For people in the United Kingdom who wish to quit smoking, a new oral pharmaceutical option, cytisine, became available on prescription through the National Health Service (NHS), as of January 22.
The plant-based drug works to reduce cravings by binding as a partial agonist to a person’s nicotinic receptors. It recently received regulatory approval in the UK. But how much of a game-changer, if at all, will it be?
Robert West, a health psychology professor and director of tobacco studies at University College London’s Cancer Research UK Health Behaviour Research Centre, told the Guardian that cystisine’s approval was “excellent news for smokers.” And the research appears promising.
“Cytisine has the potential to be one of the big answers.”
Reviewing 12 randomized controlled trials, a team in Argentina compared success rates of people who sought to quit smoking using cytisine, the smoking-cessation drug varenicline (Champix), nicotine replacement therapies (NRT) or a placebo.
They found that cytisine’s efficacy was similar to that of varenicline, maybe better than NRT, and more than twice as good as placebo.
“Worldwide, smoking is considered the main cause of preventable death. Cytisine has the potential to be one of the big answers to that problem,” said Omar de Santi, a toxicologist and lead author of the study.
However, Riccardo Polosa, professor of internal medicine at the University of Catania, Italy, told Filter he did not consider the medication to be “that revolutionary” or a “miracle drug.”
“As for varenicline and all other smoking-cessation medications, the long-term efficacy of cytisine is low.”
“Cytisine is being portrayed as the new varenicline,” Dr. Polosa said. “Don’t get me wrong, this is a good thing considering that since Pfizer’s withdrawal of varenicline in summer 2021, cessation specialists have only NRT and bupropion in their arsenal to fight against cigarette addiction.”
“The problem,” he continued, “is that, as for varenicline and all other smoking-cessation medications, the long-term efficacy of cytisine is low due to relapse. Would you take an anti-diabetic drug that keeps the glycemia at bay for only three-to-six months? Clearly not.”
Despite such concerns, tobacco harm reduction advocates aren’t generally opposed to the availability of pharmaceutical options. But many are suspicious of the medicalization of this issue, and wary of pills being touted as justification for restrictions on nicotine-containing harm reduction options.
They point out that even an effective pill won’t work for everyone, in part because it won’t replace smoking’s hand-to-mouth action or inhalation—aspects that many people who vape found critical in being able to make the switch.
“We should not be forcing people who smoke into a medical model of ‘illness, treatment, cure,’ when they see nicotine use as something they could do differently.”
“There must be honesty about the risks and benefits of all the different approaches,” British advocate Clive Bates, former director of the charity Action on Smoking and Health (ASH, UK), told Filter. “We should not be forcing people who smoke into a medical model of ‘illness, treatment, cure,’ when they see nicotine use as something they could do differently as consumers, by switching to vapes or pouches that they buy from the corner shop rather than access cessation medications via the health care system.”
With cytisine, “the problem [around approval] has never been about the safety or efficacy of the drug but about commercial interests,” he continued; “cytisine threatens to cut into the Big Pharma profit margins for other prescription smoking cessation therapies.”
Bates acknowledged that in the most recent Cochrane review of smoking cessation aids, cytisine came out well (as did vaping), and said its addition to the list of drugs available in the UK was overdue. But he noted that a 25-day course of cytisine consisting of 100 pills will cost the NHS £115 (almost $150).
“There is no reason why this drug cannot be made cheaply and sold at a price highly attractive to the NHS,” he said. ”If price is a barrier, it’s because the manufacturers are trying to extract big profits.”
Deborah Arnott, the current director of ASH, pointed out that because of the cost, some areas in the UK may choose not to offer cytisine to patients. The fact the drug is available on a prescription-only basis will also prevent some from accessing it, she added.
“People should be reassured that nicotine vaping is just as effective an aid to quit smoking.”
Arnott accepts the evidence on cytisine. But she emphasized the continuing importance of other options, saying “some smokers will prefer a quitting aid which helps them quit using nicotine.”
“Smokers who aren’t able to get cytisine on prescription should be reassured that [nicotine vaping] is just as effective an aid to quit smoking,” she said.
According to the Global State of Tobacco Harm Reduction, smoking rates have declined substantially in the UK, where vapes are widely available in stores. However, over 7 million people currently smoke, and the country still suffers over 100,000 annual smoking-related deaths.
Although it’s new to the UK, cytisine has been used safely as a smoking-cessation medication in some parts of Europe for many years. It remains unavailable in many other countries, including the United States.
“We need to have all the best and most cost-effective strategies available for quitting smoking,” Bates concluded. “The right approach is whatever works.”
Photograph by Defense Visual Information Distribution Service via NARA & DVIDS Public Domain Archive/Public Domain
The Foundation for a Smoke-Free World has provided grants to: the Center of Excellence for the Acceleration of Harm Reduction, founded by Dr. Polosa; Knowledge-Action-Change, which publishes the Global State of Tobacco Harm Reduction; and The Influence Foundation, which operates Filter. KAC has also provided restricted grants and donations to The Influence Foundation. Filter‘s Editorial Independence Policy applies.