The Pharmaceutical Journal Vol 265 No 7126 p858
December 09, 2000 News

News Feature

A pharmacist's role in smoking cessation

Last week, a new campaign to encourage smokers to seek professional help when quitting was launched and new smoking cessation guidelines were published (PJ, December 2, p809). In this issue, we publish articles on amfebutamone (p860) and nicotine replacement therapy in pregnancy (p863), and a news item on a new smoking cessation programme (p850). Following these recent developments, Clare Bellingham looks at a pharmacist's role in smoking cessation

More than 12 million people in the United Kingdom smoke and half of all regular cigarette smokers will be killed by their habit. Thirty per cent of cancer deaths (and 84 per cent of lung cancer deaths) are caused by smoking. The statistics are frightening. Is it any wonder that seven out of 10 smokers in the UK want to quit?
Pharmacists can play an important role in helping these would-be quitters. Giving up smoking is not easy and only 1 to 3 per cent of people succeed each year. Offering pharmacological treatments, as well as behavioural support, are two ways that pharmacists can help to increase a smoker's chance of giving up for good.

Ideally placed

Community pharmacists are ideally placed to provide advice on smoking cessation. Their easy accessibility can encourage people to ask a pharmacist for health advice on the "spur of the moment ". Some people ask a pharmacist for advice instead of waiting for a doctor's appointment. A Department of Health televised smoking cessation campaign featuring a pharmacist will recommence in December and is likely to encourage inquiries.
Pharmacists have a large target audience. Pharmacies are visited not just by patients but also by people who are buying, for example, cosmetics, and by people who rarely consult their doctor but still buy over-the-counter medicines for minor illnesses. So if a pharmacist displays leaflets and posters on smoking cessation, or asks customers buying cough sweets about smoking habits, the message will reach a large number of people.
At a smoking cessation workshop on November 21 co-organised by the Pharmacy Healthcare Scheme, Mr David Pruce (audit development fellow, Royal Pharmaceutical Society) said that pharmacists were pessimistic when it came to estimating the effectiveness of their interventions in smoking cessation. During the development of an audit tool to help pharmacists evaluate smoking cessation campaigns, he conducted a study of 22 pharmacies. It showed that of 281 brief interventions on smoking in one month, 31 per cent of people agreed a strategy to quit smoking, bought nicotine replacement therapy (NRT) or accepted a referral to a specialist clinic. A total of 65 per cent made a positive response towards quitting. The audit tool can be obtained by contacting Tracey Brand at the Royal Pharmaceutical Society (tel 020 7735 9141).
Proving that not all pharmacists are pessimistic, Mr Tim O'Donoghue (consultant pharmacist, Greenlight Pharmacy, London) described at the workshop how pharmacists at Greenlight were involved in smoking cessation. Advertising in the shop window, referrals from general practitioners and a website brought patients to the pharmacy's smoking cessation service. The pharmacy had consulting rooms for patients to see pharmacists on an appointment basis and also had a classroom for group sessions. Appointments were often made for after the pharmacy had closed. Patients received treatment, a support programme and follow-up, he said. The consultations were either financed by local health action zone (HAZ) funding or were paid for privately by the patient. Initially, HAZ funding had been £30 an hour but this had been cut to £20. HAZ funding also covered a one-week course of NRT. Private consultations were charged at £30 an hour and people had been happy to pay for the service, he added.

Treatments

Pharmacists supply NRT, mostly over the counter, and amfebutamone (bupropion, Zyban) on prescription.
New smoking cessation guidelines have supported the efficacy of both treatments and recommended that they should be available on prescription (PJ, December 2, p809). There appears to be no advantage of one treatment over the other.
There are many types of NRT for patients to choose: gum, patches, nasal spray, inhalator, lozenges and sublingual tablets. It is not surprising that pharmacists are often asked to advise on the type of NRT that a patient should use. The guidelines found no basis for recommending one form of NRT over another. Choice should be made on the smoker's personal preference and tolerance for side effects of each product. However, it is important to remember that the highest strength patches (21mg/24h or 15mg/16h) are more effective than lower strength patches for people who smoke more than 10 cigarettes per day. In addition, for smokers of more than 20 per day, 4mg gum is more effective than 2mg gum.
A common concern for patients using NRT is how and when they can stop treatment. Professor Robert West (co-author of the smoking cessation guidelines) says that the patch can be stopped abruptly without withdrawal problems but, for other forms of NRT, weaning is necessary.
Speaking at the smoking cessation workshop, Dr Dawn Milner (senior medical officer, Department of Health) said that this year's NHS plan for England had set out details of comprehensive smoking cessation services to be in place by 2001. This included NRT to be available on NHS prescription to complement amfebutamone.
Some smokers can obtain a short supply of free NRT through schemes in health action zones. Many smokers need NRT for longer durations and the argument that if they can afford cigarettes they can afford NRT does not always apply since an increasing number of people purchase tobacco on the black market where it costs considerably less than the equivalent supply of NRT.
The National Institute for Clinical Excellence (NICE) is to appraise NRT and amfebutamone next year. Dr Milner commented that she did not expect the NICE to make any recommendations on these therapies before June, 2001.

David Pruce: pharmacists are in an ideal position to help smokers quit

Other support

An important issue in smoking cessation is the provision of behavioural support. Behavioural support may be provided by specialist clinics and tends to involve a number of counselling sessions. There is potential for pharmacists to offer behavioural support and evidence shows that a structured package of care can be effective in smoking cessation. Further evidence to support the pharmacist's role comes from research currently in press in Addiction. It shows that one-year quit rates for patients who received behavioural intervention and NRT was 14.3 per cent compared with 2.7 per cent among patients who received NRT alone.
Pharmacists have access to a large number of smokers buying NRT who have no contact with specialist smoking cessation services. Offering even a brief amount of advice and encouragement is more effective than saying nothing at all. This advice need only take a couple of minutes. Counselling lasting longer is more effective but can be difficult for pharmacists to offer, so suggesting local or national smoking cessation services is useful. Follow-up is also important in behavioural support. For pharmacists, this can involve asking regular purchasers of NRT how they are getting on.
Smokers often resolve to quit at New Year and over a third of smokers have tried to give up at New Year in the past. These resolutions provide an opportunity for pharmacists to become involved in smoking cessation. Another opportunity is National No Smoking Day (next year on March 14). Pharmacists can, for example, display posters and leaflets or organise talks at local businesses. The Royal Pharmaceutical Society suggested in a recent press release that pharmacists taking part in next year's No Smoking Day campaign could consider using the Society's audit tool (see earlier) to evaluate their services following the event.
The Department of Health's "Don't give up giving up " television campaign will recommence in December and will continue until No Smoking Day in March. In addition, the DoH is planning to distribute a pack of new smoking cessation campaign materials to pharmacies from mid-December. These include cards and card holders, a poster and a summary of campaign activitites. Further supplies of materials can be ordered using a form sent with the pack or by telephone or internet (tel 0800 169 0 169, website www.givingupsmoking.co.uk). In particular, the material will highlight a new smoking helpline for pregnant women (0800 169 9 169).
Another campaign, "Countdown to quitting " has been launched this week by the charity QUIT. The campaign's aim is to encourage more smokers to start preparing now in order to give up at New Year. New data from research carried out by QUIT reveals that just over two million smokers will try to quit this new year and that planning, preparation and support from health care professionals are important factors in helping smokers succeed. Pharmacists can obtain support materials from Quitline (tel 0800 002200) or from Glaxo Wellcome, the campaign's sponsor.
In Wales, the health promotion division of the National Assembly for Wales is launching a "quit and win " campaign in January. It will encourage health professionals, including pharmacists, to recruit smokers to the challenge and offers prizes as incentives for people to quit smoking. Campaign materials will be distributed in December.

Mrs Bellingham is on the staff of The Pharmaceutical Journal