The Pharmaceutical Journal
Vol 270 No 7237 p273-275
22 February 2003

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Planning ahead: are customers sick of smoking?

By Naomi Kempner, MRPharmS

Pharmacists can prepare for this year's No Smoking Day, on March 12, with some new resources, fresh themes and a review of smoking cessation products

Nicotine Replacement Therapy — at a glance (PDF 300K)

There is a good chance that pharmacy customers who smoke are "sick" of their habit and would like to stop. In the United Kingdom, around 13 million adults smoke cigarettes — 29 per cent of men and 25 per cent of women. So pharmacists must have a good chance of helping at least some people to quit.

This year's No Smoking Day is on March 12. The organisers estimate that around one million smokers try to quit on the day, with an estimated 40,000 succeeding in the long term. They attribute the success of No Smoking Day to the specific target, focus and motivation for quitting. Following the findings of a new survey, this year's campaign theme asks smokers if they are "Sick of smoking?".

The survey, by the organisers of No Smoking Day, found that 72 per cent of smokers said they wanted to quit. Over 80 per cent would not smoke if they had their time again, largely because of health concerns — with good reason. Research now estimates the number of UK smoking deaths at about 120,000 each year and the annual cost to the National Health Service at £1.7bn.

Expense was another reason for regret. A smoker on 30 cigarettes a day will spend over £2,400 on their habit in one year, assuming a pack cost of £4.50.

The campaign

This year's No Smoking Day campaign pack is being sent to pharmacists via head offices (for multiples) and through local health promotion units or from NiQuitin CQ representatives (for independents). Pharmacists can also access material through the website www.nosmokingday.org.uk or by telephoning 0870 7707909.

A chat room, www.sickofsmoking.com, has been set up for quitters themselves.

Modern technology can be a good friend for the quitter. There is a huge number of websites involving tobacco and smoking cessation. Some of the most useful are listed on p274. On the NHS website, www.givingupsmoking.co.uk, smokers can register to be supported through their cessation. The website links smokers with their local NHS stop-smoking services by postcode, including those provided by pharmacists, and gives good advice on how to give up and "staying stopped". The charity Quit also runs a useful website at www.quit.org.uk.

Alternative support is available through other sources such as the NHS Smoking Helpline on 0800 1690169 or the Quitline (run by Quit) on 0800 002200 — also available in several Asian languages (see website for details).

Product-allied websites can be accessed for individual smoking cessation therapies.

Recent developments

Since last year's No Smoking Day, there have been a few new developments in smoking cessation. Perhaps the major news, announced last April, is that the National Institute for Clinical Excellence has endorsed the prescription of bupropion (Zyban) and nicotine replacement therapy (NRT). This is for smokers committed to stopping on, or before, a certain date. These prescriptions should last until two weeks after the stop date, with subsequent supplies only for those showing they are still trying to quit. For those unsuccessful in their attempt, NICE recommends a wait of six months before giving a further course of bupropion or NRT.

In August 2002, the Government claimed that around 100,000 people had given up smoking from between April 2001 and March 2002, with help from the NHS — around half those attempting to stop. It had spent over £50m on smoking cessation services up to that time and committed a further £20m this year, in addition to the cost of prescriptions for smoking cessation therapies.

November saw the launch of glycerine-based drops, NicoBloc drops, aimed at trapping nicotine and tar before they enter the body (see "Products" section). These do not have a medicines licence and are sold as a food grade product.

November also saw the launch of two publications from the group Smoking Cessation Action in Primary Care (SCAPE) — aimed largely at general practitioners. A booklet, "In the clear", gives guidance from ex-smokers themselves, including celebrities, on how to quit (available by calling 0800 221441). A new GP guide on smoking cessation consultations includes several tips that could be particularly useful to pharmacists involved in smoking cessation programmes. SCAPE's key acronym, FAGS, advises GPs to:

• Find the smoker: ask "Do you smoke?"

• Advise them to quit

• Give treatment

• Support with follow up

The guide, sponsored by GlaxoSmithKline is available by calling 020 7331 2323.

Pharmacy support

Although several pharmacies run smoking cessation clinics, more informal support can be given on a day-to-day basis. Tips for quitters are given in the Panel below.

The most successful way to help smokers stop appears to be with a combination of intensive support, such as a smoking clinic, plus bupropion or NRT. Research indicates that 13 to 19 per cent of smokers will stay off cigarettes with this programme at six months. The effect drops to 5 to 7 per cent at six months with only NRT or intensive support, and only 1 to 2 per cent with an anti-smoking leaflet or brief advice from a GP.

Although success rates are not huge, they are worthwhile because of the high risks of smoking. A UK study of smoking cessation estimates a cost of between £212 and £873 per life year saved.

NRT Pharmacists recommending smoking cessation products are likely to turn to nicotine replacement products because of their availability over the counter combined with efficacy data. There are currently six types of NRT available. These are summarised in a PDF file (300K).

There are some data showing that the different delivery methods are equally effective, though manufacturers may cite trials with differing efficacies. Patches are discreet, delivering a continual supply of nicotine, while the gum, inhalator and spray are useful to satisfy acute cravings. Lozenges and microtabs are also discreet, with doses easy to adjust.

Bupropion Bupropion (Zyban) under prescription is now firmly established in smoking cessation programmes. Its action on the central nervous system helps break addiction to nicotine.

The quit day is set during the second week of treatment. The usual dose is 150mg daily for six days, then twice a day, with a treatment course of two months. Users should discontinue therapy if abstinence is not achieved by week seven.

Despite safety concerns, a review by the European Agency for the Evaluation of Medicinal Products, published last summer, concluded that bupropion had a favourable risk:benefit balance as an aid to smoking cessation.

The Committee on Safety of Medicines reminds pharmacists and prescribers that bupropion is contraindicated in patients with a history of seizures or of eating disorders, a CNS tumour, or who are experiencing acute symptoms of alcohol or benzodiazepine withdrawal.

Bupropion should not be prescribed to patients with other risk factors for seizures unless the potential benefit of smoking cessation clearly outweighs the risk. Factors that increase the risk of seizures include concomitant administration of drugs that can lower the seizure threshold (eg, antidepressants, antimalarials, antipsychotics, quinolones, sedating antihistamines, systemic corticosteroids, theophylline, tramadol), alcohol abuse, history of head trauma, diabetes and use of stimulants and anorectics

Combination therapy Current Committee on Safety of Medicines advice is that there is insufficient evidence to recommend the combined use of NRT and bupropion. A recent Health Development Agency document gives advice on combination therapy and NRT use in high risk groups (see News p260).

Nicobrevin Nicobrevin 28 Day Capsule Course is a general sale list licensed product formulated to help relieve the withdrawal symptoms of giving up smoking. It contains quinine, menthyl valerate, camphor and oil of eucalyptus. There is little evidence of its long-term efficacy though it is not thought to be harmful.

Other products Dummy cigarettes, herbal cigarettes, filters, mouthwash and herbal chewing gum are non-nicotine methods said to help quitters. However, there is little clinical evidence to prove their efficacy. New to the market are NicoBloc drops, designed to trap nicotine and tar when applied to the filters of cigarettes immediately before smoking. One drop is used on week one, two drops on week two, etc, to wean smokers off the effects of nicotine. Clinical studies are cited by the manufacturer but, as mentioned previously, this is not a licensed medicine.

Alternative therapies Acupuncture and hypnotherapy are complementary therapies often regarded as useful for quitters. However, there are no reliable trials for these methods. This caveat also applies to a new laser treatment aimed to stimulate endorphins.

Cold turkey Of course, quitters can also go "cold turkey", although research suggests this approach will not be as successful as methods using support or clinically tested therapies, many of which can be supplied through the pharmacy.

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