Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Tobacco dependence treatment
Psychiatry · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Smoking-status change can create medicine toxicity
Abrupt smoking cessation rapidly removes tobacco-smoke enzyme induction and can raise clozapine, olanzapine, theophylline or other affected medicine exposure; severe sedation, confusion, seizure, hypotension or other toxicity requires urgent review.
Action: Document the exact smoking change, contact the responsible prescriber promptly, assess for toxicity and arrange medicine-specific monitoring and dose adjustment. Nicotine replacement or vaping does not preserve smoke-induced metabolism, so a switch away from combustible tobacco is treated as stopping smoking for interaction purposes.
Overview
Ask and act on tobacco use at every suitable contact, combine behavioural support with effective pharmacological or nicotine options, tailor treatment for pregnancy and mental illness, and anticipate clinically important medicine interactions when smoking changes.
Tobacco dependence is a relapsing condition driven by rapid nicotine delivery, conditioned cues and withdrawal. Ask at routine and acute contacts, record current and past smoking, daily amount, time to first cigarette, strongest triggers, previous attempts and household exposure. Ask what the person values about smoking and what they want to change. A lapse is information about triggers rather than treatment failure. Even when someone is not ready to stop in one step, offer support to reduce harm and revisit a complete switch away from combustible tobacco.
Behavioural support improves every pharmacological option. Give clear advice that most smoking harm comes from combustion products rather than medicinal nicotine, discuss previous experience and contraindications, agree a quit date or reduction plan, and schedule contact around the attempt. NICE identifies cytisinicline, varenicline
Practice
Two practice questions
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PsychiatryOriginal SBA
Varenicline initiation schedule
An adult chooses varenicline with behavioural support and sets a quit date in two weeks. Which standard oral starting schedule is correct?
Sources and review status6 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
, combination long- and short-acting NRT and nicotine-containing e-cigarettes as more likely to succeed when paired with behavioural support than bupropion or single-form NRT. Choice should remain individual, considering age, pregnancy, health, medicines, access and preference.
Varenicline is a nicotinic partial agonist. Standard adult treatment begins one to two weeks before the quit date and titrates over seven days to reduce nausea: 0.5 mg daily for three days, 0.5 mg twice daily for four days, then 1 mg twice daily until twelve weeks. Lower dosing may suit adverse effects or severe renal impairment according to product information. Cytisinicline is another partial agonist with a fixed twenty-five-day schedule and a quit date within the first five days; it is not offered under 18, during pregnancy or breastfeeding, or to people aged 66 and over under current NICE guidance.
Combination NRT addresses both baseline withdrawal and sudden craving. A patch provides continuous nicotine while gum, lozenge, inhalator or spray is used in anticipation of or response to triggers. Match strength to dependence and teach technique; under-dosing is common. Medicinal nicotine risks are far lower than smoking. Nicotine e-cigarettes can help adults stop and should be accompanied by accurate discussion: they are expected to be substantially less harmful than smoking but not risk-free, long-term effects remain uncertain, and complete switching avoids ongoing combustion exposure better than indefinite dual use.
Special situations need proactive planning. In pregnancy, offer specialist behavioural support and consider NRT after discussing risks and benefits; faster nicotine metabolism may require adequate dosing, and patches should be removed at night. Acute and mental-health inpatient services should provide immediate abstinence support and pharmacotherapy rather than relying on smoke-free rules alone. Stopping cigarettes reverses smoke-induced CYP1A2 activity, sometimes within days. Clozapine needs urgent specialist involvement and levels; olanzapine, theophylline and warfarin also require efficacy and adverse-effect monitoring when smoking stops or restarts.
Key points
Use very brief advice: ask and record smoking status, advise that support plus treatment improves success, and actively offer or arrange that support.
Assess cigarettes or other tobacco, time to first use, withdrawal, previous quit attempts, preferred goal, household exposure, pregnancy and medicines affected by smoke.
For adults, NICE lists cytisinicline, combination short- and long-acting nicotine replacement, varenicline and nicotine-containing e-cigarettes among the more effective options when combined with behavioural support.
Varenicline is usually started 1–2 weeks before the quit date: 0.5 mg orally once daily days 1–3, 0.5 mg twice daily days 4–7, then 1 mg twice daily through 12 weeks, with renal and tolerability adjustment.
Cytisinicline is a 25-day oral course using 1.5 mg tablets: six tablets daily on days 1–3, five daily days 4–12, four daily days 13–16, three daily days 17–20, then one or two daily days 21–25; stop smoking by day 5.
Combination nicotine replacement pairs steady background delivery, such as a patch, with a short-acting form used before expected cigarettes or for breakthrough craving; choose product strength from dependence and the SmPC.
Aetiology
01
Rapid nicotine reinforcement
Inhaled nicotine reaches the brain quickly, pairing receptor reward with repeated hand-to-mouth and environmental cues throughout each day.
02
Withdrawal avoidance
Irritability, poor concentration, restlessness and craving between cigarettes make the next dose relieve discomfort, reinforcing dependence.
03
Social and commercial exposure
Household smoking, deprivation, stress, marketing and early initiation influence uptake, consumption pattern and difficulty accessing sustained support.
Pathophysiology
1
Nicotinic receptor activation
Nicotine activates neuronal acetylcholine receptors and dopamine pathways, producing alertness and reward followed by receptor adaptation.
2
Cue conditioning
Repeated pairing with meals, alcohol, stress and social routines makes those contexts provoke craving independently of nicotine concentration.
3
Combustion toxicity
Particulates, carbon monoxide and carcinogens drive vascular, pulmonary and malignant disease far beyond the pharmacological effects of nicotine.
4
Enzyme induction
Polycyclic aromatic hydrocarbons in smoke induce hepatic enzymes, lowering some medicine concentrations until smoking stops and induction reverses.
Clinical features and red flags
Nicotine dependence
Early-morning smoking, strong withdrawal, unsuccessful attempts and smoking despite illness indicate dependence more usefully than daily count alone.
Withdrawal syndrome
Irritability, anxiety, low mood, poor concentration, restlessness, increased appetite and craving peak early and can be treated rather than endured.
Conditioned smoking
Meals, alcohol, driving, breaks, stress, social contact and specific places trigger learnt urges even after physiological withdrawal declines.
Dual use
Continuing cigarettes while vaping or using NRT may reduce neither combustion exposure nor cues unless the plan targets complete switching or structured reduction.
Interaction vulnerability
Clozapine and other smoke-affected medicines can become toxic after cessation even when nicotine replacement fully controls withdrawal.
Red flags requiring action
Marked sedation, confusion, seizure, tachycardia or other possible clozapine toxicity after stopping cigarettes requires urgent specialist assessment and plasma-level review.
Chest pain, acute breathlessness, haemoptysis, focal neurology or severe nicotine poisoning symptoms need acute medical assessment rather than routine cessation counselling.
Pregnancy or breastfeeding changes pharmacotherapy:
Investigations
01Smoking and dependence historyFirst step
Why
Identify tobacco form, amount, first use after waking, triggers, withdrawal and previous treatment response.
Interpretation and limitations
Higher dependence usually requires adequately dosed combination therapy and closer behavioural follow-up, not therapeutic pessimism.
02Exhaled carbon monoxide
Why
Provide optional feedback and biochemical validation during supported attempts, including pregnancy programmes.
Interpretation and limitations
A reading reflects recent combustion exposure, varies with timing and environment, and should support rather than police care.
03Medication interaction review
Why
Identify clozapine, olanzapine, theophylline, warfarin and other drugs affected by starting or stopping smoke exposure.
Interpretation and limitations
Notify the prescriber before the quit date and arrange product-specific clinical or level monitoring; nicotine itself is not the inducer.
04Physical and mental health review
Why
Connect smoking with cardiovascular, respiratory, cancer, pregnancy and psychiatric priorities and identify contraindications.
Interpretation and limitations
Comorbidity strengthens the reason for tailored support and may alter medicine choice without making cessation unsafe.
05
Differential diagnosis
01
Nicotine withdrawal
Irritability, anxiety, appetite and concentration change after stopping can resemble depression or medication adverse effects but follows a clear timeline.
02
Primary mood or anxiety disorder
Persistent symptoms independent of the smoking pattern require a separate diagnostic assessment and evidence-based treatment alongside continuing cessation support.
03
Medicine toxicity
Sedation or confusion after cessation may reflect rising clozapine or other smoke-sensitive drug concentrations rather than nicotine withdrawal.
04
Nicotine poisoning
Excess nicotine from concentrated liquids or combined products can cause nausea, vomiting, dizziness, tachycardia and more severe cholinergic toxicity.
Management
01Very brief adviceAsk, advise and actFirst stepA person who smokes attends any healthcare or social-care contact.+
1Ask and record smoking status and dependence, linking cessation to the person's immediate health or life goal.
2Advise that behavioural support plus an effective aid makes success more likely and offer a positive recommendation rather than a warning alone.
3Act by prescribing or arranging treatment, referral and a follow-up date, even if the initial goal is reduction rather than immediate cessation.
02Treatment choiceCombine support with an effective optionAn adult is willing to stop or make a supported complete switch from combustible tobacco.+
1Discuss cytisinicline, varenicline, combination NRT and nicotine e-cigarettes alongside contraindications, prior experience and preference.
Complications
01
Cardiovascular disease
Smoking causes endothelial injury, thrombosis and atherosclerosis, leading to myocardial infarction, stroke and peripheral arterial disease.
02
Respiratory disease
Chronic airway inflammation and parenchymal tissue damage cause COPD, heightened infection vulnerability and progressive, sometimes irreversible respiratory limitation.
03
Cancer and reproductive harm
Combustion carcinogens cause multiple cancers and contribute to infertility, pregnancy complications and fetal and infant harm.
04
Medicine-level instability
Uncommunicated stopping or restarting cigarettes can cause toxicity or loss of efficacy in medicines with smoke-sensitive metabolism.
Monitoring and follow-up
Contact around the quit date to review abstinence, lapses, craving, withdrawal, adherence, technique and treatment adverse effects.
Use carbon monoxide feedback when acceptable and useful, while measuring meaningful smoking reduction and complete combustion-free days.
Track weight, mood, sleep and alcohol-related triggers and plan a rapid response to lapse rather than waiting for full relapse.
For clozapine obtain urgent specialist advice and levels when smoking stops or restarts; monitor other affected medicines for efficacy and toxicity.
Before treatment ends, agree relapse-prevention support, ongoing NRT or vape strategy if needed and what to do if cigarettes resume.
Special situations
Combustion causes most harm
Nicotine drives dependence, but smoke toxins cause most cancer, lung and cardiovascular disease; medicinal nicotine is far safer than smoking.
Combination treats two cravings
Patch therapy covers tonic withdrawal while a fast product addresses learned, situation-specific peaks that otherwise trigger lapse.
Smoke changes medicines
Polycyclic hydrocarbons induce metabolism; replacing cigarettes with nicotine or vaping still reverses that induction and can raise drug levels.
Mental health can improve
People with severe mental illness benefit from the same active cessation treatment, with added monitoring rather than exclusion.
A lapse is actionable
Identify the cue, restore treatment promptly and adjust dose or support instead of declaring the entire attempt unsuccessful.
Common pitfalls
01
Advising cessation without offering or arranging behavioural and pharmacological support.
02
Using one NRT form at too low a dose while cravings remain uncontrolled.
03
Offering cytisinicline, varenicline or bupropion during pregnancy or breastfeeding.
04
Assuming nicotine replacement or vaping preserves cigarette-induced clozapine metabolism.
05
Stopping support after one cigarette rather than treating the trigger and preventing full relapse.
06
Describing e-cigarettes as harmless or, conversely, as equally harmful as continued combustible smoking.
Authoring state
Clinical stateAwaiting review
JurisdictionUnited Kingdom
During pregnancy, offer intensive behavioural support and consider NRT early, removing patches at night; do not offer cytisinicline, varenicline or bupropion during pregnancy or breastfeeding.
Tobacco smoke rather than nicotine induces metabolism: alert prescribers when cigarettes stop or restart, especially for clozapine, olanzapine, theophylline and warfarin.
do not
offer cytisinicline,
varenicline
or bupropion, and combine risk-assessed nicotine replacement with behavioural support where used.
Current suicidal intent or severe mental-state deterioration should be treated urgently while tobacco support continues; psychiatric illness is not a reason to withhold cessation care.
Age under 18 excludes cytisinicline, varenicline and bupropion under current NICE recommendations; cytisinicline is also not offered from age 66 onward.
Pregnancy and age assessment
Why
Apply eligibility limits and select behavioural support, NRT or adult medicines safely.
Interpretation and limitations
Do not offer cytisinicline, varenicline or bupropion in pregnancy, breastfeeding or under age 18; cytisinicline also excludes age 66 and above.
2
Provide the aid before the quit date, teach correct use and ensure dosing is sufficient to control withdrawal and breakthrough craving.
3Review near the quit date and before the prescription ends, addressing lapses, adverse effects and relapse prevention without withdrawing support.
03Special situationProtect pregnancy and medicine safetyThe person is pregnant or breastfeeding, admitted to hospital, or taking a smoke-sensitive medicine.+
1In pregnancy provide specialist behavioural support and consider NRT; avoid cytisinicline, varenicline and bupropion and remove patches at night.
2In hospital supply immediate treatment for temporary abstinence or stopping and communicate the plan across discharge.
3Alert the responsible prescriber before smoking stops or restarts and monitor affected medicines, urgently involving the clozapine team when relevant.
Key medicines and prescribing safety3 treatments · regimens, roles and cautions+
Partial nicotinic-receptor agonism reduces craving and withdrawal and makes smoking less reinforcing when combined with behavioural support.
Varenicline
Start orally 1–2 weeks before the agreed quit date: 0.5 mg once daily on days 1–3, 0.5 mg twice daily on days 4–7, then 1 mg twice daily from day 8 to the end of a 12-week course. Consider another 12 weeks at 1 mg twice daily for selected abstinent adults at high relapse risk.
Not for people under 18 or during pregnancy or breastfeeding under NICE guidance. Adjust in severe renal impairment and reduce to 0.5 mg twice daily if adverse effects are not tolerated; review nausea, sleep effects, mental state and any cardiovascular symptoms according to the current SmPC.
A short oral partial-agonist course reduces nicotine craving and supports cessation when paired with behavioural help.
Cytisinicline 1.5 mg tablets
Use one tablet every 2 hours on days 1–3, maximum 6 daily; every 2.5 hours on days 4–12, maximum 5; every 3 hours on days 13–16, maximum 4; every 5 hours on days 17–20, maximum 3; then 1–2 tablets daily on days 21–25. Stop smoking no later than day 5.
Do not offer under age 18, at age 66 or older, or during pregnancy or breastfeeding. Continuing nicotine use can worsen adverse effects; check cardiovascular disease, renal or hepatic impairment and all current contraindications and interactions in the SmPC before prescribing.
Background nicotine prevents withdrawal while the rapid formulation treats cue-driven urges; combination therapy is more effective than either form alone with behavioural support.
Combination nicotine replacement
Start a licensed long-acting nicotine patch at a strength matched to dependence and the product SmPC, plus a short-acting gum, lozenge, inhalator or spray used before the usual cigarette time and for breakthrough craving. Continue for the product course and taper or extend according to abstinence, craving and relapse risk.
Teach product-specific technique and maximum use, and avoid under-dosing. In pregnancy discuss risks and benefits, favour intermittent forms when suitable and remove patches at night; NRT and vaping do not maintain tobacco-smoke enzyme induction for interacting medicines.