© 2011 NHS Centre for Smoking Cessation and Training (NCSCT)
Author: Paul Aveyard
Editor: Andy McEwen
Reviewers: Melanie Chambers, Jennie Kenyon, Andrea Dickens, Hayden McRobbie, John Stapleton and Robert West
The need for this briefing was established when the NHS Centre for Smoking Cessation and Training (NCSCT) accompanied the Department of Health (DH) Tobacco Control Delivery Team on a number of regional seminars. Commissioners and managers of NHS Local Stop Smoking Services stated that, despite the evidence on safety and efficacy, getting primary care trusts to fund both products when clients opted for combination nicotine replacement therapy (NRT) was in some cases difficult.
This briefing is intended as a resource for commissioners, managers and staff of stop smoking services and is set out as answers to a series of questions.
Answer: There is good evidence to show that combination NRT is more effective than single product use. NICE recommends that combination NRT should be considered as a viable option for smokers wanting to quit.
The evidence: The highest quality evidence comes from the Cochrane review on NRT.1 This systematic review includes six trials with long-term smoking cessation outcomes for combination NRT versus single form NRT. Combining the results of these studies shows a clear advantage of combination versus single product NRT use (rate ratio = 1.35; 95% CI: 1.11–1.63). This means that combination NRT is likely to give a 35% increase in cessation rate, but the likely true effect lies between 11% and 63%.
Answer: The option that has been tested is patch plus a faster acting form such as gum, inhalator, nasal spray etc.
Answer: Yes, combination NRT is safe. Nicotine overdose associated with NRT use in smokers is uncommon. Smokers are used to very large doses of nicotine from tobacco use. Even with combination NRT use smokers are unlikely to receive doses of nicotine that are higher than that they receive from their tobacco use.2,3 If smokers experience adverse symptoms such as nausea they can reduce the dose.
Answer: The NHS provides life-saving treatment free at the point of delivery (or with a modest prescription charge). Combination NRT is more effective than single forms of NRT and saves lives very cheaply by treating nicotine dependence. It would be against the ethos of the NHS to require smokers to pay for such treatment or part of it.
Smoking cessation treatments are very cost-effective judged against other medical interventions. The incremental benefit of combination NRT over single form NRT is roughly in proportion to the incremental cost, so it is inevitable that combination NRT would be cost-effective as judged by NICE criteria.
Answer: If you are thinking of prescribing single form NRT, you should consider whether to use NRT in combination instead. It is suitable for anyone who has used NRT in a previous quit attempt but relapsed while using it, anyone who feels they need something more than a patch or other single form NRT, as well as heavier smokers.