First consultation

NRT or varenicline could be used as first quit attempt, however varenicline is not currently available.

• Assess motivation, offer behavioural advice and encouragement.
• Discuss strategies including choice of drug/formulation and contra-indications.
• Advise that smoking cessation, with or without pharmacological support, may cause symptoms of depression and affect the metabolism of some medicines. In particular the dose of theophylline, cinacalcet, ropinirole and some antipsychotics (including clozapine, olanzapine, chlorpromazine and haloperidol), may need to be reduced. Monitor for adverse effects.
• People with a high level of nicotine dependence, or who have failed with NRT previously, may benefit from the addition of a second NRT preparation to achieve abstinence, eg combination of a patch and one of the immediate-release preparations.
• Agree a quit date, (7 to 9 days following appointment) prescribe/arrange NRT in patient’s choice of formulation (usually 4 weeks supply, endorsing the prescription ‘Dispense weekly’ to minimise waste) and arrange follow-up, usually within a week. Advise to contact prescriber if adverse effects.
• Advise patient that normal course of NRT is an approximately 12-week period.
• At each visit measure carbon monoxide levels if possible.

Second consultation

Discuss progress and any issues and encourage and reassure. Alter NRT, if necessary. If still smoking, offer advice about risks and set new quit date. Studies have shown, if the person can remain smoke-free for one week, they're ten times more likely to remain smoke free. Ask again about motivation, suggest alternative smoking cessation strategies and arrange a follow-up appointment.

Third consultation

If not smoking, congratulate and prescribe/arrange 1 month’s NRT supply, stepping down if appropriate. Set new follow-up appointment. If still smoking, offer encouragement of how well they have been doing, acknowledge how stopping smoking can take many attempts and motivate to make another attempt in the future. Only prescribe/arrange further NRT supplies (as per first consultation) if new quit date set.

Fourth consultation

If still not smoking congratulate and prescribe/arrange final month’s supply of NRT (lowest dose) and offer advice on NRT withdrawal and dose tapering.

Fifth consultation

(face to face, by telephone or by letter)

If still not smoking, congratulate.

The aim of NRT is to reduce usage over 8 to 12 weeks as per product information. If patients require treatment beyond 12 weeks they should be referred to specialist stop smoking services for further support and advice.

It may be necessary to prescribe NRT for longer than 12 weeks. Patients must meet the following criteria if continuing treatment for more than 12 weeks:

• significant indication that to discontinue treatment would result in relapse due to withdrawal symptoms
• patient is prepared to commit and adhere to reduction plan resulting in discontinuing product within the next six weeks
• patient is completely abstinent.

For further information on the use of NRT in specific patient groups and advice on selection of formulations, refer to theBNF.

First choice - Nicotine replacement therapy (NRT)

There is no evidence that one particular type of NRT is more effective than another. The choice of formulation is down to personal preference.

For full details on doses, adverse effects, cautions and contra-indications of individual products refer to the BNF.