The Pharmaceutical Journal Vol 266 No 7133 p151-154
February 3, 2001

Articles

Getting prepared for No Smoking Day

This year, No Smoking Day is on March 14. This special feature provides background information to help pharmacists prepare for the day. It gives information about health promotion campaigns organised for No Smoking Day, facts about smoking and an update on recent developments in the area of smoking cessation. Clare Bellingham reports

Stopping smoking works
No Smoking Day
Facts about smoking
Policy developments
Don’t give up giving up
Smoking-related inequalities
Smokers lose more workdays than non-smokers
Can you do more to help?
Cutting smoking rates would save a fortune
Tips for quitting
Additional funding announced for smoking cessation drugs
Children suffer because of parents smoking
Useful information

Briefly

Mrs Bellingham is on the staff of The Pharmaceutical Journal

Stopping smoking works

Stopping smoking works. This was the view of Professor Sir Richard Peto (clinical trial service unit and epidemiological unit, Radcliffe infirmary, Oxford) speaking at a National Tobacco Control Conference in London on January 25.

Professor Peto said that the risks of smoking were big - half of smokers were killed by their habit and a quarter were killed in middle age (aged 35-69). Studies had shown that by the age of 70, 83 per cent of non-smokers were alive compared with only 60 per cent of smokers. However, stopping smoking really worked. Stopping in middle age avoided much of the risk and stopping before middle age avoided nearly all the risk. It was always worth stopping at any age and even after a heart attack, stopping smoking was beneficial. Professor Peto published a study with Professor Sir Richard Doll (emeritus professor of medicine, Radcliffe infirmary) last year showing that stopping smoking at age 60 was beneficial (see PJ, August 12, 2000, p223)

The good news was that the United Kingdom had the best decrease in premature deaths from lung cancer in the world, Professor Peto said. Half of the smoking- related deaths that would have happened had been avoided by people giving up smoking.

Professor Peto showed striking graphs of lung cancer death rates in the UK over the past 50 years which demonstrated the link between smoking prevalence and lung cancer. The male death rate peaked in the 1970s which reflected the high proportion (over 80 per cent) of the male population that smoked in the 1950s. In the 1960s and 1970s, people realised the health impacts of smoking, the prevalence of smoking in men fell and the rate of lung cancer mortality fell from the 1970s onwards. The female mortality rate never reached the epidemic level of the male rate because fewer women than men smoked. Smoking rates declined among women after a peak (of 50 per cent) in the 1970s so the proportion of women smokers, and the subsequent rate of lung cancer, had never reached the levels seen in men.

In the UK in 2000, 36 per cent of men and 28 per cent of women smoked. This contrasted with a worldwide figure of 30 per cent of people smoking - 50 per cent of men and 10 per cent of women. Of the 30 per cent of the world’s population who smoked, half, or 15 per cent of the population, would be killed by their habit. If current levels of smoking continued, this would equate to about one billion people killed by smoking in the 21st century compared with 0.1 billion in the 20th century.

It was important to encourage adults to stop smoking in addition to taking action to prevent children from taking up the habit. Mortality rates in the first quarter of this century would be affected more by getting adults to stop smoking than by preventing children from starting, Professor Peto said.

There was nothing comparable with the number of deaths caused by tobacco. People should not get the wrong impression from the media about scare stories concerning causes of cancer. Smoking was “the big one”. Nothing else was a bigger medical decision for a smoker than deciding to stop; everything else was much less significant in comparison, he said.

The simple message from Professor Peto’s talk was that giving up smoking was worth it. No matter how long people had smoked or how old they were, there were great benefits from stopping.

No Smoking Day

This year’s No Smoking Day campaign theme is “Kiss it goodbye”. No Smoking Day is on March 14 and the campaign is run by a charity of the same name. The charity says that this year’s theme was first used in 1992, a year that was one of the most successful campaigns ever.

No Smoking Day’s aims are to make as many people as possible aware of the day and to involve people and organisations in activities to help smokers stop. The charity says that it is important to see No Smoking Day as an opportunity for planned quit attempts. It suggests several ways to get involved in the day. They are:

Publicise the day well in advance
Direct smokers to services that can help them
Arrange an event or activity to mark the day and inform No Smoking Day headquarters and the media about it

The campaign’s pack contains information about No Smoking Day, ideas for activities, a poster, a leaflet, stickers and a photocopy kit of factsheets. It also contains information about other resources such as posters, banners, T-shirts, credit card-sized handouts, postcards, balloons and many more items. These can be ordered, along with large quantities of leaflets in a number of languages, using the order form enclosed in the campaign pack. Orders must be made before March 5.

According to the campaign’s handbook, 85 per cent of smokers in the United Kingdom knew about No Smoking Day last year. On No Smoking Day last year, over a third of smokers took a step towards quitting and 9 per cent of those aware of the day stopped for all or part of it. The handbook says that this was equivalent to half a million quit attempts. This is a huge number of people compared with the average number - 8,000 - who try to stop on normal days of the year. No Smoking Day campaign packs with this year’s theme "Kiss it goodbye" will be sent to pharmacists in February in association with the Pharmacy Healthcare Scheme.

Further information can be obtained from

No Smoking Day
Unit 203, 16 Baldwin Gardens
London EC1N 7RJ

T el 020 7916 8070,
e-mail mail@nosmokingday.org.uk,
website www.nosmokingday.org.uk).

Facts about smoking

Every day, 330 people die in the UK as a result of smoking
Half of all regular smokers will be killed by their habit
82 per cent of lung cancer deaths are caused by smoking
30 per cent of all cancer deaths, 25 per cent of heart disease deaths and 83 per cent of deaths from bronchitis and emphysema are caused by smoking
Smoking doubles the risk of stroke
Smoking increases the risk of many health problems including increased risk of sperm abnormalities, miscarriage and premature birth

And on the positive side . . .

Giving up smoking reduces the risk of developing smoking-related illness
Eight hours after quitting, nicotine and carbon monoxide levels in the blood are reduced by half and oxygen levels return to normal
After 24 hours, carbon monoxide is eliminated
After 48 hours, nicotine is eliminated
After three days, breathing becomes easier
After two to 12 weeks, circulation is improved and smokers’ coughs start to get better
After five years, the risk of having a heart attack is half of that of a smoker
After 10 years, the risk of heart attack is the same as a non-smoker
After 10 to 15 years, the risk of developing lung cancer is only slightly greater than that of a non-smoker
Research has shown that people who stop smoking before the age of 35 survive about as well as life-long non-smokers

Policy developments

Three initiatives announced by the Government last year will have a significant impact on the provision of smoking cessation services by pharmacists.

The availability of amfebutamone (bupropion, Zyban) and future availability of nicotine replacement therapy (NRT) was announced in the NHS national plan. In addition, the plan asked the National Institute for Clinical Excellence to give guidance on these treatments (expected later this year). The NHS cancer plan gave new targets for reducing smoking from 28 per cent to 24 per cent by 2010. Further targets were set for manual groups (from 32 per cent to 26 per cent by 2010) in an attempt to reduce health inequalities. The NHS Pharmacy in the Future plan highlighted the opportunity for pharmacists to become more involved in smoking cessation.

A paper (“Smoking cessation services: implementing the NHS National plan”) is available on the Action on Smoking and Health website (www.ash.org.uk). The paper makes many recommendations, including some about how health professionals should work together to deliver smoking cessation services. It also recommends that professional bodies should support the proposal to make more NRT products available on general sale in addition to being available on prescription and in pharmacies.

Don’t give up giving up

The Department of Health’s campaign theme “Don’t give up giving up” continues from last year.

Leaflets carry a knotted cigarette slogan with the message that stopping smoking can take time and not to give up trying. New posters show two purses - one empty, one full - with the message “Giving up smoking won’t just enlarge your lung capacity”.

The Department says that advertising for this year’s campaign began last December, to support smokers’ New Year resolutions, and will continue until No Smoking Day. All material carries the National Health Service smoking helpline number (0800 1690169). Smoking in three groups is to be targeted, in particular, this year. They are pregnant women, ethnic minorities and young people. The NHS pregnancy smoking helpline (0800 1699169) will be promoted as part of the campaign, beginning in January. The Department says that there is less awareness of the health risk associated with smoking in south-Asian communities and that it hopes to address this through specialist television, radio and press advertising and community work, again beginning in January. The campaign for young people is planned for the summer.

Campaign resources cover a number of topics and are available in a variety of formats. Campaign leaflets are produced in a number of languages, particularly for Asian communities, and also in Braille, large print and audio formats. A leaflet for people with learning difficulties is also available. Other resources include posters, telephone helpline cards, stickers and campaign packs. Resources can be ordered through the NHS Smoking helpline (tel 0800 1690169, website www.givingupsmoking.co.uk).

Smoking-related inequalities

Smoking was a major cause of health inequality, said Professor Martin Jarvis (Imperial Cancer Research Fund health behaviour unit) at a Tobacco Control Conference on January 25. People in lower social classes were more likely to start smoking, less likely to quit and more likely to become dependent on nicotine.

The proportion of people who smoked in social class one was 12-14 per cent compared with 40 per cent in social class five. Changes in smoking rates between 1973 and 1998 showed that the highest number of people who had given up smoking were in the most affluent group of the population, he said. In the most deprived groups, the rate of smoking was around 70 per cent and had hardly changed over the past 25 years.

Motivation to quit was the same across the social classes. However, nicotine dependency was higher in lower social classes (measured by nicotine intake). Possible reasons for the increased level of dependency included poorer smokers using cigarettes as self-medication for stress, tending to start smoking at a younger age and being likely to smoke cigarettes more intensively (because the cigarette was worth more to them compared with a more affluent smoker), Professor Jarvis suggested. Reducing poverty, making treatments rapidly available for poor groups and reducing the toxicity of cigarettes might reduce the health inequalities caused by smoking, he commented.

Smokers lose more workdays than non-smokers

Young people who smoke take substantially more days off work with illness than their non-smoking colleagues, a study has found.

The study, conducted in United States military personnel, found that compared with people who had never smoked, current smokers had higher rates of hospitalisation and lost workdays for a broad range of conditions. The effect was most pronounced in men. In conditions not related to injury or pregnancy, smoking was associated with a 30 per cent increased risk of hospitalisation and a 60 per cent increased risk of lost workdays in men. In women, these figures were 25 per cent and 15 per cent, respectively. There was a small increase in risk in both categories for former smokers.

The researchers comment that they could only measure lost workdays associated with hospitalisation and add that if a similar association exists between smoking and lost workdays not needing hospitalisation, the true effect of smoking would be substantially greater than their study suggests (Tobacco Control 2000;9:389).

Can you do more to help?

A booklet “Pharmacists - can you do more to help?” is available from the Pharmacy Healthcare Scheme (1 Lambeth High Street, London SE1 7JN, tel 020 7820 3213, e-mail phs@rpsgb.org.uk), priced £2 to cover postage and packaging.

It covers the effectiveness of brief opportunistic interventions based on the Health Education Authority’s “four A” approach: ask, advise, assist and arrange. The booklet suggests ways that this approach can be applied to pharmacy, for example, asking customers about smoking when they purchase cough mixture, pregnancy tests or smokers’ toothpaste. It suggests taking every opportunity to ask customers about smoking. If smokers reply that they did not wish to stop, it suggests advising them on the risks of smoking.

The booklet also gives practical tips for assisting smokers to quit including telling them about withdrawal symptoms that might occur so that they are well prepared.

The booklet also covers the use of nicotine replacement therapy, discussing the advantages of each dosage form.

Cutting smoking rates would save a fortune

Even moderate success in smoking cessation programmes has a significant effect in terms of saving money for the health service, a study has found.

Research published in Tobacco Control estimated the cost consequences to the National Health Service of achieving two smoking cessation targets.

The first target was taken from the Government’s 1998 White Paper on tobacco: to decrease adult smoking rates from 28 per cent in 1996, to 26 per cent by 2005, to 24 per cent by 2010. The second target was more ambitious: a 1 per cent reduction each year (as seen in California). In this case, adult smoking rates would decrease from 28 per cent in 1996, to 22 per cent in 2005, to 17 per cent in 2010.

The researchers calculated the number of acute myocardial infarctions and strokes that would be avoided if each of the rates were achieved.

Over the period between 1999 and 2010, achieving the first target would reduce the number of hospital admissions for acute MI by 34,460 and strokes by 25,301. In the same period, achieving the second target would reduce these figures by 76,066 and 55,755, respectively. The total cost savings for the National Health Service would be in the region of £0.5bn (at 1999/2000 prices) for the first target and nearly double that for the second target.

The researchers comment that the benefits would, in reality, be greater because the analysis was just for two of the many diseases caused by smoking. They also suggest that a more aggressive policy towards smoking cessation would achieve even greater savings for the NHS (Tobacco Control 2000;9:397).

Tips for quitting

Set a quit date, take time to prepare for it and stick to it
Get support and advice from friends, family, your pharmacist, GP, cessation clinics or helplines
Speak to your pharmacist about drug treatments
Avoid situations where you will find it difficult not to smoke
Change your routine to distract yourself from times and places you associate with smoking
Stop completely. Cutting down rarely works so do not be tempted to have “just one puff”
Get rid of all cigarettes, lighters and ashtrays before your quit date
Ask people not to smoke around you and tell everyone you are quitting
Keep busy, especially when cravings start
Reward yourself for not smoking

Additional funding announced for smoking cessation drugs

Successful smoking cessation services need to be available throughout the United Kingdom, said Ms Yvette Cooper MP (Parliamentary Under-Secretary of State for Public Health) on January 25. Speaking at a Tobacco Control Conference in London, Ms Cooper announced that funding for such services would be the same as last year and that additional funding in order to provide amfebutamone (bupropion, Zyban) and NRT on prescription would be made available through health authorities.

Smoking cessation services should be driven by what local people and patients want, she said. There was a greater role for primary care to play, especially when NRT moved to being available on prescription. This included a “considerable” role for pharmacists. Smoking cessation services would only be successful if effective working partnerships were in place, she added.

Ms Cooper said that she was concerned over reports that barriers had been put in place by primary care groups and health authorities to prevent the prescribing of amfebutamone. She said that she was keen to see it used as effectively as possible and would keep the area under close review. Resources had been allocated to allow the use of amfebutamone and NRT and she expected them to be supplied. Ms Cooper added that she hoped that the National Institute for Clinical Excellence guidance on amfebutamone and NRT [expected later this year] would provide country-wide, evidence-based guidance on the use of these drugs.

Children suffer because of parents smoking

Children with asthma whose parents smoke heavily may not be receiving adequate treatment for their asthma.

The fact that passive smoking is a major cause of respiratory morbidity in children led Scottish researchers to investigate the effect of passive smoking on risk of morbidity in children with asthma. They found that higher levels of smoking in the home and in the presence of the child resulted in fewer contacts with the health service for the child’s asthma. The researchers suggest two reasons for this effect. First, heavy smokers may be less concerned or aware of respiratory symptoms than non-smokers. Second, heavy smokers may be more reluctant to consult their general practitioner because they suspect that their smoking affects their child’s asthma and do not want to stop smoking or receive anti-smoking advice.

The researchers add that action is needed to ensure that children of heavy smokers receive adequate medical attention for asthma (Thorax 2001;56:9). The children were all receiving regular medication for their asthma and yet 14 per cent had no contact with health services over a 12-month period. Many of these children would have received asthma medication from pharmacists so perhaps this is an area where pharmacists could have a role in asking parents about the child’s asthma management - a different approach for No Smoking Day.

Useful information

Useful websites

Smoking helplines

0800 169 0 169
0800 169 9 169

Briefly

Nicotinell roadshows

In February and March, Nicotinell will be running roadshows giving advice on how to give up smoking. The roadshows, which will each last one week, will be held in Bristol, Birmingham, Croydon, Glasgow and Newcastle. Pharmacists near to each location will be informed of the exact roadshow dates.

Smoking cessation guidelines

New smoking cessation guidelines were published in Thorax in November (PJ, December 2, 2000, p809).

They emphasised the importance of pharmacological therapies and recommended that amfebutamone (bupropion, Zyban) and nicotine replacement therapy should be available on the NHS. There was insufficient evidence to recommend amfebutamone or NRT over the other, or in combination. However, combining a nicotine patch with another form of NRT was found to be safe and advantageous over single NRT therapy.

AAH training

Asmoking cessation training package is being launched for Vantage pharmacy assistants. It gives advice on how customers should use NRT products.

Wall of silence

In January, a survey conducted for the Cancer Research Campaign found that seven out of 10 people in Britain believed that in smokers, lung cancer was a self-inflicted disease. The vast majority of the 38,000 cases of lung cancer which occur in the UK each year are caused by smoking. The charity says that there is a wall of silence surrounding lung cancer that needs to be broken down.