Quitting smoking requires sustained engagement and a multifaceted approach, writes Damien O’Brien MPSI
Introduction
Despite significant progress in recent years, tobacco use remains a major public health challenge in Ireland. A substantial proportion of the population continues to smoke, and tobacco use still accounts for considerable morbidity and mortality. Smoking prevalence had been declining steadily due to legislative changes, public awareness campaigns, and improved access to cessation supports ? however, this downward trend has stalled in recent years.
Tobacco Free Ireland, the national policy framework for tobacco control, previously set a target of reducing smoking prevalence to below 5 per cent of the population by the end of 2025. However, current figures show that 17 per cent of adults smoke, with 13 per cent smoking daily and 4 per cent smoking occasionally. These rates have remained largely unchanged since 2019. Smoking remains more prevalent among men (20 per cent) than women (14 per cent).
Achieving meaningful reductions in smoking prevalence will require sustained engagement and a multifaceted approach combining pharmacological, behavioural, and public health interventions. Among people who smoked in the past year, 46 per cent attempted to quit. Some 67 per cent of these individuals did so without using any form of quitting aid.
Smoking cessation is a complex process that requires individualised support. Structured interventions can significantly increase the likelihood of long-term abstinence.
Community pharmacists, as trusted and highly accessible healthcare professionals, are ideally positioned to contribute meaningfully to improved cessation outcomes. This article will outline the major health burdens associated with tobacco use, review both pharmacological and non- pharmacological treatment options, and describe the pharmacist’s role in supporting smoking cessation.
The health burden of smoking
Tobacco use is the leading cause of preventable illness and death in Ireland. Despite progress in public health initiatives, smoking continues to exert a substantial impact on morbidity, mortality, and healthcare resources. It is estimated that smoking is responsible for approximately 6,000 deaths annually. Tobacco use affects every organ system and accounts for roughly 30 per cent of all cancer deaths. Lung cancer remains the largest contributor, but smoking is also linked to cancers of the mouth, throat, larynx, oesophagus, bladder, cervix, and bowel.
Beyond cancer, smoking significantly increases the risk of myocardial infarction, stroke, coronary artery disease, and peripheral vascular disease. Reduced circulation can also contribute to erectile dysfunction in men. Respiratory effects are equally profound, with smoking contributing to chronic obstructive pulmonary disease (COPD), emphysema, worsening asthma symptoms, and respiratory infections. Additional complications include delayed recovery from surgery, impaired wound healing, reduced fertility, and adverse pregnancy outcomes.
Smoking cessation provides both immediate and sustained health benefits. Blood pressure and heart rate begin to normalise within hours, lung function improves within weeks, and the risk of cardiovascular disease falls substantially within the first year after quitting. The earlier the intervention, the greater the overall health gain. Smoking also imposes a major economic burden, costing the
Irish health service hundreds of millions each year, further emphasising the need to intensify cessation efforts.
Pharmacological treatment
Pharmacological treatment is a cornerstone of effective smoking cessation. Evidence demonstrates that combining medication with behavioural support markedly improves quit rates compared with unassisted attempts. An individualised management plan tailored to each patient’s needs, level of dependence, and circumstances is the most effective strategy for supporting long-term abstinence. Pharmacists, as accessible medication experts, are ideally positioned to initiate, optimise, and monitor these treatments.
Smoking cessation provides both immediate and sustained health benefits
Nicotine replacement therapy (NRT)
NRT is the most widely used and accessible pharmacological option for smoking cessation. It delivers controlled doses of nicotine without the harmful toxins found in tobacco smoke, thereby reducing cravings and withdrawal symptoms.
Evidence shows that NRT increases quit rates by more than 50 per cent. Multiple formulations, including patches, gum, lozenges, inhalators, and oral sprays, allow for flexibility based on dependence patterns and patient preference.
Combination NRT, typically involving a long-acting patch for steady background nicotine levels alongside a fast-acting product for breakthrough cravings, has been shown to be more effective than single-form therapy. Concerns about dependence on
NRT are common; however, NRT is significantly safer than continued smoking, carrying a much lower long- term risk. Common adverse effects include gastrointestinal discomfort, headache, palpitations, and dizziness.
Varenicline
Varenicline is a selective partial agonist at nicotinic acetylcholine receptors. By partially stimulating these receptors, it promotes controlled dopamine release, reducing cravings and withdrawal symptoms. It also blocks nicotine from binding to the same receptors, reducing the rewarding effects of smoking.
Varenicline is effective as monotherapy and combining it with NRT may further increase quit rates in certain patients. Treatment is usually initiated one to two weeks before the planned quit date, with a gradual dose escalation over the first week to improve tolerability.
The standard dosing regimen begins with 0.5mg orally once daily for the first three days, increasing to 0.5mg twice daily for the next four days and 1mg twice daily from day eight onwards. Standard treatment typically continues for 12 weeks, with the option to extend for a further 12 weeks for those who achieve abstinence but remain at high risk of relapse.
Common adverse effects include nausea, constipation, insomnia, abnormal dreams and headache. Gastrointestinal discomfort can be reduced by taking varenicline after meals with a full glass of water.
Although early concerns were raised regarding potential neuropsychiatric effects, large studies have found no increased risk of suicidal ideation. Nevertheless, patients should still be monitored for behavioural changes, particularly if they have a history of mental health conditions.
Bupropion
Bupropion is an atypical antidepressant that has proven effective for smoking cessation. It works by inhibiting the reuptake of dopamine and norepinephrine. These are neurotransmitters involved in the brain’s reward pathways, helping to reduce cravings and withdrawal symptoms.
Bupropion is effective for smoking cessation when used as monotherapy, but it can also be used in combination with NRT which may be more effective than either treatment alone. The usual regimen for smoking cessation begins with 150mg once daily for the first six days, increasing to 150 mg twice daily thereafter.
Treatment should commence one to two weeks before the quit date and continue for seven to nine weeks. If no clinical response is observed by week seven, treatment should be discontinued. Extended courses may be considered for those who respond well.
Bupropion is typically well tolerated, with common adverse effects including insomnia, nausea, dizziness, and headache. However, it may lower seizure threshold and has the potential for worsening suicidal ideation. It is therefore not recommended for patients with seizure disorders, and individuals with depressive symptoms should be closely monitored.
Cytisine
Cytisine is a partial agonist of nicotinic acetylcholine receptors, working to reduce cravings and withdrawal symptoms while blocking the reinforcing effects of nicotine. Evidence indicates that cytisine is more effective than placebo and comparable to NRT in supporting smoking cessations. It is administered orally as a structured, tapering course over 25 days. Smoking should be stopped no later than day five of treatment.
Patients should not continue to smoke while taking cytisine, as this can increase adverse reactions. If cessation is unsuccessful, treatment
Reviews should assess withdrawal symptoms, cravings, medication use, sleep quality, and mood
should be discontinued and may be repeated after two to three months. Common adverse effects include nausea, dry mouth, gastrointestinal discomfort, and sleep disturbance. It is generally well tolerated but should be used with caution in individuals with cardiovascular disease.
Monitoring
Ongoing monitoring is an essential component of smoking cessation and supports adherence, safety, and sustained abstinence. Patients should receive follow-up at regular intervals during treatment, particularly in the first few weeks when the risk of relapse is highest. Reviews should assess withdrawal symptoms, cravings, medication use, sleep quality, and mood. Patients on varenicline and bupropion treatment should be monitored for any neuropsychiatric effects, while those using NRT may require dose adjustments or guidance on correct technique. Reinforcing the importance of medication adherence is crucial for achieving optimal outcomes. Structured follow-up enables early identification of challenges and allows timely optimisation of the management plan.
Non-pharmacological support
Non-pharmacological interventions play a vital role in smoking cessation and can significantly increase long-term abstinence rates when combined with pharmacotherapy. Behavioural support helps patients understand their smoking patterns, manage triggers, and develop effective coping strategies.
Brief intervention, which may be delivered in community pharmacy using structured advice and motivational techniques, has been shown to improve the likelihood of success. More intensive behavioural support, such as counselling or motivational interviewing, offers regular contact and personalised strategies to strengthen commitment and resilience.
Environmental and lifestyle changes are also key contributors to successful cessation. Removing smoking cues, increasing physical activity, and receiving social support from family and friends
can all reduce relapse risk. Overall, non- pharmacological interventions complement medication by addressing the behavioural and psychological dependence, offering patients the best opportunity of a sustained approach to quitting.
The role of the pharmacist
Community pharmacists are well positioned to play an expanded role in smoking cessation, providing accessible, patient-centred support within a trusted healthcare environment. Every interaction in the pharmacy, whether planned or unplanned, offers an opportunity to engage with patients about quitting.
Pharmacists can signpost individuals to HSE QUIT resources during brief interventions to reinforce key messages and ensuring continuity of support beyond the pharmacy. Continued investment in pharmacy-based cessation programmes, including training, service development, and integration with national initiatives, will strengthen the profession’s capacity to deliver impactful care.
Pharmacists’ accessibility, continuity of care, and frequent contact with patients position them uniquely to identify smokers, initiate conversations, and provide sustained guidance throughout their quitting journey. With appropriate support structures in place, community pharmacy can play a central role in helping Ireland move closer to its national tobacco-free goals.
References available upon request
