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Smoking rates are falling across the UK but for those people who still smoke, it remains the leading cause of early death, the main risk to their health and a significant cause of inequalities. In the year 2000 more than one in four adults in England smoked but by last year this had fallen to fewer than one in six, according to an All-Party Parliamentary Group on Smoking and Health document published in February this year.1
Since the last Tobacco Control Plan for England was published in 2011, smoking rates in England have fallen by a quarter, from 19.8 to 14.9 per cent in 2017, bringing the estimated number of smokers down to 6.1 million.
Smoking rates in children have also fallen. After two decades of little change, between 2000 and 2016 regular smoking by 15-year-olds fell from 23 to 7 per cent, a decline of more than two-thirds in the proportion of children of that age who smoke.
However, the national picture hides significant variations.
The Government’s Tobacco Control Plan for England sets out an ambition to achieve a smoke-free generation, meaning a smoking prevalence of 5 per cent of the population or less, by 2022. Within this, there are several elements:
Office for National Statistics (ONS) estimates from the Opinions and Lifestyle Survey suggest that in Great Britain in 2018, 60.8 per cent of people aged 16 years and above who currently smoked wanted to quit, while 59.5 per cent of those who have ever smoked had quit.
Data from NHS Stop Smoking Services in England indicate that from April 2018 to March 2019, 236,175 people had set a quit date with the number of successful quitters (self-reported) being 123,800 (52.4 per cent). This is a fall since 2014/2015 when the respective figures were 450,582 and 229,681 people (51 per cent). Anecdotal evidence suggests this may be due to an increase in people using e-cigarettes to help them stop smoking.
Financial incentives can work to help people stop smoking and remain smoke-free, according to a recent Cochrane review of 33 randomised controlled trials involving 21,600 people across eight countries.
People receiving rewards were approximately 50 per cent more likely to have stopped smoking six months or more after the beginning of the trials than those in the control groups. Of those not receiving incentives, approximately seven per cent had successfully quit for six months or longer, compared to approximately 10.5 per cent of those receiving incentives. The review also found that incentives helped pregnant women in particular to stop smoking.
Stop smoking services, including behavioural support and the provision of nicotine replacement therapy (NRT), or varenicline or bupropion as appropriate, are the most effective way to quit.
A 2016 meta-analysis published in BMJ Open2 found that behavioural support and/or NRT delivered in a pharmacy is, on average, two-and-a-half times as effective as having no support or pharmacotherapy alone and can be up to four-and-a-half times as effective. Using willpower alone is the least effective method.
NHS stop smoking services are co-ordinated centrally in each of the four UK constituent countries:
Smoking cessation services include, for example, local stop smoking groups or one-to-one sessions, telephone consultations, or a community pharmacy or hospital-based service.
In recent years, cuts in public spending have impacted on budgets for smoking cessation services. According to the APPG report, in England between 2014/15 and 2017/18, local authority spending on tobacco control and stop smoking services fell by £41.3m (30 per cent). This provides opportunities for pharmacy to be proactive in this area.
Smoking in pregnancy remains a particular challenge. Although the rate of smoking in pregnancy has fallen from 15.8 per cent in 2006/7 to 10.8 per cent in 2018 in England, this remains well above the 2022 target of 6 per cent.
And there are significant variations across regions.
According to a 2017 release from the Smoking in Pregnancy Challenge Group, while 89 clinical commissioning groups had seen smoking rates in pregnant women decline by 1 per cent or more between 2014/15 and 2018, 78 CCGs had actually seen an increase.
In cities like Sheffield, which have invested in support for pregnant women, the rate of smoking has fallen by 4.1 per cent since 2014/15. By contrast, areas that had cut services are not seeing the same rate of progress.
Many areas of the UK have commissioned community pharmacy-based smoking cessation services. These include:
Pharmacy staff are trained as stop smoking advisers to individuals or groups (e.g. providing six to 12 weekly sessions with monitoring). NRT, or varenicline or bupropion under a PGD, can be supplied depending on suitability for the client.
Providing brief advice means proactively raising awareness in a non-threatening manner by asking indirect questions and assessing a person’s willingness to engage in further discussions about smoking.
Community pharmacists have unique opportunities to provide brief advice to patients outside of smoking cessation services, including when making OTC medicine purchases or during local or national campaigns (e.g. No Smoking Day or Stoptober). Smoking status can be recorded on a patient’s medication record and he or she can be asked about their smoking status at least once a year.
Providing brief advice should take no more than three minutes. If the response is positive, this could lead to a specific brief intervention. If the person is not keen to engage, let them know they can come back at any time and record the outcome of the conversation.
A brief smoking cessation intervention can take about 30 minutes. Key elements can include:3
Carbon monoxide testing can be beneficial in assessing a smoker’s status providing a pre-quit level and a post-quit level four to 12 weeks later. The test is quick and non-invasive and can be a motivational tool for patients as readings start to decrease over a relatively short period of time.
It is important to explain to patients what the test entails, what it measures and what changes they can expect after four weeks on a smoking cessation plan (see case study).
It is also worth noting that lung function testing (spirometry) should be undertaken by all chronic obstructive pulmonary disease (COPD) patients who smoke (smoking is the commonest cause of COPD). Spirometers should be available from the local smoking cessation commissioning body.
For Rozalyn Perkins, pharmacy manager at a LloydsPharmacy near Bristol, providing a smoking cessation service is hugely satisfying. “There is no greater reward than helping people to change their lives. When someone blows into a carbon monoxide monitor and the reading is over 20 but, after a 12-week course of being smoke-free, the reading has dropped to zero, you see the look on their face and you know they have changed their life for themselves, their family and the NHS.”
Key to stopping smoking is making the most of NRT, she says. “Don’t be afraid of it. People must get to their end goal and there is no point in them suffering cravings.” What usually works best is a combination of patches and another shorter acting NRT product to help combat cravings, she finds.
Many of her clients come to the pharmacy via the smoking cessation service situated in the health centre next door but, as a qualified smoking cessation adviser, Rozalyn also sees patients herself. Advisers provide counselling and a written request for a smoking cessation product, which the client brings to the pharmacy. The customer pays a NHS prescription charge if they are not exempt.
Success rates are around 80 per cent and people often need to return when they want to try quitting again, says Rozalyn. “Being there for people and helping them through it is a great privilege.”
There are six types of NRT: patches, gum, lozenge, micro-tab, nasal spray and inhalator, with no evidence to show one form being more effective than another. It is important to agree on the most appropriate form with the patient and to be aware that smokers often want to swap products.
Smokers often benefit from dual NRT therapy using, for example, a slower-release product (e.g. patches) to deliver a baseline amount of nicotine to deal with background craving and a faster acting product (e.g. gum, lozenge, inhalator, spray) that delivers nicotine quickly to fight episodic cravings.
The MHRA has approved NRT for use in smokers over 12 years of age who have an evident addiction to nicotine. NRT is licensed for use by pregnant women and in patients with cardiovascular disease and diabetes. Although caution should be exercised in these groups, the benefits of stopping smoking will almost always outweigh any risks from NRT.
Intermittent NRT is preferable in pregnancy although sickness may mean that patches are the only realistic option. Pregnant women should remove NRT patches before going to bed. NRT can also be useful for people who want to cut down and cannot contemplate giving up in one step (nicotine assisted reduction).
Bupropion is an antidepressant medication that has been shown to be successful when used in smoking cessation as a single drug therapy. Although bupropion is a safe and effective medication, possible side-effects and contraindications should be noted when it is considered for use – see the BNF or the SPC on the electronic Medicines Compendium website.
Varenicline, like bupropion, is a prescription-only medicine that can increase long-term abstinence from smoking. Its cautions and contraindications are worth noting and can be found in the BNF or the product’s SPC. The SPC contains a note on the possibility of suicidal tendencies in some patients. Nausea is a notable adverse effect that tends to subside over time.
The combination of NRT with varenicline or bupropion is not recommended.
E-cigarettes help more than 50,000 smokers in England to quit each year, according to new research in Addiction.
Researchers analysed data collected from 222,856 adults aged 16 years and older who completed the Smoking Toolkit Study, a series of monthly cross-sectional household surveys in England. Of these, 20.27 per cent were current smokers and 22.30 per cent had smoked during the previous year. The authors adjusted for seasonality, underlying trends, spending on tobacco mass media and tobacco affordability.
No clear association emerged between the prevalence of e-cigarette use among current smokers and either quit attempts or tobacco consumption. However, e-cigarette use during an attempt to stop smoking in the past year was positively associated with overall quit rate: every 1 per cent rise in use was associated with a 0.050 per cent increase in the overall quit rate.
E-cigarettes can help
Based on previous studies, the authors estimate that 845,152 of the 7 million current smokers in 2017 used e-cigarettes during a quit attempt. Based on the new study, 50,700-69,930 additional people who smoked in the past year quit in 2017 because they used e-cigarettes.
“This study builds on population surveys and clinical trials that find e-cigarettes can help smokers to stop,” comments lead author Dr Emma Beard, senior research associate at University College London.
“England seems to have found a sensible balance between regulation and promotion of e-cigarettes. Marketing is tightly controlled so we are seeing very little use of e-cigarettes by never-smokers of any age, while millions of smokers are using them to try to stop smoking or to cut down the amount they smoke.”
Data published by Action on Smoking and Health (ASH) in September this year shows that an estimated 3.6 million people are vaping in Great Britain (just over half the number of smokers). The products are most popular among 35-44 year-olds, followed by 45-54-year-olds. The lowest rates are among young adults aged 18-24 years.
The proportion of vapers who are ex-smokers continues to grow, reaching 54.1 per cent in 2019 with the main reason given for using e-cigarettes being to help them quit smoking (31 per cent) followed by to prevent relapse back to smoking (20 per cent).
The safety of e-cigarettes is increasingly debated with some researchers suggesting that vaping inflames the airways, leading to increased production of mucus and tissue degrading enzymes, reducing the ability of the lungs to function and increasing the risk of lung disease.
US president Donald Trump recently pledged to ban the sale of most flavoured electronic cigarettes, after recent cases of lung disease were linked to vaping. The concern is that flavoured e-cigarettes may be particularly appealing to youngsters. A national FDA survey of tobacco and e-cigarette use between 2017 and 2018 found a 75 per cent increase in vaping among US high school students (aged about 14 to 18 years) and a 48 per cent increase among middle school students (aged about 11 to 13 years). By comparison e-cigarette use in the UK remains low.
According to a 2018 ASH survey, just 2 per cent of 11-18 year-olds use e-cigarettes at least weekly, another 2 per cent use them once a month or less and 12 per cent of young people have tried them once or twice. A majority haven’t tried e-cigarettes (76 per cent), while 7 per cent are unaware of e-cigarettes altogether.
Following the US announcement, Public Health England’s advice on e-cigarettes remains unchanged. On September 12, PHE tweeted: “Vaping isn’t completely risk free but is far less harmful than smoking tobacco. There is no situation where it would be better for your health to continue smoking rather than switching completely to vaping.”
The Royal Pharmaceutical Society is currently updating its e-cigarette policy, which is expected in spring 2020. In advising on smoking cessation, pharmacists should encourage the use of licensed NRT products wherever appropriate.
Where someone is unwilling to use a licensed NRT product, pharmacists should use their professional judgement on the use of e-cigarettes, taking into consideration current evidence on safety and efficacy; the risks and benefits of using unlicensed e-cigarette products; and the normalising of the smoking habit itself, particularly for young people and non-smokers.