Motivational interviewing is an evidence-based counselling technique and an effective way to talk to patients about change.  Through motivational interviewing, pharmacists can acknowledge and explore a patient’s ambivalence about their smoking behaviour.  It also allows patients who smoke to clarify what goals are important to them and organise their reasons in a way that supports action.  Pharmacists should utilize OARS (open-ended questions, affirmations, reflections and summaries), the 5A’s (ask, advise, assess, assist and arrange) and the Transtheoretical Model (pre-contemplation, contemplation, preparation, action, maintenance and lapse/relapse) when using motivational interviewing to support smoking cessation.

NRT is the most widely available (unscheduled) and best tolerated form of pharmacotherapy for smoking cessation. NRT aims to reduce unpleasant nicotine withdrawal effects (craving, anxiety, irritability, hunger) by temporarily replacing low doses of nicotine from tobacco.  Thus, NRT eases the transition from cigarette smoking to complete abstinence.  It is safer than smoking and has low addictive potential.  The choice of NRT depends on the level of nicotine dependence, patients’ preference and the suitability of individual formulations.  Pharmacists must be able to discern and counsel on the safest, most efficacious and appropriate NRT regimen for a patient.  They must also be able to recognise when a referral to a medical practitioner is warranted, such as when NRT is contraindicated.

Even though NRT is available in various formulations, all forms of NRT (at equivalent doses) have similar effectiveness in achieving smoking cessation.  The transdermal patch is a long acting form of NRT and maintains steady-state nicotine levels to reduce withdrawal symptoms.  Faster acting NRT formulations, such as gum, inhalers, lozenges and oral sprays are intended to be absorbed via the sublingual or buccal route.  These formulations offer flexible dosing that can be adjusted to reduce breakthrough cravings.

Combination NRT involves using a long-acting patch plus a faster-acting formulation and it is safe and more effective than NRT monotherapy.  NRT is usually well tolerated and some adverse effects such as sleep disturbance, dizziness, weight gain, and headache may also be related to stopping smoking.  Other adverse effects may be related to the NRT dosage form, such as application site reactions from the transdermal patch and throat or mouth irritation from the gum, lozenge, inhaler and oral spray.  Learn more about the different forms of NRT available below:

Australian guidelines recommend the following initial NRT doses:

• Smokes within 30 minutes of waking and smokes >10 cigarettes a day
  • Highest-strength patch + highest-strength gum OR highest-strength lozenge OR 1 mg oral spray OR 15 mg inhaler
• Smokes within 30 minutes of waking and smokes ≤10 cigarettes a day OR smokes more than 30 minutes after waking and smokes >10 cigarettes a day
  • Highest-strength patch + lowest-strength gum OR lowest-strength lozenge OR 1 mg oral spray OR 15 mg inhaler
• Smokes more than 30 minutes after waking and smokes ≤10 cigarettes a day
  • Lowest-strength gum OR lowest-strength lozenge OR 1 mg oral spray OR 15 mg inhaler.

Titrate the dose according to the patient’s withdrawal symptoms. Underdosing can undermine a patient’s confidence in treatment. Patients with high nicotine dependence may benefit from use of two patches at the same time, however, the evidence supporting the use of two patches is inconclusive.  Tapering the dose of NRT at the completion of a course of treatment does not influence successful long-term smoking cessation. Patients who have successfully stopped smoking after an initial 8-week course of NRT may consider a follow-up course. The optimal duration of NRT has not been established.

Planned follow-up increases cessation rates. Suggest that patients return for follow-up within 1 week of the stop smoking date and for additional planned follow-up visits to review progress.  Invite the patient to contact the pharmacy if they have any questions or concerns about NRT or the advice provided.  If relapse occurs, offer support and encourage further attempts. Acknowledge that it often takes numerous attempts to stop smoking.

Patients are unsuitable for NRT and should be referred to a medical practitioner instead in the following situations:

• Age <12 years.
• Pregnancy.
• Patient wishes to use a prescription medicine for smoking cessation.
• A medicine the patient uses may require a dose change when they stop smoking because tobacco smoking affects the metabolism of caffeine and many drugs, including antipsychotics, antidepressants and some antithrombotic drugs (e.g., warfarin).

NRT should be supplied to patients and concurrently referred in the following circumstances:

• Co-morbidities such as cardiovascular disease, diabetes or mental illness.
• Age 12-18 years.
• Breastfeeding

The following table from eTG summaries different forms of NRT: AMG2-Nicotine-replacement-v4 (1) (1)

Varenicline is the most effective drug therapy for smoking cessation, closely followed by combination NRT.  Each of these is more effective than NRT monotherapy or bupropion.  Bupropion is an option when combination NRT and varenicline are not suitable, though it is less effective.  Nortriptyline is an option when first-line drug therapies (NRT, varenicline and bupropion) are not suitable or were not effective after an adequate trial. Nortriptyline is a second-line choice and is not approved by the Therapeutic Goods Administration (TGA) for the management of tobacco smoking.

Nicotine vaping devices are also known as e-cigarettes and vapes.  These products are liquids used in devices that allow people to inhale aerosolised liquid nicotine.  Nicotine vaping products are an alternative for use when first-line drug therapies (NRT, varenicline and bupropion) are not suitable or were not effective after an adequate trial. However, evidence for efficacy is evolving and long-term safety is not certain.  There are currently no vapes for smoking cessation or the management of nicotine dependence included in the Australian Register of Therapeutic Goods (ARTG).  There are established pathways for patients to lawfully access unapproved goods, but these goods are not assessed by the TGA for quality, safety and efficacy or performance.

State and territory laws require vapes containing nicotine to be prescribed under the Special Access Scheme (SAS) or Authorised Prescriber (AP) scheme and dispensed in a pharmacy setting.  It is illegal for retailers such as tobacconists, vape shops and convenience stores to supply any type of vape, even with a prescription.  From 1st October 2024, therapeutic vapes with a nicotine concentration of 20mg/mL or less will be available in pharmacies to patients 18 years or over without a prescription.  A pharmacist will need to be satisfied it is clinically appropriate, and meet several other conditions, to supply a vape to a patient without a prescription. These changes will help facilitate patient access while maintaining appropriate controls and protections.

The only vaping products that can lawfully supplied are the products on this list: https://www.tga.gov.au/products/unapproved-therapeutic-goods/vaping-hub/table/list-notified-vapes