In August, I had the pleasure of attending the fourth international conference
on “Tobacco or health” in Chicago. Like everything in the United States
the conference was on a enormous scale: 4,500 delegates attending innumerable
workshops covering some nine conference themes that ranged from neuropharmacology
and addiction science to fundraising for smoking cessation projects and how
to influence health care policy. The conference was attended by a rich variety
of health care professionals, including nurses, health promotion specialists,
medical consultants, general medical practitioners, epidemiologists and managers
of health charities as well as pharmacists. It was a complex conference, but
there was something for everyone and it was as enjoyable as it was exhausting.
From a small beginning, this conference has grown considerably in a few years.
There are now specialties within the smoking cessation theme. One person or
one group will not solve this complex health problem but each in his or her
own way will contribute to achieving the overall objectives: a reduction in
smoking prevalence and a resultant improvement in public health. These are admirable
goals. There is good evidence that when properly co-ordinated the implementation
of smoking cessation policies can be very effective. In Massachusetts a large
amount of money, equivalent to $26 per head of population, is spent annually
on smoking cessation and this is reflected in a reduction in smoking rates to
roughly half the US average. All that is needed is the vision and then a firm
commitment to its implementation.
Pharmacy needs to learn from this. Pharmacy in the United Kingdom could contribute
considerably to achieving the Government’s goals for smoking cessation
as set out in White Paper “Smoking kills”. But to do so would require
much better co-ordination within the profession than we have seen to date. Pharmacy
not only needs to be involved with smoking cessation for professional reasons.
It must also be involved because smoking cessation is good business. Revenue
streams flow from nicotine replacement therapy income and prescription fees
for Zyban. In addition, there can be direct payments from primary care groups
for services.
Pharmacy is not fighting well for its place within primary care smoking cessation
services. As a result it is losing out considerably as the Government invests
heavily in this area and becomes more and more committed to deregulating the
NRT products used to support cessation.
We need to be better co-ordinated. Each area of the profession needs to see
where its role and responsibility lie. To me the main players are academics,
trainers, politicians, pharmaceutical advisers and practitioners.
Academia
Academia must innovate the model services and assess their impact. To date in
the UK academia has responded well to this challenge. Pharmacy practice groups
in Aberdeen, Nottingham, London and Belfast have produced work that supports
an evidence base for smoking cessation services from UK pharmacies. In essence,
academia has produced good quality evidence that pharmacy intervention is both
effective and cost-effective and, therefore, the Government should pay for it.
Trainers
All centres for pharmacy postgraduate education (CPPEs) in the UK provide workshops
on smoking cessation for pharmacists. These now reflect the real skills needed
by pharmacists, including brief motivational interviewing technique and assessing
smokers on the cycle of change. In Northern Ireland, Scotland and Wales pharmacists
can obtain from their CPPE an educational/support pack on smoking cessation,
“The smoking challenge 2000”. This model service is both a training
programme and a resource pack allowing pharmacists to develop necessary skills
and knowledge and then provide the service.
Politicians
The Pharmacy Healthcare Scheme in the early 1990s supported pharmacists by producing
booklets such as “Dispensing with cigarettes”. The National Pharmaceutical
Association initiated the “Pharmacy action on smoking” (PAS) smoking
cessation service in the mid 1990s. Initially, there was energy and enthusiasm
from politicians but commitment now appears to be less forceful. Money is being
poured into smoking cessation services. NRT will be back on NHS prescription
(most of it was never off). Soon nurses will have a prescribing role for NRT
in smoking cessation services. Yet the NPA, the Royal Pharmeutical Society and
the Pharmaceutical Services Negotiating Committee are not shouting loudly enough
that we must have a role.
Pharmaceutical advisers
Pharmaceutical advisers have been responsible for implementing smoking cessation
programmes locally. This is great in principle but many seem to be attempting
to re-invent the wheel. Rather than seeking out an effective, pharmacy-based
model, many are attempting to develop their own model that have not been properly
tested. The can result in pharmacists failing to use the model with little benefit
to smokers.
Practitioners
Many pharmacists remain to be convinced of their role and their responsibility
in the area of smoking cessation. Many believe that the barriers to involvement
are insurmountable. They think they do not have the time to provide an effective
service, they fail to appreciate that they need to develop new skills, they
feel there is little reward for their involvement, and they often question the
relevance of smoking cessation to their role. Training provided by the CPPEs
can reduce many of these barriers but politicians must be more active in encouraging
and supporting professional involvement. The Society has “Pharmacy in a
new age”, but precious little is heard of how pharmacists can take part
practically in smoking cessation. A set of standards is available from the Society
audit fellow, but this is not widely known about.
Smoking cessation provides a golden opportunity for our profession. It allows
us to undertake a professional role in primary and secondary disease prevention
and in doing so it will improve our businesses. But currently these opportunities
are passing us by and, if they are lost, the loss will cause us problems in
supporting a case for our involvement in other areas of health care. We really
do need to get our act together.
Dr Maguire is director of the Northern Ireland Centre for Postgraduate Pharmaceutical Education and Training. He owns two pharmacies in Belfast