Blog entry by _ RCGP Learning

_ RCGP Learning
What’s new in smoking cessation?
by _ RCGP Learning - Thursday, 27 March 2025, 2:49 PM
Anyone in the world

Written by Dr Toni Hazell

Stopping smoking is one of the most significant things that a person can do to improve their health. It is the second most cost-effective measure in COPD management (behind flu vaccination and ahead of all pharmaceuticals)1 and is associated with later mortality, whatever the age of quitting. It is however not an easy thing to do, with multiple studies showing that most people will relapse after their first quit event3,4,5 – encouragement to try again is therefore vital.

Smoking cessation is more likely to be successful with a combination of support and pharmacotherapy than when tried alone, or with just one of these modalities6. Our role as GPs is not usually to provide this support, but to signpost patients to stop smoking clinics and potentially to prescribe on the clinic’s behalf (depending on local commissioning arrangements). To do this effectively and safely, it helps to understand the principles of very brief advice (VBA), the basic biochemistry of smoking addiction and the pharmacology of the drugs currently available.

VBA is a NICE approved7 30-second intervention which can be delivered in a normal GP appointment; there is evidence that it is acceptable to patients and can contribute to successful smoking cessation8,9. VBA consists of three ‘As’ – ask, advise, act. Ask the patient if they smoke. Advise them how to stop smoking (by explaining that they are much more likely to succeed with support and pharmacotherapy than on their own) and advise them as to how they can access this support. This might be via referral, or by giving the patient details for the local self-referral scheme.

After attendance at a smoking cessation clinic, you may be asked to prescribe nicotine replacement therapy (NRT), or one of the three currently available drugs – varenicline, cytisinicline and bupropion7. These all act in different ways on the addiction mechanisms which keep people smoking. When a smoker inhales nicotine there is a rapid increase in dopamine10, causing an immediate sensation of pleasure; as nicotine and dopamine levels fall, the desire for the next cigarette increases. With long-term smoking, nicotine receptors are upregulated in both number and sensitivity11, causing dependence; down-regulation after quitting takes 6-12 weeks12. The table below gives brief information about what we can prescribe; more detail is available in our eLearning module, Essentials of Smoking Cessation, which also discusses e-cigarettes.

Smoking cessation drugMechanism of actionUse in pregnancy, breastfeeding and under 18sOther information (non-exhaustive list; consult BNF before prescribing)
NRT Stimulates nicotine receptors to release dopamine, reducing withdrawal symptoms13. Yes (from age 12).
  • Nine forms available.
  • NICE advice:
    • Risks much lower than smoking.
    • Combine short and long-acting forms.
    • Can be used to prevent relapse after stopping.
Bupropion Increases dopamine levels by reducing dopamine reuptake, reducing withdrawal symptoms14. No
  • Contraindicated with CNS tumour, current/previous eating disorder, history of seizures or predisposing factors for seizures (see RCGP eLearning module on Essentials of Smoking Cessation for more on what these are)15.
Varenicline Stimulates nicotine receptors to release dopamine and blocks the rapid dopamine increase from nicotine16,18,19. No
  • Recently available in UK after many years without a licensed option.
  • Weight gain possible.
  • Previous concerns about mental health adverse effects have now been disproven17.
Cytisinicline Stimulates nicotine receptors to release dopamine and blocks the rapid dopamine increase from nicotine16,18,19. No
  • UK availability as of March 2025:
    • Varies by ICB in England.
    • Available in Wales20.
    • Not yet assessed by Scottish Medicines Consortium21 and not available in Northern Ireland22.


References

  1. Murphy PB, Brueggenjuergen B, Reinhold T, et al. Cost-effectiveness of home non-invasive ventilation in patients with persistent hypercapnia after an acute exacerbation of COPD in the UK. Thorax 2023; 78: 523-525.
  2. Cho ER, Brill IK, Gram IT, et al. Smoking Cessation and Short- and Longer-Term Mortality. NEJM Evid. 2024 Mar; 3 (3): EVIDoa2300272.
  3. Gorniak B, Yong HH, Borland R et al. Do post-quitting experiences predict smoking relapse among former smokers in Australia and the United Kingdom? Findings from the International Tobacco Control Surveys. Drug Alcohol Rev. 2022 May; 41(4): 883-889.
  4. Lee SE, Kim CW, Im HB, et al. Patterns and predictors of smoking relapse among inpatient smoking intervention participants: a 1-year follow-up study in Korea. Epidemiol Health. 2021; 43: e2021043.
  5. Feuer Z, Michael J, Morton E, et al. Systematic review of smoking relapse rates among cancer survivors who quit at the time of cancer diagnosis. Cancer Epidemiol. 2022 Oct; 80: 102237.
  6. Stead LF, Koilpillai P, Fanshawe TR et al. Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane Database Syst Rev. 2016 Mar 24; 3(3): CD008286.
  7. NICE. NG209. Tobacco: preventing uptake, promoting quitting and treating dependence. Feb 2025. 
  8. Cheng CCW, He WJA, Gouda H, et al. Effectiveness of Very Brief Advice on Tobacco Cessation: A Systematic Review and Meta-Analysis. J Gen Intern Med. 2024 Jul; 39(9): 1721-1734.
  9. Papadakis S, Anastasaki M, Papadakaki M, et al. 'Very brief advice' (VBA) on smoking in family practice: a qualitative evaluation of the tobacco user's perspective. BMC Fam Pract. 2020 Jun 24; 21(1): 121.
  10. Benowitz NL. Pharmacology of nicotine: addiction, smoking-induced disease, and therapeutics. Annu Rev Pharmacol Toxicol. 2009; 49: 57-71.
  11. Govind AP, Vezina P, Green WN. Nicotine-induced upregulation of nicotinic receptors: underlying mechanisms and relevance to nicotine addiction. Biochem Pharmacol. 2009 Oct 1; 78(7): 756-65.
  12. Cosgrove KP, Batis J, Bois F, et al. beta2-Nicotinic acetylcholine receptor availability during acute and prolonged abstinence from tobacco smoking. Arch Gen Psychiatry. 2009 Jun; 66(6): 666-76.
  13. Molyneux A. Nicotine replacement therapy. BMJ. 2004 Feb 21; 328(7437): 454-6.
  14. Warner C, Shoaib M. How does bupropion work as a smoking cessation aid? Addict Biol. 2005 Sep; 10(3): 219-31.
  15. Bupropion SPC. July 2024. 
  16. Singh D, Saadabadi A. Varenicline. [Updated 2024 Oct 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-.
  17. Royal College of Psychiatrists. The prescribing of varenicline and vaping (electronic cigarettes) to patients with severe mental illness. Dec 2018. 
  18. National centre for smoking cessation and training. Cytisine. 2024. 
  19. Nides M, Rigotti NA, Benowitz N, et al. A Multicenter, Double-Blind, Randomized, Placebo-Controlled Phase 2b Trial of Cytisinicline in Adult Smokers (The ORCA-1 Trial). Nicotine Tob Res. 2021 Aug 29; 23(10): 1656-1663.
  20. NHS Wales. Cytisinicline. July 2024. 
  21. Scottish Medicines Consortium. Medicines Advice. 
  22. Stop Smoking NI. 
  23. National Centre for Smoking Cessation and Training (NCSCT). 30 Seconds to change a life. 
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[ Modified: Monday, 14 April 2025, 8:42 AM ]