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Warnings on cigarette packs encourage smokers to think about giving up
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Those who have read the latest report penned by Derek Wanless (see p274)
might be disappointed to see barely a mention of pharmacy. This seems
rather odd after the encouraging noises made about pharmacy’s public
health role in the Government report “Vision for pharmacy in the
new NHS” (PJ, 26 July 2003, p106). But maybe it is what pharmacy
has come to expect from those outside the profession.
Miriam Armstrong, chief executive of PharmacyHealthLink, does not think
pharmacists should be unduly worried about the omission of pharmacists
from the body of the Wanless report. She explains that the report’s
main focus is on health outcomes. In other words, Wanless was not necessarily
looking at how services should be provided or who should provide those
services. Rather, he was concentrating on what needs to be achieved and
in what areas the Treasury’s money can best be spent.
One area identified by Wanless as crucial to improving the nation’s
health is smoking cessation. Pharmacy-based services are already helping
the Government deliver on targets in this area and there is a growing
evidence base, something that Wanless says is generally lacking for public
health interventions.
Setting up a service
Ms McCreedy offers advice for pharmacists thinking
of setting up a smoking cessation service. “Knowledge of local NHS priorities
is key since the local primary care organisation is more likely
to fund a community pharmacy service development if it helps to
meet its targets.” It is also important to use any additional
Government policy papers as a lobbying tool.
The Health Development Agency has produced a guide for PCTs entitled “Meeting
DoH smoking cessation targets: recommendations for PCTs”.
It provides PCTs with information designed to help them plan how
to continue offering high-quality, evidence-based smoking cessation
services. “The report contains 13 recommendations, describes
numerous case studies — a significant number of which include
community pharmacy, and outlines key factors for a successful smoking
cessation service,” she adds. |
“There is undoubtedly a big role for pharmacy in smoking cessation,” says
Ms Armstrong. “We can expect to see many mentions of pharmacy in
strategy documents produced by the Department of Health in its response
to Wanless.”
Ms Armstrong also thinks it is significant that community pharmacists
are singled out in the executive summary of the report as health care
professionals who can make a greater contribution to public health. The
report states: “The role of self care, the development of the expert
patient, possibly playing a much greater role in assisting other patients,
and the role of community pharmacists will also need to be developed
to expand overall capacity.” When pharmacy is mentioned at all
in a broader context, anyone lobbying on behalf of pharmacy will appreciate
the significance, she says.
Colette McCreedy, director of pharmacy practice at the National Pharmaceutical
Association, agrees: “I do not think [pharmacy’s inclusion
in the executive summary] is an afterthought. Wanless singling out community
pharmacy is indeed intentional because the Government views pharmacy
as a currently untapped public health resource.”
When considering smoking cessation services, pharmacy’s contribution
is evident. It is a core part of many pharmacists’ professional
activities, and examples of good practice can be found across the UK
(see Panel 1).
Panel 1: Examples of good practice
Several areas across the UK have well established pharmacy-based
smoking cessation services. In Manchester, a primary care trust-funded
scheme involves 63 trained pharmacy advisers and is profiled in
our Vision for pharmacy series (see p286). In Croydon, community
pharmacist Andrew McCoig sits on the steering group of his PCT
and is actively involved in its smoking cessation scheme. In the
borough there are 22 pharmacies with trained pharmacist advisers.
Mr McCoig has helped 355 clients over the past two years and the
borough has a four-week quit rate of between 45 and 50 per cent.
The scheme is complemented by services run by practice nurses,
one doctor and a handful of specialist smoking cessation advisers.
Other examples of PCT-based schemes include those at Hillingdon,
Harrow and Hull PCTs. Perhaps significantly, all these PCTs have
a pharmacist sitting on their professional executive committees
(PECs).
Sally Hone, smoking cessation co-ordinator at Harrow PCT, says
that, unlike most other schemes, the Harrow service is mainly pharmacy-based. “We
looked at using GP-based schemes including group therapy but this
does not allow as many people to go through the service,” she
says. The scheme, which now involves 40 trained pharmacist smoking
cessation advisers, grew out of a pilot designed by five community
pharmacists and which was rolled out in November 2003. Pharmacists
in Harrow receive systems training and motivational counselling
training in line with national standards. The PCT is also working
with nicotine replacement therapy manufacturers to extend its training
capability.
Like pharmacists involved in the Manchester and Croydon schemes,
those in Harrow can supply NRT free of charge to eligible smokers.
Harrow uses a patient group direction to allow supply. Patients
exempt from prescription charges receive five weeks supply of NRT
free of charge. Those who are not exempt pay a one-off prescription
charge of £6.30. All clients fill out a pre-assessment form
that is sent to the PCT. Their progress is followed and feedback
is obtained to evaluate how well the service is received. The scheme
boasts a 60 per cent success rate for five-week quitters. At the
end of the five-week course, clients are referred back to their
GP for further supply of NRT on FP10 if appropriate.
Pharmacists in North-East London are also providing a co-ordinated
smoking cessation service. Hemant Patel, secretary to the local
pharmaceutical committee, estimates that between April and December
2003 local pharmacists helped over 2,000 people give up smoking. “Our
intention is to ensure that 90 per cent of the smoking cessation
capacity is community pharmacy based with an average quit rate
around 70 per cent [the four-week quit rate currently stands at
56 per cent].” |
An increasing number of pharmacists and pharmacy support staff are
becoming involved in formal smoking cessation services. Many more are
contributing
to the Government’s public health agenda by giving opportunistic
advice to smokers who are considering giving up their habit.
Proving pharmacy’s worth
Ms Armstrong and Ms McCreedy both agree that the evidence base for
pharmacy-based smoking cessation services is well established. As well
as the current
schemes being continually evaluated there is evidence from randomised
controlled trials to show pharmacy can be effective (see Panel 2).
Panel 2: Published evidence base for stop smoking services
Two UK randomised controlled trials, one conducted
in Scotland, the other in Northern Ireland, demonstrate that
there is good clinical
and cost-effectiveness evidence from the peer-reviewed literature
for pharmacy-based smoking cessation services. Abstinence rates
in the Scottish trial were 12 per cent for the intervention and
7 per cent for the controls at nine months,1 and in the Northern
Ireland trial, 14.3 per cent for the intervention and 2.7 per cent
for the controls at one year (P<0.001).2
Another study evaluated the Pro-Change adult smokers program in
one community pharmacy and three GP practices in Northumberland.
The service was particularly aimed at low income and unemployed
smokers. It involved an interactive multimedia computer program,
self-help material and support from trained health professionals.
The service reached the target audience of low-income smokers and
self-reported quit rates were comparable with other reported studies.
Using the service in the community pharmacy setting widened access
compared with provision in general practices alone — of the
258 people who accessed the service over the six-month pilot, 159
did so in the one community pharmacy compared with 99 in the three
general practices.
1. Sinclair HK, Bond CM, Lennox AS, Silcock
J, Winfield AJ, Donnan PT. Training pharmacists and pharmacy
assistants in the stage of
change model of smoking cessation: a randomised controlled trial
in Scotland. Tobacco Control 1998;7:253–61.
2. Maguire TA, McElnay JC, Drummond A. A randomised controlled
trial of a smoking cessation intervention based in community pharmacies.
Addiction 2001;96:325–31.
3. Anderson C. Pro-Change adult smokers program: Northumberland
pilot. International Journal of Pharmacy Practice 2002;10:
281–7. |
However, if the evidence base is to continue to grow, pharmacy needs
to co-ordinate its efforts. “There needs to be partnership between
the local pharmaceutical committees representing local pharmacists, schools
of pharmacy, and primary care trusts,” says Hemant Patel, secretary
to North-East London LPC. He adds that it is important that pharmacists
do not waste their time duplicating efforts. “There needs to be
a strategy for developing community pharmacy based models,” he
says. Where evidence already exists local pilots should not be conducted. “There
should be a commissioned service with good training and evaluation of
effectiveness and developing clinical governance standards.”
To address the training needs of pharmacists and their support staff,
PharmacyHealthLink, along with the Health Protection Agency, has developed
a national training standard for smoking cessation. Ms Armstrong says
it is important that staff are trained to nationally recognised standards
so primary care trusts have confidence in the standard of service being
commissioned.
The success being achieved by pharmacists in smoking cessation schemes
is impressive but Mr Patel has concerns. “It sometimes seems that
the NHS and workforce confederations are only interested in short-term
objectives rather than having an implementation plan for expanding and
retaining the clinical capacity in community pharmacy,” he says.
He believes that workforce planning is woefully inadequate. “Pharmacy
could be a much bigger player and help PCTs achieve targets but there
is no specific structured national plan to develop community pharmacy.”
Linked with concerns over short-term planning is the use of four-week
quit rates, which the Government uses to illustrate the success of smoking
cessation services. PharmacyHealthLink hopes the Government will continue
to use targets periods but would prefer them to be longer.
“An argument has been put forward that four weeks is too short,” says
Ms Armstrong. She suggests, instead, that three-, six- or 12-month quit rates
would be more appropriate. She has a point. When considering how cost-effective
smoking cessation services are, these four-week quit rates are used to inform
calculations of the cost per life year saved. But does this really give an accurate
picture when 60 to 70 per cent of the four-week quitters will have started smoking
again within one year?
Putting these concerns aside, it seems that pharmacy has got to grips with
service delivery for smoking cessation.
The message from Wanless is clear. Public health interventions must be based
on sound principles and good practices supported by evidence. Perhaps smoking
cessation is the model that will ensure community pharmacy is integrated with
the national public health strategy.
What’s more, it could be used by pharmacy itself as a model for service
delivery across the public health agenda.
Other strategies for tobacco control
Smoking cessation is just one strategy used to help people stop
smoking. Other strategies, either employed by the Government or
proposed
by public health bodies, include:
Tax measures
Tax on tobacco can curb smoking. It used to be the case that
for every 10 per cent increase made in tobacco taxation there
was a corresponding 3 per cent fall in consumption. With the
rise in smuggled and counterfeit cigarettes entering the UK
market tax increases do not have the same impact
Advertising campaigns
In 2002, newspaper, magazine and billboard advertising for tobacco
ended. This, together with a ban on in-pack promotion schemes
and tobacco-related sponsorship, may reduce smoking by up to
5 per cent over the long term.
Anti-smoking campaigns are also used to reduce smoking prevalence.
If sustained at a high intensity and frequency they may reduce
smoking prevalence by about 1 per cent
Smoke-free places
Measures to introduce smoke-free work places reduce exposure
to second-hand smoke and may reduce cigarette consumption by
making it harder for smokers to find somewhere to smoke. Wanless
suggests that a city or town in England should pilot a ban
on smoking in public places
Tobacco regulatory authority
PharmacyHealthLink, along with other public health organisations,
has called for a UK-wide tobacco regulatory authority. In a
letter sent to Health Minister John Reid last week, the charity
points out that, despite being the most deadly form of nicotine
delivery, the cigarette has remained largely unregulated |
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