Suggested Learning

The Government is aiming for a smoke-free generation – and there are plenty of promising therapeutic options under evaluation that could help

Learning objectives

After reading this feature you should:

  • Appreciate that effective strategies, including personalised support, can help tackle stubborn smoking
  • Understand the expert consensus on the most recent safety and efficacy evidence for e-cigarettes
  • Be able to describe potential pharmacotherapeutic options for smokers on the horizon

 

The number of smokers in England continues to fall thanks to the success of public health initiatives and the widespread implementation of the smoking ban in public places.

According to the latest figures, only 14.9 per cent of adults are currently classified as smokers (down from 15.5 per cent in 2016 and 19.8 per cent in 2011).1 However, while overall smoking rates have hit an historic low, a hard core of resistant smokers with entrenched habits remain. It is also important to remember that 6.1 million adults in the UK still smoke.1

Turning the tide on tobacco

As the cornerstone of community healthcare, pharmacies provide an important opportunity to engage with many of the harder-to- reach smokers in a familiar and relaxed setting. Personalised support is an important part of any successful smoking cessation strategy and pharmacy teams should ensure their approach is tailored to meet individual customer needs.

Any one-on-one contact offers the chance to engage in a meaningful conversation about smoking, encouraging a customer to examine the real reasons why they smoke and consider the implications of giving up. Research has shown that simply conversing about individual life experiences, alongside giving smoking cessation advice, can help boost quitting success.2

Many smokers also suffer from co-existing and often long-term health conditions that can be incorporated into the individual quit rationale. Smokers may be motivated by the knowledge that stopping smoking speeds up the body’s healing processes, boosts lung function, improves circulation, and enhances smell and taste – as well as cutting the risk of smoking-related diseases.

A key document, Pharmacy: A Way Forward for Public Health, advises that pharmacy teams should routinely discuss smoking cessation with people presenting prescriptions related to COPD, diabetes, heart disease or hypertension, or when selling relevant OTC medication.3

Behavioural advice and support from pharmacy staff can be provided alongside specific pharmacotherapy recommendations from the range of smoking cessation products available, which include nicotine replacement therapy (NRT) – available in various formulations such as transdermal patches, sprays, sublingual tablets, gums, inhalators and lozenges – as well as the drugs varenicline and bupropion.

Key facts

  • Smoking rates in England have hit an all-time low, with only 14.9 per cent of adults now classified as smokers
  • Around one in 10 pregnant women still smoke
  • Current evidence indicates that e-cigarettes pose significantly less risk to health than smoking but further research is warranted

The right combination

Combining medication with skilled support is proven to be the most effective approach to smoking cessation, making a person four times as likely to quit successfully.4 Evidence also indicates that trained pharmacy staff are as effective as pharmacists in achieving good quit rates through the delivery of stop smoking interventions.3

Choice of pharmacotherapy should be driven primarily by the patient’s own individual preference but other factors to consider include co-morbid conditions and concomitant medications, including potential adverse effects or interactions, as well as the outcome of any previous quit attempts. For patients exhibiting a high degree of nicotine dependence, single NRT products can be used in combination.

After agreeing on the stop smoking medication that best suits the customer’s individual needs, pharmacy teams can provide appropriate information and support to use it in a way that will maximise effectiveness, as well as arranging follow-up visits to check progress and provide ongoing motivation and support. It is always important to prepare customers for the myriad nicotine withdrawal symptoms they may experience and suggest strategies to help cope with these short-term effects.

Common complaints include low concentration, disturbed sleep, increased appetite and weight gain, irritability and cravings.

Carbon monoxide testing can be provided as part of ongoing support and follow-up over several months to help reduce relapse risk. Signposting is another important area in which pharmacy teams can take the lead, directing customers to local NHS stop smoking support services. Ongoing pharmacy support for national stop smoking campaigns and initiatives is also pivotal.

Unfortunately, pharmacy-led smoking cessation services are under pressure to survive amid widespread cuts to public health funding, with almost a fifth of local authorities in England decommissioning such services over the course of the past three years. Also of concern was the fact that only just over half of the local authorities questioned said that they currently commission smoking cessation services from community pharmacies.5

Pharmacy’s role

Pharmacy teams can help customers quit smoking by ensuring their knowledge is refreshed and up to date, so that they are able to provide the latest information on products and give tailored advice for each individual quitter, says Farah Ali, general manager at Perrigo’s Warman-Freed Pharmacy.

“Having tools such as a plan to quit, important milestones and, most importantly, talking through the options available OTC within the category can all help the customer to choose the right product, the right support and improve the chances of quitting,” she says. “The pharmacy team’s support in the quitting journey is very important as they are usually the first point of contact and, therefore, having this support and receiving updated information and products tailored to specific customer needs can really improve the chances of quitting.”

Mind the gap

Despite the positive overall trend in smoking rates, latest figures show a growing socio-economic gap emerging between smokers and non-smokers in England. Smoking is strongly linked to a person’s educational and employment status, suggesting that social and equality issues may underpin this public health problem. According to the latest NHS statistics, only eight per cent of graduates are current smokers compared to 28 per cent of adults who lack formal qualifications.

Similarly, smoking is almost twice as common among the unemployed (29 per cent) compared to those in work (15 per cent ).1 Adults classified as routine and manual workers are the most likely to smoke, with current smoking rates significantly outstripping the national average at 26 per cent.1 Conversely, those in managerial and professional occupations are the least likely to smoke, with only one in every 10 adults in this group classified as a current smoker.1

Given this obvious inequality, it is perhaps unsurprising that smoking accounts for approximately half the difference in life expectancy between the richest and poorest in society.6

In order to effectively target smoking cessation interventions, it is important to be alert to specific groups of customers in whom the prevalence of smoking is higher. NICE also recommends that prioritisation be given to specific groups that are at high risk of tobacco-related harm.7 Broadly speaking, this target group of higher risk and/or more prevalent smokers includes:1,6,7

  • Men
  • Those suffering from mental health problems, including diagnosed/undiagnosed mental health conditions
  • People from the lesbian, gay and bisexual community
  • People who misuse substances
  • Adults of white or mixed ethnicities
  • Those aged 25-34 years of age
  • Individuals with health conditions made worse by smoking including cardiovascular disease, diabetes, asthma and COPD – or those with a documented smoking-related illness
  • People living in disadvantaged circumstances
  • Unemployed or manual workers
  • Travellers
  • People living in specific local authority smoking ‘hot spots’ where smoking rates are consistently above 20 per cent, such as Blackpool, Hastings and Kingston Upon Hull.

Pregnant women also represent an important area for pharmacy intervention as the prevalence of smoking in this group remains above the current NHS national ambition of six per cent or less. In 2017/2018, around one in 10 mothers were still categorised as smokers at the time of their delivery.1

“Last year’s tobacco control plan laid out the Government’s ambitions and the steps we will be taking to achieve a smokefree nation but we know this requires a concerted effort to reach some of society’s most vulnerable people,” says Duncan Selbie, chief executive of Public Health England. “We will only achieve our ambitions if we make more progress in helping people from deprived areas and people suffering from poor mental health.”8

E-cigarettes

No discussion on smoking cessation would be complete without reference to e-cigarettes, now used by five per cent of all adults in England, according to latest estimates.1 E-cigarettes are widely viewed as a key smoking cessation tool and valuable harm reduction aid. Around half of e-cigarette users (48 per cent) cite the reason for use as an aid in quitting smoking and around a third perceive them to be less harmful that cigarettes.1

In its 2018 guidance, Stop Smoking Interventions and Services, NICE stops short of explicitly recommending e-cigarettes, but does note that, “many people have found them helpful to quit smoking cigarettes”.7 On the risk-benefit balance of e-cigarettes, NICE notes that: “The evidence suggests that e-cigarettes are substantially less harmful to health than smoking but are not risk-free. The evidence in this area is still developing, including evidence on the long-term health impact.”7

In early 2018, Public Health England (PHE) commissioned the fourth in a series of reports into e-cigarettes.9 Although e-cigarettes appear to have contributed to smoking cessation and reduction, all studies and analyses carried out so far have reached the same conclusion – that further randomised, controlled trials are required to conclusively prove their value.

PHE agrees, noting that: “An important focus of future research is the longer-term relapse trajectories of people who use e-cigarettes for quitting compared with other stop smoking treatments and also assess whether the uptake of e-cigarettes after quitting can prevent relapse back to smoking.”

On the health risks of e-cigarettes, the PHE report again concludes that more research is needed, including close monitoring of any potential adverse effects of passive vaping. Based on the evidence amassed to date, however, PHE did conclude that the cancer potencies of e-cigarettes are largely under 0.5 per cent of the risk of smoking, and that comparative risks of cardiovascular and lung disease are also likely to be substantially lower.9 Importantly, biomarker data for acrolein, a potent respiratory irritant, is found to be consistent with non-smoking levels among e-cigarette users.9

In its report, PHE provides specific advice for healthcare professionals on how best to convey this latest information, contextualising the health risk of e-cigarettes to consumers. “Vaping poses only a small fraction of the risks of smoking and switching completely from smoking to vaping conveys substantial health benefits over continued smoking,” it says.

“Based on current knowledge, stating that vaping is at least 95 per cent less harmful than smoking remains a good way to communicate the large difference in relative risk unambiguously, so that more smokers are encouraged to make the switch from smoking to vaping. It should be noted that this does not mean e-cigarettes are safe.”9

The BMA has adopted a similarly circumspect stance in its new position paper on e-cigarettes, reiterating that “evidence favours a combination of behavioural support and pharmacotherapy as providing the highest chance of successfully quitting tobacco use”. However, it concedes that, “while the safest option is to use neither tobacco nor e-cigarettes, there is no situation in which it is safer to continue smoking than to use an e-cigarette”.10

The Royal College of Physicians goes a step further, advocating that: “In the interests of public health, it is important to promote the use of e-cigarettes, NRT and other non-tobacco nicotine products as widely as possible as a substitute for smoking in the UK.”11

On the horizon

With e-cigarettes dominating the headlines, it is easy to overlook other promising pharmacotherapeutic options under evaluation in smoking cessation. Currently, the three drugs used most widely for smoking cessation in England are NRT, oral varenicline and oral bupropion, all of which are supported by sound efficacy evidence:

  • NRT provides a straightforward replacement for the inhaled nicotine content of cigarettes, helping to lessen urges and reduce withdrawal symptoms
  • Varenicline is a partial agonist at nicotine receptors and works by mimicking the effects of nicotine in the brain, thereby reducing cravings and withdrawal effects, while simultaneously blunting the effects of nicotine if a patient does choose to smoke
  • Bupropion, in contrast, is a nicotine receptor antagonist, with adjunctive dopaminergic and adrenergic effects. It appears to act by blocking the effects of nicotine and alleviating withdrawal, and may also help to lift depressed mood.

Renewed efforts to develop novel medicines for smoking cessation are building on our greater understanding of the neurobiology of addiction. New avenues of research are focused on the specific receptors in the brain that bind to nicotine, as well as those neural circuits and networks with a proven role in nicotine consumption. Both the orexin and glutamate signalling pathways have emerged as potentially promising.12

Looking at specific therapies in the pipeline for smoking cessation reveals several candidates under evaluation in ongoing or completed clinical trials. GABA and NMDA-mediated neurotransmissive pathways have attracted attention as a possible means of ‘dampening down’ the reinforcing properties of nicotine:

  • Topiramate has been evaluated in two phase 3 trials for smoking cessation, and appears to have gender-specific effects (working in men but not women).13 It acts to block glutaminergic signalling while at the same time boosting GABAergic tone.
  • Studies have also been carried out on drugs that act via the NMDA pathway including cycloserine, memantine and GW468816 (a NMDA glycine site antagonist for smoking relapse).13

Nicotine vaccines

Another area of ongoing research is the development of nicotine vaccines for relapse prevention.12,13 The premise is that vaccination stimulates the production of antibodies that bind nicotine and prevent it crossing the blood-brain barrier. By reducing nicotine penetration of the brain, the reinforcing effects of smoking are weakened. Late-stage clinical trials have been carried out on three anti-nicotine vaccines to date but none are commercially available yet.

It may also be possible to repurpose existing drugs for use in smoking cessation. A potential candidate in this category is N-acetylcysteine, currently used to treat paracetamol overdose, which has shown promise as a treatment for various substance use disorders including nicotine dependence.12,13

In a small, randomised, placebocontrolled trial of nicotinedependent adult smokers, N-acetylcysteine reduced self-reported daily cigarette consumption across the treatment period.13 Interesting studies in healthy adult smokers have also shown that N-acetylcysteine may have the ability to decrease tobacco smoke carcinogenicity, positively modulate cancer-related biomarkers and reduce oxidative damage.14

In other areas of clinical development for smoking cessation, new controlled-release and patch formulations of varenicline are also under evaluation.13

References

1. Statistics on Smoking – England 2018. Published 3 July 2018. Available at: digital.nhs.uk/data-and-information/ publications/statistical/statisticson- smoking/statistics-on-smokingengland- 2018/content
2. Walton R. Smoking cessation: shifting the research focus to community pharmacy. The Pharmaceutical Journal.
3 Jan 2018 3. Public Health England. Pharmacy: A Way Forward for Public Health. Published September 2017
4. Public Health England. Models of delivery for stop smoking services: options and evidence. Published September 2017
5. Robinson R. Stop-smoking services from community pharmacists cut by a fifth of local authorities in past three years. The Pharmaceutical Journal. 22 Jan 2018
6. Department of Health and Social Care. Policy paper: Towards a smoke-free generation: tobacco control plan for England. Published 18 July 2017
7. NICE guideline NG92. Stop smoking interventions and services. Published March 2018
8. Selbie D. Turning the tide on tobacco: smoking in England hits a new low. Available at: publichealthmatters.blog. gov.uk/2018/07/03/turning-the-tide-ontobacco- smoking-in-england-hitsa- new-low
9. Public Health England. Evidence review of e-cigarettes and heated tobacco products 2018: executive summary. Updated 2 March 2018
10. British Medical Association. E-cigarettes: balancing risks and opportunities. Available at: bma.org.uk/ collective-voice/policy-and-research/ public-and-population-health/tobacco/ e-cigarettes
11.Royal College of Physicians. Nicotine without smoke: tobacco harm reduction. Available at: rcplondon.ac.uk/projects/ outputs/nicotine-without-smoke-tobaccoharm- reduction-0
12. National Institute on Drug Abuse. Available at: drugabuse.gov/publications/ research-reports/tobacco-nicotinee- cigarettes/what-are-treatments-tobaccodependence
13. Aubin HJ et al. Pharmacotherapy for smoking cessation: pharmacological principles and clinical practice. Br J Clin Pharmacol 2013; 77(2): 324-336
14. McClure E et al. Potential role of N-acetylcysteine in management of substance use disorders. CNS Drugs 2014; 28(2):95-106

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