Cytisine not working? The most common reasons and what to do if you are still smoking

Cytisine, the active substance in Desmoxan, Recigar and Tabex, eases nicotine cravings and withdrawal symptoms, but it does not make the urge to smoke disappear. In a study conducted in Warsaw, 740 smokers received cytisine or a placebo, and the only additional help they were given was brief advice. For a year after the 25-day course, 8.4% of people taking cytisine and 2.4% of those taking the placebo did not smoke (1). The medicine increased the chances of quitting, and yet most participants did not manage to stay off cigarettes. If you are smoking during the course or shortly after it, check three things: how you take the medicine, what you expect from it, and the situations in which you reach for a cigarette out of habit. These determine what to change before your next attempt.

In brief

• You need to stop smoking by day 5 of the course at the latest, and the course lasts 25 days. Smoking after day 5, stopping the tablets after a week or two and taking doses irregularly are mistakes you can spot yourself.
• Cytisine eases nicotine withdrawal symptoms, but it does not remove the habit. You need to plan separately how to keep from smoking over coffee, during a break at work or over a beer.
• A course that has not worked should be stopped, and another one can be started after 2 to 3 months. You can also discuss a different medicine with a doctor and get support from an addiction therapist.
• The only authorised treatment schedule for Desmoxan, Recigar and Tabex is the 25-day one. Courses lasting 6 and 12 weeks were studied in the US at a different, fixed dose, so you should not extend treatment on your own by taking tablets from another pack.

What can you expect from a course of cytisine?

Cytisine acts on the same receptors in the brain as nicotine, but more weakly, so it eases nicotine cravings and withdrawal symptoms, and a cigarette smoked during the course is less satisfying. However, it does not remove the urge to smoke completely and does not guarantee that someone will stop smoking.

Cytisinicline is a newer name for cytisine. It binds to nicotinic receptors more strongly than nicotine and gradually displaces nicotine from them (2). In a 2023 Cochrane review, four studies involving 4623 people showed that more people quit smoking while taking cytisine than while taking a placebo. The certainty of this evidence was rated as moderate (3).

An urge to smoke in the second week of the course does not in itself mean that the medicine is not working. To judge its effect, it is better to compare the current attempt with earlier attempts without medication: are the cravings weaker, and do they pass more quickly? The day-by-day dosing schedule and how to set your quit day are described in our article on the 25-day cytisine course.

What are the most common mistakes during a cytisine course?

During a course of cytisine, you need to follow four rules that are easy to overlook: stop smoking by day 5 at the latest, take the medicine for 25 days, keep to the recommended intervals between doses, and avoid nicotine from other sources during this time. If the course did not help, start by checking whether these four rules were followed.

Smoking after day 5 of the course

You need to stop smoking by day 5 of the course at the latest, and some people read this as permission to keep smoking until the urge to smoke goes away on its own. In fact, with Desmoxan, Recigar and Tabex, day 5 of treatment is the final deadline for stopping smoking, and smoking later in the course can make side effects worse (2, 4, 5). From your quit day on, you do not smoke a single cigarette.

Studies of other medicines show how important the first week without cigarettes is. In an analysis of three clinical trials of nicotine patches, nicotine spray and bupropion (cytisine was not studied in them), people who did not smoke at all in the first week after their target quit date were much more likely to be non-smokers at the end of treatment and six months later (6). This analysis shows an association between these observations, but it does not prove that one causes the other. It does, however, support setting your quit day before you take the first tablet, rather than waiting for cigarettes to stop tasting good on their own.

Stopping the medicine after a week or two

Some people stop the course after a week or two for various reasons: they forget the tablets, already feel well or decide that the medicine is not helping.

The Warsaw study, in which cytisine helped more often than a placebo, involved the full 25-day course and does not tell us how a course stopped halfway through works. Nicotine withdrawal symptoms are strongest in the first week without cigarettes and usually last 2 to 4 weeks (7), and the urge to smoke can keep coming back long afterwards (8). If you stop smoking on day 5 of the course, day 10 or 15 of the course means only 5 to 10 days without a cigarette. From this comparison, we conclude that anyone who stops the tablets at that point gives up the medicine at a time when withdrawal symptoms are usually still present.

Taking the medicine irregularly and missing tablets

Cytisine is taken frequently. From day 1 to day 3 of the course, you take one tablet every 2 hours, and from day 4 to day 12, one tablet every 2.5 hours. After that, the intervals between doses gradually get longer. In a study of healthy volunteers who were given a single cytisine tablet, the average half-life, meaning the time it takes for the level of the medicine in the blood to fall by half, was about 4 hours. Take the tablets at the intervals given in the dosing schedule, not only when you happen to remember the medicine.

If you miss a dose of Desmoxan, do not take a double dose (2). If you have missed several doses, it is better to ask a doctor or pharmacist how to continue taking the medicine.

Nicotine from an e-cigarette, pouches or a patch during the course

Some people switch from cigarettes to an e-cigarette or nicotine pouches during the course. Nicotine-containing products used during treatment can make the side effects of nicotine worse. They should not be used during treatment with Recigar. If your main problem is using an e-cigarette or pouches, we have separate articles on how to quit e-cigarettes and how to give up nicotine pouches.

What does cytisine not change about the smoking habit?

Cytisine eases the cravings caused by nicotine withdrawal, but it does not remove the associations that for years have linked cigarettes with particular situations: morning coffee, a break at work, driving, alcohol or an argument. At such moments, the urge to smoke can appear even in someone who takes the medicine according to the schedule.

Nicotine affects the brain's reward system, and regular smoking builds associations between cigarettes and places, times of day and moods (9). The medicine acts on nicotinic receptors, but changing the habit needs separate work. Reducing nicotine cravings does not depend solely on taking the medicine. In the US ORCA-3 trial, in which cytisinicline was given at a different dosage from that of Polish products, nicotine cravings after 6 weeks had fallen more in people taking the medicine than in the placebo group, but they had fallen in both groups (10). This suggests that cravings weaken partly with time spent without cigarettes and thanks to the support that both groups received in this trial.

Before your next attempt, write down the situations in which a cigarette was a fixed part of your day and plan a different behaviour for each one:

• coffee and a cigarette after a meal: change where you drink your coffee or the order of these activities, e.g. drink your coffee at your desk instead of on the balcony
• a break at work with colleagues who smoke: take your break at a different time or go for a walk in a different direction
• alcohol: the National Cancer Institute advises drinking less alcohol, or none at all, in the first weeks after quitting; we write about combining the medicine with alcohol in our article on cytisine and alcohol
• stress and irritability: several ways to wait out the moment when you want to smoke are described in our article on nicotine cravings

Talk this plan through with a therapist or psychologist. In a Cochrane review, a pooled analysis of 65 studies with more than 23,000 participants found that people taking stop-smoking medicines were more likely to stay abstinent when they had additional supportive sessions, in person or by telephone (11). The relative increase in the proportion of people who stayed abstinent was about 15%. For example, if 20 in 100 people quit smoking without extra support, about 23 quit with such support. The studies involved nicotine replacement therapy, bupropion, nortriptyline and varenicline, not cytisine.

What should you do if you are still smoking after a cytisine course?

If the treatment is not working, the course should be stopped, and another one can be started after 2 to 3 months. The second option is a different medicine chosen by a doctor. In both cases, support from an addiction therapist or psychologist increases the chances of quitting.

The WHO guidelines (12) recommend that after a return to smoking, you first work out what made treatment difficult and only then plan the next attempt. Four questions help with this:

1. When and in what situation did you smoke your first cigarette after your quit day?
2. Did you take the tablets according to the dosing schedule until day 25 of the course?
3. Did you use an e-cigarette, nicotine pouches or a nicotine patch during this time?
4. Were your nicotine cravings weaker than during an attempt to quit without medication?

Repeating the cytisine course after 2 to 3 months

Discuss a repeat course of the same substance with a doctor, especially if during the first attempt you smoked after day 5, stopped the medicine before the end of the course or missed doses. Before starting another course, it helps to mark your quit day in your calendar, set reminders for every dose, prepare a plan for the three or four situations in which it is hardest not to smoke, and stop other sources of nicotine.

Switching products, e.g. from Desmoxan to Recigar or Tabex, does not change the active substance or its dose: they all contain 1.5 mg of cytisine.

Which medicines can replace cytisine?

For the treatment of tobacco dependence, the WHO recommends nicotine replacement therapy (NRT), varenicline, bupropion and cytisine (12). NRT, meaning nicotine patches, gum and lozenges, delivers nicotine without tobacco smoke. In a 2023 Cochrane review, combining a patch with gum or a lozenge was assessed as a separate method (13). Varenicline and bupropion are prescription-only and require a doctor to check for contraindications.

Switching from cytisine to nicotine products needs to be planned with a doctor, including when to start the new treatment. Nicotine should not be taken during a course of cytisine. Which medicine to choose after an unsuccessful attempt to quit depends on your medical conditions, the medicines you take and how your previous attempts went.

Support from an addiction therapist or psychologist after an unsuccessful course

Consider talking to an addiction therapist or psychologist if you reach for a cigarette mainly when you are stressed, if your mood drops after you stop smoking, or if repeated attempts to quit fail in the same situations. In these sessions, you describe these situations, agree on what to do instead of smoking and discuss what got in the way of quitting during previous attempts.

You can plan your next attempt to quit together with us. The nicotine dependence treatment plan at Nasz Gabinet lasts 3 months and starts with a medical interview. Once we have assessed that the treatment is suitable for you, we issue an e-prescription for the chosen medicine, and the module in the app reminds you to take your doses, counts your smoke-free days and lets you keep a diary. Consultations with a psychologist are paid for separately and booked separately. This article does not replace a medical consultation.

When should you stop cytisine and contact a doctor straight away?

After taking too high a dose of Desmoxan, symptoms similar to nicotine poisoning can occur: feeling unwell, nausea, vomiting, a fast heart rate, fluctuating blood pressure, breathing or vision problems and seizures. If even one of these symptoms appears, or a symptom that is not listed in the leaflet, stop taking the medicine and contact a doctor or pharmacist.

Low mood, rarely accompanied by suicidal thoughts, can be a symptom of nicotine withdrawal. If your mood clearly gets worse, you need to see a doctor without waiting for the end of the course, and if you have thoughts of taking your own life, you need help from a doctor that same day. We write about other side effects in our article on cytisine side effects.

Can a cytisine course be extended beyond 25 days?

In Poland, the only authorised treatment schedule for Desmoxan, Recigar and Tabex is the 25-day one, which does not provide for extending the course. Longer treatment with cytisine has been studied, but on a different schedule from the one described for Polish products, so you should not extend the course on your own by buying a second pack.

In the US ORCA-2 trial involving 810 people, participants took cytisinicline at a dose of 3 mg three times a day for 6 or 12 weeks, or a placebo. All participants also received support with quitting smoking. From week 9 to week 24, 21.1% of people in the group treated for 12 weeks and 4.8% in the placebo group did not smoke at all. In the group treated for 6 weeks, 8.9% did not smoke from week 3 to week 24, compared with 2.6% in the placebo group (14). Similar results were obtained in the ORCA-3 trial involving 792 people (10). Both trials were designed to compare each course with a placebo, and their authors include employees of the company developing this medicine.

Taking 3 mg three times a day means a dose of 9 mg a day throughout treatment, whereas in the Polish schedule the same amount (6 tablets of 1.5 mg) is taken only from day 1 to day 3, after which the doses decrease. The ORCA results therefore cannot be applied to a course consisting of two packs of Desmoxan taken one after the other. Taking tablets available in pharmacies at the dose used in these trials goes beyond the authorised dosing schedule and requires a doctor's decision. In New Zealand, trial participants were prescribed cytisine for 12 weeks, but it was compared with another medicine, not with a 25-day course, so this trial does not show whether longer treatment works better than shorter treatment (15).

The ORCA-2 authors note that the traditional dosing schedule and duration of cytisine treatment may not be optimal, and the authors of the 2023 Cochrane review recommend that future studies assess different doses and different course lengths. Anyone who still has strong nicotine cravings after 25 days should discuss with a doctor whether a break followed by a repeat course or a different medicine would be the better option.

Frequently asked questions

Can you smoke during a cytisine course?

You need to stop smoking by day 5 of the course at the latest, and if you take Desmoxan capsules, you need to cut down on cigarettes from day 1. During treatment with Desmoxan tablets and Recigar, you should not smoke, as this can make side effects worse. With Tabex and Recigar Active, you must not smoke even a single cigarette after your quit day. It is best to set your quit day before taking the first tablet and to smoke as little as possible until then.

How long does it take for cytisine to start working?

The medicine is quickly absorbed from the digestive tract, but in the first days of the course the person taking it is still smoking, so it is easier to judge any change in nicotine cravings after the quit day. Withdrawal symptoms are usually strongest in the first week without cigarettes and ease over 2 to 4 weeks. A strong urge to smoke after the first tablet does not mean that the medicine is not working.

Does one cigarette during the course ruin the treatment?

After your quit day, you should not smoke even one cigarette, because the long-term success of treatment depends on it, and smoking during treatment can make the side effects of nicotine worse. After smoking a cigarette, do not increase the doses or extend the course on your own. It helps to work out straight away what led up to the cigarette (alcohol, stress, the company of smokers, a missed dose), and to discuss whether to continue the medicine with a doctor or pharmacist. Our article on smoking again after quitting explains what to do if you smoke again after the course has ended.

Do Desmoxan, Recigar and Tabex work differently?

Desmoxan, Recigar and Tabex contain the same active substance, cytisine, at a dose of 1.5 mg and have the same 25-day treatment schedule. Switching from one product to another after an unsuccessful course therefore does not change the active substance or its dose. The same break of 2 to 3 months applies before the next attempt at treatment. The products differ in their form and excipients, which we compare in our article on the cytisine course.

Sources

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