"I want to stop smoking"

Hardly any resolution is made as often – and postponed as often – as stopping smoking. On average it takes several attempts before it succeeds. The community pharmacy is an ideal first port of call: low-threshold, competent and with access to effective products. What is decisive is the right combination: behavioural support and pharmacotherapy together raise the abstinence rate considerably more than either measure alone.[1]

Medical background: what nicotine does in the brain

Nicotine is an agonist at the nicotinic acetylcholine receptors in the central and peripheral nervous system. Through the release of dopamine and serotonin it acts psychoactively, stimulating, relaxing and anxiolytically – the basis of the rapid, strong reinforcement and thus of dependence.[8] On abrupt withdrawal, restlessness, irritability, sleep disturbances, concentration problems, low mood and ravenous hunger threaten.[8]

Central to the consultation is a distinction that surprises many: nicotine causes dependence, but other constituents of tobacco smoke are responsible for the serious damage – the carcinogenic tar and the carbon monoxide that impedes oxygen transport in the blood.[2] This message takes the fear out of controlled nicotine delivery via replacement therapy and is a strong argument in conversation.

The body recovers: the timeline

The health benefit sets in almost immediately and lasts for decades – a strong motivational argument for the conversation.[11]

The conversation: brief intervention along the five A’s

A structured brief consultation can be implemented even in everyday counter work. The model of the five A’s has proved itself, addressing readiness to change specifically and avoiding pressure.

A practical note on approach: a fixed stop date with complete abstinence is usually more successful than slowly “tapering off” consumption.[4] For further support the pharmacy points to the Swiss services: the structured pharmacy smoking cessation counselling, the smoking cessation line (0848 000 181) and internet-based programmes such as stopsmoking.ch.[10]

Nicotine replacement therapy: the foundation at the counter

Nicotine replacement therapy (NRT) supplies the body with nicotine in a controlled way – without tar and carbon monoxide – and thus mitigates withdrawal symptoms. It is available without prescription and roughly doubles the chance of success.[6] Important for the choice is the differing action profile of the dosage forms.

The most effective NRT approach is the combination: a patch covers the baseline need, a fast-acting preparation (gum, spray or inhaler) catches acute craving attacks. This is particularly sensible in strong dependence and is comparable in effectiveness to varenicline.[5] [1] Patch strength is guided by previous consumption (highest dose at more than 20 cigarettes a day), with stepwise reduction over around twelve weeks.[4]

Two reassurances for the conversation: nicotine from NRT reaches the brain considerably more slowly than when smoking and therefore hardly causes dependence.[4] And even if someone reaches for a cigarette once during ongoing NRT, no dangerous overdose is to be expected – this information noticeably improves adherence.[5]

Prescription-only options

Varenicline (Champix) is a partial agonist at the nicotinic receptor and is regarded – alongside combination NRT – as first choice.[1] It is titrated up (days 1–3: 0.5 mg once daily; days 4–7: 0.5 mg twice daily; from day 8: 1 mg twice daily) and started one to two weeks before the stop date; therapy usually lasts twelve weeks.[7] Nausea, headache and unusual dreams are frequent. Earlier warnings about neuropsychiatric risks were not confirmed by later analyses – nonetheless, careful weighing remains indicated where there is a relevant history.[1]

Cytisine is a natural alkaloid of the golden rain tree and acts similarly to varenicline. In Switzerland it is not approved, but it can be prescribed medically and obtained through the pharmacy (e.g. Asmoken, Tabex); it is taken according to a descending 25-day regimen. Its effectiveness is comparable to that of varenicline.[3] [9]

Bupropion (Zyban) is a prescription-only alternative, somewhat less effective than varenicline but combinable with NRT; the lowered seizure threshold must be borne in mind.[1] A note on cost coverage: in Switzerland the costs of varenicline or bupropion can, under certain conditions, be covered by the health insurer once within 18 months.[1]

E-cigarette: effective, but with reservations

Studies show effectiveness for the e-cigarette at the level of the most effective methods. The Swiss professional recommendation nonetheless positions it as second choice – to be used via specialised shops and with refillable rather than disposable devices – since long-term data and product purity are heterogeneous.[2] It remains an option for people for whom established methods have failed.

Particular patient groups

Some constellations call for adapted counselling.

Pregnant and breastfeeding women: stopping smoking is particularly important here. First choice is behavioural support; pharmacological options come into consideration only after a medical risk-benefit assessment – varenicline and bupropion are not recommended, and NRT only under medical supervision and preferably in a short-acting form.[8]

Cardiovascular patients: here in particular the benefit is enormous. NRT is safe even in stable coronary heart disease, and for varenicline large studies showed no increased cardiovascular risks – investigated even shortly after an acute coronary syndrome.[1]

Psychiatric patients: the smoking rate is markedly higher. Important to know: stopping smoking does not worsen mental health; varenicline and bupropion can be used with monitoring.[1] A pharmaceutically central peculiarity here concerns medicine levels (see box).

Weight gain: a moderate increase is frequent – after stopping smoking around 200 kcal fewer are burned daily. The health benefit far outweighs it, however; with exercise and a balanced diet it can be limited. Raising the subject proactively prevents relapses.[14]

The options at a glance

Relative risk (RR) for abstinence versus no intervention; rounded values from reviews on tobacco cessation. [2]