Quit Insights Clinical Series Podcast with Dr Cora Mayer, Quit Centre GP Lead and practising GP, about key pharmacological approaches to smoking cessation using case studies. We hope this will assist GPs and other clinicians in making decisions about cessation treatment.
This podcast and article are intended for health professionals and are for educational and informational purposes only. The content discussed does not constitute medical, legal, or professional advice and should not replace your own clinical judgment.
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What are some important considerations around prescribing pharmacotherapy when treating patients for smoking cessation?
There are quite a few things to consider when prescribing pharmacotherapy for smoking cessation. This might include contraindications for each medication, precautions, practice points, and safety for use in pregnancy and breastfeeding.
I thought it would be useful to go through some “theoretical” clinical scenarios to highlight some of these points.
Let’s examine the case studies, (noting that these are not real patients).
Our first case is about pregnancy and lactation?
Yes, Sarah comes to see you for antenatal care. She is 29 and recently had a normal 20-week ultrasound result. She quit smoking “cold turkey” in her first trimester, which she was able to do because cigarettes were making her feel nauseous, but lapsed after the nausea settled in her second trimester. She smokes 10-15 cigarettes a day, starting soon after getting out of bed. She would like to quit again but needs help. She plans to breastfeed.
Firstly, Quit and the Royal Women’s Hospital in Melbourne have collaborated on a fantastic guideline called Supporting Smoking Cessation in pregnancy and breast feeding our website. This is a great resource to help guide decision making with a pregnant or breastfeeding patient.
So, according to the Heaviness of smoking index that’s in those guidelines, her score puts her into the moderate nicotine dependence range.
This means you would offer a referral for multi-session behavioural intervention (e.g. Quitline), plus or minus faster-acting form of nicotine replacement therapy, if appropriate, such as nicotine gum. If cravings or withdrawal symptoms are not controlled with that, you could consider adding a nicotine patch.
So could you give us examples of the clinical considerations in this case?
You might start with looking at Sarah’s history, and reviewing existing medications to see if there are interactions with NRT. She is only taking a pregnancy supplement, so you could look at contraindications next – for instance, if Sarah had phenylketonuria, you would use a faster-acting NRT form without artificial sweetener that contains aspartame (phenylalanine).
NRT can be used in pregnancy when behavioural strategies alone aren’t enough, but it should be used at the lowest effective dose and for the shortest duration, in line with the guideline.
You can also consider avoiding mouth spray because of its small amount of alcohol content.
If you’ve decided to add a patch, the guideline also, for instance, recommends removing nicotine patches at bedtime to reduce fetal nicotine exposure.
If Sarah in this example, rather than being pregnant, was already postpartum and breastfeeding and smoking, you could counsel her that faster-acting NRT is preferred, with guidance to breastfeed first, then use the NRT immediately afterwards.
What other points would you consider in selecting and discussing pharmacotherapy? Can you give some examples?
Sarah may still be experiencing nausea in pregnancy, so we might consider that faster-acting NRT can worsen nausea, reflux, and vomiting.
So we’d give clear counselling on correct use to minimise swallowing nicotine.
Patch suitability also needs review: generalised skin disease, cholestasis, and pregnancy-related dermatoses may limit patch use.
If we eventually decide to choose combination NRT, we might use:
- A patch during the day only
- Faster-acting NRT (gum or lozenge) for breakthrough cravings.
And for the example of someone breastfeeding, you might consider breastfeeding, using a faster-acting NRT and waiting 2–3 hours before the next feed to minimise exposure in the breastfed infant.
Nicotine vapes are not recommended in pregnancy or breastfeeding. Other cessation medications such as varenicline and bupropion are also currently not recommended in pregnancy or breastfeeding.
What are the key messages for clinicians here?
Non-pharmacological interventions such as multi-session behavioural intervention from Quitline are recommended as first-line therapy in pregnancy and breastfeeding.
NRT remains a safe and effective choice in pregnancy when used with care. And in lactation, starting NRT is not a reason to stop breastfeeding.
Case 2 – someone with cardiovascular disease and high nicotine dependence
Let’s talk about Omar. He is 58 and has a history of myocardial infarction, hypertension, and type 2 diabetes. He smokes around 20 cigarettes a day and is interested in “whatever works the fastest” to help him quit.
What would the clinical considerations be for Omar?
The clinical considerations here include caution with NRT in individuals with recent MI, unstable angina, severe arrhythmias, or recent cerebrovascular events
In these cases, we need to balance vasoconstriction risk with the much higher risk of continued smoking.
We have a fact sheet on Smoking and Cardiovascular disease which can also provide additional guidance.
So, NRT can be used safely in patients with stable cardiovascular disease. In patients who have had a recent cardiovascular event, NRT can be considered under medical supervision.
In relation to using varenicline, current evidence shows that any potential increase in cardiovascular risk is small and clinically insignificant, with benefits outweighing risks.
Patients should be advised to seek medical attention in the event of new or worsening cardiovascular symptoms or if they experience signs and symptoms of myocardial infarction or stroke.
In relation to Bupropion, it can raise blood pressure, which should be monitored. Caution should be exercised in patients with Brugada syndrome, risk factors such as family history of cardiac arrest or sudden death, and in those with recent myocardial infarction or unstable heart disease.
Omar’s diabetes also matters: There might be a possible decrease in insulin absorption because of peripheral vasoconstriction from NRT. Smoking may also increase insulin resistance. So this means he might require more frequent glucose monitoring and dose adjustment, if clinically appropriate.
With bupropion there is an increased risk of seizures occurring with its use, so if there are predisposing risk factors such as diabetes treated with hypoglycaemics or insulin this is also something to consider, as they could lower the seizure threshold.
How would you select pharmacotherapy here?
You might use the NRT tool on our website to guide initial NRT dosing. This asks you to enter when he starts smoking in the day, whether it’s within 30 min of waking or longer, and how many cigarettes a day he smokes.
In Omar’s case you might consider a patch plus a faster-acting form such as sugar-free gum or lozenge, or mouth spray. The nicotine patches are subsidised on the PBS.
If you thought varenicline might be an option we need to counsel about new or worsening cardiovascular symptoms and the need for rapid medical review if they occur.
There are no known clinically significant drug interactions with varenicline. This is helpful for someone like Omar who might be on a number of medications for his conditions.
But we need to check that he does not have severe renal impairment, because varenicline requires dose reduction if creatinine clearance is less than 30 ml per minute It’s not recommended in end stage renal disease.
Another point about varenicline are the current authority criteria:
The patient must be undergoing concurrent counselling for smoking cessation through a comprehensive support and counselling program, or start it at the time of prescribing.
A good way of doing this is to do a referral to Quitline, which is easy and quick to do with the referral form on the website.
Having considered all of this information, what do you think a possible plan for Omar might be?
- Refer to for behavioural counselling such as Quitline
- Review drug interactions, contraindications, precautions and practice points
- Consider NRT: patches and faster-acting
- Consider varenicline if appropriate
- Closely monitor any cardiovascular symptoms
- Follow-up regularly
Now case 3 - a patient with complex drug Interactions and mental health history
Let’s discuss Matt. He is 36, smokes 15 cigarettes per day, and lives with depression, currently stable and treated with sertraline (SSRI). He binge drinks alcohol on some weekends but denies other drug use. He previously tried to quit using NRT and varenicline. He asks about bupropion.
Clinical considerations
Prescribing for patients with mental health conditions, particularly those on medications, can be an area that people can find a bit tricky.
Let’s start by looking at bupropion, which has a number of interactions and cautions.
Drug interactions
Bupropion interacts with:
- Specifically with SSRIs and SNRIs, with increased risk of serotonin syndrome
- Drugs that lower the seizure threshold including some antidepressant and antipsychotic medications
- Drugs metabolised by the cytochrome P450 enzymes, again including some antidepressant and antipsychotic medications
- Alcohol, which increases CNS adverse effects
- And quite a large range of other drugs.
Some of the contraindications to using Bupropion include:
- Current or past seizure disorders
- Eating disorders
- With Monoamine oxidase inhibitor use
Precautions include
- Bipolar disorder risk, as it may precipitate mania – so we would need to make sure his depression diagnosis is correct
- Hepatic or renal impairment, which may require dose changes – this is relevant as Matt appears to be drinking a fair bit of alcohol. Bupropion also interacts with alcohol.
How would you go about selecting pharmacotherapy for Matt?
Because Matt is taking an SSRI, bupropion is higher risk because of serotonin syndrome potential.
Trying NRT again is an option, making sure he is taking the correct dose and using it correctly.
Using or adding in Varenicline is an option, but there a few things to consider.
- It is important here to talk about the use of varenicline and also bupropion in people with stable mental health conditions.
The EAGLES trial published in the Lancet in 2016 did not show a significant increase in neuropsychiatric adverse events attributable to varenicline or bupropion relative to nicotine patch or placebo.
- However, it is still recommended to monitor patients taking varenicline for mood changes, depression, or suicidal thoughts
- Drinking alcohol may increase the risk of experiencing neuropsychiatric events during treatment with Varenicline – this is an important consideration in this case
- Just an extra point to mention is that varenicline also has a precaution for patients with seizure disorders. This isn’t relevant to Matt in particular but would be relevant for anyone with a seizure history and I’m mentioning it because Bupropion is contraindicated for this reason, and I wanted to note that we need to consider a seizure history with varenicline as well.
What plan would you formulate for this patient?
You could consider:
- Avoiding bupropion due to interaction with sertraline and alcohol, and perhaps psychiatric history, noting that it has a more extensive interaction and contraindication profile, making it unsuitable for some patients.
- Consider using combination NRT correctly, or varenicline with close monitoring, noting that NRT would be the safest option for him, especially first line
- Consider engaging his mental health clinician as part of the quitting plan
- Actively referring for behavioural counselling such as Quitline, noting that it offers a tailored service for those with mental health conditions
Can you summarise some of the important points here?
1. Choosing the right pharmacotherapy means tailoring it to for instance the patient’s medical and psychiatric history, and medication profile.
2. NRT can be used in many clinical situations and is suitable in pregnancy and breastfeeding.
3. Varenicline has no currently known clinically meaningful drug interactions, but requires monitoring for things like mood and cardiovascular symptoms.
4. Bupropion has a more complex interaction and contraindication profile.
Another point is that:
5. Behavioural support maximises likelihood of quitting no matter which medicine is chosen.
These cases cover smoking cessation. What about vaping cessation?
I have focussed on smoking cessation, because evidence for the use of pharmacotherapies for vaping cessation is more limited, especially in young people.
NRT and varenicline could be used for adults and NRT for adolescents where appropriate, but many are off-label for vaping, so these cases are focused on smoking where there is strong evidence. Again, behavioural support and counselling is a first line recommendation, and can be used for vaping cessation and be tailored for young people.
What about therapeutic vapes?
RACGP guidelines don’t recommend vaping products as a first-line treatment for smoking cessation, with strongest evidence supporting approved medications combined with behavioural support.
While therapeutic vapes may be considered for some people who have not succeeded with other treatments, they are not TGA approved therapeutic goods, so their safety, quality and efficacy can’t be guaranteed.
What about drug interactions and smoking?
We have some helpful information on our website about drug interactions and smoking.
Other than interactions between existing medications and smoking cessation pharmacotherapies, there are also interactions between tobacco smoke and drugs. In most cases the cause of these drug interactions is not the nicotine, but actually the polycyclic aromatic hydrocarbons in tobacco smoke.
People should be regularly monitored with regard to their smoking status and extent of cigarette consumption, and doses of relevant drugs should be adjusted accordingly.
As well as information on drug interactions and smoking, where can clinicians get more information on smoking cessation pharmacotherapy considerations, such as those we’ve talked about?
We have heard from clinicians that it would be great to have a resource that helps to make this information clear and available in one place. We are currently developing this and it will be available on our website. It will contain sections on drug interactions, contraindications, precautions and practice points, as well as use in pregnancy and breastfeeding. I’m really looking forward to making this available to health professionals.
We thank our guest Dr Cora Mayer, for these comprehensive case studies and valuable information.
Further information
Quit Centre
Research
Tobacco in Australia: Facts & Issues