Smoking kills nearly 80,000 people a year in England, 10,000 in Scotland, more than 5,000 in Wales and over 2,000 in Northern Ireland. In 2017/2018 it was responsible for almost 485,000 hospital admissions – an increase of 2 per cent on the previous year 

Smoking rates are falling across the UK but for those people who still smoke, it remains the leading cause of early death, the main risk to their health and a significant cause of inequalities. In the year 2000 more than one in four adults in England smoked but by last year this had fallen to fewer than one in six, according to an All-Party Parliamentary Group on Smoking and Health document published in February this year.¹ 

Since the last Tobacco Control Plan for England was published in 2011, smoking rates in England have fallen by a quarter, from 19.8 to 14.9 per cent in 2017, bringing the estimated number of smokers down to 6.1 million. 

Smoking rates in children have also fallen. After two decades of little change, between 2000 and 2016 regular smoking by 15-year-olds fell from 23 to 7 per cent, a decline of more than two-thirds in the proportion of children of that age who smoke. 

However, the national picture hides significant variations. 

• Around one in four (25.5 per cent) of people in routine and manual occupations smoke compared with just one in 10 (10.2 per cent) in managerial and professional occupations
• Half the difference in life expectancy between the richest and poorest in society is thought to be due to smoking
• More men (16.5 per cent) than women (13.3 per cent) smoke
• More younger people (19.9 per cent of 16-24 year-olds, 21.9 per cent of 24-34 year-olds, 21.1 per cent of 35-44 year-olds) smoke compared with older people (8.3 per cent over 60 years). 

The Government’s Tobacco Control Plan for England sets out an ambition to achieve a smoke-free generation, meaning a smoking prevalence of 5 per cent of the population or less, by 2022. Within this, there are several elements: 

• To reduce adult smoking prevalence (from 15.5 to 12 per cent or less) 
• To reduce the prevalence of 15-year-olds smoking from 8 to 3 per cent or less 
• To reduce the inequality gap in smoking across socio-economic groups 
• To reduce the prevalence of smoking in pregnancy from 10.8 to 6 per cent 
• To make sure that smokers with mental ill health are given the same priority as those with physical ill health.

Office for National Statistics (ONS) estimates from the Opinions and Lifestyle Survey suggest that in Great Britain in 2018, 60.8 per cent of people aged 16 years and above who currently smoked wanted to quit, while 59.5 per cent of those who have ever smoked had quit. 

Data from NHS Stop Smoking Services in England indicate that from April 2018 to March 2019, 236,175 people had set a quit date with the number of successful quitters (self-reported) being 123,800 (52.4 per cent). This is a fall since 2014/2015 when the respective figures were 450,582 and 229,681 people (51 per cent). Anecdotal evidence suggests this may be due to an increase in people using e-cigarettes to help them stop smoking. 

Smoking cessation services 

Stop smoking services, including behavioural support and the provision of nicotine replacement therapy (NRT), or varenicline or bupropion as appropriate, are the most effective way to quit. 

A 2016 meta-analysis published in BMJ Open² found that behavioural support and/or NRT delivered in a pharmacy is, on average, two-and-a-half times as effective as having no support or pharmacotherapy alone and can be up to four-and-a-half times as effective. Using willpower alone is the least effective method.

NHS stop smoking services are co-ordinated centrally in each of the four UK constituent countries: 

• NHS Smokefree in England 
• NHS Inform in Scotland 
• Help Me Quit in Wales 
• Stop Smoking and Helping You Quit in Northern Ireland.

Smoking cessation services include, for example, local stop smoking groups or one-to-one sessions, telephone consultations, or a community pharmacy or hospital-based service.

In recent years, cuts in public spending have impacted on budgets for smoking cessation services. According to the APPG report, in England between 2014/15 and 2017/18, local authority spending on tobacco control and stop smoking services fell by £41.3m (30 per cent). This provides opportunities for pharmacy to be proactive in this area.

Community pharmacy services

Many areas of the UK have commissioned community pharmacy-based smoking cessation services. These include:

• Voucher services 

• Nicotine replacement therapy: A pharmacist supplies a NRT product on receiving a voucher from an individual through the local stop smoking service. Pharmacy teams ensure that the NRT product is appropriate to the person’s wishes, lifestyle and smoking status. The local stop smoking service provides ongoing support
• Varenicline or bupropion: Pharmacists can supply either of these medications under a patient group direction when provided with a voucher from their local stop smoking service. The pharmacist checks whether the medication is appropriate for the person. Varenicline and bupropion are prescription-only medicines and should not be offered to those under 18 years of age or women who are pregnant or breastfeeding. The local stop smoking service will continue to provide ongoing support.

• Stop smoking services provided entirely within the pharmacy 

Pharmacy staff are trained as stop smoking advisers to individuals or groups (e.g. providing six to 12 weekly sessions with monitoring). NRT, or varenicline or bupropion under a PGD, can be supplied depending on suitability for the client.

Brief advice

Providing brief advice means proactively raising awareness in a non-threatening manner by asking indirect questions and assessing a person’s willingness to engage in further discussions about smoking. 

Community pharmacists have unique opportunities to provide brief advice to patients outside of smoking cessation services, including when making OTC medicine purchases or during local or national campaigns (e.g. No Smoking Day or Stoptober). Smoking status can be recorded on a patient’s medication record and he or she can be asked about their smoking status at least once a year. 

Providing brief advice should take no more than three minutes. If the response is positive, this could lead to a specific brief intervention. If the person is not keen to engage, let them know they can come back at any time and record the outcome of the conversation.

Brief interventions

A brief smoking cessation intervention can take about 30 minutes. Key elements can include:³

• Giving simple opportunistic advice to change
• Assessing a person’s commitment to change
• Supplying written information
• Offering pharmacotherapy and/or behavioural support
• Providing specialist support if suitably trained or signposting to specialist support
• Offering a follow-up appointment if appropriate
• Recording the outcome of the conversation.

Carbon monoxide testing can be beneficial in assessing a smoker’s status providing a pre-quit level and a post-quit level four to 12 weeks later. The test is quick and non-invasive and can be a motivational tool for patients as readings start to decrease over a relatively short period of time. 

It is important to explain to patients what the test entails, what it measures and what changes they can expect after four weeks on a smoking cessation plan (see case study). 

It is also worth noting that lung function testing (spirometry) should be undertaken by all chronic obstructive pulmonary disease (COPD) patients who smoke (smoking is the commonest cause of COPD). Spirometers should be available from the local smoking cessation commissioning body.

Nicotine replacement therapy

There are six types of NRT: patches, gum, lozenge, micro-tab, nasal spray and inhalator, with no evidence to show one form being more effective than another. It is important to agree on the most appropriate form with the patient and to be aware that smokers often want to swap products. 

Smokers often benefit from dual NRT therapy using, for example, a slower-release product (e.g. patches) to deliver a baseline amount of nicotine to deal with background craving and a faster acting product (e.g. gum, lozenge, inhalator, spray) that delivers nicotine quickly to fight episodic cravings. 

The MHRA has approved NRT for use in smokers over 12 years of age who have an evident addiction to nicotine. NRT is licensed for use by pregnant women and in patients with cardiovascular disease and diabetes. Although caution should be exercised in these groups, the benefits of stopping smoking will almost always outweigh any risks from NRT. 

Intermittent NRT is preferable in pregnancy although sickness may mean that patches are the only realistic option. Pregnant women should remove NRT patches before going to bed. NRT can also be useful for people who want to cut down and cannot contemplate giving up in one step (nicotine assisted reduction). 

Bupropion  and varenicline

Bupropion is an antidepressant medication that has been shown to be successful when used in smoking cessation as a single drug therapy. Although bupropion is a safe and effective medication, possible side-effects and contraindications should be noted when it is considered for use – see the BNF or the SPC on the electronic Medicines Compendium website. 

Varenicline, like bupropion, is a prescription-only medicine that can increase long-term abstinence from smoking. Its cautions and contraindications are worth noting and can be found in the BNF or the product’s SPC. The SPC contains a note on the possibility of suicidal tendencies in some patients. Nausea is a notable adverse effect that tends to subside over time. 

The combination of NRT with varenicline or bupropion is not recommended.

Vaping: what’s the advice?

Data published by Action on Smoking and Health (ASH) in September this year shows that an estimated 3.6 million people are vaping in Great Britain (just over half the number of smokers). The products are most popular among 35-44 year-olds, followed by 45-54-year-olds. The lowest rates are among young adults aged 18-24 years.

The proportion of vapers who are ex-smokers continues to grow, reaching 54.1 per cent in 2019 with the main reason given for using e-cigarettes being to help them quit smoking (31 per cent) followed by to prevent relapse back to smoking (20 per cent). 

The safety of e-cigarettes is increasingly debated with some researchers suggesting that vaping inflames the airways, leading to increased production of mucus and tissue degrading enzymes, reducing the ability of the lungs to function and increasing the risk of lung disease. 

US president Donald Trump recently pledged to ban the sale of most flavoured electronic cigarettes, after recent cases of lung disease were linked to vaping. The concern is that flavoured e-cigarettes may be particularly appealing to youngsters. A national FDA survey of tobacco and e-cigarette use between 2017 and 2018 found a 75 per cent increase in vaping among US high school students (aged about 14 to 18 years) and a 48 per cent increase among middle school students (aged about 11 to 13 years). By comparison e-cigarette use in the UK remains low. 

According to a 2018 ASH survey, just 2 per cent of 11-18 year-olds use e-cigarettes at least weekly, another 2 per cent use them once a month or less and 12 per cent of young people have tried them once or twice. A majority haven’t tried e-cigarettes (76 per cent), while 7 per cent are unaware of e-cigarettes altogether.

Following the US announcement, Public Health England’s advice on e-cigarettes remains unchanged. On September 12, PHE tweeted: “Vaping isn’t completely risk free but is far less harmful than smoking tobacco. There is no situation where it would be better for your health to continue smoking rather than switching completely to vaping.”

The Royal Pharmaceutical Society is currently updating its e-cigarette policy, which is expected in spring 2020. In advising on smoking cessation, pharmacists should encourage the use of licensed NRT products wherever appropriate. 

Where someone is unwilling to use a licensed NRT product, pharmacists should use their professional judgement on the use of e-cigarettes, taking into consideration current evidence on safety and efficacy; the risks and benefits of using unlicensed e-cigarette products; and the normalising of the smoking habit itself, particularly for young people and non-smokers. 

References

1. Delivering the vision of a ‘Smokefree Generation’
2. BMJ Open
3. PSNC