In August 2016, NHS England figures showed there had been a 15 per cent decline in the number of smokers seeking help from NHS Stop Smoking Services – the fourth consecutive year in which there had been a fall. The services themselves have seen no decline in efficacy – they increase a smoker’s chances of quitting by up to four-fold over a ‘cold turkey’ approach, and at the four-week follow-up, 195,170 people (51 per cent) reported that they had successfully stopped smoking.
“Stop smoking services provide a vital life-saving function for smokers addicted to tobacco, and the real difference they make to hundreds of thousands of people each year is shown by the latest figures,” says Dr Andy McEwen, executive director of the National Centre for Smoking Cessation and Training (NCSCT). “They are proven to be effective and cost-effective, and it is therefore very worrying that some local authorities are downgrading or even decommissioning these services. Such an approach is short-sighted and will end up costing lives and harming communities.
“We need a fresh approach to measuring the success of the services, with a focus on quality of care rather than simply the number of people they see.”
Action on Smoking and Health (ASH) says stop smoking services offer the best way of helping people to quit and to stay smoke-free. With proper investment, such services can be highly successful in attracting smokers from lower socio-economic groups, where smoking prevalence is highest.
According to Stuart Gale of the Frosts Pharmacy group in Banbury, it seems that all but essential services are being cut across the country and the longer-term benefits are being overlooked. “The remuneration for smoking cessation schemes in pharmacy never amounted to very much but it was a great service to offer,” he says. “Unfortunately, it was limited to counselling and nicotine replacement. Champix seems to be really effective but we were unable to supply this as it was never included on a scheme by the CCG.”
ASH is particularly concerned about those smokers who need the services most, such as pregnant smokers who find it difficult to quit unaided. “A report by ASH and Cancer Research UK found that, despite the public health budget ring fence, Stop Smoking Service budgets were cut in 39 per cent of local authorities in England last year,” says Alyssa Best, policy adviser at Cancer Research UK.
“This situation is only getting worse. Cost pressures in local authorities because of cuts from central Government are the main reason these services are declining.”
The Proprietary Association of Great Britain encourages pharmacists to offer smoking cessation services but says it is concerned that access to these services has declined by 48 per cent in the past three years – not only due to significant cuts to local authority public health budgets, but also cuts in marketing and promotional spending.
Sultan ‘Sid’ Dajani, independent community pharmacist and member of the RPS English Pharmacy Board, believes there are other issues to contend with as well. “With fewer people taking up smoking, there are now fewer people needing support,” he says. “There is also the increase in the use of e-cigarettes, which people are using instead of quitting with NRT. Of the current smokers, it is mainly heavy smokers, drug addicts and mental health patients remaining. These are hard to reach, even if they are targeted during, say, a MUR consultation or leaflet drop.”
Many people try to quit smoking without using any medication or support, but this can lead to nicotine withdrawal symptoms, which reduces their chance of success. Healthcare professionals believe the most effective way to quit permanently is by using prescription medication or NRT and professional behavioural support.
In March 2016, a review of 13,500 smokers found that behavioural support and/or NRT from a pharmacy setting was more effective than brief advice from a GP. Yet, with fewer people accessing support, many pharmacists are wondering whether they need to adapt the advice they offer – and the product choices they have available.
Prescription-only varenicline (Champix) is the most clinically effective smoking cessation medicine for reducing nicotine cravings and withdrawal symptoms. Some pharmacists supply a 12- or 24-week course to eligible patients under a PGD, but there have been concerns about varenicline safety in recent years, which is why many quitters are reluctant to try it.
In April 2016, a study of more than 8,000 people published in The Lancet revealed that varenicline and bupropion (Zyban) do not appear to increase the incidence of serious neuropsychiatric side-effects compared to placebo. This study was the largest trial to date ooking at the safety and efficacy of the three first-line smoking cessation treatments (including NRT). Smokers who took varenicline achieved higher abstinence rates than smokers on bupropion, nicotine patches or placebo.
Pharmacies can also offer NRT products to customers who wish to quit, but research from NiQuitin shows that only 30 per cent of smokers believe NRT is effective. “We think this could be down to people not using it enough,” says Alyssa Best. Customers should therefore be made aware that NRT is more effective if there is also support from stop smoking specialists.
“Pharmacists are in a great position to be able to recommend to people how to use NRT so that it is as effective as possible. Other nicotine-containing products, including e-cigarettes, have been found to help people stop smoking and are far safer than smoking tobacco, so pharmacists could recommend these to people if other methods have not worked.”
“Patches and gum are traditionally what we recommend to patients,” says Stuart Gale, “but we do have quite a few people who vape instead and who have had real success. One of our regular customers has gone from smoking 40 cigarettes a day to vaping only. Obviously, it would be better to stop altogether but vaping is certainly a good place to start and infinitely better than 40 cigarettes a day. It would be good if there was a licensed vaping product that we could recommend.”
Research published in the British Medical Journal in September 2016 revealed that e-cigarettes may have helped about 18,000 people in England to give up smoking in 2015. The use of e-cigarettes remains controversial, however, and many pharmacists have yet to embrace them. Professional guidance is still somewhat confused and the lack of a licensed product hasn’t helped take-up in pharmacies, either.
The evidence so far shows that e-cigarettes are much safer than tobacco, but more research is needed, especially into their long-term use. There have been concerns about e-cigarette safety in public settings and workplaces but, so far, there is not enough evidence to justify a ban, says Alyssa Best. Unlike the known harm from second-hand tobacco smoke, there is currently no evidence of harm from second-hand e-cigarette vapour.
In April 2016, a report by the Tobacco Advisory Group of the Royal College of Physicians concluded that e-cigarettes are a safer alternative to smoking and are beneficial to public health. The report reflected research by ASH, which found that the use of electronic cigarettes is almost exclusively confined to former or existing smokers who use the devices to cut down and quit smoking and, significantly, there is no evidence that vaping has re-normalised smoking.
“The RCP report has looked at the evidence and it is clear that it is the smoke in tobacco not the nicotine that makes cigarettes so deadly,” says Deborah Arnott, chief executive of ASH. “Electronic cigarette vapour does not contain smoke, which is why vaping is much less harmful than tobacco cigarettes. Smokers should be reassured that switching to vaping is a positive and sensible life choice, which can help them quit smoking.”
Many community pharmacists recognise that e-cigarettes are a massive growth area but these products are still surrounded by much uncertainty. Sid Dajani says he doesn’t feel comfortable about supplying e-cigarettes until there is a licensed product available.
“E-cigarettes are another form of nicotine addiction, which means it is then hard to get people off them,” he says. “Pharmacists can’t discourage [their use] or deny they are out there, but there is a difference between stocking them and telling customers they exist.”
Stuart Gale, however, has decided to stock e-cigarettes after discussing the issue with all the pharmacists working within his group. “We see conflicting reports almost daily about the health implications of using e-cigarettes,” he says. “The lack of substantial research to back them as a healthy alternative to smoking has seen them move away from pharmacy to finding a place in stand-alone shops as a recreation product. I feel it is a market that has now been lost to pharmacy, which is a real shame because people have had real success switching from tobacco.
“Now people are buying their e-cigarettes and associated vapes from shops that have no interest in helping them to quit nicotine altogether – in fact, exactly the opposite is true.”
National stop smoking campaigns provide pharmacists with an ideal opportunity to ask customers if they smoke and whether they are interested in giving up. Last year, out of the 2.5m smokers who made a quit attempt through Stoptober, 500,000 people (20 per cent) were successful. According to smoking cessation experts, taking a complete break from cigarettes for at least 28 days greatly increases the odds of being able to kick the smoking habit for life.
“Stoptober is a fantastic campaign that really helps to increase public awareness of the benefits of quitting and helps thousands of people quit every October,” says Niamh McMillan, Superdrug clinical development manager. “The Stoptober brand is very recognisable and the free posters and support materials in-store can raise public awareness of the fact that customers can get help, advice and products through their local pharmacy and do not have to see their GP. The information packs that are provided can help structure the smoking cessation conversations and consultations.”
In September 2016, ASH called on the Government to increase the frequency and the amount of money spent on these stop smoking campaigns. Research has shown that mass media campaigns, such as Stoptober, are highly effective and cost-effective in motivating quit attempts and discouraging the uptake of smoking, but they need to be run throughout the year, rather than annually. This is particularly important for heavier smokers and hard-to-reach groups.
Attracting customer attention from the outset is essential, or pharmacists or pharmacy staff lose the short window of opportunity when customers enter the pharmacy. For this reason, Stuart Gale has created a survey for his pharmacy customers to complete. “Often all you really need is an excuse to talk to patients without them feeling threatened,” he says. “This survey provided the perfect icebreaker to determine whether or not they were smokers. Once we had this vital piece of information, it was much easier to ask if they had tried to give up and whether they wanted some help.”
Sid Dajani says the main challenge is encouraging the hard-to-reach groups to take the first step. “Our efforts now need to be directed at pregnant women, drug users and those with mental health problems,” he says. “Many people see smoking as their lifestyle choice and don’t want to quit. Pharmacists need to work out a motivating factor for each individual customer, build up a good rapport and advise them to give up gradually rather than suddenly.”
Hardened smokers often need extra motivation, such as a free carbon monoxide test, which only takes a couple of minutes while they are waiting for other medication. “A carbon monoxide reading can be a wake-up call as it shows people how bad their health is due to their smoking habit,” says Dajani.
Some customers may find it off-putting if counter staff mention smoking cessation when they haven’t brought up the topic them-selves, he says. “If you can smell smoke on them or are doing a MUR, use an open-ended statement to encourage them to quit, rather than one with a ‘yes/no’ answer, as most people will say ‘no’. For example, rather than asking ‘Would you like smoking cessation advice?’, try ‘If you have ever thought of giving up smoking, or would like to, we can provide a smoking cessation service, provide NRT and offer a carbon monoxide test.’ Then you are leaving it up to them to take the next step.”
“Most people I have spoken to want to give up and more often than not they have tried and failed,” says Stuart Gale. “They are quite often despondent about not being able to quit, so we highlight the fact that they are not alone. Not many people realise that it takes on average six to seven attempts before they are able to actually quit. This information is often enough to kick start the process again.”
People are buying e-cigarettes from shops that have no interest in helping them to give up nicotine