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Kicking the habit

Local authority stop smoking services have been scaled back in recent years but pharmacists have effective ways to help people kick the habit...

 

Free locally commissioned stop smoking services were set up in 1999 and have been available in local pharmacies but recent years have seen a decline in these services because of a lack of funding and a general decline in smoking prevalence.

Recent Public Health England (PHE) figures show that 14.4 per cent of UK adults smoke - two million less people than in 2011.

“The free-to-access stop smoking services have been a great success, helping many thousands of smokers to quit,” says Louise Ross, clinical consultant at the National Centre for Smoking Cessation and Training (NCSCT).

“Community pharmacies played a significant role in this success story, giving smokers easy access to a quit programme. Around 2013 to 2014, use of the services began to decline. There were a number of reasons for this: less money was being spent on national campaigns, spending cuts began to bite and smokers were starting to use e-cigarettes to quit on their own.

“Since stop smoking services were transferred from the responsibility of the NHS to local authorities, spending has been further reduced, with some local authorities decommissioning their local services altogether.”

Despite the decline, there is still a demand for smoking cessation advice in local pharmacies according to some regional managers.

Sally Farmer, a pharmacist manager in Wiveliscombe, Taunton and regional pharmacist manager for Day Lewis, said she has seen a surge in recent years.

“I think the smoking ban in public places has really helped with this. My pharmacy is very busy as not all pharmacies offer Champix. It requires a trained pharmacist to deliver the service, so patients sometimes travel quite a way to come and see me.”

This trend is echoed in the West Midlands according to Olutayo Arikawe, superintendent pharmacist at Priory Community Pharmacy in Dudley.

“Recently, we have seen a decline in the service as it is being commissioned outside of pharmacy. But there is still demand for community pharmacies to offer smoking cessation,” she explains.

“In the Dudley area, for example, we have a new provider, but pharmacies still have customers asking for support. We make customers aware of the benefit of the service either during a consultation or an over-the-counter interaction.”

 

Clinical advice and support

Sally offers a range of prescription medicines (varenicline/Champix), nicotine replacement therapies (NRT) and behavioural support via a stop smoking service in her rural Wiveliscombe branch.

“When customers approach the pharmacy counter and pick up a nicotine replacement product, my counter colleagues are trained to engage with the customer at this point about their stop smoking plan,” she says.

“Whether it is just to give some helpful advice, or to inform them that they can get extra support through our local NHS stop smoking service, this engagement is really important. There is no pressure to quit there and then, but sometimes planting the seed and making people think about stopping smoking can help towards a successful quit attempt.”

Her first line is to offer varenicline. “I can offer this product through a patient group direction. Champix is very effective and I've had great success with it. I can also offer NRT products if Champix is not appropriate or the patient would prefer to try them.

“With NRT products the patient provides a carbon monoxide breath test. This sometimes shocks patients when they realise that they have poisonous gas on their lungs. This gives an incentive to stop smoking as they can see their recovery but also shows them their progress when they see this reducing upon each visit.” 

She tailors the consultation to suit each individual. “I also offer advice such as trying to change usual habits that trigger smoking cravings. A lot of patients want to know how to not gain weight and control their anxiety whilst stopping smoking.

“I provide verbal advice and written information. I also recommend the NHS smoke free app if patients have a smart phone, as this can give them daily support in between their visit to the pharmacy.

“In my pharmacy we have a wide range of nicotine replacement products on the shop floor such as patches, gum, lozenges, mouth spray and inhalers. We usually recommend patches with another product to control cravings.

“If a patient wants to buy these products without receiving the extra support from the stop smoking service, then they are free to do so.” 

Michelle Scott, pharmacy manager at Shadforths Pharmacy in Ingatestone, Essex, also provides the eight to 12-week programme NHS stop smoking service with weekly appointments, that is no longer offered at the local GP surgery.

“This is provided by myself or a trained smoking cessation member of staff. Community pharmacy is a good setting for this service as appointments can be flexible and clients are often known already to the team,” she says.

“We can also keep tabs on them after the programme has finished and offer continued support to prevent them starting again.

“As part of the NHS smoking cessation service we are able to offer NRT or Champix, if people do not want to quit and just want support, for instance, if they are travelling or going into hospital, we are able to advise on the best NRT for their individual need.”

Olutayo assesses a person’s willingness to stop smoking and their level of tobacco dependence before taking a reading of their carbon monoxide level and setting a date to quit smoking.

In addition, they can be supported with a nicotine replacement product, such as Nicorette and Niquitin, or Champix tablets.

“We check what other medication they are taking and, where appropriate, will notify their GP if the smoking cessation products they are taking affects their medication. We also offer strategies to cope with urges to smoke, as well as weekly support meetings,” she says.

 

Vaping and e-cigarettes

Opinions are changing about vaping. With a growing trend towards ‘harm reduction,’ e-cigarettes are now being heralded as a positive step in cessation. PHE endorses vaping as the most effective way of stopping smoking and recently stated that e-cigarettes are 95 per cent safer than tobacco.

Louise Ross, who developed the first ever e-cig-friendly stop smoking service in Leicester, has seen higher success rates with vaping compared with traditional licensed products.

“The message from ASH, PHE, CRUK and the NCSCT, among many other organisations, is that all smokers should try vaping, and all vapers should stop smoking completely. It's the complete switch that brings the biggest health gains,” she says.  

“People who switched to vaping show the same improved health that ex-smokers do using any other method of quitting: more energy, less breathlessness and fewer infections. They tell us it was a revelation, especially when they thought they had tried everything.

“As far as long-term vaping is concerned, the most important thing is to not go back to smoking. If someone continues vaping to prevent that happening, that's still a health gain. Pharmacists may be interested in informing their patients about the good news that vaping brings.”

Olutayo has recently changed her views on e-cigarettes. “A few months ago I would have given a different answer but I recently attended a panel discussion that improved my knowledge,” she says.

“Pharmacies should stock them and support people who wish to give up smoking through this means. We are best placed to give the right health advice and help patients make the right smoking cessation choices for them.

“Pharmacy teams could benefit from increasing their knowledge on e-cigarettes, to improve their confidence when advising patients.”

Sally stocks e-cigarettes in her Somerset pharmacy. “If a patient chooses to join our stop smoking service, sometimes they will use e-cigarettes alongside patches to control their cravings.

“We can't provide these on our stop smoking service as they are not licensed medicines, so patients buy these separately. However, in the future it may be useful if e-cigarettes were available on stop smoking services.

“I do worry about the long term effects that e-cigarettes may have, but they have to be better than smoking.”

 

Emerging markets

A market is emerging for heated tobacco products like Philip Morris International’s IQOS - electronic products which heat, rather burn, tobacco leaf. Their difference to e-cigarettes is the device contains addictive and harmful tobacco ingredients.

Then there is Juul which does not contain tobacco and is not a heat-not-burn product like IQOS but contains patented nicotine salts.

But our pharmacists still think ‘Juuling’ is a step too close to smoking.

“I don't think I would like to stock IQOS or Juul products," Sally insists. “These products may be safer than smoking real cigarettes but I don't believe a pharmacy is the right place to stock these products.” 

 

The pharmacist’s view

While the number of smokers in the UK is falling, smoking remains one of the biggest causes of death and related illnesses in British people. Reducing smoking rates will save the NHS up to £890 million a year.

Studies show that a person is more likely to quit smoking with NHS support and pharmacotherapies including (NRT, varenicline, buproprion and e-cigs/vapes). Research also shows that pharmacotherapy and counselling through pharmacy can increase smoking cessation success and that you are four times more likely to quit with expert support.

With NHS funding in decline, pharmacists play a vital role in being able to offer readily accessible patient education and guidance.

Pharmacists can create a point of difference by tailoring advice to the individual to give them the best chance of quitting smoking for good, no matter whether they are using NRT or vapes/e-cigs, or a combination of these aids. Establishing the best formats and plan to suit quitters’ habits and triggers is key.

Vapes/e-cigs help people cease or reduce smoking tobacco. These products are under ongoing review, given that we do not fully know the long-term health impact of their consumption. However, based on current evidence, they pose just 5% of the health risks versus smoking tobacco.

It’s widely viewed by the key UK health industry bodies as a ‘positive option’ and not a magic bullet solution. The Tobacco Products Directive has banned certain ingredients including colourings, caffeine and tourine from vapes.

Some flavours have also been removed from the vaping list due to harmful effects e.g. cinnamon. For many, the switch to vape/e-cig addresses the hand-to-mouth sensorial habit that they associate with tobacco smoking.

Smoker’s expectations, however, need to be managed as the nicotine hit will not be as rapid as smoking tobacco. It is recommended that people who are smokers, or those at risk of relapsing to smoke (ex-smokers) seek advice from a reputable vape shop or a knowledgeable pharmacy that sells these items to find the right device, strength, flavour and shown the right technique.

NRT, vapes /e-cigs all offer a cleaner, therapeutic form of nicotine versus tobacco. So when it comes to NRT in pharmacy, here are a few key points:

·       Take ownership as the medical expert – vape shops generally would not have clinical staff who know about potential drug interactions with smoking and advise on managing long-term conditions and the impact of nicotine withdrawal. Help the individual work out their goals to ensure they have a high level of commitment during a smoke-free journey and help prevent relapse.

·       Highlight that it’s not the nicotine that kills but the tar and other poisonous chemicals that arise from combustion.

·       Educate patients on the higher rigorous safety and efficacy testing of NRT products – do not discourage them from vaping if this is of interest to them but suggest e-cigarettes are just one of numerous effective stop smoking aids.

·       Recommend NRT products for smokers to sit alongside their vaping to help them reach a cleaner form of nicotine dosage to fully quit. For highly dependent users, a combination of NRT alongside vapes/e-cigs could help them stop smoking.

·       Signpost patients to local stop smoking services and support. In pharmacy, offer carbon monoxide readings and offer NRT over-the-counter to supplement their vaping.

·       Understanding what individual patient needs to quit. Vapes, e-cigs and NRT all have a place to play but it is key to identify what is appropriate for each patient.

 

Darush Attar-Zadeh is a pharmacist who has specialised in smoking cessation for over 20 years. He helped review the National Training Standards for Smoking Cessation and was part of the London Clinical Senate Helping Smokers Quit programme. He is also an executive committee member for the Primary Care Respiratory Society UK.

 

 

Picture: Terroa (iStock)




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