Guide to Smoking Cessation Guide to Smoking …...Guide to Smoking Cessation ©Ashtons Hospital...

Guide to Smoking Cessation

©Ashtons Hospital Pharmacy Services Ltd, 2015


Benefits of stopping smoking

Smoking cessation in a mental health setting

Guide to the available treatments

Interactions with medication

Smoking cessation in special groups

Cost effective choices for smoking cessation

Other guides & information packs we provideOur guides and information packs are designed to help enhance the clinical knowledge of your team. The range of available topics includes:

Guide to Diabetes

Guide to Clozapine

Guide to Controlled Drugs

Guide to Emergency Drugs

Guide to Self-Administration

Guide to Clinic Room Requirements

Guide to Drugs and Alcohol Testing

To order any of our clinical guides or information packs, please call us on 0345 222 3550.



Contents

What is in a cigarette?............................................................................................................1Benefits of stopping smoking.................................................................................................2Smoking cessation in mental health settings.........................................................................3 Depression.......................................................................................................................3 Bipolar disorder................................................................................................................3 ADHD...............................................................................................................................4 Schizophrenia..................................................................................................................4 Alzheimer’s disease and dementia..................................................................................4 Post-traumatic stress disorder..........................................................................................4Can it be done?......................................................................................................................4Available treatments..............................................................................................................5 Nicotine replacement therapy.........................................................................................5 Varenicline and bupropion..............................................................................................6Smoking cessation and harm reduction.................................................................................7 Example NRT regimen for smoking cessation..................................................................7 Example NRT regimen for harm reduction......................................................................7 Electronic cigarettes...............................................................................................................7Smoking cessation in special groups......................................................................................8 Pregancy...........................................................................................................................8 Young people...................................................................................................................8Interactions with medication.................................................................................................8 Drugs with established evidence of interaction and clinical significance........................9 Drugs with conflicting evidence of interaction or low clinical significance......................9 Tips for increasing rates of smoking cessation.....................................................................10Useful tools and resources...................................................................................................11Cost effective choices for smoking cessation.......................................................................12

Information contained in this document is Ashtons Hospital Pharmacy Services Ltd’s understanding of the general position at the date of publication and should be reviewed with an appropriate professional with regard to your particular circumstances.



Tobacco smoking is the leading preventable cause of death. It is responsible for around 5 million deaths worldwide – around 1 in 10 of all adult deaths (World Health Organisation).

Most of the damage caused by smoking is caused to the respiratory system (the airways and lungs) and the cardiovascular system (the heart and blood vessels).

What is in a cigarette?Nicotine is the chemical in cigarettes that is addictive – as soon as nicotine levels in the blood start to drop, a smoker will crave more nicotine. Although nicotine is responsible for keeping people smoking, it is not responsible for most of the health problems caused by smoking.

Nicotine does have some effects on the body. It causes the body to release adrenaline which, depending on the dose, can cause feelings of alertness or relaxation.

Tar is the major damaging chemical found in cigarettes. Tar is the sticky brown substance which stains the teeth and fingers of smokers. Far more seriously, prolonged exposure can lead to changes in cells which can lead to cancer. Different tobacco products contain different amounts of tar, and in the past manufacturers have marketed products as ‘low-tar’ or ‘light’ products. However, research has showed that the risk of cancer does not correlate strongly with the advertised amount of tar in the product used, and legislation now prevents products from implying they are safer due to low levels of tar by using such names.

Carbon monoxide is a chemical produced by burning tobacco, which attaches to haemoglobin in the blood, reducing its ability to carry oxygen. Levels of carbon monoxide in the blood reduce rapidly after a person stops smoking. Carbon monoxide levels can be detected using a breath test, and regular carbon monoxide monitoring throughout smoking cessation has been shown to be motivational by providing evidence of the effect stopping smoking is having.

Up to 4,000 other chemicals can be found in cigarettes, of which 400 are known to be toxic and 43 have shown to be carcinogenic.

The list includes:

• Formaldehyde• Ammonia• Hydrogen cyanide• Arsenic• DDT

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Benefits of stopping smokingThere are a number of benefits to stopping smoking.

After 20 minutes Blood pressure and pulse rate return to normal.

After 8 hours Nicotine and carbon monoxide levels in blood reduce by half and oxygen levels return to normal. After 48 hours Carbon monoxide will be eliminated from the body. Lungs start to clear out mucus and other smoking debris. There is no nicotine in the body. The ability to taste and smell is greatly improved.

After 72 hours Breathing becomes easier. Bronchial tubes begin to relax and energy levels increase.

After 2-12 weeks Circulation improves.

After 3-9 months Coughs, wheezing and breathing problems improve as lung function increases by up to 10%.

After 5 years Risk of heart attacks falls to about half compared with a person who is still smoking.

After 10 years Risk of lung cancer falls to half that of a smoker. Risk of heart attack falls to the same as someone who has never smoked.

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Breath smells fresherAbility to taste returnsTeeth whiten

Blood pressure and pulse rate normaliseRisk of heart disease reduces

Fertility increases

Lung function improvesBlood flow improvesBlood oxygen levels increase

Money is saved

• • •

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• • Risk of lung cancer

reduces

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Smoking cessation in mental health settings“There is a common but mistaken belief among some mental health professionals that it’s alright for patients in their care to smoke. …It’s a disgrace that this section of our NHS patient population is left to suffer the consequences of smoking.” – Professor Sue Bailey OBE, President of the Royal College of Psychiatrists

There have been legal challenges by patients as to whether smoking bans for people who reside in a metal health institution (such as patients detained under the Mental Health Act) are in breach of a person’s human rights. However, these cases have been dismissed and so the right of healthcare providers to enforce a smoking ban has been upheld (e.g. R (E) v Nottinghamshire Healthcare NHS Trust: http://bit.ly/1KIxaey).

Compared with the general population, people diagnosed with a mental disorder are more likely to:

• Be smokers – rates of smoking on mental health inpatient units are around 70%, compared with 21% in the general population.

• Smoke more cigarettes per day – smokers with a mental illness smoke around 20% more cigarettes per day than those without.

• Be dependent on nicotine – more than half of patients diagnosed with nicotine dependence also meet the criteria for at least one mental illness.

Smoking-related diseases are, therefore, more common in these patients.

Depression Smoking rates among adults with depression are twice as high as among adults without depression. Nicotine may temporarily increase levels of dopamine in the brain and hence exert an antidepressant action in these individuals, as well as the pleasurable/euphoric effects that increased dopamine signalling contributes to the reward-based mechanism for nicotine addiction.

However, it is known that smoking in the longer term decreases the overall release of dopamine, and therefore exerts a depressant effect. Numerous studies have found that smoking significantly increases the risk of major depression.

Whereas the majority of patients who have given up smoking (especially those who have an anxiety component to their depression) will experience a reduction in their symptoms, careful monitoring of this group is required, as a small minority may experience an exacerbation of their depressive symptoms, as a coping mechanism is removed.

Bipolar disorder Although an association between smoking and bipolar disorder has not been firmly established, the number of people with bipolar disorder who smoke is significantly higher than in the general population.

One study found that among patients treated for bipolar disorder, smokers were more likely to have an earlier onset of the disorder, greater severity of symptoms, a history of suicide attempts, and co-morbid anxiety or substance use disorder. The association with suicide ideation was confirmed in a separate study.

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Schizophrenia Smoking rates among people with schizophrenia are significantly higher than in the general population, with prevalence estimated to be between 58% and 88%.

One possible explanation is that people with schizophrenia use smoking to manage some of the symptoms associated with their illness, such as improving attention and short-term memory. Research has also shown that nicotine stimulates the subcortical reward system and the prefrontal cortex, both of which malfunction in people with schizophrenia. This may explain why patients with schizophrenia tend to experience more severe withdrawal symptoms in the first week than other would-be quitters.

It is also known that smoking tobacco lessens some of the side effects of antipsychotic medication by decreasing plasma levels. One study found that patients smoked more when treated with the neuroleptic (anti-psychotic drug) haloperidol than when in a medication-free state.

The metabolism of psychotropic drugs can be increased in cigarette smokers. Patients who smoke frequently need higher doses of this type of medication to have the same therapeutic effect. Consequently, some patients on drugs such as clozapine and olanzapine require a dose reduction of 25% in the first week following a quit attempt.

Alzheimer’s disease and dementia Recent research has shown that smoking is a risk factor for Alzheimer’s and vascular dementia by increasing the amount of free radicals, which impair brain and body cell functions and undermine immunity. Nicotine use appears to worsen the effects of a brain protein called tau, responsible for the fibrous tangles that are an indicator of the disease.

While there is still some minor disagreement about the relationship between smoking and dementia, the belief that smoking had a protective effect against Alzheimer’s disease through the stimulation of nicotinic receptors has now been discredited.

Post-traumatic stress disorder There is a clear bi-directional link between post-traumatic stress disorder (PTSD) and smoking.

These smokers are also significantly more likely to be heavy smokers and to have significantly higher levels of nicotine craving and lower quit rates. It has been shown that those who successfully quit or who have reduced their levels of smoking have experienced a marked reduction in their PTSD symptoms.

Can it be done? Although levels of smoking on inpatient mental health wards is high, the rate of people wanting to stop is about the same as in the general population.

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ADHD The link between Attention Deficit Hyperactivity Disorder (ADHD) and smoking is well-established, with both children and adults significantly more likely to smoke and to go on to develop drug and alcohol disorders. There is also strong evidence to show that maternal smoking during pregnancy is a risk factor for the development of ADHD in children. Studies suggest that people with ADHD use smoking to improve attention and cognitive performance. Laboratory studies have also shown that nicotine reduces the symptoms of ADHD and, in fact, acts in a similar way to medication used to treat ADHD, which may explain why people with ADHD use tobacco to self-medicate.



Although it is often considered impossible to get these service users to stop smoking, research has shown that it is possible when evidence-based strategies are used. NICE recommends that inpatient mental health hospitals should have smoke-free policies and patients should be supported to give up smoking before these take place.

One of the key barriers to achieving this is ensuring staff are fully trained in this area. Surveys show that staff working in mental health generally do not support smoke-free policies, and also show a gap in their knowledge of the benefits of smoking cessation. Therefore, ensuring all staff have received training in smoking cessation is critical to enabling service users to successfully give up.

Smoking is often seen by patients as a reward, with the privilege being withdrawn for poor behaviour. Moving away from a system of seeing tobacco as a reward can be useful in encouraging smoking cessation.

There are a number of mental health inpatient units that are completely smoke free, so it is certainly possible. All of these agree that strong leadership and high-quality staff training are essential to the success of the scheme.

Available treatments There are three main treatments used to aid people in stopping smoking.

Nicotine replacement therapy Nicotine is the chemical in cigarettes which is addictive. When people stop smoking, their body misses the nicotine and people get physical withdrawal symptoms. These symptoms in turn lead the person to start smoking again.

By replacing the nicotine from cigarettes with nicotine in another form, without the other harmful chemicals, people can stop smoking cigarettes without experiencing these physical symptoms. Using nicotine replacement therapy increases the chance of somebody successfully quitting by around 70%.

Nicotine replacement therapy is available in a number of different forms.

Patches deliver nicotine through the skin. Since they deliver a fairly constant dose of nicotine, they are useful for smokers who smoke constantly throughout the day. There are 24-hour patches which can be kept on overnight – this is useful for smokers who crave a cigarette as soon as they wake up. However, some people find having nicotine whilst they are asleep can give them vivid dreams, and so there is also a 16-hour patch designed to be removed at bedtime.

Gum, lozenges, inhalers, microtabs and mouth sprays can be used either on a regular scheduled basis, or as and when the user feels it is required. This flexibility makes these forms useful for people whose cravings vary throughout the day.

A nasal spray is also available. This is a very strong form of NRT, and is usually only used in very heavy smokers.

All forms of NRT are licensed for use in patients over 12 years of age, and can be used in pregnant women who are attempting to quit, except Nicotinell® lozenges, which are licensed for children under 18 years only when recommended by a doctor.

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Varenicline and bupropion These two drugs act on the brain to reduce the level of craving. Both have been proven to be more effective than quitting without any assistance. However, both have been associated with an increase in psychiatric side effects in the general population.

However, NICE recommends that these drugs are used with caution and patients are monitored for newly emerging psychiatric symptoms, such as psychotic symptoms, suicidal ideation or increased agitation.

Whilst buproprion has been shown to be an effective agent for those patients who have a history of depression or schizophrenia, there are some restrictions for the use of the drug in the wider psychiatric population that are of note.

From the summary of product characteristics (SPC) for Zyban® (buproprion):

• Zyban® is contraindicated in patients with a current seizure disorder or any history of seizures.• Zyban® is contraindicated in patients who, at any time during treatment, are undergoing abrupt

withdrawal from alcohol or any medicinal product known to be associated with the risk of seizures on withdrawal (in particular benzodiazepines and benzodiazepine-like agents).

• Zyban® is contraindicated in patients with a current or previous diagnosis of bulimia or anorexia nervosa.

• Concomitant use of Zyban® and monoamine oxidase inhibitors (MAOIs) is contraindicated. At least 14 days should elapse between discontinuation of irreversible MAOIs and initiation of treatment with Zyban®. For reversible MAOIs, a 24-hour period is sufficient.

• Zyban® is contraindicated in patients with a history of bipolar disorder, as it may precipitate a manic episode during the depressed phase of their illness.

Champix® (varenicline) has been reported to be more effective and have fewer restrictions and side effects than buproprion, and a recent meta-analysis found no increase in the risk of suicide or attempted suicide, suicidal ideation or depression with varenicline compared with a placebo.

However, prescribers should be aware that the warnings on neuropsychiatric adverse events remain in place within the summary of product characteristics for varenicline.

The SPC shows efficacy studies in specific patient groups, such as those with cardiovascular and respiratory disease, major depression, schizophrenia and schizoaffective disorders.

“This short-term rare risk also needs to be balanced with the long-term risks associated with smoking, as well as the risks and effectiveness of other smoking cessation therapies. This study should reassure us that varenicline can be used confidently, as per current NICE guidance. However, prescribers should be aware of the manufacturer’s warnings, and counsel people about the potential for rare neuropsychiatric symptoms, particularly in those with risk factors (such as a history of psychiatric illness). People should be informed in a balanced way about the evidence, but also encouraged to report any concerns they may have.” – Dr Anthony Cox, Senior Lecturer in Clinical Pharmacy, University of Birmingham

Both products are licensed for people over 18 years of age, but are contraindicated in pregnancy.

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Smoking cessation and harm reduction Ideally, all service users should be encouraged to completely stop smoking. For patients in inpatient services, NICE recommends the use of a long-acting NRT product plus, when required, one to be used for breakthrough cravings.

For various reasons, a patient may feel complete cessation is not an achievable option. In these patients, harm reduction should be tried. This involves using NRT and other therapies to reduce the amount a person smokes. Often NRT is stopped by staff as soon as a person smokes. However, nicotine is not the major health hazard in tobacco, and so NRT can still be used in people who reduce their cigarette consumption but continue to smoke.

Example NRT regimen for smoking cessation

For a patient on 10 or more cigarettes per day Weeks 1 to 4: 21mg 24-hour nicotine patch* daily plus 4mg lozenge** PRN Weeks 5 and 6: 21mg 24-hour nicotine patch* daily plus 2mg lozenge** PRN Weeks 7 and 8: 14mg 24-hour nicotine patch* daily plus 2mg lozenge** PRN Weeks 9 and 10: 7mg 24-hour nicotine patch* daily plus 2mg lozenge** PRN Week 11 onwards: use of 2mg lozenge** PRN alone

For a patient on 10 or fewer cigarettes per day Weeks 1 to 4: 14mg 24-hour nicotine patch* daily plus 2mg lozenge** PRN Weeks 5 and 6: 14mg 24-hour nicotine patch* daily plus 2mg lozenge** PRN Weeks 7 and 8: 7mg 24-hour nicotine patch* daily plus 2mg lozenge** PRN Week 9 onwards: use of 2mg lozenge** PRN alone

Example NRT regimen for harm reductionWhile smoking 10 or more cigarettes per day: 21mg 24-hour nicotine patch* daily If consumption drops to less than 10 cigarettes per day: 14mg 24-hour nicotine patch* daily

*Where a 24-hour patch is prescribed the equivalent 16-hour patch could be used(i.e. 21mg 24-hour patch 25mg 16-hour patch, 14mg 24-hour patch 15mg 16-hour patch, 7mg 24-hour patch 10mg 16-hour patch) ** Where a lozenge is suggested, the equivalent strength of gum or mictotab, or an inhalator or mouth spray, could be used.

Electronic cigarettes Electronic cigarettes or ‘e-cigarettes’ are battery-powered devices that allow nicotine to be inhaled. They usually consist of a hand-held device containing a cartridge filled with a liquid containing nicotine and flavouring, and a heating element. The liquid is heated to produce an aerosol, which is inhaled by the user.

E-cigarettes are generally considered safer than tobacco, since they do not contain any tar, or other burning substances, which are the primary causes of cancer. They have not, however, been tested for long-term safety and some people are concerned that some of the liquids used may cause other health risks. In addition, although people have been successful in using them to stop smoking, they have not formally been tested for this purpose. Since there is only a small amount of evidence around their efficacy and risks, health professionals are advised to only recommend

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licensed products for smoking cessation. However, where a patient is unable or unwilling to use, or continue to use, a licensed product, health professionals may advise patients that while e-cigarettes are unregulated and their safety cannot be assured, they are likely to be a lower-risk option than continuing to smoke.

It is also important to note that, since these devices contain a heating element, there is the potential for misuse either for self-harm or for fire starting.

Smoking cessation in special groups Pregnancy Smoking cessation in pregnancy is the single greatest intervention to improve outcomes. Since nicotine passes through to an unborn foetus, smoking cessation without the use of any smoking cessation product is the recommended strategy. In some cases, this may not be achievable, and so pharmacological support is required. Bupropion and varenicline are not licensed in pregnancy, so NRT is the only recommended option. NRT should not be used, however, in pregnant patients who are planning to continue to smoke, as this may produce high nicotine levels which could be damaging.

Patients should be advised that the risks from nicotine exposure from NRT are likely to be less than those from continuing smoking. Where a pregnant woman would like to use NRT, steps should be taken to reduce the exposure to nicotine. A PRN product can be used so that exposure to nicotine is only intermittent or, if a patch is used, it should be removed at bedtime. If a pregnant woman cannot stop smoking while on NRT, the prescription should be stopped, with support offered to encourage smoking cessation later in the pregnancy.

Young people Although it is illegal to sell cigarettes to a person under the age of 18, and tobacco can be seized by police from anyone under the age of 16, many young people smoke. Ideally, smokers under 18 years of age should be encouraged to quit without pharmacological support. However, if required, NRT is licensed for use in patients aged over 12 years of age, and so can be used in this patient group. The doses used should be the same as for adults, as the doses of nicotine they are replacing is the same.

Interactions with medication When smoke enters the body it produces cytochrome P450 enzymes in the liver to break it down. These enzymes are also used to break down some medicines. This means that some medicines are broken down at a quicker rate in smokers than non-smokers, and thus smokers require higher doses.

When someone stops smoking, the liver slows its production of cytochrome P450 enzymes. This can cause levels of medicines to rise once a person stops smoking.

It is important to note that it is the effect of the smoke on the lungs that causes this – not the nicotine – and so patients on NRT still go back to non-smoker levels once they stop smoking. In addition, people who do not smoke their tobacco (e.g. snuff users) do not experience this problem.

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Drugs with established evidence of interaction and clinical significance

Drugs with conflicting evidence of interaction or low clinical significance

Clozapine – High relevance

The most important of these drugs is clozapine. Clozapine levels in the blood in smokers can be half what they are in non-smokers. However, when a person stops smoking, the level quickly begins to rise up to the level of a non-smoker.

If the dose is not adjusted, patients can develop side effects, such as drowsiness, low blood pressure and even seizures.

Fortunately, it is possible to do a blood test to see how much clozapine is in the blood at a given time. It is recommended that this is done regularly for patients who stop smoking when taking clozapine, to ensure the level is kept at a therapeutic, but not toxic, level.

MonitoringSerum levels should be monitored before stopping smoking, a week after stopping smoking and upon each dosage decrease thereafter. Doses should be reduced by a suggested 25% in the first week after quitting.

Olanzapine – High relevance

Monitoring Patients should be monitored for signs of increased adverse effects, such as dizziness, drowsiness and hypotension, through regular observations and increased blood pressure monitoring. Doses

should be reduced by a suggested 25% in the first week after quitting.

Agomelatine Aminophylline Beta blockers (atenolol, propranolol) Chlorpromazine Cimetidine Clozapine

Diazepam Duloxetine Erlotinib Flecainide Fluphenazine Haloperidol

Olanzapine Ranitidine Rivastigmine Ropinirole Theophylline Warfarin

Antidiabetic drugs (gliclazide, glibenclamide, metformin and insulin) Benzodiazepines (diazepam, lorazepam, oxazepam)

Fluvoxamine Frovatriptan Irinotecan Naratriptan

Tricyclic antidepressants (amitriptyline,clomipramine, imipramine) Zolpidem

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Theophylline – High relevance

Monitoring Plasma levels should be monitored and doses adjusted accordingly. Doses will probably need reducing by 33%-25% of the initial amount. Patients should be monitored for, and asked to report, signs of toxicity such as palpitations and nausea.

Chlorpromazine – Moderate relevance

Monitoring Patients should be monitored for signs of increased adverse effects, such as dizziness, sedation and increased extrapyramidal symptoms. It is helpful to complete a side effect monitoring scale before quitting to establish a baseline, and after quitting to monitor for adverse effects as the therapy continues.

Warfarin – Moderate relevance

Monitoring Patients should have their international normalised ratio (INR) monitored closely, as this is expected to increase upon cessation of smoking.

Methadone – Moderate relevance

Monitoring Patients should be monitored for opiate toxicity and have their doses reduced accordingly. Note: Since methadone can reduce the severity of nicotine withdrawal symptoms, it is preferable not to rapidly decrease methadone doses, when commencing a smoking cessation regime.

Insulin – Moderate relevance

MonitoringPatients should be advised that if they stop smoking, their dosage of insulin may need to be reduced. Patients and staff must be alert to the signs of hypoglycaemia, and should test the patient’s blood glucose more frequently during the smoking cessation process.

Tips for increasing rates of smoking cessation

• Regularly discuss stopping smoking with the patient to assess their feeling about it – if they do not feel immediately ready consider providing NRT while they cut down their smoking.

• Ensure all staff are aware of the benefits of smoking cessation. Offer support to members of staff who wish to stop smoking.

• Have staff on site specifically trained in smoking cessation, who can advise smokers on the available products to aid stopping. Organisations such as the National Centre for Smoking

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Regularly discuss stopping smoking with the patient to assess their feeling about it – if they do not feel immediately ready, consider providing NRT while they cut down on their smoking.Ensure all staff are aware of the benefits of smoking cessation. Offer support to members of staff who wish to stop smoking.

•

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Have staff on site specifically trained in smoking cessation, so they can advise smokers on the products available to aid stopping. Organisations such as the National Centre for Smoking Cessation and Training (http://ncsct.co.uk) can assist with training staff.

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Useful tools and resources

1. NICE Quality Standard, ‘Smoking: reducing tobacco use’ (QS82). Published date: March 2015.www.nice.org.uk/guidance/qs82

2. NICE Quality Standard, ‘Smoking: harm reduction’ (QS92).www.nice.org.uk/guidance/qs92

3. NICE Guidance, ‘Smoking cessation in secondary care: acute, maternity and mental health services’.https://www.nice.org.uk/guidance/ph48

4. Baseline assessment for setting-up a smoking cessation program. PH48 ‘Smoking cessation in secondary care: acute, maternity and mental health services’ – baseline assessment tool. Link: http://bit.ly/1P9b3RK

5. Related guidance• NICE Quality Standard, ‘Smoking cessation: supporting people to stop smoking’ (QS43).• NICE Quality Standard ‘Antenatal care’ (QS22).• NICE Quality Standard ‘Chronic obstructive pulmonary disease’ (COPD) (QS10).

6. Promotional materials NHS Smokefree (http://www.nhs.uk/smokefree)

7. Training for staff National Centre for Smoking Cessation and Training (http://elearning.ncsct.co.uk/)

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Ensure people know what to expect. For the first few days, they may develop a cough as the lungs clear out some of the debris. Some people use this cough as a reason to start smoking again. Also, if medication is used to aid smoking cessation, ensure that any potential adverse effects are explained. Common side effects of NRT are: systemic reactions similar to nicotine withdrawal on initiation (malaise, headache, sleep disturbance, depression, irritability, etc.). Oral and inhaled preparations may cause irritation of the throat. Gastrointestinal side effects are also common (nausea, vomiting, dyspepsia or hiccups). Palpitations may occur.Ensure problems with medication are resolved quickly. Some people find the glue in the patches can irritate the skin; changing to the ‘clear’ patch can sometimes prevent this. Where side effects are encountered, medication should be reviewed promptly and changed or adjusted as required. The gum may stick to and damage dentures. If this occurs, consider another available preparation.

Measure carbon monoxide levels on a weekly basis, so patients have a measure of the progress they are making.

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Cost effective choices for smoking cessation

Nicotine replacement: transdermal patches

Nicotine replacement: inhalation devices

Oral nicotine substitutes

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Please note: To check the latest prices for the products listed above, please log-in to your online ordering account:http://orders.ashtonshospitalpharmacy.com/

Cost Effective Choices for Smoking Cessation.

Nicotine Replacement Transdermal Patches

Order Drug Name Notes Unit Cost (£) 3745403

NIQUITIN 21MG PRE QUIT CLEAR 7

24 hours 10.47

2728004

NIQUITIN CQ PATCHES CLEAR 14MG 7

24 hours 10.47

2728012


24 hours 10.47

0915181

NICOTINELL TTS 30 PATCHES 21MG 7

24 hours (may disturb sleep)

10.47

0909374



9.87

0909358



9.57

Nicotine Replacement Inhalation Devices


NICORETTE INHALATOR 15MG 4

Use only to replace lost inhalator devices

4.48

3649209


Replaces hand-to-mouth action 15.86

2118545

NICORETTE NASAL SPRAY 10ML

Useful for heavy smokers 19.32

3598349

NICORETTE QUICKMIST 1MG SPRAY

Quick response to cravings 12.73

Oral Nicotine Substitutes


NIQUITIN CQ GUM 4MG MINT 96

Not approved for forensic sites 8.97

2623809

NICOTINELL GUM 4MG FRUIT 96

Not approved for forensic sites (alternate flavour)

10.77

2885200



3471497

NIQUITIN CQ MINIS 4MG LOZENGES MINT 60

Releases 3 x faster than gum. For smokers who smoke > 20 cigs

10.04

3568896

NIQUITIN MINIS CHERRY 1.5MG LOZENGES 60

Releases 3 x faster than gum. For smokers who smoke < 20 cigs

9.38

3224078

NICORETTE MICROTAB 2MG 100

Small tablets which are designed to dissolve under the tongue

13.78

2963866

NICOTINELL LOZENGES 2MG MINT 96

For smokers who smoke > 20-30 cigs 11.13

2644615


For smokers who smoke < 20 cigs 9.57

3798113

NIQUITIN STRIPS MINT 2.5MG 60

Relieves craving in 50 seconds 11.39



Order Drug Name Notes Unit Cost (£)* 3745403


16 hours 10.47

2728004


16 hours 10.47

2728012


16 hours 10.47

0915181



10.47

0909374



9.87

0909358



9.57





4.48

3649209



2118545



3598349







2623809



10.77

2885200



3471497



10.04

3568896



9.38

3224078



13.78

2963866



2644615



3798113







16 hours 10.47

2728004


16 hours 10.47

2728012


16 hours 10.47

0915181



10.47

0909374



9.87

0909358



9.57





4.48

3649209



2118545



3598349







2623809



10.77

2885200



3471497



10.04

3568896



9.38

3224078



13.78

2963866



2644615



3798113





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Tel: 0345 222 3550

www.ashtonshospitalpharmacy.com

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