Nicotine dependence

Prescribing Notes:

• Initial prescriptions should be sufficient to last two weeks. Further prescriptions should only be issued if the quit attempt is continued at review.
• Symptom control of nicotine withdrawal in hospital in-patients is the only exception to a ‘quit date’ being set.
• NRT or varenicline must not be added to repeat prescribing systems.
• Stopping smoking may result in slower metabolism and a consequent rise in blood levels of drugs catalysed by CYP1A2 (and possibly CYP1A1). This is because the inhalation of induction agents such as polycyclic aromatic hydrocarbons has stopped. There are a few drugs for which this is clinically significant, e.g. warfarin, theophylline and clozapine.
• Nicotine releases catecholamines which can affect carbohydrate metabolism. Smokers with diabetes should be advised to monitor blood sugar levels more closely than usual when attempting to quit smoking (with or without treatment).
• Available evidence suggests that clients/patients are up to four times more likely to quit with the right combination of support and products. The client/patient must be committed and motivated to stop smoking.

Nicotine Replacement Therapy (NRT)

• Nicotinell patches may not suit an individual patient’s clinical need. Other options may be prescribed after exercising professional judgement.
• NRT may be prescribed to adolescents (12-18 years), these patients should be referred to a Quit Your Way service for young people for provision of suitable support.
• For use of NRT in pregnancy, please refer to pregnancy and smoking cessation pathway.
• The aim of NRT is to reduce usage over 8-12 weeks as per product information. If patients require support beyond 12 weeks they should be referred to Quit Your Way services for further support and advice.
• Moderate to severe hepatic impairment and/or severe renal impairment decreases the clearance of nicotine or its metabolites and NRT should be used with caution.
• Nicotine inhalator may be a useful option for patients within a hospital setting.

Varenicline

• Varenicline is currently unavailable, please see Medicines Supply Alert Notice Champix (varenicline) for further details.
• Prescribers should be aware of the cautions and side-effect profile of varenicline both during treatment and on treatment cessation.
• Varenicline should be used as part of a programme of behavioural support following a comprehensive assessment.
• Clients/patients who have been taking varenicline for greater than 21 days and are still smoking should be re-assessed for their motivation to stop smoking. Varenicline should be discontinued.
• The efficacy and safety of varenicline in patients with significant co-morbidity is unclear. It should be prescribed for a maximum of 12 weeks only.
• Varenicline should not be used in patients under 18 years old, in those that are pregnant or breastfeeding, women who are planning a pregnancy or those who are in end-stage renal disease.
• Patients prescribed varenicline should be advised to discontinue treatment and seek prompt medical advice if they develop agitation, depressed mood or suicidal thoughts.
• The Eagles study (April 2016) did not show a significant increase in neuropsychiatric adverse events attributable to varenicline or bupropion relative to nicotine patch or placebo.
• Those with a history of psychiatric illness should be monitored closely as varenicline may exacerbate underlying illness.
• Abnormal semen and sexual dysfunction have been reported with varenicline (uncommon). However no hazard for human fertility is evident when taking varenicline. As such there is no advice regarding the need to stop varenicline prior to conception. It should be borne in mind that smoking is known to have a detrimental effect on male fertility, causing sexual impotence, decreased sperm counts and increased proportions of abnormal sperm.

Prescribing Notes:

• Ideally, pregnant women should stop smoking without using NRT but if this is not possible NRT may be recommended to assist a quit attempt. The aim should be to discontinue NRT use after 2-3 months.
• See ‘Smoking cessation treatment’ pathway for full information on treatment choices.
• Intermittent dose regimens are preferred to minimise foetal exposure to nicotine although a patch may be appropriate if nausea and/or vomiting are a problem. If patches are used, they should be removed before going to bed at night.
• Initial prescriptions should be sufficient to last two weeks. Further prescriptions should only be issued if the quit attempt is continued at review.
• Symptom control of nicotine withdrawal in hospital in-patients is the only exception to a ‘quit date’ being set.
• NRT must not be added to repeat prescribing systems.
• Stopping smoking may result in slower metabolism and a consequent rise in blood levels of drugs catalysed by CYP1A2 (and possibly CYP1A1). This is because the inhalation of induction agents such as polycyclic aromatic hydrocarbons has stopped. There are a few drugs for which this is clinically significant, e.g. warfarin, theophylline and clozapine.
• Nicotine releases catecholamines which can affect carbohydrate metabolism. Smokers with diabetes should be advised to monitor blood sugar levels more closely than usual when attempting to quit smoking (with or without treatment).
• Nicotinell patches may not suit an individual patient’s clinical need. Other options may be prescribed after exercising professional judgement.
• NRT may be prescribed to adolescents (12-18 years), these patients should be referred to a Quit Your Way service for young people for provision of suitable support.
• For use of NRT in pregnancy, please refer to Quit Your Way service.
• The aim of NRT is to reduce usage over 8-12 weeks as per product information. If patients require support beyond 12 weeks they should be referred to Quit Your Way service for further support and advice.
• Moderate to severe hepatic impairment and/or severe renal impairment decreases the clearance of nicotine or its metabolites and NRT should be used with caution.
• NRT can be used by women who are breastfeeding. NRT products taken intermittently are preferred as their use can be adjusted to allow the maximum time between their administration and feeding of the baby, to minimize the amount of nicotine in the milk. Referral to Quit Your Way Pregnancy Team is recommended.

Prescribing Notes:

• Initial prescriptions should be sufficient to last two weeks. Further prescriptions should only be issued if the quit attempt is continued at review.
• Symptom control of nicotine withdrawal in hospital in-patients is the only exception to a ‘quit date’ being set.
• NRT must not be added to repeat prescribing systems.
• Stopping smoking may result in slower metabolism and a consequent rise in blood levels of drugs catalysed by CYP1A2 (and possibly CYP1A1). This is because the inhalation of induction agents such as polycyclic aromatic hydrocarbons has stopped. There are a few drugs for which this is clinically significant, e.g. warfarin, theophylline and clozapine.
• Nicotine releases catecholamines which can affect carbohydrate metabolism. Smokers with diabetes should be advised to monitor blood sugar levels more closely than usual when attempting to quit smoking (with or without treatment).
• Available evidence suggests that clients/patients are up to four times more likely to quit with the right combination of support and products. The client/patient must be committed and motivated to stop smoking.

Nicotine Replacement Therapy (NRT)

• Nicotinell patches may not suit an individual patient’s clinical need. Other options may be prescribed after exercising professional judgement.
• NRT may be prescribed to adolescents (12-18 years), these patients should be referred to a Quit Your Way service for young people for provision of suitable support.
• For use of NRT in pregnancy, please refer to pregnancy and smoking cessation pathway.
• The aim of NRT is to reduce usage over 8-12 weeks as per product information. If patients require support beyond 12 weeks they should be referred to Quit Your Way services for further support and advice.
• Moderate to severe hepatic impairment and/or severe renal impairment decreases the clearance of nicotine or its metabolites and NRT should be used with caution.
• Nicotine inhalator may be a useful option for patients within a hospital setting.
• Nicotinell lozenges are licensed for children under 18 years only when recommended by a doctor.