Special feature

“Kiss smoking goodbye” — how pharmacists can help

Next Wednesday, March 14, is No Smoking Day. Over a million smokers attempt to quit on this day and many of them turn to their local pharmacist for help. Clare Bellingham investigates what pharmacists are doing to promote No Smoking Day and the smoking cessation services pharmacists may offer

Pharmacists can play an important role in smoking cessation the Council of the Royal Pharmaceutical Society was told at its February meeting during a presentation of smoking cessation guidelines. Dr Ann McNeill, presenting the guidelines, said that pharmacists had an important role in terms of specialist support, opportunistic advice, advice on pharmaceuticals and sign-posting support services that were available in the community. Dr McNeill, a freelance public health consultant, is co-author of smoking cessation guidelines published in Thorax at the end of last year (see PJ, December 2, 2000, p809). Dr McNeill said that the guidelines had reinforced the combination of opportunistic advice in primary care with the backup of more intensive support where appropriate. She spoke specifically to the Council about the role of the pharmacist in smoking cessation, something that had been emphasised by the guidelines. There had been two studies in the area. One study had shown a clear and statistically significant effect of a structured protocol in smoking cessation intervention compared with unstructured care (Addiction 2001;96:325). This gave a positive message for pharmacists, she said. A second study had shown a small, but not statistically significant, effect of pharmacy smoking cessation intervention (Tobacco Control 1998;7:253). Dr McNeill said that the first consultation the pharmacist had with a smoker should be intensive, perhaps 20 to 30 minutes long. This could be used to assess the smoker's motivation to quit and dependence level and to give advice on what course of action to take. She recommended weekly, face-to-face follow-up sessions for the first month and, if possible, a longer term follow up at 12 months. Pharmacists should also take every opportunity to give advice, she said. The crucial role for pharmacist was giving advice on pharmaceuticals. This was where pharmacists had “a real added edge” over other health professionals because it was part of their usual practice, said Dr McNeill. No clear recommendations could be made about nicotine replacement therapy (NRT) and amfebutamone (bupropion, Zyban) in combination, nor was there evidence to suggest one was better than the other. Choice of product should be made on the basis of contraindications, tolerability and patient choice. Both could be used, with caution, in patients with coronary heart disease and most experts agreed that NRT was safer in pregnancy than smoking. Adolescent smokers should be treated like adults and given the same support as adults, she said. There was some evidence that combinations of NRT could be effective, combining the slow acting patch with quicker acting inhalators and lozenges. Finally, pharmacists had a role in sign-posting, or referring, smokers to local smoking cessation clinics or services, national helpline numbers, manufacturers' programmes and materials, and self-help groups. Dr McNeill said that consultation was being completed on the Government's intention to put NRT on reimbursable prescriptions. She thought that it was “very likely” to happen by April this year. In addition, Dr McNeill thought that NRT would be a good candidate for patient group directions. This was not the case for amfebutamone because it had been licensed much more recently. She added that the National Institute for Clinical Excellence (NICE) had been asked to advise on the best regimens for NRT and amfebutamone and that the Committee on Safety of Medicines had also been asked to consider whether NRT should be made available on general sale. In studies which had simulated the over-the-counter environment, success rates for smoking cessation were similar to those when NRT was given on prescription. An ethical argument existed in terms of NRT products not being less widely available than cigarettes which GSL availability of NRT would help to balance. However, behavioural support greatly increased the chances of successful cessation and would still be needed.

What are pharmacists doing? So what are pharmacists planning for No Smoking Day? A striking image in a window display is being used by pharmacist Mr Tim O'Donoghue to highlight smoking cessation. He told The Journal that the image he had used last year at Greenlight Pharmacy in north London had been so effective that he planned to use it again this year. The window display is based on the word “quit” in large letters to grab the attention of passers-by, even from some distance. Last year, it had been left up for 10 weeks after No Smoking Day. No Smoking Day was great for highlighting smoking cessation and it made people think about giving up, so keeping it up for a period after the day itself was important, he said. Greenlight Pharmacy offers a smoking cessation service that includes a support programme and follow-up. Patients are seen by appointment in consulting rooms at the pharmacy. The smoking cessation service is advertised on the pharmacy's website (www.greenlightpharmacy.com) and also on the closed circuit television systems of local businesses. To gain the interest of local businesses, Mr O'Donoghue had contacted their human resources departments and outlined the service. The website had also attracted a lot of attention to the smoking cessation service. Mrs Carol Wells, a Lloyds pharmacist based in Sheffield, is working with a local smoking cessation clinic for No Smoking Day. A part of the pharmacy will be used as a display area for smoking cessation materials and will be manned by a worker from the Sheffield smoking cessation service clinic. Mrs Wells will be at the stall for as much of the day as possible, within the contraints of other pharmacy business, but will always be available for more detailed advice if the clinic worker were to request her help. The display will be set up in the pharmacy for three days from No Smoking Day during which time the smoking cessation clinic hopes to recruit more people to its service. The clinic offers weekly meetings and a supply of free NRT by a voucher scheme which Mrs Wells provides. She hoped that the No Smoking Day project would be the start of a closer working relationship between the pharmacy and the clinic. The pharmacy had been successful in supplying NRT via a voucher scheme and had become part of the local health care team. However, she was concerned that when NRT became available on prescription that this positive effect might be lost and that the pharmacy would become excluded from the team. In addition to leaflets and a carbon monoxide detector, the display would also have a questionnaire competition available for customers about smoking and its effects. Pharmacists at Boots are getting involved in the company's Pro-Change initiative which was launched last year (see PJ, December 9, p850). In addition, pharmacists are being encouraged to hire carbon monoxide analysing machines, organise sponsored events and publicise No Smoking Day in local media, according to a Boots spokeswoman. One example of a local event is provided by Miss Clare Tudor-Jones (pharmacy manager, Boots, Swansea), who is working with Swansea University to highlight smoking cessation to the university's 10,000 students. She told The Journal that a display of materials would be set up at the university on No Smoking Day and would be manned by a Pro-change adviser and a nurse form the university's occupational health service. Another smoking cessation stand would be set up at the pharmacy for the week around No Smoking Day and she hoped that a further stand would be set up in a local shopping centre. Smoking cessation leaflets were always on display at the store, she added. To encourage pharmacists to get involved in No Smoking Day, eg, setting up in-store displays, the charities No Smoking Day and Pharmacy Healthcare Scheme are running a “No Smoking Day 2001 pharmacy award scheme”. The winner will receive a £150 gift voucher and a certificate of commendation and 10 runners-up will each receive a certificate and T-shirt. Details of the competition can be found in the No Smoking Day pharmacist's pack.

Pharmacist helps rugby team kick the habit A pharmacist in Bradford has been working with a local youth rugby team as part of a smoking cessation initiative. Mr Mark Donaghy visited Clayton rugby club's under 16s team to promote an anti-smoking message. He used a carbon monoxide detector to show the effects of smoking on fitness and provided educational leaflets and fact sheets specifically designed for young people. A couple of team members were discovered to be smokers so Mr Donaghy offered them counselling. Mr Donaghy offers a smoking cessation service at a branch of Moss Pharmacy in Bradford. The service is funded by Bradford Health Action Zone which pays for a locum while Mr Donaghy offers structured counselling to people wanting to quit smoking. Patients, who may be referred to the service by their general practitioner, have weekly appointments initially and can visit regularly for a chat or to have their progress monitored using a carbon monoxide detector. Patients may be sold or given vouchers for nicotine replacement therapy or referred to their GP for amfebutamone. Mr Donaghy also gives pharmaceutical advice at local cessation clinics run by practice nurses. Clayton rugby club's coach asked for Mr Donaghy's help with the youth team after becoming aware of the services offered at the pharmacy. “Pharmacist have an essential role in the community in helping youngsters quit and also educating them not to start smoking, as we are doing in Clayton with the under 16s rugby club,” says Mr Donaghy.

Manufacturers' help Manufacturers' of NRT offer a variety of support products to help smokers quit. They also provide materials for display in pharmacies. Dr McNeill said that there was some evidence that if a manufacturer's programme of support was tailored to the smoker then it would be effective. However, she added that it would not be as effective as professional, face-to-face advice, which was more intensive. Therefore, such programmes should be used as part of the overall package of support that pharmacists can offer. Nicorette Nicorette has been advertised on television since the beginning of March. Its manufacturer, Pharmacia & Upjohn, says that the campaign will run throughout the month to encourage quitters to give up for No Smoking Day. The campaign features the strapline “Now you can beat cigarettes one at a time”. Nicorette is also running its third Pharmasite poster initiative in over 2,300 independent pharmacies across the country. The company has point of sale materials, such as window posters, giant packs and counter units, for display in pharmacies. It says that new posters have been produced to tie-in with the new advertising campaign and No Smoking Day. Materials can be obtained by contacting the company Tel 0800 801 454 e-mail Pharmacia.OTC-Offers@eu.pnu.com). Nicotinell Nicotinell has been advertised on television since February. Its manufacturer, Novartis, has also been running smoking cessation roadshows in February which will continue in March. The company also runs a Nicotinell helpline, staffed by trained counsellors, who handle over 500 calls per month. Both smokers and health professionals can use the helpline (tel 0800 917 3333). A Nicotinell website is also available (www.nicotinell.co.uk). Niquitin Niquitin CQ is currently being advertised on television. Display materials for Niquitin are available from its manufacturer, Glaxo Smithkline (tel 020 8975 4266). Leaflets, notepads, pens and a table display are some of the materials available. Zyban Further information about Zyban can be found on two Glaxo Smithkline websites. One website (www.zyban.co.uk) is for health care professionals and pharmacists need to use their Royal Pharmaceutical Society registration number to access it. The other website (www.thetimeisright.co.uk) is for the general public.

Specific advice for providing smoking cessation services Set up a structured protocol of intervention Structured protocols have been proved to work better. Plan how interventions will be made and train pharmacy staff on the pharmacy's protocol. Arrange consultations with smokers The first consultation should be long (around half an hour) and should be followed by shorter weekly sessions for a month. Arrange the consultations for quiet times in the day or when you have additional pharmacist cover so that the pharmacy will not be left short-staffed. Keep a diary of available appointments and train other members of staff to use it. Make use of more experienced staff who could be trained to conduct the follow-up consultations. Consultations should be about preparing the smoker to quit and encouraging them to maintain a non-smoking status It is vital for smokers to be prepared for their quit attempt; if they are not prepared, there is a much greater chance that they will relapse. The initial consultation should assess motivation to quit, assess dependence level and recommend an appropriate course of action. Pharmacists can give practical help such as agreeing a quit date with the smoker, making suggestions about appropriate pharmaceutical products and giving other support. Give the smoker something to take away Give the smoker leaflets to read to encourage them in their quit attempt. It can be difficult for people to take in all the information given in a consultation so having a list of key points to remind themselves of afterwards is a good idea. Provide the smoker with details of other available support such as national helplines, local smoking cessation clinics and self-help groups. Some useful national contact details are: No Smoking Day Tel 020 7916 8070 website www.nosmokingday.org.uk e-mail mail@nosmokingday.org.uk NHS smoking helpline Tel 0800 169 0 169 website www.givingupsmoking.co.uk NHS pregnancy smoking helpline Tel 0800 169 9 169 Offer encouragement whenever the smoker visits the pharmacy All staff can be trained to offer encouragement when a regular customer is trying to quit. Make smokers aware of services A variety of leaflets should be displayed to target different groups of people. In addition to standard leaflets about quitting, include leaflets about the benefits of giving up while pregnant or about how people can help their partners to give up. Leaflets in different languages, eg, Bengali or Punjabi, according to the needs of the local population, can also help to target a larger number of smokers. Get paid for the service Some pharmacists can be paid for offering a smoking cessation counselling service. Contact the pharmaceutical adviser at your local health authority for more information. Audit Audit the service so that it can be improved. An audit tool for evaluating smoking cessation services can be obtained from Tracey Brand at the Royal Pharmaceutical Society (tel 020 7735 9141). Take opportunities to offer advice Give advice at all opportunities; ask smokers if they have thought about stopping and inform them of support available. Opportunities for such advice include purchase of cough medicines, smokers' toothpaste, pregnancy tests. Make a special effort for No Smoking Day There are many ways in which pharmacists can make a special effort to encourage smokers to give up on No Smoking Day. Other members of staff may be keen to get involved in organising a special project for the day. The most common idea is to set up a stall or display in the pharmacy or in the shop window to target passers-by. Carbon monoxide monitors can be hired to measure carbon monoxide levels in smokers' breath. The No Smoking Day pack has information about where the machines can be purchased and a chart which shows what different levels of carbon monoxide indicate. Other product areas in pharmacies can be included, eg, beauty products (smoking ages the skin and makes the hands smell so offer makeovers or manicures) or dental products (smoking causes many dental problems). Pharmacists, or their staff, could also contact local schools and colleges or employers to target a larger audience. Schools could become involved in poster competitions and the winning posters could be displayed in pharmacies.

Further information A No Smoking Day pack for pharmacists with this year's theme “Kiss smoking goodbye” will be sent to pharmacists this week by No Smoking Day and the Pharmacy Healthcare Scheme. A previous article included information about No Smoking Day and other campaigns (PJ, February 3, p151). A new smoking cessation bibliography can be downloaded (as a PDF file) from the Society's website (www.rpsgb.org.uk/pdfs/smokecess.pdf).

Clare Bellingham is on the staff of The Pharmaceutical Journal

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