As e-cigarettes become more popular, Dr Terry Maguire argues that now is the time for pharmacies to redouble efforts to help smokers quit
In 2001, some colleagues and I published a research paper on community pharmacists’ role in smoking cessation.1 This paper, along with another published in Scotland,2 identified the potential of using pharmacists in a stop-smoking role and provided the basis for a national smoking cessation service.
Apart from some regional variations in commissioning and service specifications, the service remains the most successful public health service offered from community pharmacy. In addition to supporting smokers to quit, the service has opened up vital income streams for pharmacy businesses that helped alleviate diminishing income from dispensing. The current funding crisis further endorses this point.
In 2017, community pharmacies remain the preferred site for the public to enrol on NHS smoking cessation programmes. However, experience in Northern Ireland, reflected across the UK, suggests that the number of smokers enrolling in our programmes has fallen by about half3 in the last four years. This reflects mainly the popularity of e-cigarettes used as a harm reduction rather than a cessation aid.
So, 20 years on from the time a few enthusiastic pharmacists innovated a service, where next for community pharmacy smoking cessation services? Is it time to stand them down, as some CCGs are doing, or to renew our commitment? My view is clear; we must redouble our efforts. Smoking remains the single biggest public health challenge and pharmacy is the best place to tackle it.
In this article, I will consider what action contractors should take to reinvigorate their services and support staff in delivering a higher quality service; asking about smoking more frequently, enrolling greater numbers of smokers into services and achieving higher cessation rates.
Why should we do it?
Over the past 40 years, smoking prevalence in Britain has more than halved from 46% in 1974 to 19% in 2013. As of 2016, it was down to 16.9% in 2016 as fewer people take up smoking and existing smokers quit.4 Sadly, Northern Irish prevalence remains higher at 22% and Scotland at 24% – perhaps reflecting greater levels of social deprivation. Half of all long-term smokers will die prematurely and smoking remains the principal cause of ill-health and premature death in the UK, killing an estimated 100,000 people every year – or one in six of all deaths.5
Most smoking-related deaths are from one of three main classes of disease; cancers, chronic obstructive pulmonary disease (COPD) and coronary artery diseases. However, chronic tobacco use can result in numerous lesser-known disorders including macular degeneration, digestive system disorders, skin complaints and disorders of the musculoskeletal system. Stopping is the only option. Stopping at any age improves longevity. Stopping at age 60, 50, 40 or 30 gains respectively about three, six, nine or 10 years of life expectancy.6
Brief interventions; just ask
Pharmacists and pharmacy staff in day-to-day practice do not actively ask about smoking. We must if we are to drive greater numbers of smokers into cessation programmes, where quitting is more successful. We fail to ask about smoking when dispensing medicines, undertaking medicines use reviews, dealing with common ailments, selling OTC medicines or just seeing someone picking up a smoking leaflet. This reticence is understandable; we expect a rude response, and in a minority of cases, we get one. But knowing how to categorise smokers into pre-contemplative, contemplative or ready to stop allows us to customise the advice we give.
Pre-contemplative smokers are unlikely to change and any attempt to convince them can lead to resistance, which is counterproductive. When we ask someone about smoking, perhaps when selling a cough medicine, and they respond with ‘mind your own business’, then we know they are pre-contemplative and we should back off. It seems counter-intuitive to do nothing, but you have already asked and other information such as public information campaigns over time will add to the pressure to change. Eventually, the pre-contemplative smoker will become a contemplative smoker.
For the contemplative smoker, the one who, when asked, admits to knowing they should stop and would like to, the objective is to elicit ‘change talk’. This can be done in one of four ways by getting the patient to discuss:
•Disadvantages of the status quo.
•Advantages of change.
•Their ability to change.
•Intention to change.
For example, ask the question ‘What would be the advantage for you if you stopped smoking?’ Let the smoker talk, because this process increases motivation to quit, which comes from an internal dialogue.
This process is known as motivational interviewing (MI) and is a person-centred yet directional model.7 MI helps create a drive towards change without making the patient feel threatened or pressured.
Ready to stop
When individuals are motivated and ready to change, successful change happens best when they are supported in a smoking cessation service, where they get behavioural support. Your own pharmacy might offer a service, but if not, you should refer to the most convenient service for the patient.
The format of smoking cessation services may differ from CCG to CCG, but it is likely to have the following components:
•Make sure the client is motivated to quit.
•Set a quit date.
•Explain the withdrawal syndrome.
•Assess the level of tobacco dependence.
•Measure the carbon monoxide level in expired breath.
•Discuss use of pharmacotherapy and arrange a supply.
Pharmacotherapy is an effective element of successful quitting attempts as an adjunct
to behavioural support. Nicotine replacement therapy (NRT), bupropion and varenicline are the three medicines licensed in the UK as aids to smoking cessation and on the recommendation of the National Institute for Health and Clinical Excellence (NICE), their use should be considered as part of a smoking cessation attempt.8
Eight formulations of NRT are currently licensed in the UK:
All are P or GSL medicines. NRT formulations are available on NHS prescription and are normally included in a patient group direction (PGD) to allow pharmacies to supply them and get paid for supply within a smoking cessation service. There is little evidence that any one NRT formulation is superior to another. However, patient preference is important, as they are more likely to comply with the regimen if happy with the form of NRT. There is good evidence that the use of a combination of NRT – for example, gum and patch – is more effective than using a single product.9
There is little prescribing of bupropion at the current time. Bupropion (Zyban) is licensed to control nicotine cravings as an adjunct to smoking cessation. Bupropion is licensed as an atypical antidepressant in the US. The precise mode of action is unknown, but it is thought to be linked to brain neurotransmitter levels and receptor sensitivity, particularly dopamine levels.
Varenicline is a selective nicotine receptor partial-agonist used as an aid in smoking cessation. Varenicline binds with high affinity and selectivity at the α4β2 neuronal nicotinic acetylcholine receptors, where it acts as a partial agonist – a compound that has both agonist activity, with lower intrinsic efficacy than nicotine, and antagonist activities in the presence of nicotine.
Evidence suggests that a 12-week course of the drug increases continuous abstinence rates at one year compared with placebo and bupropion. Results of a trial comparing varenicline with nicotine patch10 established that abstinence from smoking was greater. Craving, withdrawal symptoms and smoking satisfaction were less at the end of treatment for varenicline than with transdermal NRT. NICE guidance states that varenilcine is recommended as an adjunct to smoking cessation for smokers who have expressed a desire to quit smoking and should normally be prescribed as part of a programme of behavioural support.
The Eagle Study,11 published in January 2016, and a 2013 Cochrane Review12 offer the best comparators of pharmacotherapies with regards to safety and efficacy. The most effective therapy is combination NRT, for example, a patch and gum, or indeed any combination of two NRT formulations. Second to this is varenicline as monotherapy, then patch and bupropione, next NRT as monotherapy, and lastly bupropione as monotherapy.
Safety has always been a bigger issue for varenicline and buproprion compared with NRT. The Eagle study has removed concerns about varenicline’s psychiatric side-effects. This robust study did not show any difference between moderate and serious psychiatric adverse reactions for veranicline compared with placebo.
Where e-cigarettes may explain the reduced number of smokers enrolling in cessation services, they are likely to be more associated with harm reduction strategies than cessations. At best, the use of e-cigarettes offers the potential for a significant reduction in the public health burden of tobacco use; a 25% reduction in CHD, 40% reduction in cancers, 80% reduction in lung cancers and a 90% reduction in COPD prevalence.
This will only happen if all tobacco smokers switch completely to the use of e-cigarettes, which is highly unlikely. Nevertheless, even if only 10% of this was delivered, there would be a potentially impressive public health gain.
There is little evidence that e-cigarettes are a ‘gateway’ to cigarettes for the young. However, in the absence of a formal regulatory framework, the contents and performance of e-cigarettes cannot be guaranteed. In my opinion, it is for this reason that pharmacists should not sell e-cigarettes. MHRA had promised regulation by the end of 2016 but this was not delivered.
A large cross-sectional study13 showed that e-cigarettes were more successful than licensed NRT or unaided cessation attempts. This data was taken from the Smoking Toolkit Study at Imperial College, London and involved a telephone survey of smokers in England. This paper looked at unsupported attempts comparing NRT, e-cigarettes and going ‘cold turkey’. However, a publication from the same database published in the same journal in December 2013 showed a licensed stop-smoking medication plus NHS support was 325% better than going cold turkey.14 Although e-cigarettes might be helpful in unaided stopping attempts, by far the most successful quitting happens when a motivated smoker enrols in a smoking cessation service and is supplied with pharmacotherapy.
It is time for all pharmacies to redouble their efforts in smoking cessation. It is not sufficient to wait until you are approached by a motivated quitter. Asking customers about smoking offers the opportunity for a brief intervention that will eventually lead to a quitting attempt.
Dr Terry Maguire is a pharmacy contractor in Belfast. He played a key role in the development and implementation of the UK national smoking cessation service
1 Maguire T et al. Addiction 2001;96,325-31
2 McElnay J et al. Dis Manage Health Outcomes 2000;8:147-58
3 Smoking Cessation Annual Return 2015 DHSSPS NI.
4 ONS. Adult smoking habits in Great Britain. Statistical Bulletin. 25 Nov. 2014
5 Smoking statistics: Illness & death. ASH Fact sheet November 2014
6 Doll R et al. Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ 2004;328:1519
7 Miller WR, Rollnick S. Motivational Interviewing (Second Edition) New York, Guilford Press; 2002.
8 NICE guidance on NRT in smoking cessation.
9 Combination Therapy Tommison??
10 DTB Varenicline for use in smoking cessationVol 45 No5 May 2008
11 Anthenelli R et al. Lancet on line (2016) S0140-6736(16) 30294-X
12 Cahill K et al. Cochrane Database of systematic reviews (2013) DOI pub 2
13 Brown, J et al May 2014 Addiction
14 Kotz, et al; Addiction (Dec 2013)??incomplete?