Cardiovascular risk reduction - quality prescribing guidance 2026-2029: consultation

13. Smoking

Tobacco smoking is internationally recognised as a major public health threat causing over eight million deaths each year worldwide as a direct result of tobacco use, with over one million attributed to second hand smoke exposure. Along with this the production of tobacco is destructive to the environment with wide reaching health impacts. In Scotland smoking causes illness, disability and deaths from harm that is entirely preventable and the highest burden falls on the poorest members of our society.

In recent decades progress has been made to reduce the harms associated with tobacco smoking including public health policies such as the banning of smoking in public places and the Tobacco Roadmap to 2034.

13.1 Why is smoking important in CVD risk reduction?

There are no positive health benefits to smoking, and it remains a leading cause of preventable disease and premature death. In 2022 smoking accounted for an estimated 8,924 deaths (271 deaths per 100,000 population) in those aged 35 and over in Scotland.^[105] In 2024, 14% of adults in Scotland were current smokers, the same level as in 2023.1

Evidence shows that smoking cessation reduces the risk of CVD. There is no safe level of smoking.^[106]

Relapse after stopping is common. Individuals should be encouraged to learn from the experience and try again. Most smokers will make several attempts before stopping.

Considering the ‘States of change model’, described by Prochaska and DiClemente can be helpful to understand how individuals think and feel about behavioural change, including smoking cessation.^[107] The stages described are:

• Precontemplation: no intention of changing behaviour and may view their behaviour as a positive aspect of their life. Healthcare professionals (HCPs) can highlight the risks of the behaviour and rewards from change, encouraging the individual to reflect and potentially move to the next stage in time. This intervention may occur repeatedly before the individual moves onto the next stage.
• Contemplation: recognition of the negative aspects of their behaviour, but there is no commitment to change. HCPs can continue to reinforce reasons for change and revisit at a future date.
• Preparation: the individual is intent on taking action to change their behaviour. HCPs can assist the individual in setting up a plan, identifying barriers and considering solutions.
• Action: the individual attempts to change their behaviour. HCPs can assist by asking about progress and encouraging the individual to follow the agreed plan.
• Maintenance: the behaviour change continues but ongoing support and encouragement is required to prevent relapse, which HCPs can assist with.
• Relapse: the individual reverts to their previous behaviour, smoking, often returning to an earlier stage of change. HCPs should remain non-judgemental, reassure the individual that this is part of the process of change and encourage re-engagement with behaviour change.

13.2 How do we discuss smoking status?

We should make “every conversation count”. Of the people who currently smoked in the UK in 2024, 56.2% intended to quit smoking. Almost a quarter of these current smokers (24.4%) intended to quit within the next three months.^[108]

HCPs should:^[109]

• Ask individuals if they smoke
• Do you smoke?
• How many do you smoke a day?
• How do you feel about stopping smoking?
• Have you tried stopping before?

• Advice
• Explain the benefits of stopping smoking, building on the context of the healthcare consultation
• Confirm that the best way of stopping is combining medication and support provided by stop smoking services
• Individuals are three times more likely to quit with Quit Your Way Scotland (QYW) support
• Signpost to NHS Inform for further information if not ready to quit
• Refer individuals ready to quit to local services via NHS inform or local pathways

• Act
• Record smoking status in patient notes
• Signpost to NHS Inform for further information if not ready to quit
• Refer individuals ready to quit to local services via NHS inform or local pathways

13.3 Lifestyle interventions

Quit Your Way Scotland

NHS inform - Quit Your Way Scotland is run by NHS 24 and is staffed by trained advisors. It is a national advice and support service for anyone trying to stop smoking in Scotland. Quit Your Way Scotland has no minimum age limit and offers free advice on the phone or through webchat. Individuals can phone free to speak to an advisor on 0800 84 84 84 or via online chat function (Monday-Friday 9am-5pm). The service can:

• Help people get ready to stop
• Talk through all the options available, like the types of stop smoking medication that can be accessed
• Offer support and advice for people trying to stop
• Refer people to their local NHS services
• Send the person out a free Quit Your Way Scotland booklet.

The community pharmacy smoking cessation support service provides a 12-week person-centred programme offering behavioural support and evidence-based pharmacotherapies. All individuals should be offered weekly behavioural support.

13.4 Principles of prescribing

Individuals in Scotland should be referred to local Quit Your Way services for support and free supply of medication to support smoking cessation. The smoking cessation service may be offered through specialist teams or as part of the Public Health Service in local community pharmacies.

13.4.1 Medication

Varenicline

Varenicline (Champix) was withdrawn from the market in 2021 due to safety concerns. A reformulated generic version was reintroduced in 2024 and can be prescribed where clinically appropriate by GP practices, specialist smoking cessation services and via Patient Group Direction (PGD) by community pharmacists.

Varenicline is a selective nicotine-receptor partial agonist. It alleviates symptoms of craving and withdrawal and reduces the rewarding and reinforcing effects of smoking by preventing nicotine binding to the receptors.^[110]

Most people need a 12-week course of varenicline. Evidence suggests that it is the most effective medicine for helping people stop smoking. ^[111]

Do not prescribe varenicline to people:

• aged under 18 years
• with severe renal impairment or end stage renal disease – CKD stage 5, eGFR <15ml/min/1.73m²
• who are pregnant, planning pregnancy or breastfeeding

Prescribe varenicline with caution to people:

• with a history of cardiovascular disease
• with a history of psychiatric illness
• with epilepsy, or a predisposition to seizures (N.B. exclusion in PGD)
• with renal impairment – see BNF for required dose reductions
• taking insulin
• taking clozapine - before the supply of varenicline via PGD the pharmacist must inform the prescriber that the patient is making an attempt to stop smoking so that clozapine levels can be monitored

The National Community Pharmacy PGD for Varenicline excludes individuals with:

• previous history of Stevens-Johnson Syndrome or Erythema Multiforme
• history of seizures e.g. epilepsy or conditions where seizure threshold may be lowered

Individuals who are excluded from treatment should be offered alternative products, if appropriate, or referred to GP Practice or Specialist Smoking Cessation service.

Nicotine replacement therapy (NRT)

NRT works by gradually reducing the body’s addiction by using a low dose of clean and therapeutic nicotine. This doesn’t contain the other harmful chemicals found in tobacco smoke such as carbon monoxide and tar. NRT should reduce cravings and other withdrawal symptoms.105

NRT should be used for an 8-to-12-week period but check individual products for guidance. Some long-term NRT users experience mild withdrawal symptoms when they stop using it. NRT is safe to use as a tool to help individuals stop smoking and stay stopped.

Long term use is generally not recommended but is a better option than returning to smoking. This is because NRT only contains nicotine and not the other harmful chemicals found in cigarettes.

Nicotine replacement therapy (NRT) is available in a choice of formats, including:

• gum
• inhalator
• lozenge
• nasal spray
• oral spray
• sublingual tablet
• transdermal patch

Other treatments

Recently updated NICE Guidance also includes information on the prescribing of bupropion and cytisinicline for treating tobacco dependence. Neither of these medications are available currently via the national community pharmacy smoking cessation service. HCPs who wish to prescribe these medications to individuals should familiarise themselves with the indications and contra-indications as well as interactions listed in the BNF and/or the Electronic Medicines Compendium before initiating therapies. Consideration should made to local formulary restrictions.

13.5 Vaping

One approach that has gained traction in helping to reduce smoking rates is that of Nicotine Vapour Products (NVP), e-cigarettes or "vapes". On-going monitoring studies such as the Smoking in Scotland Toolkit Study have shown that NVP continue to be one of the most popular aids used in quit attempts.^[112]

An updated Cochrane Review found that NVP are around twice as effective in supporting smokers to quit compared to the use of patches and gum.^[113] It is important that we support current smokers to stop in a way that suits them.

Although NVP can be a valued tool to help smokers to quit, it is concerning that a growing number of young people and adult non-smokers are using these devices. The recent Health Behaviour in School-Aged Children 2022 report (Scotland) found that 3% of 11-year-olds,^[114] 10% of 13-year-olds and 25% of 15-year-olds said they had used an NVP in the past 30 days. The report also found that there have been increases in current NVP use since 2018 for 13-year-old girls (2% to 13%) and larger increases for 15-year-olds (girls 6% to 30% and boys 8% to 20%).

Current research indicates that there is a significantly lower relative exposure from biomarkers that are associated with the risk of cancer, respiratory conditions, cardiovascular conditions and other health conditions in vaping compared to smoking.^[115] However, the long-term effects of vaping on our health are not fully understood. Emerging evidence indicates that they are not harm-free. ^[116] The World Health Organization (WHO) states that even though many of the long-term health effects of NVP use are still unknown, there is growing evidence to demonstrate that these products are not harmless to health and should be "strictly regulated."110

This unknown risk of harm means a precautionary, low-risk approach should be taken to the use of these devices until further evidence is available regarding longer-term harms. NVP are not classed as medicines and cannot currently be prescribed in Scotland.

13.5.1 Environmental impact of vaping

Scotland banned the sale and supply of single-use NVP in June 2025. Zero Waste Scotland estimated that up to 26 million disposable NVP were consumed and thrown away in Scotland in 2023,^[117] with 10% being littered and more than half disposed of incorrectly. There was a significant cost to local authorities through litter clear up and waste management. Where NVP are incorrectly disposed of, the batteries increase risk of fires at waste centres and on collection vehicles.

13.5.2 Tobacco and Vapes legislation

As a result of the UK Tobacco and Vapes Bill, individuals born in 2009 or later will never be legally sold tobacco products. This will prevent future generations from ever legally taking up smoking tobacco.

This will be the biggest public health intervention in a generation – breaking the cycle of addiction and disadvantage and putting us on track towards a smoke-free UK. 

13.5.3 Quitting vaping

There are several online resources to support those wanting to quit vaping:

• NHS inform have information on how to quit vaping
• NHS England have advice on how to quit vaping including gradually reducing vaping by lowering the nicotine strength, increasing the time between vaping sessions and creating vape-free spaces or how to quit in one step
• NHS Greater Glasgow and Clyde also have resources for adults and young people looking to stop vaping

13.6 Special patient populations

13.6.1 Clinically significant drug interactions

For most medicines, dose adjustment will not be required when a person stops smoking. However, it is helpful to be aware of relevant medicines and to advise individuals to watch for signs of toxicity when stopping smoking. Further information is available via the Specialist Pharmacy Service webpage Considering drug interactions with smoking. The MHRA have published advice on monitoring blood clozapine levels for toxicity when an individual stops smoking.

13.6.2 Pregnancy

Quit Your Way Pregnancy Services is a free service available to help all pregnant women who want to stop smoking. The stop smoking advisor will provide relaxed, friendly advice and support. They will also discuss the use of NRT in pregnancy and can provide information about effective ways to stop smoking. The advisor can also provide help to other family members who want to quit. It is important to provide clear advice about the danger of smoking and second-hand smoke.22

A printable leaflet iQuit: stopping smoking when you’re pregnant is available.

13.6.3 Perioperative care

Perioperative care is recognised as an opportunity where there is motivation for spontaneous or health professional-prompted behaviour change.^[118] Surgical patients who smoke are at higher risk of experiencing cardiopulmonary, wound-related, and infectious complications than non-smokers and postoperative mortality is 40% greater in smokers compared to non-smokers.^[119]

Individuals with planned surgery should be advised that:

• Stopping smoking is important for improved surgical outcomes and long-term health
• The best way of quitting is with a combination of support and stop smoking medication
• Support with stopping smoking and/or managing any tobacco withdrawal symptoms is available – support referral to Quit Your Way Scotland

13.6.4 Smoke-free grounds

Since September 2022 it has been an offence to smoke within 15 metres of an NHS hospital building. This applies to any person - short or long stay patients (including mental health patients), visitors and staff. Individuals should be supported via hospital smoking cessation teams.