31 - Nicotine replacement therapy (NRT)

Nicotine replacement therapy (NRT)

Addictions and substance misuse CHAPTER 4 Nicotine and smoking cessation Tobacco smoking is the leading preventable cause of illness and premature death ­worldwide. Smoking cessation interventions are clinically and cost effective for people with and without a mental illness. In the UK, NICE recommends that every person who smokes, including those ­receiving community and in-­patient mental healthcare, should be offered support to stop smoking. For those people who feel unable or who are unwilling to give up, they should be provided with treatment to temporarily abstain from smoking.1 NICE recommends that bupropion, nicotine replacement therapy (NRT), varenicline and nicotine-­containing vaping devices should be accessible to adults who smoke.1 It advises that when combined with behavioural support, varenicline, a combination of short-­acting (e.g. mouth spray, lozenges) and long-­acting (e.g. skin patches) NRT, or nicotine-­containing vaping devices are more likely to help people successfully stop smoking, whereas behavioural support combined with either bupropion or single NRT is less likely to help people stop smoking. A component network mental analysis to assess the comparative benefits and harms of vaping and different licensed smoking cessation pharmacotherapies found the most effective interventions were nicotine vaping devices (odds ratio [OR] 2.37), varenicline (OR 2.33), cytisine (OR 2.21) and combination NRT (OR 1.93).2 The effectiveness of smoking cessation treatments appears not to be reduced in patients with a variety of mental health problems.3 Smoking induces CYP1A2, and so stopping smoking may result in increased plasma levels of CYP1A2 substrates. See ‘Smoking and psychotropic drugs’ in Chapter 11. Nicotine replacement therapy (NRT) In the UK, NRT is licensed for smokers over the age of 12 years to help those who want to stop smoking, to reduce before stopping or during a temporary period of enforced abstinence when a person is unable to smoke. NRT is also indicated for pregnant and breastfeeding women attempting to stop smoking. Clinical guidelines in other countries recommend NRT as first-­line treatment for people seeking pharmacological help to stop smoking. In recent years, vaping has become the most often used alternative to tobacco smoking in many countries. The aim of NRT in those stopping smoking is to assist the transition from cigarette smoking to complete abstinence. It may also be used for those who wish to stop vaping. This is achieved by temporarily replacing some of the nicotine obtained from tobacco cigarettes with NRT products and minimising nicotine withdrawal symptoms and the motivation to smoke. People who have stopped smoking can safely use NRT if they wish to continue using nicotine recreationally or to prevent relapse back to smoking. There are eight licensed NRT products in the UK: transdermal patches, lozenges, gum, sublingual tablets, inhalator, nasal spray, mouth spray and oral strips. All these products are General Sales List medicines and can be bought over the counter in the UK. NRT is formulated for systemic absorption through either the skin in the case of patches or the oral or nasal mucosa in the case of all the other products. This means that absorption of nicotine from NRT is much slower than nicotine from inhaling tobacco smoke and the risk of becoming addicted to NRT is lower.4