For some patients, giving up smoking may seem like an insurmountable task. But community pharmacists are well placed to help achieve successful quit attempts, says Darrush Attar
Key learning points
- There are several different smoking cessation methods that pharmacists can suggest to patients including nicotine replacement therapy (NRT)
- Pharmacists and their teams have access to specialist smoking cessation training
- Effective communication with patients looking to quit smoking is key
Public Health England (PHE) wants to see a tobacco-free generation by 2025. Despite a continuing decline in smoking rates, nearly one in six adults still smoke and many of these patients will be walking into a pharmacy. UK smoking prevalence in 2016 was 15.5% of the adult population, representing around 7.6 million individuals. England has the lowest smoking prevalence out of the four UK nations at 14.9%.
Even though smoking prevalence is dropping, we can’t rest on our laurels and expect levels to drop further. Unfortunately, in England, prevalence in smokers who are least likely to afford it are 2.44 times higher than the more well off, 40.5% of people with serious mental illness are smokers, and women smoking at time of delivery is 10.7%.
Figures from 2010 to 2011 showed over one million smokers are hospital in-patients.
There were an estimated 1,579 years of life lost per 100,000 due to smoking attributable illnesses, including various cancers, heart disease, stroke and chronic obstructive pulmonary disease.
Heath complications associated with smoking
Smoking or exposure to smoke (passive smoking) is the most commonly encountered and easily identifiable risk factor for many long-term conditions.
Smoking cessation is seen by many as a public health issue, a lifestyle choice that can prevent ill health. Pharmacy teams in all settings are a vital ingredient to spotting warning signs of ill health from tobacco dependency. The good news is that it’s never too early or late to stop smoking, and acquiring the right skills to support and treat this chronic relapsing disease is essential if we want to see further reductions in prevalence.
In respiratory patients, early warning signs come in our asthma patients who may live with a smoker or smoke themselves.
The 2014 National review into asthma deaths reported that 46% of deaths due to asthma had preventable risk factors. One third of cases had regular exposure to tobacco smoke and shockingly, deaths where smoking was a factor included child smokers with one patient as young as ten.
Pharmacy teams may spot early warning signs in patients who have chronic obstructive pulmonary disorder (COPD), many patients will visit the local community pharmacy and self-medicate on cough mixtures. In the two–10 years prior to diagnosis, people are likely to have consulted primary care on multiple occasions for lower respiratory complaints and lower respiratory tract infections and to have received multiple prescriptions for oral steroids and/or antibiotics. This suggests there is scope for earlier assessment and diagnosis.
Raising the subject of smoking – very brief advice (VBA):
The National Centre for Smoking Cessation and Training (NCSCT) offer great modules to help educate pharmacy team members. All staff are recommended to do the VBA module.
VBA (Ask –Advise – Act) is a public health intervention delivered in a one-to-one health setting. Each VBA delivered correctly can trigger a quit attempt. The frequency of exposure to this trigger is crucially important – repetition matters.VBA training takes only 20 minutes and the intervention can take as little as 30 seconds to complete in a real consultation.
Ask patients if they smoke and if they have thought about stopping. You could do this when patients are identified as smokers from medicines use review (MUR) or new medicine service (NMS) intervention. You can also ask a patient about passive smoking – for example, if someone is buying over-the-counter (OTC) treatments (eg cough mixture, sore throat remedies or cold sore treatments) or if a prescription for an inhaler is being dispensed, ask if they live with a smoker. Mention that passive smoke can make their condition worse. At this point some patients may reveal they smoke themselves.
Advise patients that stopping smoking is the single most important thing they can do to improve their health and that of others around them. Tell them the best way to stop is with a combination of medication and specialist support by trained individuals.
Act on the patient’s response by building confidence, giving information or referring to a NHS stop smoking service (Service options listed below). Varenicline, bupropion or nicotine replacement therapy (NRT) should be prescribed or provided before the person stops smoking. E-cigarettes from a reputable source may also be considered.
When smokers walk into the pharmacy, having an eye-catching health promotion zone can help raise awareness of what help and support is available to them. This will complement the routine VBA that takes place. Examples of materials to display include: NHS smokefree resources (eg health and wealth wheels), carbon monoxide charts – which can be used as a behaviour change motivational tool – tar jars, etc.
Methods of quitting smoking and advice community pharmacists can give patients on each of these
Pharmacies, are needed more than ever to make smokers aware of the support and treatment options (ACT part of the VBA).
Stop smoking support and treatment options have changed significantly since the inception of evidence-based NHS stop smoking services in 2000. It’s important to understand that not every smoker will want to attend weekly sessions of behavioural support and may prefer more flexible approaches including self-help. We also need to factor in budget cuts across many local authorities and in some instances the de-commissioning of services, including those in community pharmacies.
Examples of support and treatment options that may be available to your smoker:
- Talking to a specialist stop smoking advisor in the pharmacy who has undergone intensive training: This option will provide the best possible chance for a smoker to stop and stay stopped offering up to 300% success rates. Patients will need to commit to weekly appointments for at least four weeks after their quit date. Pharmacies are ideal places for this to occur as they are easily accessible, can offer flexibility with long opening hours and some consultations can be done over the phone.
- Using a stop smoking medicine: Community pharmacists are in an ideal position to offer this model of support. It would usually entail offering NRT (usually combination) or varenicline to a patient. The medicines will be discussed in detail prior to going smokefree and then follow-up advice at some point soon after quit date. Patients chances of stopping may increase by 100%.
- Stop smoking alone or with minimal support: For patients who want minimal support, it may be worth signposting them to reputable websites that can offer tips, chat to an advisor online and potentially telephone support. Eg Nationally there’s NHS smokefree that has plenty of information for the smoker.
Even though it is not the most effective option, patients going it alone and stopping abruptly, potentially with the support of e-cigarettes to assist, are up to 50% more likely to quit smoking.
- Buying NRT OTC: according to data from the STS (Smokers Toolkit Study) conducted each year, buying NRT OTC has shown not to improve (0%) a smoker’s chances of stopping. This is a large reason why pharmacists shouldn’t encourage this option.
How to motivate and help patients to go smokefree
For pharmacy staff who are offering more intensive stop smoking support and treatment, it is recommended to do the NCSCT core knowledge and skills online course, pass the assessment and attend a locally commissioned accredited face to face training that follows national training standards.
The standard treatment programme has a set of competencies that should be covered in the sessions to help motivate a smoker to stop and stay stopped using motivational skills. Part of it will be to ask the smoker questions about their current smoking, motivation to stop, past quit attempts, using reflective listening skills. Discussing medication options offering patients informed choice will further support the patient. Conducting a carbon monoxide (CO) reading on each visit is a great motivational tool to highlight improved levels. Offering a summary throughout, with plenty of encouragement will hopefully bolster confidence further.
In each of the sessions, asking the patient to make a commitment to not have a single puff of a cigarette (including roll ups, shisha, cigars, etc), will help the patient to see themselves as a proud non-smoker and set them up for longer term success. If there are lapses, it’s important to remind the patient that we’re all human and mistakes can happen on the way to them becoming a lifelong non-smoker. Many patients will need multiple attempts before successfully going smokefree.
Darush Attar-Zadeh is a medicines optimisation pharmacist at London Procurement Partnership and clinical lead (respiratory project) for medicines optimisation at Barnet Clinical Commissioning Group.
 Szatkowski L, Murray R, Hubbard R, et al. Thorax 2015;70:498–500