Tobacco dependence treatment — Rapid

Synopsis

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.

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.
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.

Key red flags

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: 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.

Investigation priorities

Smoking and dependence historyFirst step

Identify tobacco form, amount, first use after waking, triggers, withdrawal and previous treatment response.

Management branches

Very brief adviceAsk, advise and act

A person who smokes attends any healthcare or social-care contact.

Ask and record smoking status and dependence, linking cessation to the person's immediate health or life goal.
Advise that behavioural support plus an effective aid makes success more likely and offer a positive recommendation rather than a warning alone.
Act by prescribing or arranging treatment, referral and a follow-up date, even if the initial goal is reduction rather than immediate cessation.

Key medicines

VareniclineStart 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.

Cytisinicline 1.5 mg tabletsUse 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.

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