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Q&A: NICE guidance on harm-reduction approaches to smoking

What is the purpose of the new NICE guidance?

To give people who cannot or refuse to give up smoking in one step help to cut down on smoking. These may be people who:

- are not able, or do not want to stop smoking in one step

- want to stop smoking but without necessarily giving up nicotine

- are not ready to stop smoking, but want to reduce the amount they smoke

What is does the evidence show?

The guidance is based on evidence showing ‘harm reduction’ approaches - behavioural techniques with or without nicotine replacement therapy (NRT) - help to reduce harm from cigarette smoke to the person and those around them and increase their chance of quitting long-term.

Importantly, people who reduce their smoking are more likely to quit in the future, especially if they use NRT to help cut down, even if they do not initially intend to quit completely.

By controlling acute withdrawal symptoms, NRT can stop people inhaling more deeply to compensate for smoking fewer cigarettes.

What should GPs do?

GPs should still advise all smokers that the best way to reduce their harm from smoking and quit for good is to stop smoking in one step.

But they should now offer help to reduce smoking, which includes prescribing licensed forms of NRT, to people who say they do not want to quit or feel they are not ready to.

They should explain to patients that NRT products have been shown to be safe to use for at least five years and will help make it easier for them to cut down, avoid compensatory smoking and increase their chance of stopping altogether.

Also, there is no evidence NRT will increase addiction to nicotine in people who continue to smoke – NRT delivers much lower levels of nicotine and so is less addictive than smoking tobacco.

People should receive support to work out what level of nicotine they need, but there is no evidence of a risk of ‘overdosing’ on nicotine.

What NRT products should be recommended?

Those products with MHRA marketing authorisation - so nicotine patches, inhalation cartridges, gum, lozenges or spray. These should be used either singly or in combination, according to the patient’s preference and level of dependence.

What is not recommended?

- Electronic cigarettes or topical gels containing nicotine. These products are not regulated by the MHRA at the moment and are currently under review. GPs can advise patients that electronic cigarettes are probably less harmful than continuing to smoke as normal, but they should explain that the safest approach is to use licensed NRT products to help cut down.

- Any licensed smoking cessation aids other than nicotine-containing products, such as bupropion or varenicline. NICE says there is not enough evidence on the effects of these drugs in people who continue to smoke to recommend them.

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