quitting.
• Inform the person that NHS stop smoking services offer evidence-based interventions, including:
  • Behavioural support (individual and group, such as Allen Carr's Easyway seminars).
  • Advice about stop smoking treatments (nicotine replacement therapy [NRT], cytisinicline, varenicline, and bupropion) and e-cigarettes.
  • Can supply or arrange for a prescription, or give a voucher for, smoking cessation medicines.
    • Note: Local or national incentives to reduce harm from smoking may mean that additional interventions are available through NHS stop smoking services.
• Explain that a combination of drug treatment and behavioural support has been shown to improve smoking cessation rates and may be the best option.
• For people who are unwilling or unable to be referred: 
  • Inform the person about sources of information and support for smoking cessation.
  • Offer practical advice, encouragement, and support to help them stop smoking.
  • Offer drug treatment to reduce withdrawal symptoms.
  • Discuss the risks and benefits of drug treatment.
  • Provide appropriate follow up. 

What practical advice can I give adults over 18 years to help them to stop smoking?

• Advise the person: 
  • That the best way to stop smoking is to use a combination of behavioural support and medication. 
  • To set a quit date and commit to it.
  • That the first few days after quitting are often the most difficult and they may experience withdrawal symptoms, but this usually starts to improve after the third or fourth day.
    • Advise the person to concentrate on the benefits of stopping smoking during this period.
• Explain that cravings are powerful urges to smoke, often set off by:
  • Stress.
  • Seeing other people smoking.
  • Becoming intoxicated.
• Inform the person that licenced stop smoking medicines help with withdrawal symptoms and cravings:
  • Discuss stop smoking medicines. 
• Discuss ways the person can manage cravings, for example, distraction strategies such as:
  • Short bouts of moderate exercise, for example, brisk walking.
  • Talking to a friend or family member.
  • Keeping busy, for example, looking at the Smokefree app (www.nhs.uk), playing a game on a mobile phone, or drinking a glass of water.
  • Changing the environment, for example, going into another room or going outside.
• Explain the importance of abrupt cessation and the ‘not-a-puff’ rule:
  • This is where the person resolves to stop smoking altogether on or before a date — the target stop date. From this date, the person should not have a single puff on a cigarette.
  • Advise that stopping smoking in one step (abrupt quitting) gives them the best chance of success.
  • Explain that a first 'lapse', such as taking a puff from a cigarette, almost always leads to the person going back to regular smoking.
• Discuss how the person can get support to quit:
  • Inform the person about sources of information and support, and give the contact details for these.
  • Consider which family members and friends can support the person.
  • If another person in the household smokes, consider stopping smoking together.
• Discuss how to avoid relapse.
  • Advise that just smoking one cigarette could lead to the person returning to regular smoking (relapse).
  • Help the person think of ways of managing stress, instead of smoking a cigarette.
  • Advise the person to avoid being around people who smoke.
    • Approximately three-quarters of people who relapse do so as they have been with other people who have been smoking.
  • Advise the person to change their routine, and to avoid situations in which they would normally smoke until they can comfortably resist the urge to smoke. For example, recommend the person drinks no alcohol (or only has minimal amounts) in the first few weeks.
  • Help the person work out ways to cope in situations in which they would normally smoke.
• Discuss any barriers to quitting the person may have, for example, stress or weight gain.
  • Give examples of how the person can deal with stress, such as breathing and relaxation techniques.
  • Explain that some, but not all, people put on weight after stopping smoking.
  • Advise that even if the person puts on weight, they can always lose it in the future, and the risks of continuing to smoke are greater than those associated with gaining a small amount of weight.
  • Give healthy lifestyle advice regarding exercise and healthy eating, including portion control www.nhs.uk.
  • Advise the person to ensure they use their stop smoking medicines correctly, to minimise withdrawal symptoms and cravings. 

Which sources of information and support should I direct adults who wish to stop smoking to?

• Inform people who wish to stop smoking how to access local NHS Stop Smoking Services:
  • In England — the free Smokefree National Helpline on 0300 123 1044 or online www.nhs.uk. This offers support via a smartphone app, email programme, text messages, and a Facebook page.
  • In Scotland — the free Smokeline on 0800 84 84 84 or online www.nhsinform.scot.
  • In Wales — the free Help Me Quit Wales Helpline on 0800 085 2219 or online www.helpmequit.wales.
  • In Northern Ireland — online https://www.stopsmokingni.info.
• Inform the person about other sources of information and support, such as:
  • NHS A-Z www.nhs.uk.
  • ASH (Action on Smoking and Health) ash.org.uk.
  • QUIT, a national charity which provides telephone support www.quit.org.uk.

What drug treatment should I prescribe to an adult to help them stop smoking?

• If the person does not wish to, or cannot, attend a stop smoking service, advise them they are more likely to stop smoking using medication and offer to prescribe nicotine replacement therapy (NRT), cytisinicline, varenicline, or bupropion.
  • Do not prescribe NRT with cytisinicline, varenicline, or bupropion.
  • Do not prescribe cytisinicline or varenicline in combination with bupropion. 
  • Do not prescribe cytisinicline, varenicline, or bupropion to people under the age of 18.
  • Do not prescribe cytisinicline to people aged 66 years or older. 
• Inform the person that NRT, cytisinicline, varenicline, and bupropion have all been shown to be effective. 
  • Explain that there is no evidence that one form of NRT is more effective than another.
• The choice of treatment should be made on an individual basis, taking into account:
  • The individual's previous experience with smoking cessation drugs.
  • Their preference for treatment.
  • Contraindications, cautions, possible interactions, and risk of adverse effects of the treatments.
• Prescribe sufficient NRT, cytisinicline, varenicline, or bupropion to last the person until 2 weeks after their stop date. Usually, this will be after 2 weeks of NRT, and 3-4 weeks of cytisinicline, varenicline, or bupropion.
• For people who would like to start NRT, discuss the available NRT formulations, the duration of treatment, and the possible adverse effects. Advise them:
  • That patches are applied for 16 hours (and taken off overnight) or for 24 hours.
  • That a 24-hour patch may be helpful if they smoke shortly after waking.
  • That if they are using combination NRT, a nicotine patch will help with 'background' cravings, and a faster-acting product (such as lozenge or mouth spray) will help with 'breakthrough' urges to smoke.
  • Not to have acidic drinks, such as coffee or fruit juice in the 15 minutes before using oral NRT. 
  • To start NRT on the quit date.
  • For more information, see the prescribing information section for NRT.
• For people who would like to start cytisinicline — discuss the dose, duration of treatment, and the possible adverse effects.
  • Explain that it needs to be started 5 days before the quit date.
  • For more information, see the prescribing information section for cytisinicline. 
• For people who would like to start varenicline — discuss the dose, duration of treatment, and the possible adverse effects.
  • Explain that it needs to be started 7-14 days before the quit date.
  • For more information, see the prescribing information section for varenicline.
• For people who would like to start bupropion — discuss the dose, duration of treatment, and the possible adverse effects.
  • Explain that it needs to be started 7-14 days before the quit date.
  • For more information, see the prescribing information section for bupropion.
• For people who wish to try to stop smoking using e-cigarettes, recommend they use a licensed stop smoking medicine instead.
  • Explain that the combination of behavioural support from the local stop smoking service and licensed stop smoking medication is the most effective way of stopping smoking. There is less evidence available on the safety and effectiveness of e-cigarettes for stopping smoking. 
• If the person prefers to use e-cigarettes, inform them that:
  
  • Some people find e-cigarettes help them stop smoking.
  • They can still receive support and advice from a smoking cessation clinic, and recommend that they do this to give themselves the best chance of quitting.
• Consider suggesting e-cigarettes as a way of stopping smoking to people who have tried unsuccessfully to stop smoking using other methods, using clinical judgement, and on an individual basis. 

How do I follow up adults who have started treatment to stop smoking?

• Initially, follow the person up after:
  • 2 weeks of nicotine replacement therapy (NRT).
  • 3-4 weeks of treatment with varenicline or bupropion.
• Measure the carbon monoxide (CO) level 4 weeks after quitting.
  • A CO level of 10 ppm or less suggests the person is a non-smoker.
• Thereafter, use professional judgement about the number, timing, and frequency of appointments offered.
• Ask the person:
  • How the quit attempt is going.
  • Whether they are abstinent from smoking.
  • About adverse effects from treatment — if the person is experiencing significant adverse effects, consider reducing the dose of the current treatment, or trying an alternative treatment (or formulation in the case of NRT). 
    • For people taking varenicline, consider reducing the dose to 500 micrograms twice daily.
    • People taking varenicline or bupropion should stop treatment if they develop agitation, depressed mood, or suicidal thoughts.
  • Withdrawal symptoms — if the person is having significant nicotine withdrawal symptoms, consider one of the following options:
    • Increase the dose of the treatment (up to the maximum licensed dose that is tolerated).
    • For people using NRT patches, combine with a rapid-release NRT product to relieve breakthrough symptoms, or if they experience withdrawal symptoms first thing in the morning, consider using a 24-hour patch.
• If the person has smoked cigarettes, but has not fully relapsed (returned to regular smoking), give encouragement to continue to try to stop smoking. Advise the person to:
  • Commit to the 'not a puff' rule, and stay positive.
  • Consider why they want to quit, and use this as motivation. 
  • Telephone the free NHS Smokefree helpline (0300 123 1014) to speak to a trained adviser if they feel tempted to restart smoking. 
  • Avoid places where people are smoking.
  • If they experience cravings to smoke, wait 2 hours, and then decide if they are going to do so.
  • Continue to take use NRT, varenicline, or bupropion, unless they have started smoking regularly.
• If the person has gone back to smoking regularly, advise them to:
  • Stay positive, and set another quit date.
  • Reassure them that most smokers make several quit attempts before they succeed.
  • Review why they relapsed, and to think how they could avoid smoking in a similar situation in the future.
  • Contact the local stop smoking service. 
• If the person wants to quit, but cannot or does not want to stop in one step, ask them if they would like to try a harm reduction approach.

How do I manage pregnant or breastfeeding woman who want to stop smoking?

• Offer referral to a local smoking cessation service, or inform the woman how to access local NHS stop smoking services. 
  • People who are more dependent on nicotine should be especially encouraged to attend a smoking cessation service, as they are likely to need higher levels of support, a higher dose of medication, and several attempts at quitting.
  • Give the woman the NHS Smokefree Helpline number (0300 123 1044), and advise her to phone if she would like to talk to someone while she is awaiting referral.
  • Also refer pregnant women who have quit in the past 2 weeks and those with a carbon monoxide (CO) reading of 4 ppm or more. 
    • Light or infrequent smokers should also be referred, even if they register a lower reading – for example, 3 ppm.
• Inform the woman that NHS stop smoking services offer evidence-based interventions, including:
  • Behavioural support (individual and group).
  • Advice about stop smoking treatments.
  • Can supply, arrange for a prescription, or give a voucher for stop smoking medicines.
    • Note: Local or national incentives to reduce harm from smoking may mean that additional interventions are available through NHS Stop Smoking services.
• Explain that a combination of drug treatment and behavioural support has been shown to improve smoking cessation rates and may be the best option. 
• For women who are unwilling or unable to be referred: 
  • Inform them about sources of information and support.
  • Give the woman information about the risks of smoking to the unborn child, the risks of exposure to second-hand smoke for her and her baby, and the benefits of stopping smoking. 
    • Explain that the only way of making sure that the unborn baby is not at risk of harm from smoking is to stop completely, rather than reduce the number of cigarettes smoked.
  • Offer practical advice, encouragement, and support to help them stop smoking.
  • Consider offering nicotine replacement therapy (NRT) to reduce withdrawal symptoms.
  • Provide appropriate follow up throughout pregnancy and after the baby is born.
• Ask whether the woman's partner or anyone in the household smokes.
  • If they do, recommend they contact the NHS Stop Smoking Services.
  • Give clear advice about the dangers of second-hand smoke to the pregnant woman and the baby before and after birth. For further information, see the section on the harms caused by smoking.   
  • Advise them not to smoke around the pregnant woman, mother, or baby, and that they should not smoke in the house or car.

What practical advice can I give pregnant or breastfeeding women to help them stop smoking?

• Provide verbal and written information on:
  • The risks of smoking in pregnancy and the hazards of exposure to second-hand smoke for both mother and baby. For further information, see the section on the harms caused by smoking.
  • The health benefits of stopping smoking to both mother and baby.
• Offer pregnant and breastfeeding women who smoke referral to an evidence-based smoking cessation service.
  • Advise that the best way of stopping is with behavioural support through the local stop smoking service. 
  • Explain the service will also give information on NRT. This information can help the woman to decide whether to use this to stop smoking. 
  • Advise that there is a service locally that is effective, and that other women have found it useful. 
  • Give her the NHS smokefree Helpline number (0300 123 1044) and inform her that she can receive telephone support. Direct her to the NHS Smokefree and Start4life websites. For further information, see the section on sources of information and support.
• If the woman does not wish to be referred to a smoking cessation service:
  • Inform her about sources of information and support for smoking cessation.
  • Offer practical advice, encouragement, and support to help her stop smoking.
  • Discuss the risks and benefits of NRT. 
• Ask if her partner or anyone in the household smokes. 
  • If they do, recommend they contact the NHS Stop Smoking Services. For further information, see sources of information and support.  
  • Give clear advice about the dangers of second-hand smoke to the pregnant woman and the baby before and after birth. For further information, see the section on the harms caused by smoking. 
  • Advise them not to smoke around the pregnant woman, mother, or baby, and that they should not smoke in the house or car. 
• Ask if she has any concerns about stopping smoking, and discuss these with her.
• Discuss why the woman wants to quit and the benefits of doing so.
  • Advise her to write a list of these. 
  • Advise her to think of the above reasons during difficult times in her quit attempt to help her. 
• Explain that:
  • Many people who smoke keep smoking because they are dependent on nicotine, which is quickly sent to the brain each time they inhale cigarette smoke, rather than out of choice.  
  • Explain that most of the pleasure of smoking comes from relieving the symptoms of nicotine withdrawal.
• Describe withdrawal and recovery symptoms, including cravings. 
  • Explain that once a person stops smoking, their body begins a recovery process.
  • During this time the person may feel restless, irritable, low in mood, frustrated, tired, have difficulty sleeping or concentrating, and have an increased appetite.
• Advise that the first few days after quitting are often the most difficult, and that this usually starts to improve after the third or fourth day.
  • Advise the woman to concentrate on the benefits of stopping smoking during this period.  
• Explain that cravings are powerful urges to smoke, often set off by:
  • Stress
  • Seeing other people smoking. 
• Inform the woman that NRT can help with withdrawal symptoms and cravings.
• Discuss ways the woman can manage cravings, for example, distraction strategies such as:
  • Short bouts of moderate exercise, for example, brisk walking. 
  • Talking to a friend or family member.
  • Keeping busy, for example, looking at the Smokefree app (www.nhs.uk), playing a game on a mobile phone, or drinking a glass of water.
  • Changing the environment, for example, going into another room or going outside.
• Explain the importance of abrupt cessation and the ‘not-a-puff’ rule.
  • This is where the person resolves to stop smoking altogether on or before a date, the target stop date. From this date, the person should not have a single puff on a cigarette.
  • Advise that stopping smoking in one step, 'abrupt quitting', gives the person the best chance of successfully stopping smoking. 
  • Explain that a first 'lapse', such as taking a puff from a cigarette, almost always leads to the person going back to regular smoking. 
• Discuss how the woman can get support to quit:
  • Inform the woman about sources of information and support and give the contact details for these.
  • Consider which family members and friends can support the woman.  
  • If another person in the household smokes, consider stopping smoking together. 
• Set a quit date and commit to this.
• Advise the woman to be positive and believe that she will succeed. 
• Discuss how to avoid relapse.
  • Help the woman think of ways of managing stress, instead of smoking a cigarette. 
  • Advise the woman to avoid being around people who smoke. Approximately 3/4 of people who relapse do so as they have been with other people who have been smoking.
  • Advise the woman to change her routine, and to avoid situations in which she would normally smoke, until she can comfortably resist the urge to smoke.
  • Help the woman work out ways to cope in situations in which she would normally smoke.
• Discuss any barriers to quitting the woman may have, for example, stress.
  • Give examples of how the woman can deal with stress, such as breathing and relaxation techniques.

Which sources of information and support should I direct pregnant or breastfeeding women who wish to stop smoking to?

• Inform pregnant and breastfeeding women who smoke how to access local NHS Stop Smoking Services:
  • In England: call the free Smokefree National Helpline on 0300 123 1044 or online www.nhs.uk. This offers support via a smartphone app, email programme, text messages, and Facebook page.
  • In Scotland: call the free Smokeline on 0800 84 84 84 or online www.nhsinform.scot.
  • In Wales: call the free Help Me Quit Wales Helpline on 0800 085 2219 or online www.helpmequit.wales.
  • In Northern Ireland: online www.want2stop.info.
  • Via NHS A-Z www.nhs.uk.
• Inform the woman about other sources of information and support, such as:
  • Start4life www.nhs.uk
  • The Royal College of Obstetricians and Gynaecologists information leaflet, Smoking and Pregnancy, www.rcog.org.uk.

What drug treatment should I prescribe for a woman who is pregnant or breastfeeding to help her stop smoking?

• Preferably, women who are pregnant should stop smoking abruptly without using medication, such as nicotine replacement therapy (NRT), and they should be referred to the local smoking cessation service for behavioural support. 
• If the woman does not wish to be referred to the local smoking cessation service:
  • Consider offering to prescribe NRT— NRT can be considered in women who wish to use it and who have had a previous failed smoking cessation attempt without medication. 
  • Do not offer to prescribe varenicline or bupropion to pregnant or breastfeeding women.
• Discuss the risks and benefits of NRT.
• Inform the woman that NRT has been shown to be safe in pregnancy, may help aid smoking cessation in pregnancy, and that combination NRT (a patch plus a short-acting preparation) is considered the most effective treatment option.
  • Explain that there is no evidence that one form of NRT is more effective than another.
• The choice of NRT should be made on an individual basis, taking into account the woman's:
  • Previous experience with smoking cessation drugs.
  • Preferences.
  • Level of nicotine dependence.
• When prescribing NRT: 
  • Preferably prescribe intermittent dose forms (such as gum and lozenges) in preference to patches. Consider prescribing patches if the woman has significant pregnancy-related nausea and/or vomiting.
    • Advise pregnant women to remove nicotine patches prior to going to bed. 
  • Advise not to have acidic drinks, such as coffee or fruit juice, in the 15 minutes before using oral NRT. 
  • Advise breastfeeding women to use NRT immediately after feeds, where possible.  
  • Prescribe sufficient NRT to last for 2 weeks after the stop date.
  • For more information, see the prescribing information section for NRT.
• Reassure the woman that all nicotine products are licensed for use by pregnant and breastfeeding women. 
  • Explain that it is the tar and carbon monoxide in tobacco smoke that cause the most harm to the baby, and that these are not present in NRT.
  • Explain that nicotine is present in small amounts in breastmilk, however, exposure to second-hand smoke is a much greater health risk to the baby.
  • Encourage the woman to access behavioural support from the local smoking cessation clinic in order to increase her chance of successfully stopping smoking. 
• If a pregnant woman asks about vaping or e-cigarettes, explain that:
  • Vaping/electronic cigarettes are harmful to health compared to not smoking tobacco.
  • It is not known if vaping is a safe way to stop smoking tobacco in pregnancy.
  • Vapes do not contain some of the most toxic chemicals found in tobacco cigarettes and do appear to be less harmful to lung health in non-pregnant people for those who switch from smoking tobacco to vapes.
  • However, vaping is not regulated for smoking cessation and they contain chemicals which are not present in tobacco. The impact of these chemicals on the fetus is not known. 
  • Recommend the use of NRT rather than e-cigarettes. 
• If the woman has already chosen to use e-cigarettes to stop smoking or reduce the number of cigarettes smoked.
  • Accept her decision. 
  • Provide encouragement to reduce reliance on vaping or smoking over time.
  • Strongly caution against continuing to smoke tobacco whilst using vapes.  
  • Advise her that she can receive support from her smoking cessation service and offer referral.

How do I follow up pregnant or breastfeeding women who wants to stop smoking?

• For women stopping smoking without NRT, review after 1 week and assess their quit attempt.
  • For those remaining smoke-free and managing well, offer further encouragement. Review weekly for the first month, then monthly thereafter.
  • For those who continue to smoke or have significant nicotine withdrawal symptoms, give advice and offer NRT. For further information, see the section on Drug treatment for pregnant or breastfeeding women.
• For women stopping smoking completely with NRT, review 1-2 weeks after the quit date, ask. 
  • How the quit attempt is going.
  • Whether they are abstinent from smoking.
  • About adverse effects from treatment — if the person is experiencing significant adverse effects, consider reducing the NRT dose or trying an alternative formulation.
  • About withdrawal symptoms — if the person is having significant nicotine withdrawal symptoms, consider increasing the dose of the treatment (up to the maximum licensed dose that is tolerated).
• For women remaining smoke-free and managing well, review again one month after their quit date, and then monthly during pregnancy and after the baby has been born.
• Measure CO level 4 weeks after quitting.
  • In pregnancy, a CO level of 4 ppm or lower suggests the person is a non-smoker.
• If the woman has smoked cigarettes, but has not fully relapsed (returned to regular smoking), advise her to:
  • Commit to the 'not a puff' rule, and stay positive.
  • Consider why she wants to quit and use this as motivation. 
  • Telephone the free NHS Smokefree helpline (0300 123 1014) to speak to a trained adviser if she feels tempted to restart smoking. 
  • Avoid places where people are smoking.
  • If she has a craving to smoke, to wait 2 hours, and then decide if she is going to do so.
  • Continue to use NRT unless she has started smoking regularly.
• If the woman has gone back to smoking regularly, advise her to:
  • Stay positive and set another quit date.
  • Reassure her that most people make several quit attempts before they succeed. 
  • Review why she relapsed, and to think how she could avoid smoking in a similar situation in the future
  • Contact the local stop smoking service.
• If a pregnant woman has stopped smoking tobacco and is using e-cigarettes instead, encourage her to continue to abstain from tobacco, even if this means she will continue using e-cigarettes. 

How do I manage young people aged from 12-17 who want to stop smoking?

• Advise all young people who smoke to stop.
• Offer referral to a local smoking cessation service, or inform them how to access local NHS Stop Smoking Services. 
  • People who are more dependent on nicotine should be especially encouraged to attend a smoking cessation service, as they are likely to need higher levels of support, a higher dose of medication, and several attempts at quitting.
  • Give them the NHS Smokefree Helpline number (0300 123 1044), and advise them to phone if they would like to talk to someone while awaiting referral.
• Inform them that NHS Stop Smoking services offer evidence-based interventions, including:
  • Behavioural support (individual and group).
  • Advice about nicotine replacement therapy (NRT). 
  • Can supply, arrange for a prescription, or give a voucher for stop smoking medicines.
    • Note: Local or national incentives to reduce harm from smoking may mean that additional interventions are available through NHS Stop Smoking services.
• Explain that a combination of drug treatment and behavioural support has been shown to improve smoking cessation rates and may be the best option.
• For people who are unwilling or unable to be referred:
  • Inform the person about sources of information and support for smoking cessation.
  • Offer practical advice, encouragement, and support to help them stop smoking.
  • Discuss the risks and benefits of NRT.
  • Use professional judgement when deciding whether to offer NRT to young people.  
    • Do not prescribe varenicline or bupropion to people aged under 18 years.
  • If the person is going to use NRT, explain they are more likely to stop smoking if they also use behavioural support from the stop smoking service, than NRT alone. Encourage them to take up referral to the local smoking cessation service. 
  • Follow up the young person appropriately.

What practical advice can I give people aged 12-17 years to help them to stop smoking?

• For information on advice to give young people aged over 12 years who want to stop smoking, see the section on advice in the Scenario: Adults.

What drug treatment should I prescribe to young people aged 12-17 years to help them stop smoking?

• If the young person does not wish to be referred to the local smoking cessation service:
  • Offer to prescribe nicotine replacement therapy (NRT) — do not prescribe varenicline or bupropion to people aged under 18 years.
• Inform them that NRT has been shown to be effective, and that combination NRT (a patch plus a short-acting preparation) is the most effective treatment.
  • Explain that there is no evidence that one form of NRT is more effective than another.
  • Discuss the risks and benefits of NRT.
  • Elicit and address any concerns the person may have about NRT. 
• Discuss the available NRT formulations, the duration of treatment, and the possible adverse effects. The choice of NRT formulation should be made on an individual basis, taking into account:
  • Previous experience with smoking cessation drugs.
  • Preferences.
  • Level of nicotine dependence.
• Advise them:
  • That patches are applied for 16 hours (and taken off overnight) or for 24 hours.
  • That a 24-hour patch may be helpful if they smoke shortly after waking.
  • That if they are using combination NRT, a nicotine patch will help with 'background' cravings and a faster-acting product (such as lozenge or mouth spray) will help with 'breakthrough' urges to smoke.
  • Not to have acidic drinks, such as coffee or fruit juice, in the 15 minutes before using oral NRT. 
  • To start NRT on the quit date.
  • That stopping smoking in one stop ('abrupt quitting') gives the best chance of a person successfully stopping smoking. 
  • For more information, see the prescribing information section for NRT.
• Prescribe sufficient NRT to last for 2 weeks after the stop date.
• If the young person asks about using e-cigarettes, explain that e-cigarettes cannot be sold to under-18s, and it is illegal for an adult to buy e-cigarettes for someone under 18.

How should I follow up young people aged 12-17 years who have started treatment to stop smoking?

• Initially, follow the person up after 2 weeks of nicotine replacement therapy (NRT).
• Measure the carbon monoxide (CO) level 4 weeks after quitting.
  • A CO level of 10 ppm or less suggests the person is a non-smoker.
• Thereafter, use professional judgement about the number, timing, and frequency of appointments offered.
• Ask the person:
  • How the quit attempt is going.
  • Whether they are abstinent from smoking.
  • About adverse effects from treatment — if the person is experiencing significant adverse effects, consider reducing the dose or trying an alternative formulation of NRT.
  • Withdrawal symptoms — if the person is having significant nicotine withdrawal symptoms, consider one of the following options:
    • Increase the dose of the treatment (up to the maximum licensed dose that is tolerated).
    • For people using NRT patches, combine with a rapid-release NRT product to relieve breakthrough symptoms, or if they experience withdrawal symptoms first thing in the morning, consider using a 24-hour patch.
• If the young person has smoked cigarettes, but has not fully relapsed (returned to regular smoking), give encouragement to continue to try to stop smoking. Advise the person to:
  • Commit to the 'not a puff' rule and stay positive.
  • Consider why they want to quit and use this as motivation. 
  • Telephone the free NHS Smokefree helpline (0300 123 1014) to speak to a trained adviser if they feel tempted to restart smoking. 
  • Avoid places where people are smoking.
  • If they experience cravings to smoke, wait 2 hours, and then decide if they are going to do so.
  • Continue to take use NRT unless they have started smoking regularly.
• If the person has gone back to smoking regularly, advise them to:
  • Stay positive and set another quit date.
  • Reassure them that most smokers make several quit attempts before they succeed.
  • Review why they relapsed and to think how they could avoid smoking in a similar situation in the future.
  • Contact the local stop smoking service. 
• If the person wants to quit, but cannot or does not want to stop in one step, ask them if they would like to try a harm reduction approach.

How do I manage an adult who is not ready to stop smoking?

• For people who are unwilling or not ready to stop smoking: 
  • Ensure they understand the health risks associated with smoking.
  • Encourage them to seek help to quit smoking completely in the future.
  • Offer a harm-reduction approach to smoking.
    • Stopping smoking, but continuing to use nicotine replacement therapy (NRT). 
    • Cutting down before stopping smoking, with or without NRT.
    • Smoking reduction, with or without NRT.
    • Temporary abstinence from smoking, with or without NRT.
    • NRT may be used as long as necessary to prevent relapse.
  • Record the fact that they smoke and at every opportunity ask them about it again in a way that is sensitive to their preferences and needs.
• Advise them that:
  • It is better to use NRT and decrease how much they smoke, than to keep on smoking as they are currently. 
  • NRT preparations are a safe and effective way of cutting down on how much they smoke. 
    • Their use improves their chance of stopping smoking in the long-term and helps reduce compensatory smoking (inhaling more deeply when fewer cigarettes are smoked).
• If the person agrees to try a harm reduction approach, ask about:
  • Their reasons for smoking. 
  • Their smoking triggers.
  • Their smoking behaviour.
  • Previous attempts to quit smoking.
  • Their health and social circumstances.
• Use shared decision-making to decide which harm-reduction approach is most suitable for the person. 
• Offer referral to a smoking cessation service if more intensive support is needed or if the person prefers this.  
• For people who would like to start NRT, discuss the available formulations and the possible adverse effects. The choice of treatment should be made on an individual basis, taking into account:
  • The individual's previous experience with smoking cessation drugs.
  • Their preference for treatment.
  • Level of nicotine dependence. 
• Advise them:
  • That long-acting products, such as patches, deliver a steadier supply of nicotine, whereas fast-acting products help with cravings.
  • That patches are applied for 16 hours (and taken off overnight) or for 24 hours.
  • That a 24-hour patch may be helpful if they smoke shortly after waking.
  • Using a combination of NRT products is more effective, especially for people who are highly dependent on nicotine (for example a patch with a short acting form such as gum or lozenge). 
  • That if they are using combination NRT, a nicotine patch will help with 'background' cravings, and a faster-acting product (such as lozenge or mouth spray) will help with 'breakthrough' urges to smoke.
    • Ensure the person knows how to maintain a nicotine dose high enough to control cravings and therefore avoid compensatory smoking and relapse. 
    • Advise the person to use a licensed nicotine-containing product, such as a lozenge or piece of gum instead of each cigarette, and to use this before the time they would usually smoke the cigarette (as the nicotine release from NRT products is slower than from cigarettes).
    • Advise to not have acidic drinks, such as coffee or fruit juice, in the 15 minutes before using oral NRT. 
  • For more information, see the prescribing information section for NRT.
• Prescribe NRT to the person, or advise them where they can buy it.  
• Offer support — use the information gathered when assessing the person's smoking behaviour and nicotine dependency to set goals and develop reduction strategies (such as lengthening the time between cigarettes, smoking the first cigarette later in the day, or choosing times during the day when they will not smoke).
  • Help people who are cutting down before stopping to decide upon a quit date, and how they are going to cut down in preparation for this — the quit date should usually be within 6 weeks of starting support.  
  • Help people who wish to cut down on smoking, without actually stopping, decide how they are going to do this and plan a date to have achieved their goal.
• Arrange follow up to review and support the person — use professional judgement to decide the timing and frequency of follow up appointments. 
  • If the person has successfully cut down on their smoking, explore how motivated they are to continue to smoke at that level, or to reduce this further or stop smoking. 
  • If the person has managed to abstain temporarily, encourage them to think of other times or situations in which they could abstain. 
  • Ask whether daily activities, such as climbing a flight of stairs, have become easier. Use this information to discuss the benefits of cutting down their smoking, and whether the person could reduce their smoking further or stop. 
  • If the person has not achieved their goals, support them to try again. Discuss whether to make changes to their approach, for example, trying a different licenced nicotine-containing product, or a combination of these. 
  • If available, measure exhaled CO level to monitor the person's progress and help encourage them. 
• If the person wishes to use e-cigarettes in their harm-reduction approach, recommend they use a licenced nicotine-containing product instead.
  • If a young person asks about using e-cigarettes, explain that e-cigarettes cannot be sold to under-18s, and it is illegal for an adult to buy e-cigarettes for someone under 18. Young people should use a licensed nicotine-containing product when attempting a harm reduction approach.
• If the person prefers to use e-cigarettes, inform them that:
  • E-cigarettes can be used to deliver some of the nicotine that the person would have otherwise received from regularly smoking cigarettes. 
  • Some people find e-cigarettes can help them stop smoking or cut down the number of cigarettes they smoke or with temporary abstinence.
  • E-cigarettes cannot currently be prescribed or supplied by NHS smoking cessation clinics. However, the majority of local authority smoking cessation clinics do provide them as part of a harm reduction approach. 
  • The quality and safety of e-cigarettes cannot be assured (for example the ingredients, or how much nicotine they contain). 
  • Although e-cigarettes are not risk free, using these is thought to be around 95% less harmful to health than smoking. However, the long-term risks are unknown, but these are likely to be much smaller than the risks of smoking. 
  • They can still receive support and advice from a smoking cessation clinic, and recommend that they do this to give themselves the best chance of quitting.

Available formulations of NRT

• Nicotine replacement therapy (NRT) is available in a choice of formats, including:
  • Gum — nicotine is absorbed through the buccal mucosa, with peak plasma concentrations occurring after 20–30 minutes. Available in different flavours and strengths, one piece of gum lasts for about 30 minutes. Gum is difficult to use with dentures and may damage them.
  • Inhalator — nicotine is absorbed through the buccal mucosa. When used like a cigarette, on average it delivers 1 mg in 80 puffs, and 2 mg of nicotine is released during 20 minutes of intensive use. Each 15 mg cartridge can be used for approximately eight 5-minute sessions, with each cartridge lasting for approximately 40 minutes of intense use.
  • Lozenge — nicotine is absorbed through the buccal mucosa. Available in different strengths and flavours, lozenges dissolve completely in 10–20 minutes. The lozenge should not be chewed or swallowed.
  • Nasal spray — nicotine is rapidly absorbed through the nasal mucosa, delivering peak plasma levels within 10–15 minutes.
  • Oral spray — nicotine is rapidly absorbed through the buccal mucosa, delivering peak plasma levels within 13 minutes. 
  • Sublingual tablet — nicotine is absorbed through the buccal mucosa. 
  • Transdermal patch — nicotine is absorbed through the skin. Available in 16-hour and 24-hour preparations, in a range of strengths, peak plasma levels are reached within 8–10 hours.  
    • The 24-hour preparation may be suitable for people who experience strong cravings for cigarettes on waking.
    • Some patches are translucent and may be preferred by some people as they are more discrete.
• See the section on Dose and duration of NRT for details on how to prescribe and use each product. 

[ABPI, 2021a; ABPI, 2021b; ABPI, 2021c; ABPI, 2021d; ABPI, 2021e; ABPI, 2022; ABPI, 2023a; ABPI, 2023b; BNF, 2023]

Dose and duration

• Prescribe nicotine replacement therapy (NRT) by brand name, as dosage instructions vary between brands of NRT.
  • For information on the dose, duration, and usage instructions for specific brands of NRT products, see the appropriate Summary of Product Characteristics (SPC) in the electronic Medicines Compendium.
• Smokers must use sufficient NRT in order to achieve good success rates.
  • As insufficient use is the main problem with intermittent (non-patch) formulations of NRT, some expert reviewers advise regular hourly use with topping-up as needed for all intermittent formulation products.
• The duration of treatment with NRT is 8–12 weeks (depending on which form of NRT is used and which dose is initiated), followed by a gradual reduction in dose. 
  • Use of NRT for longer than nine months should be under the direction of a healthcare professional.
• For children over the age of 12 years, treatment should be limited to 12 weeks.
• Treatment with NRT can be stopped abruptly or tapered gradually — abruptly stopping NRT does not seem to reduce its effectiveness.
• Higher doses of nicotine replacement therapy (NRT) may be more effective in people who are more highly dependent on cigarettes, and more dependent smokers may need to use NRT for longer than 3 months — if treatment is stopped too soon these people might relapse.

[Hartmann-Boyce, 2018; BNF, 2023; BNFC, 2023]

Contraindications and cautions

• Prescribe nicotine replacement therapy (NRT) with caution to people with:
  • Diabetes mellitus (users should be encouraged to monitor blood glucose closely when initiating treatment).
  • Gastrointestinal disease.
  • Phaeochromocytoma.
  • Moderate to severe hepatic impairment.
  • Severe renal impairment.
  • Uncontrolled hyperthyroidism.
  • History of epilepsy.
• Also prescribe NRT with caution to haemodynamically unstable people hospitalised with:
  • Cerebrovascular accident.
  • Myocardial infarction. 
  • Severe arrhythmias.
• Specific NRT formats should also be prescribed with caution in certain circumstances: 
  • Inhalator — people with chronic throat disease and bronchospastic disease.
  • Gum — people with dentures.
  • Nasal spray — people with asthma.

[ABPI, 2021a; ABPI, 2021b; ABPI, 2021c; ABPI, 2021d; ABPI, 2021e; ABPI, 2022; ABPI, 2023a; ABPI, 2023b; BNF, 2023]

Adverse effects

• Common adverse effects of nicotine replacement therapy (NRT) include:
  • Headaches and dizziness.
  • Nausea and vomiting.
  • Rash and urticaria.
  • Hyperhidrosis.
  • Palpitations. 
• Uncommon adverse effects of NRT include:
  • Dyspnoea.
  • Flushing and hypertension.
  • Malaise.
  • Myalgia.
  • Paraesthesia.
• Rare adverse effects of NRT include:
  • Anaphylaxis.
  • Angioedema and erythema.
  • Atrial fibrillation.
  • Gastrointestinal discomfort.
• Other common adverse effects for specific formulations include:
  • Gum — throat irritation, increased salivation, dry mouth, and jaw pain.
  • Inhalator — cough and irritation of the mouth and throat (in about 40% of people), nasal congestion, and altered taste.
  • Lozenge — irritation of the mouth and throat, jaw pain, increased salivation, and dysphagia.
  • Nasal spray — nasal irritation, running nose, epistaxis, sneezing, and watery eyes.
  • Oral spray — taste disturbance, mouth ulcers, gingival bleeding, increased salivation, dry mouth, toothache, partial loss of sensation in the throat, and eye disorders.
  • Patch:
    • Mild local reactions such as urticaria, itching, and redness at the patch application site(s). In some people the skin reaction may become more severe (blistering and burning sensation) or be more widespread.
    • Sleep disturbances; for example, vivid dreams and insomnia, have also been reported with patches. Removing the patches before bed (that is changing from a 24-hour patch to a 16-hour patch) may help.
  • Sublingual tablet — sore mouth or throat, dry mouth, burning sensation in the mouth, and rhinitis.
• Adverse effects may occur at initiation of treatment with NRT, especially in people using high-strength preparations. However, it is possible to confuse adverse effects of NRT with nicotine withdrawal symptoms (for example malaise, headache, sleep disturbance, and irritability).
• Adverse effects are generally mild and are unlikely to lead to discontinuation of treatment, but people may prefer to try an alternative formulation (for example changing from a 24-hour patch to a 16-hour patch if sleep is disturbed).

[ABPI, 2021a; ABPI, 2021b; ABPI, 2021c; ABPI, 2021d; ABPI, 2021e; ABPI, 2022; ABPI, 2023a; ABPI, 2023b; BNF, 2023]

Drug interactions

• There are no known clinically relevant drug-drug interactions with nicotine replacement therapy (NRT).
• Acidic beverages, such as coffee or fruit juice, may decrease the absorption of oral nicotine and should be avoided for 15 minutes before the use of oral NRT.

[ABPI, 2021a; ABPI, 2021b; ABPI, 2021c; ABPI, 2021d; ABPI, 2021e; ABPI, 2022; ABPI, 2023a; ABPI, 2023b; BNF, 2023]

Pregnancy and breastfeeding

Pregnancy

• Stopping smoking is the single most effective intervention for improving the health of both the pregnant smoker and her baby. NRT should only be used if smoking cessation without NRT fails.
  • Intermittent therapy is preferred, but patches may be necessary.
  • Where patches are used, these should be removed prior to going to bed.

Breastfeeding

• Small amounts of nicotine are excreted in breastmilk, however, this is less hazardous than second-hand smoke.
  • Intermittent therapy is preferred in women who are breastfeeding. 

[LactMed, 2020; RCOG, 2020; ABPI, 2021a; ABPI, 2021b; ABPI, 2021c; ABPI, 2021d; ABPI, 2021e; ABPI, 2022; ABPI, 2023a; ABPI, 2023b; BNF, 2023]

Mode of action of bupropion

• Bupropion is a relatively weak but selective dopamine and noradrenaline reuptake inhibitor. Although the exact mechanism by which it aids smoking cessation is unclear, it is presumed to work directly on the brain pathways involved in addiction and withdrawal.

[EMC, 2024]

Dose

• Bupropion should be started while the person is still smoking.
  • Advise the person to stop smoking 7–14 days after starting bupropion.
• The dose of bupropion is 150 mg once a day for 6 days, increasing to 150 mg twice a day (doses at least 8 hours apart) for a total of 7–9 weeks.
  • If no effect is seen after 7 weeks, discontinue treatment with bupropion.
• The lower dose of 150 mg once a day should be continued if the person:
  • Is elderly.
  • Has mild to moderate hepatic impairment.
  • Has renal impairment (estimated glomerular filtration [eGFR] rate less than 50 mL/min).
  • Has risk factors for seizures.
• After the course is completed discontinuation reactions are unlikely and bupropion can be stopped without tapering the dose.
  • However, if required, a tapering-off period can be considered. 

[BNF, 2023; EMC, 2024]

Contraindications and cautions

• Do not prescribe bupropion to people aged under 18 years, or people with:
  • A current seizure disorder, or a history of seizures.
  • Acute alcohol or benzodiazepine withdrawal.
  • A central nervous system (CNS) tumour.
  • A current or previous diagnosis of bulimia or anorexia nervosa.
  • A history of bipolar disorder.
  • Severe hepatic cirrhosis.
• Prescribe bupropion with caution to the elderly and to people with: 
  • A predisposition to seizures. Risk factors include:
    • Alcohol abuse.
    • A history of head trauma.
    • Diabetes.
    • Taking other drugs which lower the seizure threshold (for example antipsychotics).
    • Use of stimulants or anorectic products.
  • Hepatic impairment.
  • Renal impairment.
  • A hereditary risk of Brugada syndrome, which is a rare hereditary disease of cardiac sodium channel with specific ECG changes (ST segment elevation and T wave abnormalities in the right precordial leads). Buproprion may unmask Brugada syndrome which can lead to cardiac arrest and/or sudden death. 

[BNF, 2023; EMC, 2024]

Adverse effects

• Adverse effects of bupropion include: 
  • Metabolism and nutrition — anorexia (uncommon).
    • Rarely: blood glucose disturbances and hyponatraemia.  
  • Psychiatric — insomnia (very common), depression, agitation, anxiety (common), and confusion (uncommon). 
    • Rarely or very rarely: irritability, hostility, hallucinations, depersonalisation, abnormal dreams including nightmares, delusions, aggression, and paranoia.
  • Nervous system — tremor, concentration disturbance, headache, dizziness, and taste disorders (common).
    • Rarely: seizures, dystonia, ataxia, Parkinsonism, incoordination, memory impairment, paraesthesia, and syncope.
• Other common adverse effects include: 
  • Dry mouth, nausea, vomiting, abdominal pain, and constipation.
  • Fever.
  • Hypersensitivity reactions (for example urticaria).
  • Rash, pruritus, and sweating.
• Other rare adverse effects include: 
  • Angioedema, dyspnoea/bronchospasm, and anaphylactic shock.
  • Arthralgia and myalgia.
  • Erythema multiforme and Stevens-Johnson syndrome.
  • Palpitations.
  • Urinary frequency/retention.
  • Vasodilation and postural hypotension.
  • Alopecia.
• Other adverse events where the incidence is unknown:
  • Hyponatraemia.
  • Suicidal ideation and suicidal behaviour.
  • Psychosis.
  • Serotonin syndrome (see Drug Interactions for more detail).
  • Systemic or cutaneous lupus erythematosus 
  • Panic attacks.

[BNF, 2023; EMC, 2024]

Drug interactions

• Drug interactions may occur if bupropion is taken concurrently with: 
  • Benzodiazepines — concurrent use is contraindicated when withdrawing benzodiazepines (or any other drug associated with seizures on withdrawal).
  • Carbamazepine, phenytoin, phenobarbital, and primidone — monitor for evidence of reduced efficacy of bupropion (most likely) and/or increased toxicity (due to raised metabolite). Note that bupropion is contraindicated in people with current or past seizure disorders.
  • Flecainide — levels may be increased if taken concurrently with bupropion. Reduce the dose of flecainide if required.
  • Digoxin — levels may be decreased if taken concurrently with bupropion. Digoxin levels may rise on discontinuation of bupropion and the patient should be monitored for possible digoxin toxicity.
  • HIV protease inhibitors (ritonavir) — levels of bupropion are reduced. Start bupropion at the recommended dose and titrate as required. 
  • Levodopa — monitor carefully for increased toxicity of levodopa.
  • Monoamine oxidase inhibitor (MAOI) — bupropion toxicity may be enhanced if taken concurrently with an MAOI, leading to severe hypertension. Concurrent use is contraindicated for two weeks after stopping an MAOI.
    • For moclobemide (a reversible MAOI), this period can be reduced to 24 hours.
  • Sodium valproate — monitor for evidence of increased bupropion toxicity (due to increased levels of an active metabolite) or sodium valproate toxicity as high-dose bupropion may increase valproate levels. Note that bupropion is contraindicated in people with current or past seizure disorders.
  • Tamoxifen — concurrent use with bupropion may reduce the metabolism of tamoxifen to one of its active metabolites. Avoid concurrent use. 
  • Selective serotonin reuptake inhibitors (SSRIs) and serotonin noradrenaline reuptake inhibitors (SNRIs) — risk of serotonin syndrome if taken concurrently with bupropion. If concurrent treatment is required, monitor for adverse effects, particularly when initiating treatment or increasing doses. The MHRA advises that people using bupropion with an SSRI or SNRI should never exceed their prescribed dose and should be counselled on the milder symptoms of serotonin syndrome and advised to seek medical attention should these occur.
  • Other drugs known to lower the seizure threshold — concurrent use with bupropion will increase the likelihood of seizures. A maximum dose of 150 mg is recommended when taken with drugs that lower the seizure threshold, including: 
    • Antipsychotics (risperidone and thioridazine).
    • Antidepressants (fluoxetine, paroxetine, and sertraline).
    • Antimalarials (mefloquine).
    • Aminophylline and theophylline.
    • Corticosteroids.
    • Quinolones (ciprofloxacin and ofloxacin).
    • Sedating antihistamines (chlorphenamine and clemastine).
    • Tramadol.

[Preston, 2016; BNF, 2023; EMC, 2024]

Monitoring

• The manufacturer recommends that a baseline BP should be measured at the start of treatment and monitored during treatment, especially in people with pre-existing hypertension.
• If there is a clinically relevant increase in BP, bupropion should be stopped.

[EMC, 2024]

Pregnancy and breastfeeding

Pregnancy

• Bupropion should be avoided in women who are pregnant.

Breastfeeding

• Bupropion and its active metabolites are excreted in breastmilk.
  • Bupropion should be avoided in women who are breastfeeding.

[BNF, 2023; EMC, 2024]

Mode of action of varenicline

• Varenicline is a partial nicotinic receptor agonist. It alleviates symptoms of craving and withdrawal, and reduces the rewarding and reinforcing effects of smoking by preventing nicotine binding to the receptors. 

 [ABPI, 2021f; MHRA, CAS Alert, 2021]

Dose and duration

• Varenicline should be started while the person is still smoking.
  • Advise the person to stop smoking 7–14 days after starting varenicline.
• The recommended treatment dose is 1 mg varenicline twice daily following a 1-week titration as follows:
  • Days 1–3: 500 micrograms once a day.
  • Days 4–7: 500 micrograms twice a day.
  • Day 8 onwards: 1 mg twice a day.
    • For people who cannot tolerate the adverse effects of higher doses (1 mg twice daily) of varenicline, the dose may be reduced to 500 micrograms twice a day.
• For people with severe renal impairment (estimated creatinine clearance less than 30 mL/min), the recommended dose is varenicline 1 mg once a day. Dosing should begin at 0.5 mg once a day for the first 3 days, then increased to 1 mg once a day.
• The recommended course of treatment is 12 weeks.
  • For people who have successfully stopped smoking at the end of 12 weeks, an additional course of 12 weeks of treatment with varenicline at 1 mg twice daily may be considered to help maintain abstinence.
• Varenicline may be stopped without tapering the dose. However, immediately after stopping treatment with varenicline, up to 3% of people experience an increase in irritability, urge to smoke, depression, or insomnia.
  • Consider tapering the dose in these people. 

[ABPI, 2021f; BNF, 2023]

Contraindications and cautions

• Do not prescribe varenicline to people:
  • Aged under 18 years. 
  • With end-stage renal disease.
• Prescribe varenicline with caution to people with:
  • A history of cardiovascular disease.
  • A history of psychiatric illness.
  • Epilepsy, or a predisposition to seizures. 
  • Moderate renal impairment (creatinine clearance [CrCl] 30–50 mL/min) — for people who experience adverse reactions that are not tolerable, reduce dose to 1 mg once daily.
  • Severe renal impairment (CrCl less than 30 mL/min) — the starting dose is 0.5 mg once a day for the first 3 days, then 1 mg once daily.   

[ABPI, 2021f; BNF, 2023]

Adverse effects

• Adverse effects of varenicline include: 
  • Cardiac — myocardial infarction, angina pectoris, tachycardia, and palpitations (uncommon).
    • Rarely: atrial fibrillation, ST segment depression, and T wave amplitude decreased.
  • Gastrointestinal — nausea (very common); vomiting, constipation, diarrhoea, abdominal distension and discomfort, dyspepsia, flatulence, toothache, and dry mouth (common).
    • Rarely: haematemesis, abnormal faeces, and coated tongue. 
  • Nervous system — headache (very common); somnolence, dizziness, and dysgeusia (common).
    • Rarely: cerebrovascular accident, hypertonia, dysarthria, coordination abnormal, hypogeusia, and circadian rhythm sleep disorder.
  • Psychiatric — abnormal dreams, insomnia (very common); suicidal thoughts and behaviours, aggression, panic reaction, restlessness, depression, anxiety, and hallucinations (uncommon).
    • Rarely: psychosis, somnambulism, abnormal behaviour, dysphoria, and bradyphrenia.
    • Note: people should be advised that if serious neuropsychiatric symptoms occur while taking varenicline, it should be discontinued and they should contact a healthcare professional for re-evaluation of treatment.
• Other adverse effects include:
  • Arthralgia and myalgia.
  • Bronchitis, nasopharyngitis, and fungal infection.
  • Chest pain.
  • Dyspnoea and cough.
  • Fatigue.
  • Rash, pruritus, Stevens-Johnson syndrome, erythema multiforme, and angioedema.
  • Tinnitus.
  • Visual disturbances. 
  • Weight increases, appetite changes, hyperglycaemia, and diabetes mellitus.

[ABPI, 2021f; BNF, 2023]

Drug interactions

• There are no known clinically relevant drug interactions with varenicline.

[ABPI, 2021f; BNF, 2023]

Pregnancy and breastfeeding

Pregnancy

• The manufacturer advises that varenicline should be avoided in women who are pregnant.

Breastfeeding

• It is unknown whether varenicline is excreted in breastmilk — it should be avoided in women who are breastfeeding. 

[ABPI, 2021f; BNF, 2023]

• Cytisinicline is a partial nicotinic receptor agonist. It alleviates symptoms of craving and withdrawal, and reduces the rewarding and reinforcing effects of smoking by preventing nicotine binding to the receptors. 

[EMC, 2025]

• One pack of cytisinicline contains 100 tablets which should be sufficient for a complete course, as the duration of therapy is 25 days. 
  • Advise that smoking should be stopped no later than the fifth day of treatment.  
• People with renal or hepatic impairment should not be prescribed cytisinicline. 
• The treatment schedule is outlined in table 1. 

Table 1: Treatment schedule 

[EMC, 2025]

• Do not prescribe cytisinicline to:
  • People under 18 years of age.
  • People 66 years of age, or older.
  • People with unstable angina, arrhythmias, recent myocardial infarction, or recent stroke.
  • People with renal or hepatic impairment. 
• Prescribe cytisinicline with caution in people with:
  
  • A history of cardiovascular disease, including peripheral vascular disease.
  • Hypertension.
  • Gastric or duodenal ulcer or gastrointestinal reflux.
  • Phaeochromocytoma. 
  • Hyperthyroidism. 
  • Diabetes mellitus.
  • History of psychiatric illness (may exacerbate underlying illness including depression). 
  • Schizophrenia. 

[BNF, 2025; EMC, 2025]

• Common adverse effects of cytisinicline include:
  • Anxiety or mood alteration, appetite change, impaired concentration and fatigue, constipation, diarrhoea, nausea, dizziness, drowsiness, dry mouth, headache, tachycardia, vomiting, and myalgia. The manufacturer advises that some of these may also be the result of smoking cessation. 
• Less common adverse effects include: 
  
  • Dyspnoea, excessive lacrimation, hyperhidrosis, decreased libido, and increase in sputum production. 

[BNF, 2025; EMC, 2025]

• Cytisinicline should not be used with antituberculosis medications. 
• Cytisinicline may reduce the effectiveness of combined hormonal contraceptives. The manufacturer recommends the use of additional (barrier) methods of contraception.

[BNF, 2025; EMC, 2025]

• The manufacturer advises that cytisinicline should be avoided in pregnancy and breastfeeding. 

[BNF, 2025; EMC, 2025]