Smoking cessation and pulmonary rehabilitation

• Tobacco dependence is a chronic, relapsing disorder; asking, advising and offering help at every visit is itself an effective intervention.
• Combining medicines with behavioural support gives the best quit rates: nicotine replacement therapy (NRT) raises the chance of success by about 50 to 60%, bupropion by about 49 to 72%, and varenicline more than either.
• The strongest regimen is a long-acting plus a short-acting NRT together, or varenicline, prescribed before the quit date.
• Pulmonary rehabilitation is a supervised, multidisciplinary programme of exercise, education and behaviour change that improves breathlessness, exercise capacity and quality of life in chronic respiratory disease.
• Every patient with chronic lung disease should be offered the guideline vaccines: influenza every year, pneumococcal vaccine, COVID-19 vaccine, and, by age and guideline, RSV, pertussis and shingles vaccines.

By the end of this page you should be able to:

1. Deliver very brief advice to stop smoking and explain why it matters.
2. Choose and dose NRT, varenicline and bupropion, and manage renal adjustment and common adverse effects.
3. Explain why combination NRT outperforms single-product NRT, and what "preloading" means.
4. Describe the core components of a pulmonary rehabilitation programme and who should be referred.
5. State the vaccination schedule recommended for adults with chronic lung disease and the reasoning behind it.
6. Handle a quit attempt that has failed, and know when to refer.

This procedure page covers two linked parts of respiratory care. The first is smoking cessation: the single most effective intervention for slowing lung disease, from a brief conversation to pharmacotherapy. The second is pulmonary rehabilitation and vaccination in chronic lung disease: what remains once the smoker has stopped, and how to protect damaged lungs from infections. ^[1][10][11]

Much of the same population needs both. A person with chronic obstructive pulmonary disease (COPD) who still smokes gains more from stopping than from any inhaled drug, and then gains again from rehabilitation and immunisation. The two are therefore taught together.

Smoking cessation support is indicated for every person who smokes and is willing to try, and it should be offered to those not yet ready to quit, using harm-reduction approaches. ^[1] Adults, young people aged 12 and over, and pregnant people are all within scope of the NICE guideline. ^[1]

Pulmonary rehabilitation is strongly recommended for adults with stable COPD, after a hospitalisation for a COPD exacerbation, and for adults with interstitial lung disease. It is conditionally recommended for adults with pulmonary hypertension. ^[10] It also helps asthma, bronchiectasis, lung cancer and people preparing for or recovering from lung surgery or transplantation, who are referred in the same way. ^[10]

Vaccination is indicated for all adults with chronic lung disease. The specific vaccines follow the GOLD 2025 recommendations, which in turn follow the United States Centers for Disease Control and Prevention (CDC). ^[11] Regional schedules vary; always follow local recommendations. ^[11]

• Bupropion must not be used in anyone with a seizure disorder or an eating disorder, or within 14 days of stopping a monoamine oxidase inhibitor. The maximum daily dose is 300 mg, because seizure risk rises with dose. ^[8]
• Varenicline needs no adjustment in mild to moderate renal impairment, but in severe renal impairment (estimated creatinine clearance under 30 mL per min) it is started at 0.5 mg once daily and titrated only to 0.5 mg twice daily; in end-stage renal disease on haemodialysis the maximum is 0.5 mg once daily. ^[7]
• NRT patches are applied to intact skin and should be removed 24 hours before microvascular reconstructive surgery or surgery using vasopressin injections. ^[1] A history of recent heart attack or irregular heartbeat should be reviewed before starting; patch labels advise asking a clinician. ^[9] Guidance differs by country.
• Combined varenicline and bupropion has not been clearly shown to differ in safety from single therapy in trials, but serious-adverse-event numbers were small, so confidence is limited. ^[5][6]
• Cytisinicline, varenicline and bupropion are not offered to people under 18. ^[1] Cytisinicline is not offered to people aged 66 or over in the UK guidance. ^[1]
• Young people aged 12 and over who are dependent on tobacco may be offered NRT with behavioural support. ^[1]

Very brief advice is a short, structured conversation. It has three parts: ask about smoking at every opportunity, advise that stopping is the best thing the person can do for their health and that support is available, and act by offering help or referral. ^[1] Even a short clinician conversation raises quit rates: advice from a clinician carries a relative risk of 1.76 (95% CI 1.58 to 1.96) compared with minimal support. ^[2]

The tone matters more than the time. Say that stopping smoking in one go is the best approach, explain how stop-smoking support can help, and leave the door open if they are not ready. ^[1] Record smoking status and everything you discuss, and ask again next time. ^[1]

For someone who is not ready to stop in one go, identify how many cigarettes they smoke and how soon after waking, talk about harm reduction (cutting down before stopping, smoking reduction, or temporary abstinence, with or without medicinally licensed products) and set a quit date within 6 weeks where possible. ^[1]

NRT replaces some of the nicotine the smoker used to inhale, so withdrawal symptoms ease while the cigarette is withdrawn. It is available as a patch (slow, steady delivery) and as gum, lozenge, inhalator, nasal spray and oral spray (faster, used for cravings). All licensed forms increase quit rates. ^[3]

A Cochrane review of 136 trials with 64,640 participants found that any form of NRT raised the chance of abstinence at 6 months or longer by about 50 to 60% compared with control (relative risk 1.55, 95% CI 1.49 to 1.61). ^[3] The review's pooled relative risks were 1.64 (95% CI 1.53 to 1.75) for the patch, 1.49 (95% CI 1.40 to 1.60) for gum, 1.52 (95% CI 1.32 to 1.74) for oral tablets and lozenges, 1.90 (95% CI 1.36 to 2.67) for the inhalator and 2.02 (95% CI 1.49 to 2.73) for the nasal spray. ^[3] NRT works with or without additional counselling and does not need a prescription. ^[3]

• Patch. A common 24-hour schedule uses 21 mg daily for 4 weeks, then 14 mg for 2 weeks, then 7 mg for 2 weeks. If the smoker has 10 or fewer cigarettes a day, start with the 14 mg patch for 6 weeks, then the 7 mg patch for 2 weeks. Follow the product's directions. ^[9]
• Gum and lozenge. Available in more than one strength; match the strength to the daily cigarette count as directed on the product, and use a piece when a craving is expected, before the usual cigarette time, because release is slower than from smoke.
• Inhalator and nasal spray. Useful when the hand-to-mouth ritual or a fast "hit" is the trigger.
• Combination. Use a long-acting patch plus a short-acting form. A Cochrane review found combination NRT (patch plus a fast-acting form) produces higher quit rates (relative risk 1.27, 95% CI 1.17 to 1.37) than a single form, a 17 to 37% relative improvement. ^[4] Higher-dose patches (21 to 25 mg) also outperform lower-dose ones (14 to 15 mg). ^[4]
• Preloading. Starting NRT before the quit day may help more people to quit (relative risk 1.25, 95% CI 1.08 to 1.44 in pooling of 9 studies), and modern labels and practice encourage this. ^[4]
• Duration. NRT is continued for as long as it helps prevent relapse, often several months; there is no evidence that gradual withdrawal is better than abrupt stopping. ^[4]

Safety is reassuring. There was no evidence that NRT increases the risk of heart attack in pooled trials. ^[3] Skin irritation from patches and mouth irritation from gum and tablets are the common effects; chest pain and palpitations are rare. ^[3]

Varenicline is a partial agonist selective for the alpha-4 beta-2 nicotinic acetylcholine receptor. It eases craving and withdrawal, and it blocks some of the reward from smoking if the person lapses. ^[5][7]

In pooled trials varenicline more than doubled quit rates compared with placebo (relative risk 2.32, 95% CI 2.15 to 2.51, 41 studies, 17,395 participants), and beat bupropion (relative risk 1.36, 95% CI 1.25 to 1.49) and a single form of NRT (relative risk 1.25, 95% CI 1.14 to 1.37). ^[5] Absolute quit rates in those trials were about 21 to 25 per 100 with varenicline versus 18 per 100 with bupropion or single-form NRT. ^[5] There was no clear difference between varenicline and dual NRT (patch plus a fast-acting form). ^[5]

Standard adult dosing is a 1-week titration followed by 12 weeks of treatment: ^[7]

• Start 1 to 2 weeks before the quit date, or start the drug and let the person stop smoking between day 8 and day 35. ^[1][7]
• Reassess near the end of the 12 weeks. If the smoker has quit, a further 12-week course is recommended to consolidate abstinence. ^[7]
• For people unwilling or unable to quit abruptly, a gradual schedule is licensed: halve cigarette use in the first 4 weeks, halve it again in the next 4 weeks, aim for complete abstinence by 12 weeks, then continue for a further 12 weeks (24 weeks in total). ^[7]
• Renal adjustment as above for severe impairment (clearance under 30 mL per min) and haemodialysis. ^[7]

Nausea is the most common effect and is usually mild to moderate, settling with time. ^[5][7] Headache, insomnia and vivid dreams are also common. ^[7] In pooled trials people on varenicline were more likely to report serious adverse events (relative risk 1.23, 95% CI 1.01 to 1.48), but event numbers were small and included events unrelated to the drug; there was no clear increase in cardiac or neuropsychiatric serious events. ^[5] A very small absolute rise in nausea-driven discontinuation is the main practical issue.

Bupropion (bupropion hydrochloride sustained-release, SR) is an antidepressant used as a smoking-cessation aid. It is started before the quit date and continued for 7 to 12 weeks. ^[6][8]

A Cochrane review found bupropion raised quit rates versus placebo (relative risk 1.60, 95% CI 1.49 to 1.72, 50 studies, 18,577 participants), and USPSTF pooling gave 1.64 (95% CI 1.52 to 1.77). ^[6][2] Bupropion may be as effective as single-form NRT and less effective than combination NRT or varenicline. ^[6] In the same review's terms it makes a quit attempt 49 to 72% more likely. ^[6]

Bupropion SR is started 1 week before the quit date, while the person is still smoking, and the target quit date is set within the first 2 weeks of treatment: ^{[8] [1]}

• 150 mg each morning for 3 days.
• Then 150 mg twice daily, at least 8 hours apart, maximum 300 mg a day.
• Continue for 7 to 12 weeks. If the smoker has not quit by then, further treatment in that attempt is unlikely to help; reassess. ^[8]
• Dose adjustment: in moderate to severe hepatic impairment, give 150 mg every other day; consider reducing the dose or frequency in renal impairment. ^[8]

• Seizure. The risk is dose-related: about 0.1% (1 in 1,000) at up to 300 mg a day and rising to about 0.4% (4 in 1,000) at up to 400 mg a day. Keeping the dose at or below 300 mg a day, titrated gradually, lowers the risk. Stop the drug and do not restart if a seizure occurs. ^[8]
• Other effects. Insomnia, dry mouth, agitation and headache are common; tolerability problems cause more people to stop bupropion than placebo (relative risk 1.44, 95% CI 1.27 to 1.65). ^[6]
• Neuropsychiatric events have been reported in post-marketing use for smoking cessation; monitor mood, especially in people with a mood disorder, although pooled trial data are imprecise and the confidence interval includes no difference in serious adverse events (relative risk 1.16, 95% CI 0.90 to 1.48). ^[6]
• Drug interactions. Bupropion is used carefully with drugs that lower the seizure threshold (antipsychotics, antidepressants, theophylline, systemic steroids) and with MAO inhibitors. ^[8]
• Blood pressure should be checked if bupropion is used together with NRT. ^[8]

When the person is motivated, present the options and let them choose, taking health, current medicines, contraindications, cost and past experience into account. ^[1]

Numbers are relative risks for abstinence at 6 months or longer against minimal support or placebo, rounded. ^{[2][3][4][5][6]}

Start any pharmacotherapy before the quit date, not on it: NRT should be in hand the day before, varenicline 1 to 2 weeks before, bupropion and cytisinicline a week or two before with the quit date set within the first 2 weeks. ^[1]

Relapse is expected; it is not a reason to abandon the patient. Discuss triggers and coping, and offer another course. ^[1] Switching drug class or combining treatments raises the chance of success for the next attempt. ^[6] Varenicline can be prescribed for relapse prevention in ex-smokers, and NRT or bupropion for the same purpose, although this is off-label for bupropion in UK guidance. ^[1]

People with mental health conditions need tailored intensity and duration of support, often from a specialist adviser. ^[1]

Pregnancy and the year after childbirth have their own recommendations in NICE NG209 (2025). In brief, NRT is recommended with behavioural support in pregnancy; cytisinicline, varenicline and bupropion are not offered. ^[1]

Pulmonary rehabilitation is a structured, supervised programme that begins with a thorough patient assessment and moves through a patient-tailored plan of exercise training, education and behaviour change, delivered by a multidisciplinary team, with outcome measurement. ^[10] CORE components are patient assessment, structured and progressive individually tailored exercise training, self-management education and outcomes measurement. ^[10]

Published trials of pulmonary rehabilitation have lasted from 4 weeks to one year, and most programmes for stable COPD ran 8 to 12 weeks. ^[10]

Benefits include reduced dyspnoea, increased exercise capacity, better health-related quality of life and emotional function, social support, fewer hospital admissions and lower mortality risk after hospitalisation in COPD. ^[10]

• Adults with stable COPD, at any level of impairment, regardless of forced expiratory volume in one second (FEV1) (strong recommendation). ^[10]
• Adults after hospitalisation for a COPD exacerbation (strong recommendation). ^[10]
• Adults with interstitial lung disease (strong recommendation). ^[10]
• Adults with pulmonary hypertension (conditional recommendation). ^[10]
• Adults with asthma, bronchiectasis, lung cancer, and those before or after lung surgery or transplant. ^[10]
• After an exacerbation hospitalisation, refer as soon as the patient is stable; pulmonary rehabilitation in this window reduces readmissions. ^[10]

A common rule of thumb is FEV1 below 50% for referral under older guidance, but the 2023 guideline removes this threshold: patients with mild symptoms (modified Medical Research Council (mMRC) dyspnoea grade 1 or less) also benefit, and there is no relationship between severity of lung-function impairment and response to rehabilitation. ^[10]

1. Assessment. History and examination with emphasis on cardiopulmonary status and smoking; post-bronchodilator spirometry; exercise capacity (incremental cycle or treadmill, 6-minute walk, or shuttle walk); questionnaires for health status (CAT, CRQ or SGRQ) and mood (HADS); respiratory and limb muscle strength; and the patient's own goals. ^[10]
2. Multidisciplinary team. Physician (ideally a pulmonologist), physiotherapist, respiratory therapist, exercise physiologist, occupational therapist, nurse, dietitian, psychologist and smoking-cessation counsellor. No single profession covers it alone. ^[10]
3. Exercise training. The cornerstone: supervised, progressive aerobic work (treadmill or cycle, or ground walking), resistance training for upper and lower limbs, and inspiratory muscle training, breathing retraining (pursed-lip and diaphragmatic), and neuromuscular electrical stimulation in selected patients. Also whole-body vibration and aquatic exercise in some programmes. ^[10]
4. Education and self-management. Smoking cessation, basic COPD information, correct inhaler technique, early recognition and self-management of exacerbations, nutrition, when to seek help, advance directives and palliative care discussion. ^[10]
5. Psychosocial support. Cognitive behavioural therapy, anxiety and depression screening, and mind-body techniques (mindfulness, yoga, tai chi, relaxation). ^[10]
6. Outcome measurement. Exercise capacity, symptom scores and health-related quality of life at baseline and end, to document benefit and justify the service. ^[10]
7. Maintenance. Supervised maintenance rehabilitation versus usual care after the initial programme is a conditional recommendation. ^[10]

Telerehabilitation (centre-based or remote, with or without video supervision) is recommended as an equivalent choice for adults with chronic respiratory disease. ^[10]

Red flags during rehabilitation that stop or modify exercise include severe desaturation, chest pain suggesting ischaemia, malignant arrhythmia, sudden severe breathlessness and an unstable condition; these are managed in the supervision protocol of the centre, which always includes oxygen where indicated.

Respiratory infection is the commonest trigger of exacerbations in COPD, so vaccination is part of pulmonary care, not an afterthought. ^[11] The GOLD 2025 recommendations summarised by the 2025 review are: ^[11]

GOLD and many guidelines categorise the RSV recommendation as the highest evidence level (Category A) and the others as Category B. ^[11] Pneumococcal vaccination reduces exacerbations (odds ratio 0.60, 95% CI 0.39 to 0.93) and community-acquired pneumonia (odds ratio 0.62, 95% CI 0.43 to 0.89) in pooled studies, without a significant effect on specifically pneumococcal pneumonia. ^[11]

PCV20 needs no booster after it is given; PCV15 is followed by PPSV23. ^[11] Where guidelines differ, the evidence base for some vaccines in COPD alone is limited (RSV evidence, for example, comes from older and high-risk adults, not COPD-specific trials). ^[11]

• The cheapest and most effective intervention in any setting is brief advice plus support to stop smoking; combine it with NRT where it is available. ^[1][3]
• Where varenicline or bupropion are unavailable or costly, use a combination of NRT forms plus behavioural support, which beats single-form NRT. ^[4]
• Pulmonary rehabilitation needs a physiotherapist, a space and a basic kit (timer, pulse oximeter, chairs, resistance bands) more than it needs machinery. Supervised walking programmes and telerehabilitation are effective alternatives. ^[10]
• Vaccines follow local programmes: at minimum, ensure influenza annually and complete any pneumococcal course available locally. ^[11]
• Refer early: surgical or specialist care (for advanced COPD, transplantation) is concentrated in a few centres; plan travel and costs in advance.

• Ask, advise and act at every visit: very brief advice raises quit rates (relative risk 1.76). ^[2]
• Combine pharmacotherapy with behavioural support whenever possible; the best regimens are combination NRT or varenicline. ^[1][5]
• NRT increases quit rates by 50 to 60% (relative risk 1.55) and is safe in people with cardiovascular disease. ^[3]
• Combination NRT beats single-form NRT (relative risk 1.27). Use a patch plus a fast-acting form. ^[4]
• Varenicline (0.5 mg twice daily titrated to 1 mg twice daily for 12 weeks, started 1 to 2 weeks before the quit date) is the most effective single medicine. ^[7][5]
• Bupropion (150 mg for 3 days, then 150 mg twice daily, maximum 300 mg/day, for 7 to 12 weeks) helps but has seizure and psychiatric cautions. ^[8]
• Refer every adult with stable COPD, every patient after an exacerbation hospitalisation, and every patient with ILD to pulmonary rehabilitation, regardless of FEV1. ^[10]
• Core rehabilitation components are assessment, individualised exercise (aerobic plus resistance), self-management education, psychosocial support and outcome measurement, delivered by a multidisciplinary team. ^[10]
• Vaccinate against influenza yearly, give pneumococcal vaccine (PCV20 once, or PCV15 then PPSV23), COVID-19, RSV once over 60, pertussis if not received in adolescence, and two doses of recombinant zoster vaccine over 50. ^[11]
• Plan for relapse: switching drug class or using combination works better than repeating the same failed approach. ^[6]

These topics are related and worth reading alongside this one: chronic obstructive pulmonary disease; asthma; interstitial lung disease; bronchiectasis; pneumonia and community-acquired pneumonia; influenza; COVID-19; pharmacology of antidepressants; drugs for tobacco dependence. In UK practice, NICE NG209 and TA123 (varenicline) are the relevant guidance documents. ^[1]