Nicotine dependence treatment

The addictive substance in cigarettes is nicotine. Nicotine dependence is also called nicotine addiction. As described in a review published in the New England Journal of Medicine, nicotine stimulates nicotinic receptors in the brain and increases the release of dopamine, a substance linked to feelings of pleasure. With regular smoking, the brain gets used to a steady supply of nicotine, so when the nicotine level drops after a cigarette, irritability, anxiety and cravings set in, and the next cigarette relieves them for a while. The WHO classifies this condition as a disease: in ICD-10 as tobacco dependence syndrome (F17.2) and in ICD-11 as nicotine dependence (6C4A.2), regardless of whether the nicotine comes from a cigarette or an e-cigarette.

Tobacco-related diseases are caused mainly by the smoke. According to the WHO description in ICD-11, nicotine plays only a partial role in these diseases, and most of the damage is done by the carcinogens and other harmful compounds inhaled with the smoke. Nicotine replacement therapy is built on this distinction: a patch or gum supplies nicotine, which eases withdrawal symptoms, and the patient does not inhale smoke. According to a 2025 report by Poland's National Institute of Public Health (PZH), 28.8 percent of men and 20.3 percent of women in Poland smoke tobacco every day, and according to the Chief Sanitary Inspectorate about 70,000 people die of tobacco-related diseases every year.

Why do levels of some medicines rise after quitting smoking?

Components of tobacco smoke speed up the breakdown of some medicines in the liver. Nicotine does not have this effect, so levels of these medicines rise after smoking stops even if the patient switches to nicotine patches or e-cigarettes. The effect of smoke on liver enzymes gradually wears off after quitting. According to the UK's Specialist Pharmacy Service, changes may be noticeable within 3 days, while the effect may take 2 to 4 weeks to disappear completely. Most of these medicines do not require a dose change, but some need monitoring:

• clozapine: before quitting, the patient should tell their psychiatrist without delay, and the psychiatrist orders a blood level test, reduces the dose if needed and repeats the test a week later;
• olanzapine and haloperidol: if the patient has marked drowsiness, dizziness or other side effects, the doctor reduces the dose by 25 percent;
• theophylline: the doctor considers gradually reducing the dose by 25 to 33 percent over a week and checks the level of the medicine in the blood;
• warfarin: the risk of bleeding goes up, so at follow-up visits the doctor checks the INR, a measure of how quickly blood clots.

If a patient starts smoking again, they should tell their doctor, as the doses of these medicines may need adjusting again.

The sooner someone reaches for a cigarette after waking up, the more strongly dependent they are. The Fagerström test is based on this link: a person who lights their first cigarette within 5 minutes of waking up gets 3 of the possible 10 points, the same as for smoking more than 30 cigarettes a day. The whole test has six questions:

1. How soon after waking up do you smoke your first cigarette? Within 5 minutes scores 3 points, 6 to 30 minutes 2 points, 31 to 60 minutes 1 point, later 0.
2. Do you find it hard not to smoke in places where smoking is banned, such as a cinema? If yes, 1 point.
3. Which cigarette would be hardest to give up? The first one in the morning scores 1 point, any other 0.
4. How many cigarettes do you smoke a day? Up to 10 scores 0 points, 11 to 20 scores 1 point, 21 to 30 scores 2 points, 31 or more scores 3 points.
5. Do you smoke more often in the first hour after waking up than during the rest of the day? If yes, 1 point.
6. Do you smoke when you are so ill that you spend most of the day in bed? If yes, 1 point.

A score of 6 or more indicates strong dependence and affects the medicine dose: according to the nicotine gum product information, someone with this score, or who smokes more than 20 cigarettes a day, starts with 4 mg gum rather than 2 mg. The product information for 4 mg lozenges considers a person strongly dependent if they smoke their first cigarette within 30 minutes of waking. In a study of 5934 cancer patients, the test score was a poor predictor of who would manage to quit.

In a UK study involving more than a million women, even those who smoked fewer than 10 cigarettes a day were twice as likely to die within 12 years as women who had never smoked, and across all smokers the risk of death was almost three times that of non-smokers. In a US study involving more than 200,000 adults, smokers lived more than 10 years less than people who had never smoked.

The earlier someone quits, the more years of life they gain. In the US study, people who quit between the ages of 25 and 34 gained about 10 years of life compared with those who kept smoking. Quitting between 35 and 44 gave about 9 years, and between 45 and 54 about 6 years. In the UK study, women who quit before the age of 40 avoided more than 90 percent of the extra risk of death that comes with continued smoking, and those who quit before 30 avoided more than 97 percent.

According to WHO, blood carbon monoxide levels return to normal just 12 hours after the last cigarette. Circulation and lung function improve within 2 to 12 weeks, while coughing and breathlessness decrease within 1 to 9 months. After a year, the risk of coronary heart disease is about half that of a smoker, and after 15 years it is similar to that of a non-smoker.

Coughing and spirometry results after quitting smoking

In the first weeks, the cough may get worse. A UK study followed 174 people who were quitting with a patch and counselling. After a week without cigarettes, they reported coughing, a sore throat and sneezing more often than before quitting, and after 1 and 2 weeks also mouth ulcers and cold symptoms. Coughing up blood, or shortness of breath that gets worse from day to day, needs urgent medical help.

The Lung Health Study included smokers aged 35 to 60 with mild or moderate chronic obstructive pulmonary disease. In those who quit, the volume of air breathed out in the first second (FEV1) rose by an average of 47 ml in the first year and then fell by 31 ml a year, compared with 62 ml a year in those who carried on smoking. After 5 years, chronic cough, phlegm, wheezing and shortness of breath were least often reported by people who had not smoked at all during that time.

Does quitting smoking help after a heart attack?

Yes. In a review of observational studies, people with heart or blood vessel disease who quit smoking had a 39 percent lower risk of dying from cardiovascular causes than those who kept smoking. Studies of this kind show a link but do not prove that the whole difference comes from quitting. In a review of 82 studies of hospital patients, the number of people who stopped smoking increased with support that started in hospital and continued for more than a month after discharge, while support that ended earlier showed no clear benefit.

How many weeks before surgery should you quit smoking?

The sooner the better, but a shorter break also makes a difference. In a 2025 analysis of 55 studies, mostly observational, people who had stopped smoking at least 4 weeks before surgery had 31 percent fewer complications overall and 33 percent fewer wound healing complications than people who smoked up to the day of the operation. After at least 8 weeks without cigarettes there were 37 percent fewer lung complications, and after 2 weeks 27 percent fewer. In two small studies, intensive support started 4 to 8 weeks before surgery, with weekly sessions and nicotine replacement therapy, reduced the number of complications. Brief advice did not reduce complications. The patient should tell the anaesthetist that they are using a patch or another stop-smoking medicine.

Does blood sugar go up in people with diabetes after quitting smoking?

It may, for a while. In a UK study of 10,692 smokers with type 2 diabetes, glycated haemoglobin (HbA1c) in those who quit rose by an average of 0.21 percentage points in the first year, and after 3 years it was similar to that of people who kept smoking. The rise was not explained by weight gain. The manufacturers of nicotine gum and patches advise people with diabetes to check their glucose more often after quitting, and any change in the dose of diabetes medicines is a decision for the doctor.

Smoking damages the gums and the tissues that hold the teeth in place. In a review of prospective studies, smokers had an 85 percent higher risk of periodontitis, and in a review of long-term studies a more than two and a half times higher risk of losing teeth than people who had never smoked. The WHO also lists stained teeth, a changed sense of taste and bad breath. After quitting, the risk goes down: in former smokers, the risk of periodontitis was not significantly different from that of people who had never smoked, and the risk of tooth loss was close to that of people who had never smoked. These were observational studies.

Smoking also gets in the way of dental treatment. Dry socket is a painful complication after a tooth extraction in which the blood clot falls out of the wound or breaks down. In a review of studies, this complication occurred in about 13.2 percent of smokers and 3.8 percent of non-smokers. In an analysis of 32 studies involving 14,115 patients, smokers were twice as likely to have an early dental implant failure. According to a meta-analysis of 115 studies, the risk of mouth and throat cancer is more than three and a half times higher in smokers than in people who have never smoked. It doubles with as few as 6 cigarettes a day or after 7 years of smoking. Within 10 years of quitting, it falls by half.

Do cigarettes and e-cigarettes harm young people's gums?

In a Polish study of 992 15-year-olds, 25.1 per cent had bleeding gums. After accounting for factors including oral hygiene habits, cigarette smoking was associated with more than two and a half times the odds of bleeding gums, and e-cigarette use with almost twice the odds. However, a cross-sectional study cannot establish causation, and a review of studies on adolescents and young adults rated the certainty of evidence on e-cigarettes and oral health as low. E-cigarettes are very popular among school students: in the 2024 ESPAD study, 37.2 per cent of students aged 15 and 16 and 50.9 per cent of those aged 17 and 18 had used them in the preceding 30 days.

Smoke also harms people who do not smoke themselves, and there is no level of exposure that is safe for them. The WHO estimates that of the more than 7 million deaths caused by tobacco worldwide each year, more than 1.6 million are among non-smokers who breathed in other people's smoke. Data from 192 countries gathered in an analysis for 2004 show that at the time 33 percent of non-smoking men and 35 percent of non-smoking women were exposed to other people's smoke.

Children are especially at risk. In 60 studies of babies and young children, smoking at home was linked to a 54 percent higher chance of lower respiratory tract infections and a more than two and a half times higher chance of bronchiolitis. In children whose mothers smoked after giving birth, the chance of middle ear disease was 62 percent higher, and wheezing and asthma occur at least 20 percent more often in children who breathe in smoke, according to a review of studies that followed children for many years. In 2022, 28.8 percent of Polish students aged 13 to 15 were exposed to tobacco smoke at home.

Does smoking on the balcony protect a child?

It is unclear whether it provides enough protection. A Swedish questionnaire study included 1990 children aged 12 to 24 months. Significant differences in persistent cough after infection and wheezing without infection were found between children whose parents smoked indoors and those whose parents did not smoke. The authors concluded that the belief that smoking outdoors protects children needs further study, and the survey could not establish the causes of these differences.

How can you protect a child from nicotine poisoning from stop-smoking medicines?

According to the manufacturer of Nicorette gum, a dose of nicotine that an adult smoker tolerates well can cause severe or even fatal poisoning in a small child. Patches, gum, lozenges and spray should be kept out of children's reach, and a used patch should be folded in half, sticky side in, before it goes in the bin. If you suspect that a child has swallowed nicotine gum or a lozenge, sucked on a patch or stuck one on their skin, get urgent medical help.

Smoking tobacco is the leading cause of death among men in Poland. According to a report by the Agency for Health Technology Assessment and Tariff System (AOTMiT), which cites the Global Burden of Disease analysis, in 2019 smoking was responsible for 26.6 percent of deaths among men, and among women it was the second leading cause of death, responsible for 13.8 percent of deaths.

How much does smoking cost the state budget and the NFZ?

In 2025, the state collected PLN 31.1 billion in tobacco excise duty, or PLN 33.4 billion including excise on e-cigarette liquids and novel tobacco products. According to the Supreme Audit Office, tobacco excise revenue was 9.3 per cent below forecast, while cigarette sales fell by 18.2 per cent. An NFZ report states that treating patients whose primary diagnosis was one of the selected tobacco-related diseases cost at least PLN 2.28 billion in 2019. This figure excludes sick leave, disability pensions and lost work, so it cannot be compared directly with excise revenue.

How much do cigarettes cost smokers and their families?

According to Statistics Poland (GUS), a pack of 20 cigarettes cost PLN 21.61 on average in 2025. A person who smokes a pack a day therefore spends about PLN 7,888 a year on cigarettes, and about PLN 79,000 over 10 years, even without price rises. Price rises, however, are built into a law passed in October 2024: the fixed part of the excise duty on cigarettes is PLN 345 per 1,000 cigarettes from March 2025, PLN 414 in 2026 and PLN 476.10 from 2027. In the household budget survey, tobacco products accounted for an average of PLN 20.40 a month per household member in 2024, counting children and non-smokers too.

Are fewer people smoking in Poland?

For many years, yes. In a GUS survey, the share of men who smoked every day fell from 29 to just under 21 percent between 2014 and 2019, and the share of women from 17 to 14 percent. According to Poland's National Institute of Public Health (PZH), this decline stopped after 2020, and the share of men who smoke rose slightly. The two surveys used different methods, so their results are not compared directly. Some smokers also use other nicotine products: in the PZH survey, 23 percent of daily smokers also used e-cigarettes, heated tobacco, nicotine pouches or chewing tobacco, and excise revenue from e-cigarette liquids rose by 76.9 percent in 2025. Since July 2025, the law has banned selling or giving e-cigarettes and nicotine pouches to anyone under 18.

The benefits of stopping smoking begin within the first hour and grow over the years. According to WHO, heart rate and blood pressure fall just 20 minutes after the last cigarette. After 10 years, lung cancer risk is about half that of a smoker, and after 5 to 15 years, stroke risk falls to that of a non-smoker. Giving up a pack a day also saves almost PLN 8 thousand a year from the household budget.

No one has to quit smoking alone. Without any help, only 3 to 5 people out of 100 are still not smoking after six months or a year; medication and sessions with an addiction therapist improve those chances. At Nasz Gabinet clinics, both treatment options include a medical consultation. The Anti-Nicotine Treatment Plan also includes 10 sessions with an addiction therapist, who helps patients build lasting habits that support life without cigarettes. Medical consultations are available at clinics in many cities or in the Nasz Gabinet app, with no referral needed.

A review of studies on unaided quit attempts found that only 3 to 5 per cent of people who tried to quit without help were still not smoking after six months or a year. Yet in a 2025 study by Poland's National Institute of Public Health PZH, only 18.4 per cent of those who tried to quit sought help from a doctor, psychotherapist or stop-smoking programme.

Medicines improve the chances of quitting. Adding support from a therapist improves them further. A Cochrane review included 65 studies involving more than 23 thousand people taking medication. Among people using medicines, additional support from a therapist, in person or by telephone, increased the chance of quitting by about 10 to 20 per cent in relative terms compared with less intensive support or none. In studies combining medication with support, professionals usually provided 4 to 8 sessions. Telephone counselling also helps people quit. A Cochrane review of 104 studies found that, among people who called a helpline themselves, those who received several follow-up calls from an adviser were more likely to quit than those who received only materials or a single conversation.

The table shows the percentage of people who were not smoking after at least six months, separately for groups using a given medicine and for groups without it, based on a Cochrane analysis of 319 studies involving 157,000 adults. We checked prices in online pharmacies in September 2026.

The price of a patch course in the table is for the 24-hour patch; the 16-hour 25 mg patch costs PLN 57 to 112 for 7 patches. The cost of treatment with gum, lozenges or spray depends on how many doses are used each day. Nicotine mouth spray costs PLN 62 to 85 for 150 sprays.

The doctor asks how long and how much the patient has smoked, what health conditions they have, which medicines they take and how previous attempts to quit went. This helps them decide whether to use nicotine replacement therapy, such as Nicorette patches or gum, or cytisine, such as Desmoxan. They take account of heart disease, pregnancy, the patient's age and medicines whose levels rise after smoking stops.

The doctor supports the patient particularly during nicotine withdrawal: assessing symptoms, checking how the patient is tolerating the medicine and adjusting treatment if needed. Follow-up appointments are arranged individually. No referral is needed for the consultation. Patients can attend at the clinic or by video in the Nasz Gabinet app.

Course or treatment plan?

Treatment is purchased in the Nasz Gabinet app, with two options available. The Anti-Nicotine Course costs PLN 350 and includes a medical consultation with an e-prescription for a medicine selected by the doctor. The Anti-Nicotine Treatment Plan costs PLN 2499 and includes a medical consultation with prescriptions for 3 months of medication and 10 sessions with an addiction therapist. Patients buy the medicine at a pharmacy.

Cytisine, called cytisinicline in newer package leaflets, is a plant alkaloid found in the seeds of the laburnum tree, among other plants. Its structure resembles nicotine and it acts on the same receptors in the brain, but more weakly. That is why it eases cravings and withdrawal symptoms, and a cigarette smoked during treatment gives less pleasure. The Polish Register of Medicinal Products lists 17 cytisine products, 11 of which are sold without a prescription, and a pack for the whole course costs PLN 40 to 78 in online pharmacies.

Cytisine has been tested in several trials, including a study carried out in Warsaw: among 740 smokers who, apart from the medicine, received only brief advice and a few follow-up phone calls, 8.4 percent of those taking cytisine and 2.4 percent of those taking placebo did not smoke for a year after treatment. In a New Zealand study of 1,310 people, after one month 40 percent of those taking cytisine and 31 percent of those using nicotine replacement therapy said they were not smoking. In an Australian comparison with varenicline, 11.7 percent of people taking cytisine and 13.3 percent of those taking varenicline stayed smoke-free for six months. The study did not show that cytisine is at least as effective, but side effects led 16.5 percent of patients to stop taking cytisine, compared with 34.3 percent for varenicline.

According to the Summary of Product Characteristics, one pack of 100 tablets is enough for the whole course:

• days 1 to 3: one tablet every 2 hours, up to 6 a day;
• days 4 to 12: one tablet every 2.5 hours, up to 5 a day;
• days 13 to 16: one tablet every 3 hours, up to 4 a day;
• days 17 to 20: one tablet every 5 hours, up to 3 a day;
• days 21 to 25: 1 or 2 tablets a day.

Smoking has to stop by day 5 of treatment at the latest, and smoking during treatment can make side effects worse. If the course does not help, the patient stops it and can start another one after 2 to 3 months. Cytisine is not used in unstable angina, after a recent heart attack or stroke, in clinically significant heart rhythm disorders, or during pregnancy and breastfeeding. The Summary of Product Characteristics does not recommend it for people under 18 or over 65, or for patients with impaired liver or kidney function, and advises caution in conditions including ischaemic heart disease, high blood pressure, diabetes, peptic ulcer disease, an overactive thyroid and schizophrenia. Women who could become pregnant should use effective contraception during treatment, and those on hormonal contraception should also use a barrier method, such as a condom. The most common side effects include dry mouth, nausea, heartburn, headache, sleep problems, irritability and increased appetite.

Nicotine replacement therapy supplies nicotine, which eases withdrawal symptoms, without the patient inhaling smoke that contains carcinogens. All of its forms are available in Poland without a prescription: 16-hour patches in strengths of 10, 15 and 25 mg, 24-hour patches in strengths of 7, 14 and 21 mg, 2 and 4 mg gum, lozenges and pastilles, and a mouth spray. A patch releases nicotine slowly over many hours, while gum, a lozenge or the spray helps you get through a sudden craving. In a Cochrane review of 16 studies involving more than 12,000 people, a patch combined with a fast-acting form, such as gum, helped people quit more effectively than a single form used on its own, and the product information allows this combination for strongly dependent people and for those whom a single form did not help.

The dose depends on the strength of nicotine dependence. According to the product information, a 24-hour patch is used at 21 mg for 6 weeks, then 14 mg for 2 weeks and 7 mg for 2 weeks. People smoking up to 10 cigarettes a day start at 14 mg; treatment must not exceed 10 weeks. A strongly dependent smoker uses a 25 mg 16-hour patch for 8 weeks, then gradually reduces the dose to 15 and 10 mg over 4 weeks. Patients usually chew 8 to 12 pieces of 4 mg gum a day, up to a maximum of 15, for at least 3 months, then gradually stop using it.

The product information advises caution after a recent heart attack or stroke, in unstable angina, severe heart rhythm disorders and uncontrolled high blood pressure, and a person diagnosed with heart or blood vessel disease should not combine a patch with gum or lozenges without a doctor's assessment. Young people aged 12 to 17 may use 24-hour patches only if a doctor recommends them, and lozenges if a doctor or pharmacist recommends them; the spray is not given to anyone under 18.

Can nicotine patches or gum be used during pregnancy and breastfeeding?

The nicotine patch product information states that it is best to stop smoking without medicines during pregnancy. The UK's NICE guidelines base treatment during pregnancy on behavioural support and advise against cytisine, varenicline and bupropion during this time. According to their product information, cytisine is contraindicated during pregnancy and breastfeeding, bupropion should not be used during pregnancy, and varenicline is best avoided during pregnancy. If a woman cannot quit without medication, a doctor may recommend nicotine replacement therapy for 2 to 3 months. The product information suggests that gum or lozenges may be preferable because they provide a lower daily dose than a patch, although a patch may be more suitable if nausea is a problem. In a Cochrane review of 9 studies involving 2336 pregnant women, nicotine replacement therapy may have increased the chance of quitting later in pregnancy, but placebo-controlled studies did not confirm a difference. Nor was a difference found in miscarriage, premature birth, low birth weight or birth defects compared with the control group, although the certainty of this evidence is low. Nicotine used in replacement therapy passes into breast milk. According to the NiQuitin product information, the infant's exposure is relatively low and less harmful than passive smoking. Mothers should agree with their doctor how to use nicotine while breastfeeding. If using gum or lozenges, they should breastfeed just before the next dose.

Varenicline works in a similar way to cytisine. In a Cochrane review of 75 studies, more than twice as many people quit smoking on varenicline as on placebo. Varenicline also helped more often than a single form of nicotine replacement therapy or bupropion, and in two studies comparing it directly with cytisine, the difference in effectiveness between the two medicines could have been down to chance. In July 2021, batches of Champix were found to contain the impurity N-nitroso-varenicline above the permitted limit, and the Chief Pharmaceutical Inspectorate issued a notice about halting distribution of the medicine and recalling several batches. The marketing authorisation remains valid, and the European Medicines Agency considers the shortage to be over. Even so, in September 2026 none of the online pharmacies we checked had Champix for sale.

Of the bupropion products in Poland, only Zyban is authorised for treating nicotine addiction; the others whose product information we checked are authorised for depression. According to the Medicinal Products Register, Zyban's marketing authorisation expired in December 2023, and in September 2026 the medicine was unavailable at every pharmacy checked. According to its product information, Zyban is taken for at least 7 weeks and must not be used by people who have ever had a seizure, bulimia, anorexia or bipolar disorder, or who are abruptly stopping alcohol or benzodiazepines, among other contraindications. At a dose of 300 mg a day, seizures occur in approximately 1 in 1000 people.

The Anti-Nicotine Treatment Plan includes 10 sessions with an addiction therapist in the Nasz Gabinet app. The first sessions focus on motivation: patients identify their own reasons for quitting, which they can return to when cravings are strong. Together with the therapist, they also explore their smoking habits: when, where and with whom they smoke, and how they feel at the time. These conversations help identify the situations in which the urge to smoke is likely to be strongest.

One way to work on motivation is motivational interviewing: a conversation that helps patients explore their reasons for quitting and any doubts about that decision. However, a review of 37 studies involving more than 15 thousand smokers could not establish with confidence whether motivational interviewing alone increased quit rates, and the certainty of the evidence was low. It is therefore one part of therapy, rather than a treatment on its own.

How do you prepare for your quit day?

The quit day is the day from which the patient stops smoking completely. Its timing depends on the medicine chosen: with cytisine, smoking must stop by day 5 of treatment at the latest; with a 24-hour patch, it usually stops before the first patch is applied. Beforehand, patients discuss situations that may make the change difficult, such as morning coffee, the journey to work or meeting friends who smoke, and plan what to do when they feel the urge to smoke.

What happens in sessions after you stop smoking?

In subsequent sessions, the patient and therapist review difficult moments from the past few days. They work on changing daily routines, managing stress and emotions, and making any necessary lifestyle changes. Patients can also discuss worries about gaining weight.

Later in therapy, the focus is on making new habits last. Patients develop their sense of themselves as non-smokers and prepare a plan for dealing with a lapse, so that one cigarette does not lead to a return to smoking.

Some methods advertised as a way to quit smoking did not work in studies, or there is not enough evidence that they work. These include:

• acupuncture, acupressure, laser therapy and electrostimulation: a review of 38 studies found no reliable evidence that acupuncture, acupressure or laser therapy help people stay off cigarettes for at least six months, and electrostimulation turned out to be ineffective;
• hypnosis: 14 studies involving 1,926 people were not enough to tell whether hypnosis helps more than other forms of support or quitting without help, and if it does bring a benefit, the authors say it is small at most;
• anti-anxiety medicines such as diazepam and buspirone: a review of studies found no consistent evidence that they help people quit, and diazepam belongs to the benzodiazepines, which can themselves cause dependence;
• SSRI antidepressants such as fluoxetine, paroxetine and sertraline: a review of 115 studies of antidepressants did not show that they help people stop smoking, unlike bupropion;
• dietary supplements: under EU law and Polish food safety legislation they are classed as food, so before they go on sale they do not have to pass the effectiveness testing required for medicines, and their labels and advertising must not present them as treating disease.

A nicotine e-cigarette helps people stop smoking cigarettes, but someone who has switched to one is still taking nicotine. In a Cochrane review from August 2026, after at least 6 months of follow-up, 4 more people in every 100 had quit cigarettes among those given a nicotine e-cigarette than among those using nicotine replacement therapy. Serious side effects probably occurred about equally often in both groups; the certainty of this result was rated as moderate. In a UK study of 886 smokers, 18 percent of e-cigarette users and 9.9 percent of people using nicotine replacement therapy were not smoking after a year, but 80 percent of those who had given up cigarettes with the help of an e-cigarette were still using it. The WHO considers e-cigarettes harmful to health.

Heated tobacco products contain tobacco and, according to WHO, do not help people stop using it. In a 2022 Cochrane review, no study assessed whether they helped anyone quit smoking, and every randomised trial was funded by tobacco companies. WHO describes nicotine pouches as highly addictive and not risk-free. Cigarette alternatives are particularly popular among younger adults: according to PZH, 19.8 per cent of men and 12 per cent of women aged 20 to 39 use e-cigarettes, heated tobacco, pouches or chewing tobacco daily.

The medicines described on this page have been studied mainly in cigarette smokers, but according to its product information the 24-hour patch can also be used by people who want to stop using e-cigarettes or nicotine pouches.

Nicotine withdrawal symptoms usually start 6 to 24 hours after the last cigarette. According to the WHO description in the ICD-11 classification, they include low mood, insomnia, irritability, anger, anxiety, difficulty concentrating, restlessness, a slower heart rate, increased appetite and cravings, as well as a worse cough and mouth ulcers. The cough and mouth ulcers can last 2 to 3 weeks.

A review of research on tobacco withdrawal shows that anger, anxiety, low mood, difficulty concentrating and insomnia are strongest in the first week and last 2 to 4 weeks. According to a review of studies of people who quit without help, most relapses also happen within the first 8 days.

Cravings come back in situations in which the patient used to smoke. The National Cancer Institute lists stress, driving, drinking coffee or tea, meals, drinking alcohol, boredom and spending time with smokers. It advises reminding yourself that the urge to smoke will pass in a few minutes, waiting it out with a short walk, and taking a different route to work than usual.

Can quitting smoking cause anger or aggression?

Yes. Anger and impatience are common symptoms of nicotine withdrawal. American researchers measured this in a laboratory experiment in 1991. Strongly dependent smokers played a computer game in which a fictional opponent occasionally took away their points, and they could take points away in return. On a day without cigarettes, they retaliated more often than on a day when they smoked. After chewing nicotine gum, they reacted as often as on a smoking day; gum without nicotine did not have this effect.

According to a review of studies on gum and other oral forms of nicotine, 9 well-designed studies assessed irritability in the first week without cigarettes. All of them showed that nicotine in this form reduces irritability. Irritability usually eases after 2 to 4 weeks, so someone who is quitting can warn family and colleagues that they may lose their temper more easily during that time. Anyone who is losing self-control or thinking about harming themselves or someone else needs urgent medical help.

Does a short walk help you get through a craving?

Yes, for a while. In an analysis of data from experiments in which smokers either exercised or rested after a break from smoking, the urge to smoke was clearly weaker after a short bout of exercise, even moderate exercise, and the authors rated this evidence as strong. Exercise programmes added to treatment, however, did not clearly increase the number of people who stopped smoking for good, although in a review of 24 studies involving 7,279 adults the certainty of this result was low. A person with heart disease should agree with their doctor what kind of exercise is safe for them.

A missed tablet of cytisine, varenicline or bupropion

The Desmoxan tablet leaflet advises against taking a double dose after a missed dose. Patients should therefore not exceed the maximum daily dose in the schedule, for example 6 tablets on days 1 to 3, and should discuss how to continue treatment with a doctor or pharmacist if several tablets have been missed. According to the Champix leaflet, a forgotten tablet should be taken as soon as possible unless the next dose is due within 3–4 hours. In that case, the missed dose should be skipped. Do not take a double dose. After a missed Zyban dose, take the next one at the usual time without doubling it. No more than 150 mg of bupropion should be taken at once, and doses must be at least 8 hours apart.

A late patch change and the daily limit for nicotine gum

A 24-hour patch is applied once a day at the same time. It should not be worn for longer, as it then releases less nicotine. If a patient is late changing their patch, they should not apply two patches at once. Gum, lozenges and sprays are used when cravings occur, so there is no missed dose to make up, but there is a daily limit, for example 15 pieces of gum.

How can you tell you are getting too much nicotine?

According to the manufacturers of NiQuitin patches and Nicorette gum, the people most likely to take too much nicotine are those who smoked little before treatment and those who keep smoking or using an e-cigarette during treatment. The symptoms resemble nicotine poisoning. They include nausea, vomiting, excessive salivation, abdominal pain, diarrhoea, pallor, sweating, headache, dizziness and marked weakness. The patient should then stop using nicotine, remove the patch, rinse the skin with plain water, without soap, and contact a doctor. Low blood pressure, a weak or irregular pulse, difficulty breathing and seizures need immediate medical help. A cytisine overdose causes similar symptoms and also needs urgent medical help.

Many smokers feel that a cigarette calms them down. What a cigarette actually does is relieve, for a short time, the irritability and anxiety caused by nicotine withdrawal. In a Cochrane review of 102 studies, people who stopped smoking later had slightly fewer symptoms of anxiety and depression and a better mood than people who carried on smoking. The same was true for people with mental illness. The authors say the certainty of these data ranges from very low to moderate. They also write that, on average, mental health did not get worse after quitting in these studies.

However, the product information for cytisine and varenicline warns that low mood can be a symptom of nicotine withdrawal and can, rarely, lead to suicidal thoughts or suicide attempts. Quitting smoking, with or without medication, can also be linked to a worsening of mental illness, such as depression. A person under psychiatric care should tell their psychiatrist about the plan to quit, especially if they take clozapine, olanzapine or fluvoxamine, because the levels of these medicines rise after quitting smoking.

The EAGLES trial, which involved more than 8,000 smokers, looked at whether stop-smoking medicines increase the risk of psychiatric symptoms. Among people with mental disorders, moderate or severe neuropsychiatric symptoms occurred in 6.5 percent of those taking varenicline, 6.7 percent of those taking bupropion, 5.2 percent of those using a nicotine patch and 4.9 percent of those taking placebo. The authors did not find that the medicines significantly increased the risk of such symptoms. Even so, the Summary of Product Characteristics for varenicline advises stopping the medicine straight away and seeing a doctor if serious symptoms appear, such as suicidal thoughts, aggression or sudden mood swings.

After a year without cigarettes, body weight is on average 4.67 kg higher, and it rises fastest in the first 3 months. In a meta-analysis of 62 studies published in the BMJ, people who quit without medication weighed an average of 1.12 kg more after a month, 2.85 kg more after 3 months and 4.23 kg more after six months. The differences between people are large: according to the authors' calculations, after a year about 16 percent of people weigh less than before they quit, while 13 percent gain more than 10 kg. Weight went up in a similar way in people taking stop-smoking medication. Increased appetite is one of the symptoms of nicotine withdrawal.

Even with weight gain, stopping smoking still protects the heart. In a follow-up of Framingham study participants, people without diabetes who had quit within the previous 4 years gained more weight than those who had quit longer ago. Even so, their risk of cardiovascular disease was about half that of smokers. Patients can discuss concerns about weight gain in sessions with their therapist, who can also help with necessary lifestyle changes. If obesity develops after quitting, it needs treatment.

Does quitting smoking put abstinence from alcohol at risk?

Research does not support this. Among people dependent on alcohol or drugs, the proportion of smokers is two to four times higher than in the population as a whole. In a review of 35 studies involving 5,796 such people, either in treatment or after treatment, help with quitting smoking did not change the proportion of patients who stayed off alcohol and drugs. In these studies, stop-smoking medicines increased the number of people who stopped smoking, especially when combined with sessions with a therapist, while sessions alone made no clear difference. The authors rate the quality of these data as low.

Does smoking cannabis with tobacco make it harder to quit?

Yes, because tobacco added to a joint delivers nicotine. In an international survey of 33 687 cannabis users, 77 to 91 per cent of respondents from European countries mixed it with tobacco, compared with 4 to 16 per cent from the Americas. A review of 47 studies found cannabis withdrawal symptoms in 47 per cent of regular users. Irritability, anxiety and sleep difficulties can follow withdrawal from either substance. A review of 20 studies did not find a clear treatment benefit for stopping either substance, so it remains uncertain whether tobacco and cannabis are best stopped together or one after the other.

Is a hookah less harmful than a cigarette?

Studies do not show that. In an experiment involving 31 people who smoked a hookah for up to 45 minutes on one occasion and a single cigarette on another, the highest blood nicotine levels were similar. After the hookah, however, carbon monoxide levels in the blood were about three times higher, and participants inhaled an average of 48.6 litres of smoke, compared with 1 litre from a cigarette.

Most people who try to quit without help go back to cigarettes, most often in the first week. Anyone who smokes even one cigarette during treatment should talk to their doctor or therapist about what led up to it: stress, alcohol, being around smokers or a missed dose of medicine. According to the Summary of Product Characteristics for cytisine, a course that has not worked should be stopped, and a new one can be started after 2 to 3 months. According to WHO guidelines, after a relapse it is important to work out what made treatment difficult and to plan the next attempt.

Extending treatment after a successful quit attempt may reduce the risk of relapse, but the benefit depends on the medicine. In a Cochrane review of 81 studies on relapse prevention, taking varenicline for an additional 12 weeks reduced relapses, although this medicine is currently difficult to obtain in Poland. Nicotine replacement therapy may help prevent relapse in people who quit without assistance. Among people who quit with treatment, programmes teaching them to recognise difficult situations did not reduce relapses when they began only after smoking had stopped. This finding should not be taken as an assessment of the whole course of therapy, which starts before quit day and includes preparation for it.

Is it easier to quit when your partner quits too?

People who are close to each other often quit smoking at around the same time. In an analysis of data on 12,067 Framingham Study participants, the chance that someone was still smoking was 67 percent lower when their spouse had quit and 36 percent lower when a friend had quit. This was an observational study, so it does not prove that one person quits because the other one did. Programmes that taught partners and friends how to support someone who was quitting did not clearly increase the proportion of non-smokers after six months or a year, according to a summary of 14 studies.