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For the first time, fewer than one in 10 adults in England now smoke, marking a major public health milestone and reinforcing the importance of accessible cessation support.
Office for National Statistics data published last month shows that only 9.5% of adults smoked in 2025, down from 10.4% in 2024, meaning that the rate has more than halved since 2011. The fall follows sustained national and local action involving NHS and private stop smoking services – including from community pharmacy – and national public health campaigns.
More than 141,000 people successfully stopped smoking through local services in the past year from more than 250,000 quit attempts, according to the DHSC. Meanwhile, smoking in pregnancy is also at a record low, falling to 4.2% this year – down from 10.6% a decade ago.
The Government has promised further investment of £260m over the next three years to continue to drive down smoking, with at least £153m a year ring-fenced for local stop smoking services, targeted at communities with the highest prevalence. In 2023-25, smoking prevalence was 19.4% in the most deprived neighbourhoods, more than four times that in the least deprived areas. “Stark inequalities remain,” the Government concedes.
Policy measures are also reshaping tobacco and vaping regulation. The Tobacco and Vapes Act, which received Royal Assent in April, will prohibit tobacco sales from January 2027 to anyone born on or after January 1, 2009, extend smoke-free requirements to specified outdoor settings (outside schools and hospitals, and children’s play areas) and introduce vape-free places.
A UK-wide consultation has also considered measures to reduce the appeal of vapes to children, alongside the Vaping Products Duty and Vaping Duty Stamps Scheme introduced on October 1. The aim is to help reduce vaping’s affordability and appeal, particularly among young people and non-smokers.
The latest data shows that more than a million people who have never smoked are now vaping. Although vaping can support adult smokers to quit, it should never be used by children or adult non-smokers, making clear, balanced conversations in community pharmacy increasingly important.
For community pharmacists, the prevalence milestone is both encouraging and a prompt for renewed action to help long-term smokers quit. Pharmacy teams can help to identify tobacco dependence, initiate brief interventions, explain evidence-based treatment options and provide ongoing support, particularly for people in higher-prevalence groups. It is time to capitalise on these opportunities.
Pharmacy teams are well placed to support people who want to stop smoking and can draw on an expanding range of cessation treatments. The following article reviews smoking-related harm, patient assessment, and pharmacological and behavioural approaches that can improve the likelihood of successful quit attempts.
It also considers how to assess tobacco dependence and select an appropriate, individualised regimen for smokers wishing to quit, as well as utilising the opportunities created by independent prescribing.
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Smoking-associated harms
The link between smoking and lung cancer was first proposed by Richard Doll and Bradford Hill in 1950, although smoking was not officially recognised as a cause of lung cancer until 1964. The World Health Organization (WHO) states that tobacco “damages nearly every organ in the body, causing cancer, heart disease, stroke, lung disease, reduced fertility, weakened immunity and premature death”.
WHO estimates that tobacco kills more than 7 million people each year, including approximately 1.6 million people exposed to second-hand smoke. Action on Smoking and Health (ASH) adds that tobacco kills up to two in three long-term users and causes approximately 70,000 deaths in England each year. But why exactly is smoking so addictive?
Tobacco smoke contains thousands of chemicals, including at least 70 known carcinogens, including arsenic, benzene, cadmium, chromium and several polycyclic aromatic hydrocarbons. However, as pharmacists will be aware, it is nicotine that is the principal driver of dependence: it acts on nicotinic cholinergic receptors and releases dopamine in the brain’s reward centre, reinforcing continued smoking.
Nicotine also reduces activity in brain aversion circuits during withdrawal, creating negative reinforcement: continued use helps avoid unpleasant withdrawal effects. More than two-thirds of people who try even a single cigarette may progress to daily smoking.
Inhaled cigarette smoke delivers nicotine to the brain particularly efficiently. Nicotine levels begin to rise after approximately seven seconds and peak within 3-5 minutes.
Pharmacy and smoking cessation: a quick history
The UK Government first addressed tobacco-related harm in its 1998 White Paper, Smoking Kills, which committed £100 million over three years to tobacco control, including up to £60 million for NHS smoking cessation services.
In a recent survey of more than 25,000 UK smokers, 40% of quit attempts were made without support. Quitting may require repeated attempts, and one analysis has suggested that current smokers may try as many as 30 times before achieving abstinence for at least one year.
Community pharmacies historically sold various smoking cessation aids, including lobeline hydrochloride, ferrous sulfate and even quinidine. This changed in the late 1980s with the introduction of nicotine replacement therapy (NRT), initially as gum – nicotine 2mg gum became available for OTC purchase in 1991, followed by 4mg gum in 2000. Transdermal patches, lozenges, inhalators, sprays and microtabs quickly followed.
While these products were available to buy from pharmacies, it wasn’t until 2022 that a national NHS Community Pharmacy Smoking Cessation Service was commissioned, enabling eligible people to receive cessation support and products without charge on hospital discharge.
Assessment
NRT products deliver less nicotine than the average cigarette and do not contain harmful constituents such as tar, making them a harm reduction option. Table 1 summarises the main factors to consider when assessing someone who wants to quit smoking.
Time to the first cigarette is a strong indicator of nicotine dependence – smoking within 30 minutes of waking suggests high dependence. Although evidence does not indicate substantial differences in efficacy between NRT formulations, any product should be matched to a person’s needs and preferences, as outlined in Table 2.
All NRT formulations can cause headache, nausea, dizziness and sleep disturbance, although these symptoms may also occur during nicotine withdrawal. Formulation-specific effects include mouth soreness and throat irritation with gums, lozenges and inhalators.
| Table 1: Relevant factors in assessing patients who wish to stop smoking | |
| Assessment factor | Rationale |
| Extent of nicotine dependence |
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| Daily consumption |
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| Smoking pattern |
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| Extent of cravings |
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| Patient-related factors |
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| Previous use of NRT |
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| Table 2: Matching NRT preparations to patient preferences | |
| Form of NRT | Suitability and advice on use |
| Patches |
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| Lozenges and gum |
Fast-acting options for current or anticipated cravings. Avoid food and drink for 15 minutes before and after use because acidity can reduce nicotine absorption. Allow a lozenge to dissolve for approximately 20 minutes, moving it between the gum and cheek without sucking or chewing. Chew gum until it tingles, then ‘park’ it between the gum and cheek. |
| Oral spray, microtabs and inhalator |
These are fast-acting options. Oral spray suits acute cravings, while an inhalator may help people who miss the hand-to-mouth action of smoking. |
Electronic cigarettes
For people who are unwilling or not yet ready to stop smoking, a harm reduction approach may be considered without requiring immediate complete cessation – which is where electronic cigarettes come in. E-cigarettes, or vapes, are battery-powered devices that heat a nicotine-containing liquid with flavourings to produce an inhalable aerosol.
Vaping is generally perceived as less harmful because it does not involve combustion or exposure to the same range of carcinogens found in tobacco smoke. ASH estimates that 10% of adults in Great Britain vape – approximately 5.5 million people aged 18 years and over – and that 60% of vapers are former smokers.
They can be used to aid quit attempts but evidence on their long-term safety continues to develop. One recent analysis concluded that e-cigarettes could even be carcinogenic, while a review of respiratory effects linked their use with a higher risk of respiratory symptoms, chronic obstructive pulmonary disease, asthma and lung inflammation.
Other pharmacological options
Three oral pharmacological treatments are available to support smoking cessation: bupropion, varenicline and cytisinicline.
Bupropion
Bupropion was developed as an antidepressant and was found to have smoking cessation properties in 1996. Its precise mechanism in smoking cessation is unclear, but inhibition of dopamine reuptake in the nucleus accumbens (part of the brain’s reward centre) may reduce the dopamine deficiency associated with nicotine withdrawal.
Treatment should begin at 150mg daily, one to two weeks before a quit date, for the first six days. The dose is then increased to 150mg twice daily for up to nine weeks. Common adverse effects include rash, gastrointestinal disturbances, impaired concentration, headache and anxiety.
Varenicline
Developed in the 1990s, varenicline is a partial agonist at the nicotinic cholinergic receptors activated by nicotine. It produces a weaker response than nicotine while helping to reduce withdrawal symptoms.
Treatment should start before the quit date, with smoking stopped 7–14 days after initiation. The dose is 500 micrograms daily initially, increasing from day 4 to 500 micrograms twice daily and, from day 8, to 1mg twice daily for up to 12 weeks. Common adverse effects include nasopharyngitis, appetite changes, nausea, insomnia, headache, rash and muscle aches.
Cytisinicline (cytisine)
Plant-based cytisinicline has a similar mechanism of action to varenicline, with evidence suggesting comparable efficacy. First marketed in 1964 and widely used in Eastern Europe, it was authorised in the UK in 2019 and became available in 2024.
Cytisinicline provided an alternative to varenicline after the latter was temporarily withdrawn in 2021. The starting dose is 1.5mg every 2 hours on days 1–3, to a maximum of 9mg daily; smoking should stop no later than day 5 of the 25-day course. Common adverse effects include dizziness, mood changes, tachycardia, dry mouth, heartburn, rash and muscle aches.
Behavioural support
Everyone who wants to stop smoking should be offered behavioural support. This may range from brief advice and practical information to more intensive programmes involving multiple counselling sessions. A 2021 Cochrane review concluded that behavioural interventions can increase quit rates.
Treatment guidelines
NICE guidance (2021; updated 2025) recommends the following options, alongside behavioural support:
- Cytisinicline (for people aged 18–66 years)
- Combination short-acting and long-acting NRT
- Varenicline (18 years and over)
- Bupropion (18 years and over)
- E-cigarettes.
In all cases, NICE recommends that patients agree on a quit date and start oral treatment before this date. And although NICE suggests several therapeutic options for smoking cessation, the relative effectiveness of these interventions varies. A Cochrane review has summarised the likelihood of successfully stopping cigarette use with each option, as shown below in Table 3.
| Table 3: Comparative efficacy of major smoking cessation aids | |
| Intervention | Estimated successful quitters per 100 people |
| Varenicline | 21–25 |
| Cytisinicline | 18–23 |
| Bupropion | 18 |
| NRT (single product) | 18 |
| NRT (two or more products) | 20 |
| E-cigarettes | 10–19 |
Pharmacy uptake
Community pharmacy offers a highly accessible route to smoking cessation support, but provision remains uneven. A recent Company Chemists’ Association report found that fewer than half of local authorities have commissioned a service and fewer than 5% of pharmacies receive referrals.
In England, access to the NHS pharmacy service currently depends on referral from hospital, limiting opportunities for contact. By contrast, Scotland’s community pharmacy smoking cessation service is open to anyone aged 12 years and over who is registered with a GP in Scotland. A similar service operates in Wales.
Smoking is estimated to cost England £43.7bn each year, substantially more than the £6.8bn potentially raised through tobacco taxation. Wider access to community pharmacy smoking cessation services – especially in areas of social deprivation – could help further reduce both smoking-related illness and its associated costs.
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