8 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
Key facts
- Smoking rates are falling in the UK, but there is still progress to be made
- Community pharmacies are ideally placed to offer smoking cessation advice and therapies to customers of all ages
- Vapes have become a popular stop smoking aid, but single use vapes are to be banned.
Learning objectives
After reading this feature you should be able to:
- Understand the benefits of offering an individualised, patient-centred approach to stopping smoking
- Be familiar with the different types of smoking cessation therapies available
- Be able to provide advice to customers and support them to quit smoking.
Smoking in the UK has fallen to a record low, with latest ONS figures reporting that 11.6 per cent of the adult population (around 6 million people) are smokers.1 The greatest progress has been made in the youngest age groups, with smoking falling from 25.7 per cent in 2011 to 9.8 per cent in 2023 among 18 to 24-year-olds.
Public health charity Action on Smoking and Health (ASH) notes that the chances of a person being a smoker have been going down ever since records began in 1974. However, while smoking rates may be falling, pharmacists and their teams “need to be mindful that there is still work to be done”, says Darush Attar-Zadeh, pharmacist and respiratory clinical fellow at North West London Integrated Care Board.
Attar-Zadeh says that smoking rates among people with mental health issues and those living in the more deprived parts of society are still high.
Research published last month in BMC Medicine noted that casual, non-daily smokers – many of whom are younger adults – often minimise the health effects of smoking and are less motivated to quit.2 “It is important to understand more about non-daily smoking in England to inform interventions to further reduce smoking in the population, including public health messaging and provision of cessation support,” the study says.
Royal Pharmaceutical Society (RPS) president Claire Anderson says that supporting people to quit smoking remains one of the “most important interventions” pharmacy teams can provide to improve public health.
However, National Pharmacy Association chief executive Paul Rees has criticised central government cuts to local public health budgets, which have led to the decommissioning of “vital” stop smoking services in community pharmacies. “If we are to turbo charge this reduction in the rates of smoking, we need to reverse these cuts and invest in these services in our community pharmacies,” he said.
“Pharmacies should also be able to provide a nationally commissioned walk-in smoking cessation service, which would end the postcode lottery for accessing support.”
Claire Anderson says the RPS would like the Government to invest in more accessible services in England, similar to the funded programmes in Wales and Scotland. “With adequate resource in place,” she says, “community pharmacies are well placed to provide effective and well received smoking cessation support.”
Opportunities to help
While pharmacy-based stop smoking services may be under-funded, the contractual framework still offers opportunities to help patients quit. “The New Medicine Service in England, for example, includes the provision of opportunistic healthy living advice,” says Lila Thakerar, superintendent pharmacist at Shaftesbury Pharmacy in Harrow, Greater London.
Attar-Zadeh adds that if pharmacies are Healthy Living Pharmacies, and/or doing work around health promotion, or when people are purchasing OTC products or bringing in prescriptions for certain medicines, “there will be opportunities to raise the subject of smoking”.
When conducting asthma reviews or counselling patients with COPD, for instance, there is an opportunity to approach the topic of stopping smoking, if a patient is a smoker. “Pharmacists could talk about risk factors and smoking, for example,” Attar-Zadeh says.
He sees activities that aim to support people to stop tobacco smoking not as smoking cessation but rather as “treating tobacco dependence”. For many years, “smoking has been seen as a lifestyle choice – that people choose to smoke”, he says. “But we know this is a powerful addiction.”
Ade Williams, pharmacist at Bedminster Pharmacy in Bristol, supports a harm reduction approach, as recommended by NICE.3 He says that many smokers will try to quit but are unable to give up completely. A harm reduction approach is about reducing smoking-related harm and can include cutting down before stopping smoking, recognising that it is better to smoke, say, three cigarettes a day than a whole pack, he points out.
First ever WHO guideline
Earlier this year, the World Health Organization (WHO) released its first clinical guideline for tobacco cessation in adults.4 This recommends a set of tobacco cessation interventions, including behavioural support delivered by healthcare providers, digital cessation interventions and pharmacological treatments.
Combining pharmacotherapy with behavioural interventions significantly increases quitting success rates, WHO says. The organisation’s recommendations include nicotine replacement therapy (NRT) and cytisine as effective treatments for tobacco cessation.
It also recommends behavioural interventions, including brief health worker counselling (30 seconds to three minutes) offered routinely in healthcare settings, alongside more intensive behavioural support (individual, group or phone counselling) for interested users. Digital interventions such as text messaging, smartphone apps and internet programs can be used as adjuncts or self-management tools.
NRT patches are easy to use and can form part of a combination therapy approach.
Tailored approach
Claire Anderson recommends that pharmacists should tailor their advice based on the patient’s health profile, nicotine dependency, preferences and long-term goals. “Research shows that smokers are more likely to quit with one-to-one behavioural support and regular contact with an adviser compared to those who have no behavioural support,” she says.
Attar-Zadeh agrees. “If we can offer patients advice and treatment together, they are more likely to stop smoking,” he says. Support and advice can be given in the pharmacy or via telephone, text or online. Weekly support from a well-trained adviser over six weeks “would be the gold standard”, he adds.
During a first advice session, which should take around 30 minutes, pharmacists should look at the person’s motivation to stop smoking, how many cigarettes they smoke a day, as well as past quit attempts and any learnings that can be taken from those, says Attar-Zadeh.
Pharmacists should also discuss the person’s experience of nicotine withdrawal and look at ways to manage that, going through the options available, including medication. A quit date that appeals to the individual should then be set.
Pharmacists should have a more active role
The International Pharmaceutical Federation (FIP) wants pharmacists to take a more active role in preventing people from starting to use tobacco. In an updated policy statement, FIP also urges pharmaceutical organisations to support tobacco cessation services in pharmacies by developing guidelines and implementation tools.
The statement makes recommendations for pharmacists and stakeholders including educators, regulatory agencies and policy- makers, and calls on governments to “ensure remuneration for cessation services”.
To increase public engagement, FIP encourages pharmacists to participate in awareness campaigns and use digital and social media to highlight the risks of tobacco and nicotine use as well as exposure to second-hand and third-hand smoke.
It says community pharmacists should also promote cessation interventions delivered through digital technologies, such as mobile-optimised websites, text messaging services and apps.
FIP makes commitments itself, including advocating for reform of reimbursement systems for cessation medicines and services, and supporting the empowerment of pharmacists to act as champions and advocates in the fight against tobacco and nicotine dependence.
‘The role of the pharmacist in establishing a future free from tobacco and nicotine dependence’ is available online at: fip.org/file/6049
Cytisine
The smoking cessation drug cytisine (also known as cytisinicline) has been available in the UK since January this year. Claire Anderson believes it offers a valuable new option for those struggling to quit. “Pharmacists should incorporate this into the available treatments and continue to work closely with patients to determine the most suitable cessation method,” she says. “As with all methods, combining cytisinicline with behavioural support will improve the chances of long-term success.”
A Cochrane analysis of more than 150,000 smokers reveals that cytisine is one of three stop smoking aids most likely to help people quit smoking – the others being nicotine e-cigarettes, and varenicline.5 Pfizer announced a wholesale and pharmacy recall of Champix (varenicline) in October 2021, after all Champix batches were found to contain above-acceptable levels of N-nitroso-varenicline, a ‘probable human carcinogen’. However, nitrosamine-compliant generic varenicline is now available in the UK via Thistle Pharma.
Cytisine works in a similar way to varenicline, reducing the urge to smoke by attaching to some of the same neuronal receptors in the brain as nicotine. Its side-effects (gastric symptoms and sleep disturbance) are similar to those of varenicline but, according to the National Centre for Smoking Cessation and Training (NCSCT), are less common. “The tablet does release some nicotine, but nothing like the high levels you get from smoking,” says Attar-Zadeh. He adds that it is not a “magic pill” and that individuals still need to be motivated to quit.
The standard course of cytisine treatment is currently 25 days. “Using it for up to 12 weeks is probably more effective and it appears to be roughly as effective as varenicline when taken for the same duration (12 weeks),” says the NCSCT. However, it adds that even with 25 days’ dosing, “evidence suggests that it is as effective as nicotine replacement therapy”.6
Nicotine replacement therapy
- Combination therapy – combining a patch with a faster acting product like gum or mouth spray – has been shown to be more effective in helping smokers to quit than using just one form of NRT.7 “A long-acting patch will give people steady nicotine throughout the day and then gum or an inhalator can be used for breakthrough nicotine cravings,” says Attar-Zadeh. “It is easily available and there are minimal side-effects.” He adds that pharmacists need to be able to diagnose a person’s nicotine dependency level to ensure they have the right strength of product. For example, if someone has a high dependency and smokes more than 10 cigarettes a day, they will need a higher strength patch or gum.
- Patches are “very convenient to use”, says Lila Thakerar, and can be hidden under clothing. However, some users may have an allergic reaction to patch adhesive or the patch may come off, she says. To help avoid this, people should avoid using moisturisers or rich creams on the upper arm or wherever the patch is to be placed, advises Thakerar. She notes that patients can be weaned off the patches month by month, staying on the lowest strength until they no longer have the urge to smoke. Another potential downside of NRT patches is that while they help to control nicotine cravings, they don’t address the behavioural aspect of smoking, says Ade Williams.
- Inhalators can help with this as they mimic the hand-to-mouth habit of smoking. They deliver nicotine through the lining of the mouth and throat, and work faster than patches, gum and lozenges. Nicotine inhalators are an option for people who are not able to use patches or who don’t like to chew gum, says Thakerar.
- Gums and lozenges are “convenient and discreet” methods of helping people to quit smoking, says Williams. Nicotine is delivered in small doses so these products can be used alongside other forms of NRT or towards the end of a person’s smoking cessation journey, he says.
Vaping
There is ongoing discussion and debate about vaping with e-cigarettes and how it fits into the smoking cessation armoury.
This August, an ASH survey found that vapes have been the most popular aid to quitting among those who have successfully stopped smoking in the last five years.
The survey found that around 5.6 million UK adults currently vape, with 53 per cent being ex-smokers. It also found that 32 per cent of vapers are still smoking, while 8 per cent have never smoked. Among those who have stopped smoking in the last five years, just over half said they used a vape to quit, equating to 2.7 million people. Of these, 64 per cent said they were still vaping while 29 per cent had quit vaping as well.8
Claire Anderson says e-cigarettes may be “a useful tool for smoking cessation” for some patients, particularly those who have struggled with other methods. “However, it is important to inform patients that e-cigarettes are not risk free,” she says. “Until more is known about their potential risks, pharmacists should continue to provide evidence-based, personalised advice to support patients in their journey to quit smoking entirely.”
While Attar-Zadeh is positive about vaping as an aid to stopping smoking, he describes as “problematic” their sale via newsagents and supermarkets, which is done without training or advice and makes these products easily accessible to children and young people. He also believes young people may be resorting more to vaping to help “manage the stresses of life”.
Healthcare professionals need to acknowledge the evidence that vaping has “use and value”, says Williams. When supporting people to quit smoking, he and his team talk about the patient’s goals and aims. “We let patients know vaping is an option to give up smoking,” he says. “We tell them about the evidence – that it is a less harmful, but not a ‘no harm’ option. And we lead them to realise that switching to vapes is not the same as freedom from nicotine.”
Thakerar advises: “Customers should be made aware that vaping products come in different strengths of nicotine. If they are going through withdrawal, they may need to start on a higher dose of nicotine.” While vaping may have its advantages, “vapes haven’t been around long enough for anyone to analyse and confirm that they are totally harmless”, she emphasises.
Pharmacists looking to stock vapes can visit the MHRA website to check its list of products that meet the requirements for supply in the UK, says Attar-Zadeh. Customers should be advised to dispose of vapes safely as they have batteries which pose a fire risk, adds Thakerar.
Single use vapes to be banned
Subject to parliamentary approval, single use vapes will be banned in the UK from June 2025. Businesses have until then to sell any stock they hold.
“Single use vapes are a strong contender for being the most environmentally wasteful, damaging
and dangerous consumer product ever made,” says Scott Butler of pro-recycling organisation Material Focus. Research carried out by Material Focus has found that the number of disposable vapes being thrown away in the UK soared to nearly 5 million a week in 2023 – almost four times higher than in 2022. These vapes contain valuable materials like lithium and copper that could instead be powering nearly 5,000 electric vehicles, says the organisation.
From a health point of view, it is known that single use vapes are attractive to children. “It is deeply worrying that a quarter of 11 to 15 year-olds used a vape last year,” says minister for public health and prevention Andrew Gwynne. “Banning disposable vapes will not only protect the environment but, importantly, reduce the appeal of vapes to children and keep them out of the hands of vulnerable young people.”
Smoke-free generation?
Although the Conservative Government’s Tobacco and Vapes Bill, which advocated a ban on the sale of tobacco to anyone born on or after January 1, 2009, was never passed, the Labour Government says it plans to table its own version.
Currently, no countries have laws making it illegal to sell tobacco to young people. New Zealand’s groundbreaking legislation to ban the sale of tobacco products to anyone born in or after 2009 was repealed earlier this year. But according to a study published last month in The Lancet Public Health, an estimated 1.2 million lung cancer deaths could be prevented in 185 countries if smoking was eliminated among people born between 2006 and 2010.9 This equates to 40.2 per cent of the total lung cancer deaths expected to occur in this birth cohort by 2095.
In the meantime, Attar-Zadeh says pharmacists should “remember to offer brief advice” about stopping smoking. “It takes less than 30 seconds to ‘ask, advise and act’,” he says.
Supporting people to stop smoking is about “making every contact count”, says Thakerar. Every time there is a consultation – whether over the phone or face-to-face – advice about giving up smoking, if relevant, should be brought into any conversation, she says.
Williams adds that pharmacists need to be “more empathetic” with patients who are looking to quit smoking and should ensure the stop smoking support they give is tailored to the needs of individuals. “We need to clearly understand this to help them to stop,” he says.
Stop smoking resources
- Department of Health and Social Care (DHSC): Better Health Quit Smoking: campaignresources.dhsc.gov.uk/campaigns/better-health-quit-smoking
- NHS England: NHS Community Pharmacy Smoking Cessation Service: england.nhs.uk/primary-care/pharmacy/pharmacy- services/nhs-community-pharmacy-smoking-cessation-
service - Royal Pharmaceutical Society (RPS) e-cigarettes policy: rpharms.com/recognition/all-our-campaigns/policy-a-z/ e-cigarettes
- WHO clinical treatment guideline for tobacco cessation in adults: who.int/publications/i/item/9789240096431
References
- ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2023#main-points
- Jackson SE, Brown J, Shahab L et al. Trends in non-daily cigarette smoking in England, 2006-2024. BMC Med 22, 426 (2024). https://doi.org/10.1186/s12916-024-03635-1
- cks.nice.org.uk/topics/smoking-cessation/management/harm-reduction
- who.int/publications/i/item/9789240096431
- cochrane.org/news/e-cigarettes-varenicline-and-cytisine-are-most-effective-stop-smoking-aids-analysis-over-150000
- ncsct.co.uk/library/view/pdf/Cytisine.pdf
- ncsct.co.uk/library/view/pdf/Combination%20NRT%202021.pdf
- ash.org.uk/uploads/Use-of-vapes-among-adults-in-Great-Britain-2024.pdf?v=1723194891
- thelancet.com/journals/lanpub/article/PIIS2468-2667(24)00166-X/fulltext
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In Clinical
Let’s get clinical. Follow the links below to find out more about the latest clinical insight in community pharmacy.