Elaine Londesborough-van Rooyen, Public Health Registrar at Action on Smoking and Health (ASH), and Joanna Feeney, Stop Smoking Systems Strategic Manager at Fresh, provide an update on evidence-based smoking cessation approaches and describe how newly available medications can support the progress of Stop Smoking services
The government at Westminster has committed to creating a smoke-free generation through the Tobacco and Vapes Bill, currently passing through parliament. This will make it illegal to sell tobacco products to anyone born after January 2009, preventing the next generation from becoming addicted to tobacco.
This ambition is admirable, but we mustn’t forget the 6 million people who still smoke in the UK. Tobacco is the UK’s leading cause of premature death and preventable ill health, and the single largest driver of health inequalities in England.
In recent years, we have seen a shift from smoking being seen as a lifestyle choice to it being recognised as a long-term chronic condition. Treating tobacco dependency is a clinical priority, and the good news is that there are effective evidence-based stop smoking aids, with even more options now available.
How effective are Stop Smoking services?
At ASH we regularly talk to Stop Smoking services around the country. They tell us that sometimes people don’t understand how these services can help them to quit smoking, or feel that the ‘right’ way to quit is by going ‘cold turkey’.
However, once people are through the door, they find that Stop Smoking services provide free, friendly support and encouragement to help them stop. These services provide evidence-based stop smoking aids to manage withdrawal symptoms and behavioural support to develop quit plans and track progress. All of this means that people are three times more likely to quit for good with support from a Stop Smoking service.
Services closely with individuals to understand their goals and support them with options they are comfortable with, which may include behavioural support, Nicotine Replacement Therapy (NRT) and access to e-cigarettes/vapes as well as smoking cessation medications. And now we have two additional tools in the box – the stop smoking medications varenicline and cytisine.
How do these two stop smoking medications fit in?
Varenicline and cytisine (also known as cytisinicline) are nicotine analogues, so unlike NRT or vapes they do not contain nicotine but instead work on the nicotine receptors in the brain to reduce withdrawal symptoms and reduce satisfaction from smoking.
Cytisine is new in the UK, while varenicline was previously available until 2021 under the trade name Champix, and is now back on the market as a generic medication.
A 2023 Cochrane review found that vapes, varenicline and cytisine are the most effective stop smoking aids available. This review pulled together studies that collectively included over 150,000 people and found that the medications more than doubled the success of quit attempts compared to not using any aids.
While vapes and NRT can be very effective, we know that for some people the use of a smoking cessation medication like varenicline or cytisine is what helps them to quit for good. A recent study estimated that thousands of people missed the opportunity to quit due to varenicline (Champix) being taken out of the market in 2021.
Both varenicline and cytisine are approved for use in the UK as stop smoking aids for people over the age of 18. They are both now recommended for use by the National Institute for Health and Care Excellent (NICE) as part of overall treatment plans for tobacco dependence. While they do essentially the same thing, they have slightly different contraindications and course lengths. For example, varenicline has a recommended course of 12 weeks whereas cytisine is 25 days, and cytisine is not recommended for those aged over 65 years whereas varenicline has no upper age range. It’s important for Stop Smoking advisors to work closely with people to identify what would work best for them.
How are these medications being rolled out?
ASH recently hosted a webinar on the roll out of varenicline and cytisine, covering some key challenges and solutions. It was clear from the response that passionate practitioners up and down the country are keen to support people to access these life-saving medications and what’s needed is the support to act on this.
Varenicline and cytisine are prescription-only medications and so they can only be issued via a prescription or a Patient Group Directive (PDG). Local authorities in some areas across the country are still negotiating terms for prescribing varenicline and cytisine as part of Stop Smoking services. However, the aim is for all such services and Stop Smoking advisors to offer varenicline and cytisine as the standard.
There have been some challenges with supply of the medications and so it is essential for services to collaborate with community pharmacies and Local Pharmaceutical Committees (LPC), who can work with wholesalers to ensure that availability of medication is not a barrier to providing the most effective treatment options.
There have also been some concerns about whether the medications are safe and effective for people with mental health conditions. However, the EAGLES study found that there was no significant difference in adverse events when use of varenicline was compared to nicotine patches or a placebo. Given the compounding health inequalities of mental health and smoking it is essential that those with severe mental illness have access to the most effective medications.
The National Centre for Smoking Cessation and Training (NCSCT) have updated their commissioning, delivery and monitoring guidance for Stop Smoking services and provided training resources on the new medications.
What now?
Too many of our friends, family and colleagues are still dying from tobacco dependency. This is everyone’s problem and as the Royal College of Physicians has argued: ‘Failure to identify and treat smokers is no less negligent than failure to identify and treat patients with cancer.’
Varenicline and cytisine becoming available provides a new opportunity to move faster towards a smokefree future. While there are challenges, by working together and learning from one another we can make sure that people with tobacco dependency are offered the best possible treatment in all our communities.
Elaine Londesborough-van Rooyen is a Public Health Registrar currently on placement at ASH and Joanna Feeney is Stop Smoking Systems Strategic Manager at Fresh
