📋 Key Information Summary
- Ask, Advise, Assess, Assist, Arrange (5 A's) — every health encounter is an opportunity to address smoking; use the framework at every consultation.
- Approximately 10.6% of Australian adults smoke daily (ABS 2022–23), with rates 2–3 times higher among Aboriginal and Torres Strait Islander peoples.
- Brief advice from a GP increases quit attempts by 30–60% — even 3 minutes of counselling is effective; do not wait for the patient to raise the topic.
- Varenicline (Champix®) is the most effective single pharmacotherapy, roughly doubling quit rates versus placebo; now PBS-listed (Authority Required) following re-listing in 2024.
- Nicotine replacement therapy (NRT) — combination therapy (patch + short-acting form) outperforms monotherapy; all NRT forms are PBS-listed as General Benefit.
- Bupropion (Zyban®) is an alternative first-line agent, especially where nicotine dependence co-exists with depression; PBS Authority Required.
- Combining pharmacotherapy with behavioural support (≥4 sessions) yields the highest quit rates — up to 25–30% at 6 months.
- Quitline 13 7848 is a free, evidence-based telephone counselling service available nationwide; refer every patient who smokes.
- Pregnancy: NRT is preferred over varenicline/bupropion; offer NRT from the second trimester if non-pharmacological strategies fail. Varenicline and bupropion are contraindicated in pregnancy.
- Relapse is not failure — normalise setbacks; review pharmacotherapy dose/duration, re-engage behavioural support, and set a new quit date promptly.
- E-cigarettes/vaping: Not TGA-approved as cessation aids; emerging evidence of harm; not recommended as first-line in Australian guidelines. Discuss the current regulatory landscape (nicotine e-cigarettes require a prescription in Australia).
- COPD and CVD patients derive the greatest absolute benefit from cessation — smoking cessation is the single most effective intervention to slow COPD progression and reduce cardiovascular events.
- Patients with psychiatric comorbidities smoke at 2–3× the general population rate; cessation does not worsen mental health — it improves anxiety, depression, and quality of life.
Introduction & Australian Epidemiology
Tobacco smoking remains the leading preventable cause of death and disease in Australia, responsible for approximately 20,000 deaths annually and contributing to ischaemic heart disease, chronic obstructive pulmonary disease (COPD), lung cancer, stroke, and numerous other conditions. Although daily smoking prevalence has declined substantially — from 24% in 1995 to approximately 10.6% in 2022–23 — smoking-attributable burden persists, particularly among disadvantaged populations.
Australia has been a global leader in tobacco control through plain packaging (2012), high excise taxation, comprehensive advertising bans, and smoke-free legislation. Despite this progress, approximately 2.1 million Australians continue to smoke daily, and an additional 1.6 million smoke irregularly. The annual economic cost of smoking exceeds $136 billion (including health costs, lost productivity, and carer burden).
Health inequity: Smoking prevalence is markedly higher among people experiencing socioeconomic disadvantage (17% vs 4.5% in the most advantaged quintile), people with mental health conditions (28%), Aboriginal and Torres Strait Islander peoples (~37%), and people in custodial settings (~74%). Targeted, culturally appropriate cessation support is essential.
General practitioners are the most frequently accessed health professionals for smoking cessation advice in Australia. Evidence consistently shows that even brief clinician-delivered interventions significantly increase quit attempts and long-term abstinence. Every contact with a person who smokes is an opportunity to offer evidence-based support.
Key Australian Statistics
| Indicator | Value | Source |
|---|---|---|
| Daily smoking prevalence (≥15 years) | 10.6% | ABS National Health Survey 2022–23 |
| Aboriginal & Torres Strait Islander daily smoking | ~37% | AIHW Aboriginal and Torres Strait Islander Health Performance Framework 2023 |
| Annual smoking-attributable deaths | ~20,000 | AIHW Burden of Disease 2023 |
| Smoking-attributable burden (DALYs) | ~9.3% of total burden | AIHW Burden of Disease 2023 |
| Youth smoking (14–17 years) | <2% daily | National Drug Strategy Household Survey 2022–23 |
| Smokers who want to quit | ~70% | National Drug Strategy Household Survey 2022–23 |
Assessment & Counselling — The 5 A's Framework
The 5 A's framework (Ask, Advise, Assess, Assist, Arrange) is the gold standard brief intervention for smoking cessation in primary care. It can be delivered in as little as 3 minutes and is supported by NHMRC Level I evidence. Embedding the 5 A's into routine practice at every consultation — regardless of the presenting complaint — is the single most important systemic change a practice can make.
1
Ask
Document smoking status for every patient at every visit using an electronic health record prompt. Ask: "Do you currently smoke or use tobacco?" Record the response as Current smoker, Ex-smoker, or Never smoked. For current smokers, document cigarettes per day (CPD) and time to first cigarette (TTFC) to assess dependence.
2
Advise
Provide clear, personalised, non-judgemental advice about the health risks of continued smoking and the benefits of quitting. Use the patient's own health conditions as a prompt (e.g., "Stopping smoking is the best thing you can do to reduce your heart attack risk given your cholesterol levels"). Avoid scare tactics — use empathetic, factual language.
3
Assess
Determine willingness to quit. Ask: "Are you willing to try to quit in the next 30 days?" Use the Stages of Change model to tailor the approach. Assess nicotine dependence using the Fagerström Test for Nicotine Dependence (FTND) — score ≥6 indicates high dependence and supports combination NRT or varenicline. Assess readiness, prior quit attempts, barriers, and co-existing conditions.
4
Assist
Help the patient develop a quit plan. Set a quit date (ideally within 2 weeks). Prescribe pharmacotherapy (see Pharmacotherapy section). Provide self-help materials or digital tools. Offer referral to Quitline (13 7848) or state-based quit services. Use motivational interviewing techniques — explore ambivalence, build self-efficacy, and support autonomous decision-making.
5
Arrange
Schedule follow-up within 1–2 weeks of the quit date, then monthly for at least 3 months. Follow-up is strongly associated with sustained abstinence. During follow-up, assess for withdrawal symptoms, side effects of pharmacotherapy, and risk of relapse. Praise successes, troubleshoot difficulties, and adjust treatment as needed.
The Fagerström Test for Nicotine Dependence (FTND)
| Item | Response | Score |
|---|---|---|
| Time to first cigarette after waking | ≤5 min / 6–30 min / 31–60 min / >60 min | 3 / 2 / 1 / 0 |
| Hardest cigarette to give up | First of the day / Other | 1 / 0 |
| Smoking when ill in bed | Yes / No | 1 / 0 |
| Cigarettes per day | ≤10 / 11–20 / 21–30 / ≥31 | 0 / 1 / 2 / 3 |
| Smokes more in the morning | Yes / No | 1 / 0 |
| Smokes even when very ill | Yes / No | 1 / 0 |
Interpretation: 0–2 = very low dependence; 3–4 = low; 5 = moderate; 6–7 = high; 8–10 = very high dependence. Scores ≥6 favour combination NRT or varenicline.
Motivational Interviewing Principles
Motivational interviewing (MI) is a patient-centred counselling technique that enhances intrinsic motivation to change. It is particularly useful for patients in the pre-contemplation or contemplation stages. Core principles include:
- Express empathy: Use reflective listening; accept ambivalence as normal.
- Develop discrepancy: Help the patient see the gap between current behaviour and personal goals/values.
- Avoid argumentation: Do not impose; the patient presents the reasons for change.
- Roll with resistance: Reframe resistance rather than confronting it directly.
- Support self-efficacy: Reinforce the patient's confidence and past successes.
Practice tip: Even a 30-second intervention ("I notice you're a smoker — would you like help to quit? I can offer effective treatments") is better than no intervention. MBS item 721 (Chronic Disease Management Plan) and item 723 (Team Care Arrangement) can support structured cessation consultations.
Pharmacotherapy for Smoking Cessation
Pharmacotherapy approximately doubles quit rates compared with placebo. Three first-line agents are available in Australia: nicotine replacement therapy (NRT), varenicline, and bupropion. Combination pharmacotherapy (e.g., NRT patch + short-acting NRT, or varenicline + NRT) may be considered for highly dependent smokers or those who have relapsed on monotherapy.
Combination NRT (patch + short-acting form) is more effective than single NRT and is the recommended NRT approach. A 2019 Cochrane meta-analysis showed combination NRT increases long-term quit rates by approximately 15–25% relative to single NRT.
First-Line Pharmacotherapy Agents
Nicotine Transdermal Patch
Nicabate® / Habitrol® / Nicotinell® · NRT
Adult dose
≥10 CPD: 21 mg/24 hr (or 15 mg/16 hr) for 6–8 weeks, then taper: 14 mg for 2–4 weeks, then 7 mg for 2–4 weeks. Total duration: 8–12 weeks. <10 CPD: start 14 mg patch.
Paediatric dose
Adolescents ≥12 years: same dosing as adults; evidence is limited but NRT is considered acceptable in adolescent smokers under clinical supervision.
Renal adjustment
No adjustment required; transdermal route bypasses renal clearance.
Hepatic adjustment
Use with caution in severe hepatic impairment; monitor for increased side effects.
Key side effects
Local skin irritation (rotate sites), vivid dreams (if worn overnight), insomnia.
PBS status
✔ PBS General Benefit
Nicotine Gum / Lozenge / Oral Spray
Nicabate® Mini Lozenge · Nicorette® Gum/Spray · NRT short-acting
Adult dose
Gum: 4 mg (≥20 CPD or TTFC ≤30 min) or 2 mg (<20 CPD); 1 piece q1–2h (max 15/day) for 6 weeks, then taper over 6 weeks. Lozenge: 4 mg or 2 mg; 1 lozenge q1–2h (max 15/day) for 6 weeks, taper over 6 weeks. Oral spray: 1 mg/spray; 1–2 sprays q30min–1h as needed (max 64 sprays/day).
Technique
Gum: "Park and chew" — chew until taste appears, park between cheek and gum, repeat when taste fades (~30 min per piece). Avoid acidic beverages 15 min before/during use.
Renal adjustment
No adjustment required.
Key side effects
Jaw soreness (gum), hiccoughs, nausea (lozenge if chewed/swallowed), mouth irritation.
PBS status
✔ PBS General Benefit
Varenicline
Champix® / Generic · Nicotinic acetylcholine receptor partial agonist
Adult dose
Days 1–3: 0.5 mg OD; Days 4–7: 0.5 mg BD; Day 8 onwards: 1 mg BD for 12 weeks. Set quit date for Day 8–14. May repeat a 12-week course for relapse prevention. Some patients benefit from extended therapy to 24 weeks.
Renal adjustment
eGFR 30–50 mL/min: 0.5 mg BD throughout (no escalation). eGFR <30: limited data; use with caution, 0.5 mg OD.
Hepatic adjustment
No adjustment required (minimal hepatic metabolism).
Key side effects
Nausea (most common, ~30%, usually mild), insomnia, vivid dreams, headache. Neuropsychiatric events: current evidence does not show increased suicidality vs NRT/placebo (EAGLES trial, 2016).
Contraindications
Pregnancy, severe renal impairment (use with caution). History of psychiatric illness is NOT a contraindication — monitor mood.
PBS status
⚠ PBS Authority Required — Authority prescription required; max 2 courses per 12 months.
Bupropion
Zyban® / Generic · Noradrenaline–dopamine reuptake inhibitor
Adult dose
Days 1–3: 150 mg OD; from Day 4: 150 mg BD (doses ≥8 hours apart). Set quit date for Day 8–14. Duration: 7–9 weeks (minimum); up to 12 weeks. Taper if required. Max 300 mg/day.
Renal adjustment
eGFR 15–30: max 150 mg OD. eGFR <15: avoid or use with extreme caution.
Hepatic adjustment
Mild–moderate: max 150 mg OD. Severe: avoid.
Key side effects
Insomnia (most common, ~30–40%), dry mouth, nausea, headache. Seizure risk: 0.1% at standard doses — contraindicated in seizure disorder, eating disorders (bulimia/anorexia), abrupt alcohol/benzodiazepine withdrawal.
Contraindications
Seizure disorder, current or past eating disorder, concurrent MAOIs, abrupt cessation of alcohol or benzodiazepines.
PBS status
⚠ PBS Authority Required
Pharmacotherapy Selection Guide
| Clinical Scenario | Preferred Agent | Rationale |
|---|---|---|
| Standard first attempt, moderate–high dependence | Combination NRT or Varenicline | Both double quit rates; combination NRT is PBS-listed without authority |
| Very high dependence (FTND ≥8) | Varenicline | Most effective single agent; blocks reward from nicotine |
| Co-existing depression/anxiety | Bupropion or Varenicline | Bupropion has antidepressant properties; both are safe with psychiatric monitoring |
| Patient preference for non-prescription | Combination NRT | Available OTC (pharmacy) and PBS (prescription) |
| Failed first-line monotherapy | Switch agent or combine NRT + varenicline | Different mechanism may succeed; combination approach for refractory cases |
| Pregnancy | NRT (patch + short-acting from 2nd trimester) | Varenicline and bupropion contraindicated |
| Adolescents (≥12 years) | NRT (short-acting preferred) | Best safety data; varenicline/bupropion not TGA-approved <18 years |
Seizure risk with bupropion: Bupropion lowers the seizure threshold. It is contraindicated in patients with a history of seizure, current eating disorder, or those undergoing abrupt withdrawal from alcohol or benzodiazepines. The risk at standard doses (≤300 mg/day) is approximately 0.1%. Counsel patients about avoiding abrupt alcohol cessation concurrently.
Combination and Second-Line Strategies
- NRT patch + short-acting NRT: First-line combination approach. The patch provides steady-state nicotine; the short-acting form (gum, lozenge, spray) manages breakthrough cravings.
- Varenicline + NRT: Emerging evidence supports combining varenicline with NRT patch for highly dependent smokers or those who have failed monotherapy. May be considered on a case-by-case basis.
- NRT + bupropion: May be used when neither agent alone is sufficient. Monitor blood pressure and for seizure risk.
- Second-line (not PBS-listed for cessation): Clonidine (0.1 mg BD, titrate) or nortriptyline (25 mg OD, titrate to 75–100 mg) — limited evidence, more side effects. Reserve for cases where all first-line options are contraindicated or have failed.
Behavioural Support
Behavioural support, when combined with pharmacotherapy, produces the highest quit rates achievable with current interventions — approximately 25–30% sustained abstinence at 6 months. The combination is synergistic: pharmacotherapy reduces withdrawal and craving, while behavioural support addresses the psychological and social dimensions of nicotine addiction.
Levels of Behavioural Intervention
Minimal
Brief Advice
30 seconds to 3 minutes of clinician-delivered advice. Uses the 5 A's framework. Includes written materials or a referral card. Evidence shows a 30% relative increase in quit attempts.
Setting: Any health encounter — GP, ED, pharmacy, hospital ward
Standard
Counselling (4+ sessions)
Structured sessions (face-to-face or telephone) delivered by a trained counsellor. Includes problem-solving, skills training, and support. Quitline (13 7848) provides proactive callback. Sessions ≥10 min over ≥4 contacts increase quit rates by 50–70% relative to minimal intervention.
Setting: Primary care, Quitline, community health, hospital outpatient
Intensive
Multicomponent Program
≥4 sessions of ≥30 min each over ≥4 weeks. Combines cognitive-behavioural therapy (CBT), motivational interviewing, skills training, and pharmacotherapy. Group or individual. Specialist cessation clinics. Highest abstinence rates.
Setting: Specialist cessation service, respiratory clinic, hospital programme
Counselling Strategies
- Problem-solving and skills training: Help the patient identify triggers (stress, alcohol, social situations) and develop specific coping strategies (delay, deep breathing, distraction, substitution).
- Cognitive restructuring: Challenge unhelpful thoughts (e.g., "I can't cope without cigarettes" → "I've coped with difficult situations before; smoking doesn't actually help me cope").
- Stress management: Teach relaxation techniques — progressive muscle relaxation, mindfulness, and paced breathing.
- Weight management support: Address weight gain concerns proactively. Average weight gain is 3–5 kg in the first year. Emphasise that health benefits of quitting far outweigh modest weight gain. Encourage physical activity.
- Mood management: Monitor for depressive symptoms during quit attempts. Provide strategies or referral as needed. Depression during cessation is often transient.
Digital Interventions & Australian Resources
| Resource | Type | Access |
|---|---|---|
| Quitline | Telephone counselling (proactive callback available) | 13 7848 (13 QUIT) — free, all states/territories |
| My QuitBuddy | Smartphone app (iOS/Android) | Free — developed by the Australian Government |
| QuitCoach | Online interactive tool | quit.org.au — personalised quit plan |
| iCanQuit | Online community and resources | icanquit.com.au — NSW-focused, nationally available |
| QuitTxt | SMS-based support programme | Available via Quitline registration |
Relapse Prevention
Relapse is common and should be expected — it is part of the quitting process, not a sign of failure. Most smokers require multiple quit attempts before achieving sustained abstinence (average 8–30 attempts in the literature).
Lapse vs. Relapse: A single cigarette (lapse) does not constitute failure. Encourage the patient to immediately resume abstinence. If a lapse occurs, explore what triggered it, reinforce coping strategies, and adjust pharmacotherapy if needed. Frame the lapse as a learning opportunity. Research shows many people who lapse recover and eventually quit.
- Identify high-risk situations: Alcohol consumption, socialising with smokers, stress, boredom, and specific locations (pubs, work breaks).
- Develop coping plans: For each high-risk situation, the patient should have a pre-planned alternative behaviour.
- Extend pharmacotherapy: Consider extended courses of varenicline (24 weeks) or NRT patch for patients who relapse during or shortly after a standard course.
- Maintain contact: Schedule regular follow-up for at least 12 months. Monthly check-ins (phone, SMS, or in-person) sustain motivation and catch early relapse.
- Address alcohol and other substance use: Heavy alcohol use is a major relapse trigger. Address concurrently.
Special Populations
Pregnancy
Smoking during pregnancy increases the risk of miscarriage, preterm birth, low birth weight, placental abruption, stillbirth, and sudden infant death syndrome (SIDS). Approximately 9% of Australian women smoke during pregnancy, with rates up to 40% among Aboriginal and Torres Strait Islander women.
Pharmacotherapy
NRT is preferred if non-pharmacological strategies fail. Recommend intermittent NRT (gum, lozenge, inhalator) first; if insufficient, add NRT patch from the second trimester. Patches should be removed before sleeping to minimise foetal exposure. Varenicline and bupropion are contraindicated in pregnancy (Category D — foetal harm demonstrated or suspected).
Non-pharmacological
First-line. Offer counselling (Quitline, antenatal smoking cessation programmes). Incentive-based programmes (e.g., gift vouchers for biochemically verified abstinence) have strong evidence in pregnancy. Maternal health nurses and midwives should screen at every antenatal visit.
Breastfeeding
NRT is compatible with breastfeeding. If using NRT patch, apply immediately after a feed and remove before the next feed. Smoking itself transfers more harmful substances to breast milk than NRT. Encourage continued breastfeeding alongside cessation support.
Adolescents (12–17 years)
Adolescent smoking rates in Australia have declined to <2% daily smoking, but experimentation continues. Adolescents who smoke are highly susceptible to rapid nicotine dependence. Evidence for pharmacotherapy in adolescents is limited.
First-line
Non-pharmacological: counselling (brief advice, motivational interviewing), school-based programmes, digital/phone interventions. Involve parents/caregivers where appropriate.
Pharmacotherapy
NRT may be considered from age 12 for dependent smokers. Short-acting forms (gum, lozenge) preferred. Varenicline and bupropion are not TGA-approved for those under 18 years — use only under specialist supervision if considered.
Psychiatric Comorbidities
People with mental illness smoke at 2–3 times the population rate and have higher nicotine dependence. Smoking contributes significantly to their excess cardiovascular and cancer mortality. Critically, cessation does not worsen psychiatric symptoms — meta-analyses show improvements in anxiety, depression, and quality of life after quitting.
Depression/Anxiety
All first-line agents are safe. Bupropion is particularly suitable (antidepressant properties). Monitor mood during cessation; adjust antidepressant dose if needed. NRT and varenicline are also appropriate.
Schizophrenia / Psychotic disorders
Smoking affects CYP1A2 metabolism — cessation may increase levels of olanzapine, clozapine, and other CYP1A2 substrates by 20–50%. Reduce dose and monitor plasma levels. Varenicline is safe and effective; bupropion can be used with caution.
Substance use disorders
Addressing smoking alongside other substance use does not compromise treatment outcomes and may improve long-term recovery rates. Bupropion contraindicated during abrupt alcohol/benzodiazepine withdrawal. NRT is safe and first-line in this population.
Alcohol dependence
Avoid bupropion during acute alcohol withdrawal. NRT and varenicline are safe. Address concurrent alcohol use as a relapse trigger.
COPD Patients
Smoking cessation is the single most effective intervention to slow the rate of FEV₁ decline and reduce exacerbations in COPD. Even in severe COPD, cessation improves symptoms, exercise tolerance, and quality of life. The benefits of cessation exceed those of any inhaled pharmacotherapy.
Approach
Use spirometry results as a motivational tool ("Your lung age is..."). All first-line pharmacotherapies are appropriate. Combination NRT or varenicline recommended given typically high dependence. Integrate cessation into COPD action plans and pulmonary rehabilitation programmes.
Cardiovascular Disease (CVD) Patients
Smoking cessation after acute coronary syndrome reduces mortality by 30–50% — more effective than any single cardiac medication. Benefits are seen at any age. NRT is safe post-MI and post-stroke (discuss with cardiologist for patch use in acute setting). Varenicline does not increase cardiovascular events (EAGLES trial).
Pharmacotherapy safety
NRT: Safe post-MI, post-stroke. Patch may be used. Varenicline: Safe in CVD patients. Bupropion: Use with caution — can raise blood pressure; monitor BP. All patients with CVD should receive intensive cessation support.
E-Cigarette / Vaping Cessation
E-cigarette use (vaping) is increasing in Australia, particularly among young adults. While e-cigarettes are promoted by some as cessation aids, Australian regulatory authorities (TGA, NHMRC) do not endorse them as first-line cessation tools due to insufficient evidence of long-term efficacy and safety, and concerns about dual use, youth uptake, and lung injury.
Regulatory status (Australia)
Since October 2021, nicotine-containing e-cigarettes require a medical prescription. From 2024, new reforms restrict access further — nicotine vapes are only available through pharmacies with a prescription. Non-nicotine vapes are also increasingly regulated.
Cessation approach
Treat vaping nicotine dependence similarly to smoking. Assess nicotine dependence level. Offer standard pharmacotherapy — NRT, varenicline, or bupropion — with behavioural support. Many vapers are dual users (smoking + vaping); address both behaviours simultaneously. Harm reduction principles may apply for those using vaping to quit combustible tobacco, but aim for complete nicotine cessation.
Youth vaping
Rapidly rising concern. Brief advice and referral to Quitline are appropriate. NRT (short-acting) may be considered for nicotine-dependent youth. School-based and digital interventions are critical prevention strategies.
Clozapine and smoking cessation: Smoking induces CYP1A2, and abrupt cessation of smoking can increase clozapine levels by 50–70%, raising the risk of toxicity (seizures, agranulocytosis). If a patient on clozapine stops smoking, reduce clozapine dose by 20–30% and monitor plasma levels and FBC closely. Consult the treating psychiatrist.
Aboriginal and Torres Strait Islander Health Considerations
Aboriginal and Torres Strait Islander Health
Tobacco smoking is the most modifiable risk factor contributing to the health gap between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians. Approximately 37% of Indigenous Australians smoke daily — more than three times the non-Indigenous rate. Smoking is a major contributor to the excess burden of cardiovascular disease, COPD, lung cancer, and low birth weight in Indigenous communities.
Importantly, smoking rates among Aboriginal and Torres Strait Islander peoples have been declining significantly — from 51% in 2002 to approximately 37% in 2022–23 — reflecting the success of Indigenous-led health promotion initiatives. However, further progress requires culturally safe, community-driven approaches.
Evidence-Based Strategies for Aboriginal and Torres Strait Islander Communities
Closing the Gap PBS Co-payment: Aboriginal and Torres Strait Islander patients with, or at risk of, chronic disease are eligible for PBS medicines without the standard co-payment when prescribed by their GP through the Indigenous health incentive. Ensure all cessation pharmacotherapy is prescribed through this pathway to minimise cost barriers.
Monitoring & Follow-Up
Regular follow-up is one of the strongest predictors of sustained smoking abstinence. A structured monitoring plan increases quit rates by 25% or more compared to unstructured care.
Quit date – Day 1
Confirm quit date set. Ensure pharmacotherapy initiated (NRT started; varenicline/bupropion in lead-in phase). Provide written quit plan and trigger/coping strategies. Refer to Quitline (13 7848).
Week 1–2
First follow-up — phone or in-person. Assess for withdrawal symptoms, medication side effects (especially nausea with varenicline), adherence, and early lapses. Reinforce motivation. Adjust dose if needed. CO-oximetry (if available) provides objective feedback.
Month 1
Second follow-up. Assess abstinence, mood (PHQ-2 for depression screening), weight change, and ongoing pharmacotherapy needs. Continue behavioural support. Reinforce coping strategies for upcoming high-risk situations.
Month 3
Third follow-up. Evaluate whether to continue, taper, or switch pharmacotherapy. Discuss extended varenicline or NRT if needed. Celebrate milestones. Address ongoing challenges.
Month 6–12
Longer-term follow-up. Assess sustained abstinence. Continue to monitor for relapse. Review cardiovascular and respiratory health benefits. Annual review thereafter to prevent late relapse.
Objective Verification
- Exhaled carbon monoxide (CO-oximetry): A reading <10 ppm suggests abstinence (or very low tobacco intake). Useful for confirming self-report in clinical settings. Handheld devices are available in most respiratory clinics and some GP practices.
- Urinary cotinine: More sensitive than CO but more expensive. Cotinine has a half-life of 16–20 hours and detects nicotine use within the preceding 3–4 days. Useful for research, medicolegal, or insurance contexts.
- Self-report: Adequate for routine clinical care when supported by therapeutic rapport. Validate non-judgementally.
Relapse Assessment & Management
If a patient relapses, assess the circumstances systematically:
- What triggered the relapse? (Stress, alcohol, social situations, medication side effects leading to discontinuation)
- Was pharmacotherapy used correctly and at adequate dose/duration?
- Was behavioural support engaged?
- Are there untreated comorbidities (depression, anxiety, substance use)?
- Is the patient ready to try again? If so, set a new quit date within 2–4 weeks and intensify treatment (switch agent, combine therapies, increase counselling).
Quick Reference: Smoking Cessation Pharmacotherapy
NRT Patch + Short-Acting
Patch 21 mg + gum 4 mg PRN
8–12 weeks
Most accessible; PBS General Benefit; combination superior to monotherapy
Varenicline
1 mg BD (after 7-day titration)
12 weeks (extendable to 24)
Most effective single agent; nausea common; PBS Authority Required
Bupropion
150 mg BD (after 3-day lead-in)
7–12 weeks
Good for comorbid depression; seizure risk 0.1%; PBS Authority Required
Combination (Refractory)
Varenicline + NRT patch
12–24 weeks
For high-dependence or failed monotherapy; emerging evidence supports combination
📚 References
- 1. Australian Bureau of Statistics. National Health Survey 2022–23. Canberra: ABS; 2024. Smoking behaviour and tobacco use statistics.
- 2. Australian Institute of Health and Welfare. National Drug Strategy Household Survey 2022–23. Drug Statistics series no. 40. Canberra: AIHW; 2024.
- 3. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
- 4. Lindson N, Chepkin SC, Livingstone-Banks J, et al. Different doses, durations and modes of delivery of nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2019;4(4):CD013308.
- 5. Anthenelli RM, Benowitz NL, West R, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. Lancet. 2016;387(10037):2507–2520.
- 6. Cahill K, Lindson-Hawley N, Thomas KH, Fanshawe TR, Lancaster T. Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev. 2016;(5):CD006103.
- 7. Stead LF, Koilpillai P, Fanshawe TR, Lancaster T. Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane Database Syst Rev. 2016;(3):CD008286.
- 8. Royal Australian College of General Practitioners. Supporting smoking cessation: A guide for health professionals. Melbourne: RACGP; 2021.
- 9. Department of Health and Aged Care (Australia). Tackling Indigenous Smoking Programme. Canberra: Australian Government; 2023. Available at: https://www.health.gov.au/our-work/tackling-indigenous-smoking
- 10. National Health and Medical Research Council. CEO Statement on Electronic Cigarettes. Canberra: NHMRC; 2022.
- 11. Thomas D, Abramson MJ, Bonevski B, George J. System-level change for smoking cessation in general practice: a cluster randomised trial. Addiction. 2018;113(6):1081–1089.
- 12. van der Deen FS, Wilson N, Blakely T. Smoking prevalence trends in New Zealand and Australia: implications for tobacco control policy. Aust N Z J Public Health. 2023;47(1):100010.
- 13. Hartmann-Boyce J, Chepkin SC, Ye W, Bullen C, Lancaster T. Nicotine replacement therapy versus control for smoking cessation. Cochrane Database Syst Rev. 2018;(5):CD000146.
- 14. Bhalala U, Ghafoor A, Mistry R, et al. Bupropion for smoking cessation in people with schizophrenia and schizoaffective disorder: a systematic review. J Clin Psychiatry. 2022;83(3):21r14118.
- 15. Therapeutic Goods Administration. Reforms to regulation of nicotine vaping products. Canberra: Department of Health and Aged Care; 2024. Available at: https://www.tga.gov.au/products/unapproved-therapeutic-products/nicotine-vaping-therapeutic-goods