This guideline will really change how we manage smoking cessation. Until now the emphasis has been on getting patients to stop smoking. This guideline recognizes the fact that although the nicotine is the addictive part of the cigarette, it is not the really harmful part.
Many patients will be ready to try to stop smoking and that is still what we should promote as a first-line. However, many patients do not want to give up nicotine, or want to cut down instead. Cutting down can then induce ‘compensatory smoking’ where patients increase the amount of toxins they inhale from each cigarette, so although they are smoking fewer cigarettes, they are not reducing their toxin intake that much.
So what options can we promote?
- Stop smoking!
- Cut-down. To avoid compensatory smoking, consider using NRT alongside cigarettes. Patients can cut down with an intent to stop smoking, or without an intent to stop completely. Both can be encouraged as all patients who cut down have a higher chance of stopping smoking in the long term, even if they don’t initially intend to.
- Temporary abstinence. Patients can use NRT for short breaks off cigarettes.
What products can be advised?
MHRA regulated NRT. Electronic cigarettes aren’t regulated at the moment (but will be in the future). We can advise patients who wish to use them that as they are not regulated, their quality and safety can not be guaranteed, though it is likely that they are better than smoking.
So what should we do?
- Use NRT and keep using NRT for as long as it is needed. There is safety data for up to 5 years of use and expert opinion is that it is likely to be safe for the longer term too.
- It is cost-effective to prescribe the NRT, rather than have people smoking, even in the long term.
In practice, I’m not sure how this will work. Surely there will be a huge upfront burden to be continually prescribing NRT to patients? I would also be concerned about the potential for some patients to sell-on products that they no longer need. I would also be concerned that if patients know that they can be prescribedNRT for the long term, that they may have less incentive to stop. That’s just my thoughts!