Clozapine and smoking cessation: why joined-up care matters

The death of Jack Burton from clozapine toxicity after he suddenly stopped smoking, highlighted in a recent Prevention of Future Deaths report, is a deeply sad reminder that smoking cessation must always be accompanied by careful medication monitoring.

Clozapine is one of the most effective treatments available for people with treatment-resistant schizophrenia, so it is crucial that those who could benefit from it are able to access it safely. There are clinically important interactions between tobacco smoke and a range of medicines, which certified stop smoking practitioners are trained to recognise. The fact that stopping smoking increases clozapine levels – and can lead to clozapine toxicity - is essential knowledge for all mental health professionals, enabling them not only to inform patients about medication adjustments but also to provide advice and support for smoking cessation. While clozapine is one of the best-known examples, smoking can also affect the metabolism of other medicines, meaning that reducing or stopping smoking should always require a medication review by the prescribing clinician.

Supporting someone to quit smoking is therefore only one part of the role of a stop smoking service. Effective care depends on clear communication between patients, stop smoking practitioners, psychiatrists, GPs and the wider healthcare team, so that changes in smoking status prompt timely medication reviews where needed.

Too often, these conversations depend on changes in smoking status being volunteered or recognised by chance. Embedding them as a routine part of mental health care helps ensure opportunities for medication review are not missed.

The publication of Wim's Protocol by the Royal College of Psychiatrists is a welcome step. Developed following the death of William Northcott, it brings together existing evidence and guidance into a practical framework for safer clozapine prescribing and monitoring. The protocol aims to strengthen patient safety while giving clinicians greater confidence to prescribe clozapine by providing a clear, evidence-based approach to monitoring and responding to potential adverse effects. 

Smoking is embedded throughout the protocol as part of routine clozapine care. It recommends discussing smoking before treatment begins, providing smoking cessation support, and revisiting smoking status alongside red flag symptoms, alcohol and other substances at regular reviews throughout treatment. In doing so, it reinforces that changes in smoking status should form part of routine clinical care, rather than depending on patients to raise it them themselves. 

This tragic case should strengthen our resolve to ensure that everyone taking clozapine can access evidence-based stop smoking support as part of coordinated, joined-up healthcare. Nobody should miss out on the benefits of becoming smokefree and coordinated communication between healthcare professionals is essential to achieving this safely.

Resources: 

• Royal College of Psychiatrists. Wim’s Protocol: for the safe prescribing and monitoring of clozapine. June 2026.
• NCSCT. Tobacco Dependence and Mental Health: A briefing for front-line staff. Updated 2026.
• National Institute for Health and Care Excellence (NICE). Tobacco: preventing uptake, promoting quitting and treating dependence. NG209. Updated 2025.
• National Institute for Health and Care Excellence (NICE). Psychosis and schizophrenia in adults: prevention and management. CG178. 2014.
• National Institute for Health and Care Excellence (NICE). BNF: Clozapine.
• Specialist Pharmacy Service. Clinical considerations for patients prescribed clozapine. 2024.
• ASH. Smoking and Mental Health. Fact sheet. 2019.
• ASH. Leaflet for service users: quitting smoking. 2020.