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Stop smoking services need a new way forward 

Covid-19 boosts quit attempts but funding cuts have hit services, finds Kathy Oxtoby...

The smoking cessation services offered by community pharmacies have been a major contributor to the fall in smoking rates across the UK. “Local pharmacies help thousands of people each month successfully kick the habit. They offer an accessible, non-stigmatising environment where behavioural support can be given in combination with products like nicotine patches or gums,” says Helga Mangion, NPA policy manager. 
Pharmacy now has an even greater role to play in smoking-related health, by helping to achieve the target set out in the NHS Long Term Plan that, by 2023/24, all people admitted to hospital who smoke will be offered NHS-funded tobacco treatment services. 
A pilot based in the Oldham area is testing the referral of patients to community pharmacies to continue the stop-smoking journey they started in hospital. People can choose the community pharmacy they wish to be referred to on discharge.  
After referral, the pharmacist or a trained pharmacy team member will arrange an initial consultation to discuss their quit progress and review the nicotine replacement therapy (NRT) or medication prescribed by the hospital team and make any necessary adjustments. 
Further pilot sites are expected to be up and running in early 2021. The pilot will be evaluated to inform potential inclusion of a smoking cessation service in the Community Pharmacy Contractual Framework in the near future. 
“Such a service, commissioned via the CPCF, would be a welcome addition to the range of public health services all pharmacies now provide," says PSNC director of NHS Services, Alastair Buxton. 
Sandra Gidley, president of the Royal Pharmaceutical Society, says the pilots for smoking cessation schemes in England, which are referring people from secondary care to community pharmacies, are “a really positive step and should be rolled out more widely as soon as possible”. 
 
Impact of Covid-19 
The pandemic appears to have had a positive impact in reducing smoking rates, Public Health England (PHE) data suggests. According to its Smoking Toolkit study, prevalence of cigarette smoking in England dropped from an average of 15.8 per cent in October 2019 to 14.8 per cent in October 2020. 
The study also finds that there has been an increase in the number of people attempting to quit smoking during the pandemic, with two-fifths of smokers attempting to quit in the three months up to September 2020. 
Martin Dockrell, tobacco control lead at Public Health England, says the last year had seen “near seismic shifts in smoking patterns with large numbers quitting and those who do succeeding in record numbers”. 
But he says they could be “even more successful if they used effective quit aids and received behavioural support, as smokers are increasingly going cold turkey”. 
Over-the-counter nicotine replacement therapy (NRT) and e-cigarettes remain the most commonly used aids to quitting, the Smoking Toolkit study shows. However, during the pandemic there has been a reduction in their use and a corresponding increase in the people attempting to quit unaided. 
“Getting enough nicotine is key to a successful quit attempt and pharmacists have a range of nicotine replacement products which can be used separately, or better yet, in combination,” says Mr Dockrell. 
 
Commissioning landscape 
Local councils spent £77 million in 2019 on tobacco control and smoking cessation, according to the Local Government Association (LGA). The LGA has previously highlighted a £700 million funding reduction to councils’ public health grants over the last five years.  
Ms Gidley says decisions which have resulted in many free, stop smoking services to be decommissioned “need to be reversed as it’s critical that we help with creating greater access for patients within their local communities and give them as many options as possible to quit”. 
Lila Thakerar, superintendent pharmacist at Shaftesbury Pharmacy in Harrow, hopes for a return to the commissioning of services to “to support people who have started, or gone back to smoking, to quit”. 
Once the pharmacy had “one of the most successful quitting rates in Harrow”, she says. But when the commissioning of such services moved to local authorities in 2015 the pharmacy stopped receiving funding for offering smoking cessation support. 
“Without any reimbursement for the service it’s just not possible to deliver it,” says Ms Thakerar.  
Smoking cessation services through community pharmacies in Scotland, which sit within the Public Health Service section of their NHS contract, have been “incredibly successful”, says Ms Gidley. In fact, the free stop smoking services accounted for just over three quarters of quit attempts made in Scotland in 2019/20. 
Meanwhile in Wales a new development in smoking cessation services means that in 2021 pharmacies will be able to prescribe varenicline through a national programme for smokers who have been unsuccessful in trying to quit using traditional NRT products. 
“These schemes, on top of the pilots being rolled in England, are a really positive way of providing seamless transition of care for patients into community pharmacies,” says Ms Gidley. 
 
Latest guidance 
Guidance on stop smoking interventions and services continues to evolve. NICE guidance now features some recommendations on e-cigarettes for health and social care workers in primary and community settings. This includes explaining to people that many have found them helpful to quit, and that the evidence suggests ecigarettes are “substantially less harmful to health than smoking but are not risk free”. 
The Scottish Intercollegiate Guidelines Network’s (SIGN) position on the role of vaping in helping people quit smoking is covered in SIGN guideline 149 – Risk estimation and the prevention of cardiovascular disease. The guideline recommends several areas for research. These include long-term surveillance studies “to consider the potential health impacts of inhaling the contents of e-cigarettes, electronic nicotine delivery systems and vaporisers”. 
While there are many replacements for cigarettes and numerous ways to quit, products are only part of the stop smoking story. Personal support from pharmacies can play a vital role in encouraging people to quit for good, but they need funding to deliver smoking cessation services. As Ms Thakerar says: “We need support from government so we can encourage smokers to quit using the reputable smoking cessation services pharmacists can - and want – to offer.” 




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