For updated information on smoking cessation, including detailed use of pharmacological products, see "Update on smoking cessation", BPJ 33 (December, 2010).
Primary care has a central role in increasing the number of quit attempts, which is the key to increasing quit rates.
The emerging evidence seems to be that this role should be "broad" rather than "deep" - very brief advice to a lot of
smokers is better than intensive advice to a few. Ensuring that patients are provided with NRT and shown how to use it
is a good investment of time - any additional follow-up by primary care may be of lesser value and is resource intensive.
The basic principles of support are:
- Set a quit date
- Prescribe medication
- Emphasise the importance of complete abstinence
- Provide at least four support sessions
Nicotine replacement therapy (NRT) is safe and effective
Key points presented in the guideline are:
- NRT is safe and effective (NNT=14 for abstention at six months).
- The choice of NRT product can be guided by individual preference.
- Combining two NRT products (for example, patch and gum) increases abstinence rates.
- NRT should be taken for at least eight weeks.
- People who need NRT for longer than eight weeks (for example, people who are highly dependent) can continue to use
- NRT can be used to encourage reduction prior to quitting.
- People with cardiovascular disease can use NRT. However, if they have experienced a serious cardiovascular event (e.g.
MI or stroke) in the past two weeks or have a poorly controlled disease, treatment should be discussed with a physician.
Intermittent NRT products, for example, gum, inhaler, microtabs or lozenges are recommended rather than the longer-acting
patches for such people.
- Pregnant women can use NRT after discussion of the risks and benefits. Intermittent NRT should be used in preference
- Young people (12-18 years of age) who are dependent on nicotine can use NRT if it is believed that the NRT may help.
However, it is not recommended for occasional smokers, such as those who smoke on weekends only.
Nortriptyline, as effective as NRT
Nortriptyline is approximately as effective as NRT for smoking cessation (NNT=11 for abstinence at six months). There
is no evidence that it is any more effective when combined with other smoking cessation medications.
Nortriptyline needs to be used with caution in people with cardiovascular disease and the other well known problems
of the tricyclics need to be considered. There is insufficient evidence to recommend its use in adolescents or pregnant
Bupropion, as effective as NRT
Bupropion appears to be as effective as nortriptyline and has less potential for serious side effects. It is safe when
used by people with stable cardiovascular or respiratory disease but has some contraindications, such as seizure disorders,
CNS tumour, bulimia or anorexia nervosa, abrupt alcohol or sedative withdrawal, MAOI use and lactation. In addition, there
is a wide range of precautions.
Bupropion is not currently subsidised in New Zealand.
Varenicline is effective
Varenicline is effective (NNT=8 for abstention at six months). It binds to nicotine receptors in the brain, reducing
the severity of tobacco withdrawal symptoms and reducing the rewarding effects of nicotine.
Although it appears to have a good safety profile, adverse event data from general use are not yet available. There
is insufficient evidence for its use in adolescents, pregnant women or people with unstable cardiovascular disease.
Varenicline is not currently subsidised in New Zealand.
Multiple telephone calls for proactive telephone support increase long-term abstinence rates and the addition of telephone
support to medication increases smoking cessation rates above those of medication alone. Quitline works.
There appears to be no additional benefit from adding telephone support to multiple session face-to-face support.