The Pharmaceutical Journal
Vol 268 No 7188 p321-322
9 March 2002

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Pharmacists can help smokers stop so why are they not properly funded?

No Smoking Day is on Wednesday 13 March. Pharmacists have a key role to play in smoking cessation but there are problems. Clare Bellingham reports

Related websites
No Smoking Day [www.nosmokingday.org.uk]
ASH [www.ash.org.uk]
NHS smoking helpline [www.givingupsmoking.co.uk]
Quit [www.quit.org.uk]

Pharmacists can help people stop smoking. There is no doubt about it. Many examples of good practice exist (see below) and evidence backs this up. So why do primary care organisations appear reluctant to fund pharmacists to run smoking cessation services? Certainly this is not the case for every PCO but enough concern existed for the Royal Pharmaceutical Society to write to the Department of Health about the matter in November. Although the Society says that the content of the letter remains confidential, it did confirm that no response had been received.

This is not the first time that concerns have existed over the provision of smoking cessation services. At the end of last year, the Government announced that £20m would be invested in smoking cessation services in 2002–03 (PJ, 15 December 2001, p839). The announcement followed months of speculation over whether or not the services would have to be wound down once funding for 2001–02 ran out.

Results from a recent study, "Pharmacists against smoking", conducted by the Europharm Forum Smoking Cessation Task Force, found that in 12 European countries at least 50 per cent of pharmacists considered smoking cessation services a normal part of their work. Community pharmacists had a positive attitude towards smoking cessation work and, in the United Kingdom, over 80 per cent thought that pharmacists should be trained to assist patients who want to stop smoking. However, the report also concluded that work done in pharmacy-based services is not well documented and is usually not well-known among other health care providers.

Good practice

The Pharmacy Healthcare Scheme and the Royal Pharmaceutical Society recently commissioned a survey of pharmacy-based smoking cessation projects around the UK. This forms part of a report on the evidence base for community pharmacy involvement in health development. Although currently unpublished, it is hoped that it will be available later this year.

Miriam Armstrong, chief executive, Pharmacy Healthcare Scheme, comments: "Although we are only part-way through this search for unpublished evidence, it is apparent that smoking cessation schemes dominate the picture of health development activity."

Pharmacists are involved in a scheme organised by Manchester Smoking Cessation Service. Over 100 pharmacists have attended training courses to become intermediate level service providers. The scheme's aim is to increase accessibility to smoking cessation support through pharmacies.

Nicotine replacement therapy was originally supplied using vouchers funded by the health action zone but when it became available on prescription last April, this had to be stopped. Jane Sunter, the service's team co-ordinator, explains: "A lot of people were disappointed so we took the issue, along with the extended role of pharmacists, to the local PCTs. They have top-sliced some of the prescribing budget in order to run a voucher scheme."

There are 71 pharmacies in Manchester involved in what is locally referred to as the "new" voucher scheme. It allows for a six-week supply of NRT through pharmacies. The supply is free for people who are exempt from prescription charges. The voucher scheme also allows people who pay prescription charges to obtain supplies of NRT at a reduced rate: they are asked to pay one prescription charge for a two-week supply. Pharmacists are paid £13 per week per product supplied. There is a restriction on the maximum number of vouchers that can be used but any excess can be reallocated from one pharmacy to another where there is higher demand.

Another part of the service is monitoring smokers' progress. This involves recording data on any person who requests help with giving up smoking in the pharmacy, including those people who do not use NRT. Pharmacists are paid £6 for each monitoring form filled out.

And data for the past two years reflects the service's success. Since April 2000, 3,856 clients who have assigned quit dates have been seen by pharmacists (many more have been seen but only those who have chosen a quit date are recorded). Of these, 29 per cent had not started smoking again four weeks later. "Pharmacists are exceptional contributors to the scheme. The quit rates reflect how good the pharmacists' input is," says Ms Sunter. "The service has extended the pharmacists' role as primary health care practitioners and has helped to bridge the gap between pharmacists and general practitioners. It has also improved methods of good practice."

The team is keen for the service to continue but, as always, this will depend on funding being made available. "We have got the money ring-fenced for next year's monitoring service and are currently waiting to hear about the budget top-slicing for the vouchers," comments Ms Sunter. In the meantime, she hopes that more pharmacists will be keen to participate in the scheme.

In Northern Ireland, community pharmacist Dr Terry Maguire is also producing evidence to demonstrate the effectiveness of pharmacists' input in smoking cessation.

The service is advertised in window displays, in the pharmacy and through leaflets. Patients are also asked about smoking when purchasing items such as cough medicines. "When patients say that they want to stop, they can enter the programme and set a quit date," he says. "Getting patients to assign their own quit dates involves them entering the cycle of change putting the onus back on the smoker and saving time for the pharmacist."

The patient then arranges a time to talk to the pharmacist on a one-to-one basis. The Smoking Challenge 2000 model is used and involves the pharmacist going through motivational information about the nature of addiction and positive reasons for giving up smoking. The initial consultation takes about 10 minutes and the patient then visits the pharmacy weekly for four weeks. At the fourth visit, the patient has a carbon monoxide test to verify cessation. The pharmacist also records information about the patient including their name and address and current medication. Over the four-week period, how the patient is getting on and any difficulties encountered are recorded. "Since January this year we have had 31 people through the programme and 16 have stopped smoking," says Dr Maguire.

Dr Maguire has published evidence on the efficacy of this type of service. A trial published last year (Addiction 2001;96:325) shows that of 484 smokers, 14.3 per cent were abstinent at 12 months if they had undergone structured counselling for a four-week period at the pharmacy compared with 2.7 per cent who received ad hoc advice from pharmacists.

The current programme can be entered at any time but certain dates provide a focus for promotional activity. "No Smoking Day and New Year's Day, are key dates to stop, although people also pick their own dates," says Dr Maguire. "We currently have a number of people who have chosen 13 March to quit and they will come back to the pharmacy a couple of days before then in order to have their first consultation with the pharmacist."

Although it has not been funded before, the local health board will be funding the service from 13 March. "Proposals for funding are being negotiated between the health board and local pharmacy group. We expect funding in the region of £30 per intervention." He adds: "The service is terrific for the profession because it marries the business and professional aspects of pharmacy including helping someone to stop smoking, being paid to do this and the selling of NRT."

Looking to the future, Dr Maguire hopes to see a uniform national smoking cessation service with defined standards of service and collecting data. "Many regions are starting services from scratch. There is enough good evidence on best practice to get pharmacy services up and running quickly." He adds: "We need the service available quickly. It is an issue of accessibility: a key issue in current Government policy. We can't deny people access to a proven service."

Offering smoking cessation services might also be key in expanding pharmacists' roles. Dr Maguire says: "This is the first time that pharmacists are really moving beyond the traditional dispensing role. It is one of the first services that all pharmacists can provide as part of an extended role."

Patient group directions

Patient group directions are supposed to have offered a new way for patients to access medicines through health professionals other than doctors. It was expected that smoking cessation would be one such area where pharmacists would use PGDs to supply NRT on the National Health Service.

However, it has not happened. Miriam Armstrong says there are few, if any, areas with a PGD for supplying NRT in operation. "This is raising concerns because pharmacists are ideally placed to supply clients on low income with NRT directly (without them having to make an appointment with their GP first). It also provides the opportunity to supply NRT to groups who would benefit from having NRT but who currently fall outside the licence indications, for example, pregnant women and under-18-year-olds," she says.

As a consequence, the PHS is conducting a survey of pharmaceutical advisers, specialists and directors of pharmaceutical public health to try to ascertain the real level of use of PGDs — whether the PGD is written locally or adapted from the PHS sample PGD and service specification for the supply of NRT through pharmacies. Copies of any PGDs in use can be sent to the Pharmacy Healthcare Scheme (1 Lambeth High Street, London SE1 7JN, e-mail phs@rpsgb.org.uk).

However, the picture might not all be doom and gloom. Dr Maguire thinks that more PGDs might be used next year. Although none is currently in operation in Northern Ireland, he says that there has been interest in using the Pharmacy Healthcare Scheme's model PGD for supply of NRT. He points out that, under the old scheme, vouchers were widely used but that the PGD will provide an important tool for future pharmacy-supply of NRT on the NHS. "I think it will be six to 12 months before the use of PGDs is up and running."

Whether or not supply of NRT through PGDs by pharmacists becomes widespread, it is clear that pharmacists have a key role to play in smoking cessation. Local health care providers should support them wholeheartedly.