A pharmacy guide for smoking cessation consultations

In 2024, the Office for National Statistics estimated that 10.6% (5.3 million) of people aged 18 years and over smoke cigarettes in the UK. This is the lowest proportion of current smokers since records began and is the latest data point to show a long-term decline in cigarette use.

In contrast to this, the same data from 2024 indicated that around 10% (5.4 million) of adults aged 16 years and over use e-cigarettes daily or occasionally, with other forms of tobacco and smoke-free nicotine products gaining in popularity^​1​.

Although the long-term trend is encouraging, smoking is still the leading cause of preventable illness and premature death in the UK, responsible for around 78,000 deaths per year. Smoking is also one of the largest drivers of preventable health inequalities. It is associated with most indicators of disadvantage and accounts for half of the difference in life expectancy between the most and least affluent communities in England^​1​.

The importance of smoking cessation and tobacco dependency treatment have been recognised in the ‘Ten-year health plan for England’, which includes providing opt-out smoking cessation support for people admitted to hospitals and referrals to community pharmacy smoking cessation services following discharge^​2​. This strategy is aligned with government ambitions to have a smoke-free generation by 2030^​2​.

Tobacco is highly addictive. National Institute for Health and Care Excellence (NICE) guidelines state that the evidence-based way to most effectively support patients with smoking cessation is through a combination of both pharmacological and behavioural support.

This article provides a structured approach to smoking cessation consultations supporting pharmacists and pharmacy teams to increase their confidence and ability to provide effective holistic support to patients in their smoking cessation journey. 

Step 1: Initiate the consultation

Patients may smoke in various forms including tobacco, shisha and vapes. NICE recommends that the smoking status of all patients should be enquired at every opportunity^​3​. This could be triggered by patients seeking medical advice or during a new medicines review. Purchase of a nicotine replacement therapy (NRT) could also be an opportunity to initiate a conversation about smoking.

Step 2: Assess medical history and medication use

Step 3: Is the patient willing to quit?

Step 4: Gather information 

If the patient indicates a willingness to quit the next step is to gather information so you can provide personalised advice and information about the options available to them.

Past quitting attempts

Smoking habits

It is also important to identify triggers and behavioural patterns so that appropriate relapse prevention strategies can be put in place. For example, if a person smokes more when drinking alcohol then it may be beneficial to avoid this trigger.

Step 5: Advise

Several pharmacological options can be combined with behavioural therapies as a dual approach that increase chances of successful smoking cessation. 

Nicotine replacement therapy

Often used as a first-line therapy, NRT allows patients to receive sufficient levels of nicotine without the presence of the other harmful chemicals found in cigarette smoke. NRT is aimed to reduce the desire to consume tobacco products while minimising withdrawal symptoms. NRT treatment strategy should contain an optimised mix of products that provide long-acting nicotine release alongside short-acting products that provide rapid, temporary relief from acute smoking cravings and withdrawal symptoms. Studies have shown that NRT use increases the chances of cessation by 50–60%^​4​. Anecdotally, NRT is often underprescribed and underdosed in practice. Patients should be provided with individualised treatment that matches their level of smoking.

Figure 1 provides additional information on a selection of NRT options^​5–7​

Figure 1: Nicotine replacement therapy options

Side effects

Some systemic effects occur on initiation of NRT, particularly if the patient is using high-strength preparations; however, the patient may confuse side effects of the nicotine-replacement preparation with nicotine withdrawal symptoms. Common symptoms of nicotine withdrawal include malaise, headache, dizziness, sleep disturbance, coughing, influenza–like symptoms, depression, irritability, increased appetite, weight gain, restlessness, anxiety, drowsiness, aphthous ulcers, decreased heart rate and impaired concentration^​5​.

Other pharmacological options

Other medications have been licensed for smoking cessation, such as cytisinicline (often shortened to cytisine), varenicline or bupropion. Choice of therapy should be guided by the individual’s preferences, previous experience of smoking cessation therapies, including adherence and potential side effects and contraindications^​3​. 

These options should not be offered to people aged under 18 years^​3​.

Figure 2 provides further information on mode of action, dosing and common side effects^​6,8​.

Figure 2: Varenicline, bupropion and cytisinicline

Some people may feel sleepy or dizzy when taking varenicline or bupropion, so it is important that care is taken when driving or operating machinery until an individual’s reaction to the drug is known. Common side effects of cytisinicline include dizziness, irritability, mood changes, insomnia, headache, and gastrointestinal issues and is not recommended for individuals with severe kidney or liver impairment, pregnant/breastfeeding women, or those who have recently had a heart attack or stroke.

Advice on nicotine-containing e-cigarettes

Give clear, consistent and up-to-date information about nicotine-containing e-cigarettes to adults who are interested in using them to stop smoking explaining that while likely to be substantially less harmful than smoking, e-cigarettes are not licensed medicines and that there is not enough evidence to know whether there are long-term harms^​3​. They are widely available in shops and via the internet but are currently unregulated and can be mixed with other noxious agents. Explain that vaping is not risk-free, particularly for people who have never smoked.

Discuss the length of time for which the person intends to use nicotine-containing e-cigarettes, ensuring they use them for long enough to prevent a return to smoking. Explain how to stop using them when ready to do so.

Explain to adults who choose to use nicotine-containing e-cigarettes the importance of getting enough nicotine to overcome withdrawal symptoms, and that failure to get enough nicotine is likely to increase their risk of returning to smoking. Patients should be encouraged to use as much as they need and told how to use the products effectively.   

Stop smoking services

All patients should be offered referral to a stop smoking service^​3​. Engaging with a service can improve a person’s chances of quitting by up to three times if combined with pharmacotherapy^​9​. 

There are one-to-one and group options depending on patient preference. Some find that group sessions can be a good source of mutual support.

These programmes generally run for 12 weeks, with weekly contact in the first 4 weeks becoming less frequent as the patient progresses. 

Stop smoking services supply pharmacotherapy free of charge. Explain to the patient that you can provide them with NRT but they will have to visit their GP or a stop smoking service if they would like to start varenicline, bupropion or cytisinicline.

Step 6: Discuss relapse prevention

Smoking cessation requires ongoing, proactive support. Counselling can help people to identify high-risk situations and triggers encouraging the patient to rearrange routines to change previous smoking habits^​3​. Possible coping strategies should be discussed early in the process. Encourage social support from friends and family members to support the patient on their smoking cessation journey.

Step 7: Close the consultation

• Give the patient the opportunity to ask questions or raise any concerns;
• If they have chosen to purchase pharmacotherapy, ensure they have an adequate supply and invite them to return if needed; 
• Make sure the patient understands how to contact their local stop smoking service and if feasible make a referral, providing them with any relevant resources; 
• Thank the patient for their time and congratulate them on taking this important step to becoming smoke free.