With Stoptober on the way, how can pharmacy teams support even more smokers to give up?
The last 60 years have seen the UK switch from topping the global tobacco consumption charts to becoming a leader in tobacco control. According to a recent Royal College of Physicians report on tobacco entitled ‘Smoking and health 2021: A coming of age for tobacco control’, the UK has experienced a reduction in smoking prevalence of about 75 per cent since 1962.
Despite this, smoking remains the largest avoidable cause of premature death and disability in the UK, and the biggest preventable cause of cancer. The latest figures from the charity Cancer Research UK (CRUK) show that 14.1 per cent of people aged 18 years and above smoke cigarettes, which equates to around 6.9 million individuals. Worryingly, a new study published in the journal Addiction found that the number of 18 to 34-year-olds in England who smoke increased by 25 per cent during the first lockdown – that means there are over 652,000 more young adults who smoke than before the pandemic.
This shows there’s still a long way to go to achieve the Government’s ambition of a smoke-free England by 2030 – that would mean fewer than five per cent of people smoking. CRUK warns that this goal requires smokers to quit at a rate of around 40 per cent faster than is currently predicted.
“It’s clear that the Government is going to miss this target, primarily because of big cuts in funding for local authorities’ smoking cessation services”, says Jon Foster, senior policy officer at Asthma UK and the British Lung Foundation. “This means around 50 per cent fewer people are now supported to quit their addiction to smoking than they were five years ago.”
What’s more, Jon’s prediction is that without a significant increase in anti-smoking work, the Government “will not hit its smoke-free target until 2037”.
New NICE guidance
The National Institute for Health and Care Excellence (NICE), in conjunction with Public Health England (PHE), has published draft guidance to tackle the problem. Echoing recommendations from the smoke-free charity Action on Smoking and Health (ASH) that e-cigarettes – also known as vapes – are included in standard protocols to treat tobacco dependency, the draft guidance recommends that people should be able to use e-cigarettes as one of several options to support smoking cessation, combined with behavioural support.
“Vaping is the most popular and effective way of stopping smoking,” says Louise Ross, clinical consultant at the National Centre for Smoking Cessation and Training (NCSCT). She adds that pharmacy staff have “a vital role to play in increasing people’s confidence” about this quitting method.
Myra Battle, smoking cessation advisor and accuracy checking technician (ACT) at Boots Market Hill in Sudbury and service support officer for Suffolk LPC, advises that people who attend a stop smoking service and wish to use an e-cigarette should be supported to do so. “Be open to vape use in people keen to try it, especially in those who have tried and failed to stop smoking using licensed stop smoking medicines,” she says.
The draft NICE guidance also advises that while e-cigarettes are substantially less harmful than smoking, their long-term health effects are still uncertain, so pharmacy teams should know how to answer people’s queries about this too.
“The evidence on both the safety and efficacy of vaping as a cessation aid is reviewed annually,” says Myra. “PHE supports that vaping is significantly less harmful than smoking tobacco and can assist with quitting smoking. Although some health risks from vaping may yet emerge, these are likely, at worst, to be a small fraction of the risks of smoking, as the vapour does not contain the products of combustion that cause lung and heart disease and cancer.”
Short- and long-term health risks of smoking
Smoking increases the risk of developing more than 50 serious health conditions. It causes around seven out of every 10 cases of lung cancer, as well as cancer in other parts of the body, including the mouth and throat, bladder, bowel, cervix, kidneys, liver, stomach and pancreas.
Smoking damages the lungs in other ways, too, leading to conditions such as chronic obstructive pulmonary disease (COPD), and worsening or prolonging the symptoms of respiratory conditions such as asthma, or respiratory tract infections such as the common cold.
The heart and blood circulation can also be damaged, increasing the risk of developing conditions such as coronary heart disease, heart attack and stroke. It can also reduce the fertility of both men and women. And while many people smoke in a bid to calm their stress levels down, research into smoking and stress has shown that smoking increases anxiety and tension.
More than half (52.7 per cent) of people aged 16 years and above in Great Britain who currently smoke said they wanted to quit, according to results from the Government’s Opinions and Lifestyle Survey (OPN).
With this in mind, Louise says it’s worth remembering that e-cigarettes are only one of a range of quit options and each person has to choose the one they want and are confident with – see panel on page 12.
But it’s not just finding the right smoking cessation product that will help a person quit. “Research clearly shows that face-to-face behavioural support given over multiple sessions doubles the chances of a successful quit attempt,” says Myra. “A 2021 review by the Cochrane Tobacco Addiction Group provides strong evidence that smokers who receive counselling are more likely to quit long term.”
Jacqueline Douglas is a pre-registration trainee pharmacy technician at Boots in Forfar and she specialises in stop smoking support. Alongside advice on smoking cessation products, Jacqueline also talks to her customers about the psychological aspects behind their smoking habit. “When our customers talk through the reasons they need to smoke, allowing us to help them figure out what to focus their behaviours on instead of seeking the release of a cigarette, we are better able to help them through their complete journey,” she says. “Mostly it isn’t for enjoyment, but for a release – a break from a stressful situation – so it isn’t just about replacing the nicotine, it’s helping that person cope with stress and learn to change behaviours.”
Research shows the most effective way of stopping smoking is a combination of behavioural support and a product designed to help with stopping smoking. The best treatment depends on the person’s preference, age, whether they are pregnant or breastfeeding and any medical conditions they have.
Nicotine replacement therapy (NRT)
The main reason people smoke is because they are addicted to nicotine. NRT provides a low level of nicotine, without the tar, carbon monoxide and other poisonous chemicals present in tobacco smoke.
NRT is available from pharmacies and some other retail outlets. It is also available on prescription from a doctor or NHS stop smoking service in the form of skin patches, chewing gum, inhalators (which look like plastic cigarettes), tablets, oral strips and lozenges, nasal and mouth sprays.
Patches release nicotine slowly. Inhalators, gum and sprays act more quickly and may be better for helping with cravings. There is good evidence to show that using a combination of NRT is more effective than using a single product.
Treatment with NRT usually lasts eight to 12 weeks, before the quitter gradually reduces the dose and eventually stops. Most people are able to use NRT, including adults and children over 12 years of age, pregnant and breastfeeding women.
Varenicline is a medicine that, like NRT, works to reduce cravings for nicotine, but it also blocks the rewarding and reinforcing effects of smoking. It is only available on prescription, and is taken as one to two tablets a day, starting a week or two before the person’s intended quit date. A course of treatment usually lasts around 12 weeks.
Varenicline is safe for most people to take, although it’s not suitable for children under 18 years of age, women who are pregnant or breastfeeding, and people with severe kidney problems. Side effects can include nausea and vomiting, insomnia, dry mouth, constipation or diarrhoea, headaches, drowsiness or dizziness.
As of 24 June 2021, all Champix products are unavailable until further notice due to a supply disruption. Patients currently prescribed this treatment will require a review and switching to NRT where suitable. No new patients should be initiated onto Champix until further notice, and NRT or bupropion should be considered instead. Stop smoking support should not be delayed.
Bupropion is another medicine only available on prescription. It is taken as one to two tablets a day, starting a week or two before the smoker’s intended quit date, with a course of treatment lasting around seven to nine weeks.
Bupropion is safe for most people to take, but is unsuitable for children under 18 years of age, pregnant or breastfeeding women, and people with epilepsy, bipolar disorder or eating disorders. Possible side effects include nausea and vomiting, insomnia, dry mouth, constipation, headaches, dizziness and difficulty concentrating.
An e-cigarette – or vape – is an electronic device that delivers nicotine in a vapour, allowing users to inhale nicotine without most of the harmful effects of smoking as the vapour contains no tar or carbon monoxide. Some even contain no nicotine at all.
E-cigarettes are not currently available on prescription, and costs can vary, but generally they are much cheaper than cigarettes and evidence suggests they are considerably less harmful.
If there’s one time in the year when pharmacy teams have the best chance of striking up conversations with customers about how they can support them to stop smoking, it’s October.
PHE’s Stoptober initiative encourages smokers to abstain from smoking for 28 days in October, based on the evidence that if a person can quit smoking for 28 days, they are five times more likely to quit permanently. This year’s Stoptober campaign will focus on a core audience of smokers aged 35-60 and a secondary audience of younger smokers aged 18-35, with the free programme including a personal quit plan, online communities and the Stoptober app.
But while pharmacy teams are often the first point of contact for smokers and those wanting to quit, it’s not always easy to start the conversation.
“If someone is buying smoking-related products or you are aware that they smoke, try starting a conversation about all the services you offer and include stop smoking as part of the bigger picture,” says Rachel Orritt, Cancer Research UK’s health information manager. “For example, say, ‘we have lots of support for people making lifestyle changes – just ask if you would like more information’. Try to keep it non-judgemental and allow the person to lead the conversation so you can focus on what they want to know.”
Louise says another good conversation starter is to take the initial focus off the customers themselves. “In my former service, we asked the counter assistants to say things like ‘I don’t know if you know anybody who smokes, but we’ve launched a new stop smoking service and are getting really good results’,” she explains. “This is especially relevant if you are bagging up medicines for things like asthma, high blood pressure or breathing problems. Once you’ve got their attention, they often say, ‘well, actually, I smoke myself’, which opens up the conversation.”
Very brief advice
The NICE-recommended Very Brief Advice (VBA) training on the NCSCT website is a useful guide for pointers on evidence-based ways to have conversations with smokers. The VBA approach involves asking, advising and acting. If done properly, it “only takes 30 seconds”, according to Jon.
“First, you ask the person whether they smoke. If they do, there’s no need to ask whether they want to quit – just move straight on to the advice and tell them that the best way to quit is with a combination of medication and support,” says Jon. “Then comes the act: signpost them to local services and to their GP. If there are no local stop smoking services in your area, you can still refer them to their GP, and send them to the British Lung Foundation website, where there are lots of resources.”
Jon advises that customers be given two weeks’ worth of appropriate nicotine replacement products. “Encourage them to return every two weeks for two months so they can continue to get the right support with their quit attempt,” he adds. If the person is not interested, Jon’s advice is to say that is okay, but that the pharmacy is there to help when they are ready to quit.
“Giving up smoking doesn’t have to be a one-person journey any more, where we only see someone after they have thought about giving up for a while then Googled how to give up,” says Jacqueline. “If we advertise it better in our stores, make it okay and easy to open a conversation, then we might just snatch that person’s attention and start them thinking about it.”
Pharmacy teams can complete a short training module on how to deliver very brief advice on smoking via the National Centre for Smoking and Training.
Customers can be signposted to the following resources for inspriation and further support:
Viatris has created this short video based on a publication reviewing global research into the potential impact of the Covid-19 pandemic on mental health. It identifies six areas where psychiatrists can play a role in supporting people's mental health through these difficult times.
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