Guidelines to manage nicotine withdrawal and cessation support in nicotine dependent patient

There is no safe level of exposure to environmental tobacco smoke, also known as second hand smoke. All public hospitals and community health facilities across WA are smoke free.

Smoking is not permitted on hospital or health service grounds or car parks.

Electronic cigarettes (e-cigarettes) and other personal vaporisers for delivery of nicotine or other substances are not permitted to be used in any area where smoking is restricted.

These guidelines provide information on how to manage WA Health patients with nicotine dependence and support those wanting to quit while in hospital.

All information is based on best practice for smoking cessation and nicotine withdrawal management.


  • Patient – a person who has been through a formal admission process to a hospital.
  • Resident – a person assessed as requiring residential care.

Hospital setting

Emergency Department

The Emergency Department (ED) will need to meet the needs of patients presenting who may be stressed, anxious, grieving or aggravated.

A smoking assessment should be carried out as per regular admissions. However, the screening and assessment will be shorter and potentially completed more quickly,  providing rapid relief for withdrawal symptoms if required.

Rapid release Nicotine Replacement Therapy (NRT) such as lozenges, inhalers and gum should be readily available in the ED.

Planned admissions


  • All patients must be advised of the OD 0414/13 Smoke Free WA Health System Policy (external site) (the policy) and informed that smoking is prohibited on hospital grounds.
  • Patients should be assured that the health service will provide assistance with nicotine withdrawal management and further support.

On admission

Patients must be advised (or reminded) of the policy and informed that smoking is prohibited on hospital grounds. On admission patients should be screened, and their smoking status recorded.


  • The patient’s intention to remain abstinent after discharge should be assessed.
  • If a patient chooses to quit, a minimum 7 days’ supply of NRT should be provided.
  • Patients should be provided with points of referral to smoking cessation services such as:
    • Quitline – 13 7848 (13 QUIT)
    • Health service staff trained in brief intervention
    • Local Cancer Council WA Fresh Start program
    • Quitnow (external site)
    • General Practitioner (GP)
    • Pharmacist
  • A copy of the Nicotine Withdrawal Management Plan should be provided with the discharge plan.
  • Those who choose not to quit should be provided with points of referral as above, and encouraged to consider a quit attempt in the future.
  • Smoking status and nicotine dependence management during hospitalisation to be included in discharge summary to GP.

Brief intervention training for WA Health staff

Brief intervention is the delivery of brief opportunistic advice to quit and can be delivered by all health professionals in the course of their work.

A brief intervention can take between 3 to 20 minutes to conduct.

Interventions can be repeated or followed up at appropriate intervals, either by the same provider or multiple providers.

All WA Health staff should have the capacity to provide brief intervention on nicotine dependence and cessation support.

The Brief Tobacco Intervention Training Program (external site), developed by the National Drug Research Institute (external site) to support the policy, is available at no charge to health professionals with an interest in smoking cessation.

Staff are encouraged to complete the training to achieve competency in brief intervention and motivational interviewing.

Help to quit smoking

Patients should be encouraged to access quit smoking services to improve the likelihood of a successful quit attempt and for ongoing support.

  • Call 13 7848 (13 QUIT) or visit QuitNow (external site).
    Quitline provides smoking cessation information, advice and counselling to WA smokers. Counsellors can provide support through a tailored call back program which can assist smokers throughout the quitting process. Quitline is available 24 hours a day, every day.
  • GP or pharmacist
    Encourage patients to talk to their GP or pharmacist for more information, including advice, support and information on the best and most appropriate quit medication.
  • Quit Coach is an online, interactive tool to help patients quit smoking, giving support before and during the quitting process.
  • My QuitBuddy is a personalised interactive free app with quit tips, daily motivational messages and countdown to quitting reminders. It can be downloaded on a mobile device.

Nicotine replacement therapy products

Patches, lozenges, gum and inhalers are available free of charge for inpatients and residents during their hospitalisation as directed by product information guidelines and usage recommendations.

Recommended level of treatment

The appropriate treatment to manage nicotine dependence is determined by:

  • the level of nicotine dependence
  • previous attempts to quit
  • product suitability for the patient

When administering NRT products, the Fagerstrom Test for Nicotine Dependence will be used to determine level of dependence and the Nicotine Withdrawal Management Plan should be completed.

The Commonwealth Therapeutic Goods Administration (external site) has de-scheduled the nicotine patch, lozenge and gum. This means that non-pharmacist staff can supply these products.

Rapid response to nicotine withdrawal anxiety

In some situations patients and residents will have an immediate need for nicotine and may experience high anxiety and problematic behaviour when denied a cigarette.

In this instance NRT such as nicotine gum, lozenges, sublingual tablets or inhalers are suitable as they provide fast acting delivery of nicotine.

Combination therapy

This method provides additional support especially for those who may need a higher dose of therapy.

Combination therapy is the provision of fast acting products such as gum, lozenge or inhaler in combination with the patch. It is suited for more highly dependent smokers.

Table 1: Recommendations for NRT use
Fagerstrom score Dependence level Recommended action
1 - 4 Low Gum, inhaler or lozenge (used intermittently)
5 - 6 Moderate Patch
6 + High Patch (combination if necessary)


  • If a smoker with a low-medium nicotine dependence score chooses not to use NRT, advise they have access to NRT if required.
  • If a smoker with a medium to high nicotine dependence score refuses NRT, encourage them to reconsider their choice at any time. These patients should be closely monitored.


It is necessary to note there are precautions for using NRT for:

  • people with cardiovascular disease
  • pregnant and breastfeeding women.

NRT can be considered during pregnancy if the mother has tried to quit without success and the benefits of quitting outweigh the risk of pharmacotherapy and continued smoking.

Cost of NRT patches

The cost price of 28 day supply of either 7 mg, 14 mg or 21 mg strength NRT patches, from hospital pharmacies is approximately $44.00 per pack (price correct September 2014). Costs may vary slightly between pharmacies. A full course of NRT patches is usually 12 weeks, however 8 weeks of patch therapy is as effective as longer courses.

More information

Produced by

Public Health