Time to quit? Seek support to succeed!

No, I’m not talking about jacking in the day job! The focus of this week’s blog is smoking cessation, with a new update to the NICE guideline  NG209 just released. The health benefits of stopping smoking are abundantly clear, and many patients would like to stop. We know those with support are more likely to succeed. So, what does the update add to our arsenal?

NICE have reviewed and approved a new medication for treating tobacco dependence: cytisinicline, otherwise known as cytisine (brand and generic name in the UK).

So what is cytisine? It is a selective partial agonist to the α4β2 nicotinic acetylcholine receptor. Similarly to the more widely known Champix (varenicline), it stimulates the receptor involved in nicotine addiction enough to treat cravings, but blocks full activation. This means that if someone has a lapse and smokes a cigarette whilst on treatment, they are less likely to feel a benefit, and therefore less likely to spiral into a full relapse. 

Hang on a minute, some of our European colleagues may be thinking, this medication has been around for ages! As discussed in this helpful guide from the National Centre for Smoking Cessation and Training, cytisine was invented in the 50’s, and has been widely used in parts of central and Eastern Europe for decades. However, until January 24 it was not available in the UK. So, although new to the UK market, it is a well established treatment with lots of real world use.

What’s triggered the recent arrival? You may recall that Champix (varenicline) was withdrawn in 2021 following concerns over impurities (MRHA alert 2021). This led to a greater interest in the use of cytisine as an alternative (BMJ 2024). Notably, varenicline is now off patent and back in the game as a generic (NHS England).

What is the evidence that cytisine works? A Cochrane analysis including over 150,000 smokers identified cytisine, varenicline and E-cigarettes as the ‘most effective stop-smoking aids’ (Cochrane 2023).  For every 100 people treated with each aid, 10-18 are likely to successfully quit (defined as going a least 6 months without smoking) using cytisine. 10 - 19 are successful using an e‐cigarette; and 12 - 16 using varenicline. This is roughly double the likelihood of quitting without any aid (6 in 100). The DTB drug review discussed evidence from multiple RCTs in different populations supporting the efficacy of cytisine. 

As ever there are some important considerations to be aware of. Unfortunately cytisine is contraindicated in a number of high risk patient groups that may be especially motived to quit smoking; namely those with unstable angina, recent MI, recent stroke, and pregnant or breast feeding patients (see here for SmPC).  Frustratingly there is no clear definition of ‘recent’ here, implying a need for clinical judgement. 

Licenced treatment duration is 25 days, and the dosing regime is a bit intense initially: one tablet every 2 hours (max 6 tablets daily), gradually tapering to 2 tablets/day (see helpful visual summary from NCSCT). Side effects include nausea and insomnia. It is also worth noting that barrier methods should be used in addition to systemic contraception whilst on treatment.

Nevertheless, it offers a great evidence-based addition to the options for treatment of tobacco dependence, alongside the welcome return of varenicline. We can advise patients that use of cytisine or varenicline is more likely to result in successfully quitting smoking. NICE stress the importance of offering behaviour support alongside all treatments for smoking cessation. Ideally treatment should include referral to specialist stop smoking services, as evidence shows people are 3 times more likely to quit than if unaided (NCSCT). 

Click here for a reminder on delivering Very Brief Advice on Smoking: ‘30 seconds to save a life’