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How cytisine works

Tobacco contains nicotine. When you smoke, nicotine is absorbed through your lungs into your blood. When nicotine reaches your brain it stimulates the release of neurotransmitters including dopamine, which acts to cause feelings of pleasure, often leading to nicotine addiction.

When you stop smoking you no longer stimulate the production of dopamine and you may experience a variety of symptoms such as craving a cigarette, feeling restless, a change in mood, or trouble sleeping. For most people who stop smoking, these withdrawal symptoms are worse in the first few days to a couple of weeks, then they reduce in strength and frequency.

Cytisine works by attaching to some of the same receptors in the brain as nicotine, reducing the pleasurable feelings experienced when using nicotine-containing products. Cytisine increases the likelihood you will stop smoking by approximately 75% compared with placebo, but also allows a gradual reduction in nicotine dependence. Compared with nicotine replacement therapy, where the body remains addicted to nicotine, cytisine has the additional benefit of weaning you off nicotine.

Managing nicotine cravings and increased appetite

Cravings are powerful urges to smoke for which there may be triggers, e.g. stressors, situations where you would usually smoke, seeing others smoking. You are more likely to give in to cravings if your inhibitions are reduced, e.g. by drinking alcohol or using recreational drugs.

Nicotine can also reduce your appetite, therefore stopping smoking may inadvertently increase your appetite. If you choose to eat as an alternative to smoking, you may gain weight. Suggestions for keeping your hands and mouth busy are:

• Have to hand a 'fiddle toy'.
• Drink water if you are tempted to eat between meals which also keeps you hydrated.
• Take a short walk or do 5 minutes exercise which also good for your general health.
• Further information and advice: Manage Weight Gain After Quitting.

How to take cytisine

• Each tablet contains 1.5mg of cytisine.
• One pack of cytisine contains 100 tablets - a complete course of treatment (25 days).
• Cytisine should be taken with water according to the schedule below.
• Each day, following your 1st dose of cytisine, we suggest you set a reminder / alarm for the next dose.
• Note: your quit smoking date should be no later than day 5. Continued smoking may worsen any treatment reaction.
• If you miss a dose of cytisine you should not take a double dose to make up for it. You should just take the next dose as indicated.

Cytisine 25-day schedule of treatment to reduce nicotine cravings

Days of treatment	Recommended dosing	Maximum daily dose
From the 1st to the 3rd day	1 tablet every 2 hours	6 tablets
From the 4th to the 12th day	1 tablet every 2.5 hours	5 tablets
From the 13th to the 16th day	1 tablet every 3 hours	4 tablets
From the 17th to the 20th day	1 tablet every 5 hours	3 tablets
From the 21st to the 25th day	1-2 tablets a day	2 tablets

An alternative version of the treatment schedule which you may find easier to follow (from the National Centre for Smoking Cessation and Training).

Does cytisine work 1st time?

Cytisine is likely to increase the chances you will quit smoking successfully by approximately 75% compared with placebo. The standard course of treatment is 25 days. If you don't manage to quit smoking on your first attempt, cytisine can be used again, but it is advised that you wait 2-3 months.

Improving your chances of quitting smoking

If you are mindful, notice your cravings, and find strategies to manage them that work for you, you are more likely to succeed in your quit smoking attempt. Here are some hints and tips for you to consider:

• Make a quit plan - think ahead about ways you will manage your cravings if and when they happen. Choose a quit date, stick to it, and seek support from family, friends, and colleagues.
• Know your triggers - cravings and thoughts about smoking can be triggered by the people you spend time with, the places you go, and the situations you encounter. Avoid your triggers, at least temporarily, after you quit to help lessen your cravings and give you time to build confidence and skills for remaining smoke free.
• Distract yourself - practice mindfulness and remember your reasons for quitting. Quitting smoking is great for your health, the health of those around you, and your bank account! Calculate how much money you will save per week / per year and what you could spend your money on instead.
• Get TXT message support - TXT the word CRAVE to 47848 to get 24/7 immediate support whenever you have a craving, or TXT QUIT to 47848 to sign up for SmokefreeTXT, a 6-8 week program of daily TXT message support, tips, and encouragement.
• Try a quit smoking medication like cytisine. If nicotine withdrawal symptoms are difficult for you, prescription quit smoking medications or nicotine replacement therapy can make your symptoms easier to handle.
• Use the free Smokefree.gov app – track your cravings and understand your smoking patterns with one of the Smokefree.gov apps.

If you don't manage to quit 1st time, or if you relapse, then try again having learned from your previous experience. To read more see Managing Nicotine Withdrawal.

Cytisine warnings and cautions

During the assessment process with Dr Fox you are required to complete a medical questionnaire to determine suitability.

Cytisine should not used if you have:

• Hypersensitivity to cytisine or any of the non-active ingredients (mannitol, microcrystalline cellulose, magnesium stearate, glycerol dibehenate and hypromellose).
• Unstable angina (chest pain due to reduced blood supply to the heart that occurs at rest and minimal exercise. Your GP or cardiologist should be able to advise if you are unsure).
• Had a heart attack within the last 6 weeks.
• A clinically significant abnormal heart rhythm. Your GP or cardiologist should be able to advise you if you are unsure.
• Had a stroke within the last 6 months.
• Are taking anti-tuberculosis drugs.
• Are pregnant or breastfeeding.

Pregnancy, breastfeeding, & risk of pregnancy

The impact of cytisine on the effectiveness of oral contraceptives is unknown. If you are of childbearing age and wish to use cytisine, you should use contraception if you are having sexual intercourse. If you take tablet-form hormonal contraception, you should also use a secondary barrier method (e.g. condom).

Cytisine should not be used if you are pregnant or breastfeeding as the effects of cytisine on your baby are unknown.

Every cigarette contains more than 4,000 chemicals, many of which are dangerous. Smoking during pregnancy can restrict the essential oxygen supply, harming your unborn baby. In many areas of the UK there are specialist NHS services to assist pregnant women to stop smoking. It is highly advisable to speak to your midwife or doctor for advice. For more information see:

• NHS - Stop smoking in pregnancy
• RCOG - Smoking and pregnancy patient information leaflet

Cytisine cautions

If you are of childbearing age and wish to use cytisine, you should use contraception if you are having sexual intercourse. If you take tablet-form hormonal contraception, you should also use a secondary barrier method (e.g. condom) because the impact of cytisine on the effectiveness of oral contraceptives is unknown.

Cytisine should be taken with caution if you have:

• Angina (ischemic heart disease) where your heart doesn't receive enough oxygen.
• Heart failure.
• Untreated high blood pressure.
• Pheochromocytoma (a tumour in the adrenal glands).
• A diagnosis of atherosclerosis (a build-up of fatty deposits in arteries which restricts blood flow).
• Peripheral vascular disease (blood flow is restricted to areas other than the heart and brain).
• Gastric or duodenal ulcer (stomach or small intestine ulcer).
• Acid reflux disease.
• Hyperthyroidism (overactive thyroid).
• Diabetes.
• Schizophrenia.

Dr Fox cannot supply cytisine if you have any of the above conditions. Please check with your regular doctor whether cytisine is suitable for you.

Please note: If you have a history of a mental health condition

Stopping smoking has been associated with worsening of underlying mental health illness. Developing a depressed mood may be symptomatic of nicotine withdrawal. This is rarely severe enough to include suicidal ideation or attempted suicide. If you have a history of psychiatric illness, it is strongly advised that you seek advice from your relevant health care professional before using cytisine or other quit-smoking medication.

Cytisine - interaction with other medicines

Cytisine should not be used with anti-tuberculosis drugs.

If you take theophylline (to treat asthma), clozapine (to treat schizophrenia) or ropinirole (to treat Parkinson's disease) it is particularly important you speak to your GP before taking cytisine, as your medication dose/monitoring schedule may need changing.

Dr Fox cannot supply cytisine if you take any of the above medications.

Please note: If you take theophylline, warfarin, or insulin, the effect of these medications may be altered if you simply stop smoking. It is therefore recommended that you seek advice from your usual GP regarding the need for dose adjustment.

If you take tablet-form hormonal contraception, you should also use a secondary barrier method (e.g. condom) while taking cytisine. This is because the impact of cytisine on the effectiveness of oral contraceptives is unknown.

If you use products containing nicotine, or continue to smoke while taking cytisine (beyond the first 5 days), you are more likely to experience adverse reactions.

Possible side effects of Cytisine

Clinical studies and experience indicate that cytisine is well tolerated, however you may experience the following side effects:

• Very common (may affect more than 1 in 10): change in appetite, weight gain, dizziness, irritability, mood changes, anxiety, high blood pressure, dry mouth, diarrhoea, rash, fatigue, sleep disorders, headaches, fast heart rate, nausea, change in taste, heartburn, constipation, vomiting, abdominal pain, muscle pain.
• Common (may affect upto 10 in 100): difficulty concentrating, slow heart rate, abdominal distension, burning tongue, malaise.
• Uncommon (affects upto 10 in 1,000): a feeling of heaviness in the head, decreased sex drive, excessive tears, shortness of breath, increased phlegm, excessive spit production, sweating, decreased skin elasticity, tiredness.

For a full list of side effects please read the manufacturer's cytisine patient information leaflet.

Overdose

If you accidentally take more than the recommended dose of cytisine you may experience symptoms similar to nicotine overdose.

Mild symptoms are malaise (a general feeling of discomfort) and nausea.

More severe symptoms (usually associated with larger overdoses) include vomiting, palpitations (sensation of the heart beating due to an increased heart rate), changes in blood pressure, breathing problems, blurred vision, and convulsions (seizures/fits). If you develop any of these symptoms, you must seek immediate medical advice and stop taking cytisine.

Reporting of suspected adverse reactions

Most adverse reactions occur in the first few days of cytisine treatment but they usually resolve quickly.

If you suspect you have experienced a concerning adverse reaction to a medicine, reporting it allows the product to be monitored. You can report your suspicions of a safety concern or incident by using the MHRA Yellow Card scheme - also available from Apple App Store or Google Play Store.

Stopping taking cytisine

If you stop taking cytisine abruptly and you are no longer smoking (beyond day 5), you may experience the return of some nicotine-withdrawal symptoms such as mood change, irritability, sleep disturbance, and/or an urge to smoke. Symptoms can be minimised by gradual dose reduction to a stop, rather than stopping abruptly.

Please note that if you stop smoking without using cytisine, withdrawal symptoms may occur due to lack of nicotine from cigarettes.

Alternative stop smoking treatments

In the UK several treatments to help you to quit smoking are available in addition to cytisine.

Varenicline (generic Champix) is licensed for use as a 'stop smoking' aid in the UK, usually as a 12 or 24 week course, and is available from Dr Fox. Branded Champix is not currently available. Champix was withdrawn in the UK in 2020 due to manufacturing issues.

Nicotine replacement therapy (NRT): transdermal patch, gum, lozenge, nasal spray, inhalator & mouth spray. Use of a longer-acting transdermal patch in combination with a faster-acting gum, lozenge, or inhalator is called 'combination NRT' and is more effective than using a single product. Used in approximately 15% of quit attempts in the UK. Available over the counter from pharmacies and some supermarkets.

Nicotine vapes (e-cigarettes) allow you to inhale nicotine in a vapour rather than smoke. They are generally more effective than NRT. People who use vapes to stop smoking are still experiencing the addictive effects of nicotine and therefore tend to continue to use them for months or years after stopping smoking tobacco. Used in approximately 35% of quit attempts in the UK. Available over the counter from pharmacies and some supermarkets.

Bupropion (Zyban) is licensed for use in the US as an antidepressant and as a stop smoking aid. Zyban is available only on prescription. Used in less than 1% of quit attempts in the UK.

Dr Fox does not supply Zyban, NRT, or nicotine vapes.

For more information see the NHS Stop smoking treatments and Using e-cigarettes to stop smoking advice.

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Further information and support

GP surgeries, pharmacies, and local councils may provide access to a variety of stop smoking support services. Also:

• The Guardian - Smokers twice as likely to quit by using cytisine, study finds
• NHS England's Smoke Free National Helpline on 0300 1231044 or online NHS stop smoking services help you quit
• NHS Better Health - Quit smoking offers support via a smartphone app, email programme, TXT messages, and a Facebook page
• NHS Scotland - the free Smokeline on 0800 848484, or online NHS inform - Stopping smoking.
• NHS Wales — the free Help Me Quit Wales Helpline on 0800 0852219, or online Help Me Quit
• NHS Northern Ireland: Public Health Agency — Stop smoking
• ASH (Action on Smoking and Health)
• QUIT is a national charity which provides telephone support
• MedlinePlus Medical Encyclopedia - Weight gain after quitting smoking: What to do