1 Min In Clinical
Let’s get clinical. Follow the links below to find out more about the latest clinical insight in community pharmacy.
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Record learning outcomes
Learning objectives
After reading this feature you should be able to:
- Discuss the recommendations made in the Khan Review
- Summarise the NICE guidance updated this summer
- Recognise the role pharmacy can play in helping reach the smoke-free 2030 target.
Introduction
“Most people don’t see smoking as a problem anymore. As a nation, we’ve moved on… Is this really still an issue?”
These are the opening words of the Khan Review, an independent report commissioned by England’s Department of Health and Social Care to gauge how well the Government is doing in meeting its ambition for the nation to become smoke-free by 2030. This aim is defined as achieving a smoking rate of 5 per cent or less, as this is deemed to be the tipping point at which smoking is no longer viewed as a societal norm.
When the smoking ban was introduced in England 15 years ago, it drew a significant line in the sand. Smoking prevalence dropped from 24 per cent in 2005 to 21 per cent in 2007 when the legislation came into force, and in 2019 – the most recent year for which data is available – only 13.5 per cent of the population (6 million people) smoked, the lowest it has ever been.
Behind the headline data, however, lie some hard truths:
- Smoking remains the single biggest cause of preventable illness and death, killing around 64,000 people each year
- Smokers are 36 per cent more likely to be admitted to hospital and need social care 10 years earlier than would otherwise be the case
- Smoking is estimated to cost society around £17bn, £2.4bn of which is absorbed by the NHS.
“It is extraordinary really. If we had the same rate of deaths from terrorism, people would be jumping up and down and demanding emergency measures,” says Robert West, emeritus professor in behavioural science and health at University College London. “Yet when it comes to smoking, we seem to regard such figures as acceptable. The Khan Review could have been just window dressing, but it wasn’t. It set out a strong and very realistic agenda which, if followed, would cut the death rate by around 1,000 per year each year for the next 10 to 15 years.”
Briefly, the Khan Review made the following recommendations:
- Put £125m a year into high quality and easily accessible support for smokers, £70m of which should be ring-fenced for smoking cessation services. This could be funded by introducing a tobacco industry levy or generating additional corporation tax
- Abolish duty-free tobacco products, tackle illicit tobacco, and introduce more smoke-free places
- Increase the age at which tobacco products can be purchased by one year every year to stop young people starting smoking
- Rethink the appearance of cigarettes and their packaging to reduce the appeal
- Promote vaping as an effective tool to help people quit smoking tobacco
- Ban vaping packaging and descriptions that make it appealing to younger audiences
- Improve prevention by offering smokers quit advice and support every time they access health services, including through pharmacies, opticians, dentists and midwives as well as GP practices and hospitals, and provide additional support for the most deprived areas and groups disproportionately impacted by smoking
- Check progress in 2026, 2030 and 2035 so proposals can be refined and spends adjusted to match changing needs.
The full Khan review can be accessed here.
Sign of the times
The smoking ban in 2007 was a huge step forward but was just one of a series of measures introduced to address smoking over the years...
Timeline of events
Royal College of Physicians publishes a damning report laying bare the health harms wreaked by smoking. Tobacco industry agrees to implement a code to make cigarette advertisements less glamorous.
Cigarette advertising on television banned
Health Education Council launches first anti-smoking campaign
Tobacco industry and Government draw up voluntary agreement for health warnings on cigarette packaging. London Transport bans smoking on single decker buses. It took another 20 years for the ban to apply to double deckers
Tobacco industry agrees to extend health warnings to cinema adverts and those sent through the post, as well as brand advertisements at sporting events.
Adult smoking rate stands at 45%. Tobacco advertising standards strengthened as the Advertising Standards Authority takes over monitoring the Code of Advertising Practice. This included banning ads from screenings of U-rated films
Tobacco advertising on radio banned. Tyne and Wear bans smoking on all public transport. Central Middlesex Hospital becomes the first hospital to introduce a smoking policy.
Adult smoking rate stands at 34.5 per cent.
Smoking banned on London Underground trains.
National No Smoking Day launched.
Tobacco ads banned in cinemas and major women’s magazines.
...continued
Liverpool Council becomes the first to have power to prosecute retailers who sell cigarettes to children.
Health warnings legally required for the first time on tobacco packaging.
Legislation tightened to make all tobacco sales to under-16s illegal. Smoking included for first time on death certificates.
The Department of Health announces that NRT products are to be made more widely available by prescription and general sale.
Adult smoking rate at 26 per cent. Ban on all tobacco advertising passed by Parliament.
Smoking ban comes into effect in England and the legal age for purchasing tobacco is raised from 16 to 18 years
Adult smoking rate at 17.2 per cent. All retailers banned from displaying tobacco products at counters.
Smoking banned in cars carrying children.
Standardised (plain) packaging regulations passed by Parliament.
What does NICE say?
NICE guidance on preventing uptake, promoting quitting and treating dependence on smoking was published in 2021 and updated in the summer of 2022. The relevant recommendations for pharmacy teams include:
- Smoking and second-hand smoke cause many harms and awareness of this needs to be raised
- Smokers can reduce the risk of illness and death to themselves and others by using one or more medically licensed nicotine-containing products, as a partial or complete substitute for tobacco, either temporarily or long-term
- Compared to tobacco, such products contain less nicotine, are less addictive, and are therefore less risky, but need to be used correctly to control cravings and prevent compensatory smoking. They can be used for as long as needed to stop someone going back to their previous level of smoking
- Stopping smoking in one go is the best approach, but a harm reduction method should be encouraged in all smokers; the health benefits of reducing the amount smoked are unclear but increases the likelihood of stopping smoking in the future
- Behavioural harm reduction measures can help, such as increasing the time interval between cigarettes, delaying the first cigarette of the day, or choosing specific periods when the individual doesn’t smoke
- Support and advice for smokers should be individualised and include talking about ways to prevent a relapse to smoking; for example, by identifying coping strategies and reiterating the
benefits of stopping or cutting down (such as the positive impact on daily activities) as a way of staying motivated - All adult smokers should be able to access behavioural interventions such as support (group and individual) and brief advice, medicinally licensed products (including bupropion, NRT and varenicline), and nicotine-containing e-cigarettes
- NRT with behavioural support, but not other pharmacological measures, should be offered to smokers aged 12-17 years with tobacco dependence. This approach is also appropriate for pregnant women, with additional incentives considered due to the high level of risk posed by foetal exposure to tobacco smoke
- Age-appropriate advice on combining stop smoking options should be supplied
- Clear and up-to-date information on e-cigarettes should be given to adults interested in using them to stop smoking. This includes highlighting that e-cigarettes are likely to be substantially less harmful than smoking but are not licensed medicines and the long-term effects are unknown
- Medicines that are affected by smoking or stopping smoking – such as clozapine, olanzapine, theophylline and warfarin – should be monitored for efficacy and side-effects.
Harnessing vaping
Pharmacy has had an uncertain relationship with vaping ever since electronic cigarettes appeared in the UK just over a decade ago. A lot of this uncertainty revolves around safety.
“We advocate the precautionary principle approach to minimise exposure to e-cigarette vapour until more safety data becomes available,” says Royal Pharmaceutical Society chief scientist Parastou Donyai.
“While e-cigarettes are considered likely to be significantly less harmful than smoking tobacco, more research is required on the long-term effects of inhalation of e-cigarette constituents to establish their absolute risk.
“Although many of the substances used in e-cigarettes may be considered safe for oral ingestion, little is known about the long-term effects of inhalation, or how the heating process can alter their chemical composition. The full picture of health risks from smoking tobacco products did not emerge until decades after cigarettes were first introduced.”
Professor Donyai says that “pharmacies should offer a full range of smoking cessation options to help smokers quit their addiction to nicotine”, but the associated statements have left many in the sector feeling conflicted about where they stand on vaping as a quit tool.
“Pharmacy didn’t deal with e-cigarettes very well when they first appeared and that led to them going into unregulated premises, such as vape shops, instead of coming under a healthcare framework,” says Ade Williams, superintendent pharmacist and clinical lead at Bristol’s Bedminster Pharmacy.
Hung up
“We got hung up on the potential harms instead of looking at the potential good, which was – and is – that vaping offers people an alternative way of accessing nicotine to smoking, and we know smoking to be extremely harmful.
“By not engaging with e-cigarettes early on, we missed the opportunity not only to help smokers in this way, but also to shape the way that the vaping industry unfolded in terms of putting in safeguards, regulations and clear guidance.
“Now people are more likely to go into a vape shop than a pharmacy for e-cigarettes, and the staff there will certainly encourage people to move from smoking to vaping because it is a commercial opportunity, not because they are concerned about their health.
“These places aren’t offering the same level of care, advice and support smokers can get from pharmacists and their staff. Even though there is now a lot of evidence supporting vaping as a stop smoking tool, and that is reflected in the NICE guidance which we should be following [see panel], the offer still isn’t clear to the profession
– so how can it be to the public?”
OHID verdict
Anyone left in any doubt about vaping would do well to look at the evidence summary published by the Office for Health Improvement and Disparities.
The OHID report, the eighth in a series aiming to track the growing evidence base for vaping in order to inform policy and regulation, opens with the line: “Alternative nicotine delivery devices such as vaping products can play a vital role in reducing the huge health burden caused by cigarette smoking.”
As director general of the UK Vaping Industry Association (UKVIA), John Dunne is an advocate of vaping but stresses that there is a technique to using the products which users need to be shown. “To get the best experience from their device, people need to be counselled on the difference in technique between smoking and vaping,” he says. “They need to inhale for two to two-and-a-half seconds to get the device to produce the vapour and deliver the nicotine, compared to just one second with a cigarette.
“And then it is important to get the strength right – most come in 18-20mg and 10mg, so most regular smokers would need to start at the higher level, then reduce down over time. A disposable device is a good starting point, as these are relatively inexpensive, easy to use and come in a range of flavours, but if they feel vaping is a good fit for them, they are likely to want to move onto a pod or open tank system as they last longer and are more cost-effective.”
Healthcare professionals should not wait for an e-cigarette that is a licensed medical product, says Dunne. “A product that is going through licensing won’t emerge ... for four or five years but is likely to become obsolete within six months of being submitted because the technology is moving so fast. In my opinion, it is commercially risky for manufacturers to go down this route, especially when good devices are already commercially available.”
That said, it is vital that the risks – both known and unknown – are spelled out to users, as part of wider efforts to stop vaping replacing smoking as a societal norm. Vaping is rising among young people. Action on Smoking and Health (ASH) data showed an increase in 11 to 17-year-olds from 4 per cent in 2020 to 7 per cent in 2022.
Wrong restrictions
John Dunne also thinks that current advertising restrictions aren’t finding the right balance. “E-cigarettes can’t be promoted on TV, radio or in newspapers – the channels used most by the older demographic that is looking to give up smoking, so that’s a missed public health opportunity.
“On the flip side, ‘soft advertising’ such as influencers on social media platforms such as TikTok with poor age gating are showing vapes to a young audience, and this isn’t well regulated or enforced at all. What would work well would be pre-approved switching messages that the industry could use across all media.”
Government inaction doesn’t surprise UCL’s Professor West. “Vaping has made a significant dent in smoking rates, so it definitely has a role, but it isn’t enough on its own. The Khan Review describes other measures that would probably make an even bigger contribution – increasing the age of sale or raising the price of cigarettes, for example – and shows that the Government needs a comprehensive strategy, including regulations that are targeted and matched to problems as they arise. At the moment, there doesn’t seem any sign that England’s government, at least, is going to do that.”
There is significant public momentum to do more. An ASH report published this summer showed that over two-thirds of people supported the inclusion of information on quitting in cigarette packets and the printing of health warnings on cigarettes themselves. In fact, all the recommendations made in the Khan Review gained majority support, regardless of socio-economic status, political allegiance or even smoking status.
It is vital to capitalise on this impetus. As Javed Khan says in his review: “Without further action, England will miss the smoke-free 2030 target by at least seven years and the poorest areas in society will not meet it until 2044… if we do nothing different, by 2030 over half a million more people in England will have died from smoking.”
While societal change will, for the most part, be driven by government policy, those on the ground – including pharmacists and their teams – still have a valuable role to play in supporting individuals to become smoke-free.
Key facts
- Smoking remains the single biggest cause of preventable illness and death
- A major report says vaping products can play a vital role in reducing the huge health burden caused by cigarette smoking
- Vaping is rising among young people
Clinical
In Clinical
Let’s get clinical. Follow the links below to find out more about the latest clinical insight in community pharmacy.