Despite smoke-free legislation, countless public health initiatives and numerous alternatives, an estimated 10 million adults in Great Britain still smoke. How can pharmacy get involved in tackling the smoking epidemic?

Each year, more than 100,000 adults die from smoking-related causes, including cancers, respiratory ailments and cardiovascular diseases. Indeed, smoking-related conditions eventually kill about half of all smokers. The tide, however, might be turning.

In 1974, 51 per cent of men and 41 per cent of women smoked. Today, rates have fallen to 22 per cent and 17 per cent respectively. As the continuing death toll suggests, however, there’s no room for complacency. So, a recent report – Smoking Still Kills – published in June by 120 public health organisations, set out a vision “in which the smoking epidemic is finally brought under control”.

Smoking Still Kills proposes that by 2035, no more than five per cent of adults in England should smoke. This means cutting the proportion of adults who smoke to 13 per cent by 2020 and nine per cent by 2025. Community pharmacies could have a major role in meeting these challenging, but attainable, targets.

Smoking and deprivation

Local pharmacies are close to the heart of their communities and meet their population’s needs, whether they’re in the wealthiest parts of Westminster or the poorest parts of Paisley. So, community pharmacies are ideally placed to tackle the high rates of smoking among poorer people. Overall, people from the poorest backgrounds are more than three times more likely to die prematurely than the most affluent.

Numerous diseases and lifestyle factors drive this inequality. Smoking, however, accounts for more than half the difference in premature deaths. As Smoking Still Kills notes, a non-smoker from the least privileged group has a better chance of survival than a smoker from the most privileged.

Nevertheless, according to the Office for National Statistics, in 2012, men and women in the most deprived areas of England were more than twice as likely to smoke (32.9 per cent and 26.1 per cent respectively) than those in the least deprived areas (14.3 per cent and 10.2 per cent respectively). Smoking Still Kills suggests reducing smoking in the ‘routine and manual’ socioeconomic group to 21 per cent by 2020 and 16 per cent by 2025. In addition, several other groups smoke disproportionately, including people with mental health problems and those suffering from other long-term conditions.

Smoking Still Kills says that smokers in these groups should receive help to stop smoking as a routine part of their care. Pharmacies can use MURs and other enhanced services to deliver stop smoking interventions to these patients.

Myths and misconceptions

Pharmacy staff and other health professionals should be equipped to provide accurate, high-quality information and advice about the relative risks of nicotine and nicotine-containing products, Smoking Still Kills suggests. Certainly, myths and misconceptions are common. For example, a survey for the Royal Society for Public Heath (RSPH) found that 90 per cent of non-smokers and 78 per cent of smokers believe nicotine is harmful to health.

However, the RSPH remarked that: “In low concentrations, nicotine is not deleterious [harmful] to health”. Nicotine, for instance, does not seem to be a carcinogen (cancer-causing chemical) or increase the risk of acute cardiovascular events, such as heart attacks or strokes. “Scientists have known for many years that it’s the smoke in cigarettes that’s deadly, not the nicotine,” says Hazel Cheeseman, director of policy at Action on Smoking and Health (ASH).

“Unfortunately, this is not yet well understood by smokers, medical professionals or the media, many of whom still think nicotine causes cancer and heart disease. The persistence of this misconception will cost lives as smokers, who otherwise would switch to alternative sources of nicotine, are put off. The time for this misunderstanding to be put right is long overdue.”

A smoker-centred approach

Against this background, pharmacy teams can adopt a ‘smoker-centred approach’ to help individuals quit. In some cases, this means referring people to NHS smoking services. According to ASH, smokers supported by local stop smoking services are four times more likely to quit than those who try unaided.

Between April 2014 and March 2015, however, 450,582 people set a quit date with the stop smoking services in England, a 23 per cent reduction on the previous year and the third consecutive year to show a fall. “The stop smoking services provide a vital service to smokers seeking help to quit,” Hazel adds.

“However, there is a risk that the decline in use could increase health inequalities as smoking is one of the biggest causes of the difference in health outcomes between the rich and the poor. Local authorities need to ensure that their stop smoking services are reaching those with the greatest need.” For other people, a ‘smoker-centred approach’ could mean encouraging appropriate use of nicotine replacement therapies (NRT).

According to Will Smoking Meet its Match? – a report from University College London (UCL) School of Pharmacy – NRT and other smoking cessation medicines are often under-used and “the doses received fail to provide clinical benefit”. A range of NRT, including gums, patches, inhalators and nasal sprays, are available over the counter and pharmacy teams can help smokers find the right combination for their individual needs.

In other cases, Smoking Still Kills suggests a ‘smoker-centred approach’ should help those unable to quit to switch to less harmful sources. E-cigarettes, for example, lack most of the harmful chemicals in tobacco smoke, and they’re certainly popular.

ASH estimates that 2.6 million people in Great Britain use e-cigarettes regularly. Yet e-cigarettes remain controversial.

E-cigarettes: friend or foe?

According to ASH, tobacco smoke contains more than 7,000 chemicals, including carbon monoxide, formaldehyde, arsenic, cyanide and 70 carcinogens. Essentially, smokers smoke for their nicotine fix, but die from the tar. The RSPH noted in a briefing document that some researchers describe nicotine “as the third strongest ‘dependence-forming drug’, behind heroin and crack cocaine”.

Reducing exposure to tar by providing the nicotine smokers crave should reduce the harm. Smokers can then wean themselves off the nicotine. The UCL report suggests that e-cigarettes probably helped 20,000 people to quit in 2013/14 who would have not otherwise stopped. Indeed, 66 per cent of people who quit using stop smoking services did so using e-cigarettes.

E-cigarettes seem rarely to encourage tobacco use or vaping by non-smokers, two of the main concerns about vaping. Recently, the Health and Social Care Information Centre (HSCIC) reported that awareness of e-cigarettes increased from 80 per cent of 11-year-olds to 93 per cent of 15-year-olds. Thirty-five per cent of 15-year-olds had tried e-cigarettes, but just two per cent of 15-year-old boys and three per cent of girls used them regularly (at least once a week).

A PHE report suggests e-cigarettes are 95 per cent safer than cigarettes

 

Most of those who tried them already used tobacco – 89 per cent of regular smokers had tried e-cigarettes compared with just 11 per cent of those who had never smoked. By way of comparison, 18 per cent of pupils had tried smoking regular cigarettes at least once. “This is the lowest level since the survey began in 1982 and continues the decline since 2003, when 42 per cent of pupils had ever used cigarettes,” notes HSCIC.

Against this background, Public Health England (PHE) recently published an independent review “to ensure that practitioners, policy makers and, most importantly of all, the public have the best evidence available”. PHE suggests that, for smokers who cannot or do not want to stop, switching to e-cigarettes “could help reduce smoking related disease, death and health inequalities”. People who attempted to quit and failed with other methods “could be encouraged to try e-cigarettes”, it says.

In addition, the report calls for stop smoking services to offer behavioural support for those using e-cigarettes to quit. “While smoking cessation services continue to be the most successful way to help people stop smoking, the highest successful quit rates are being seen among smokers who are also using e-cigarettes. Providing healthcare professionals with accurate advice and information on their use is necessary if we are to unlock the full potential of e-cigarettes in helping people to kick their habit,” comments Dr Penny Woods, chief executive of the British Lung Foundation.

“Concerns do remain as to the long-term health impact of e-cigarettes and while there is no evidence to suggest that they pose anywhere near the same dangers as smoking, we must continue to monitor this area carefully. In the meantime, we do advise that anyone using e-cigarettes to quit smoking should do so with a view to eventually quitting them too.”

A controversial figure

The PHE report notes that “while vaping may not be 100 per cent safe, most of the chemicals causing smoking-related disease are absent and the chemicals which are present pose limited danger. It has been previously estimated that [e-cigarettes] are around 95 per cent safer than smoking. This appears to remain a reasonable estimate”.

Despite this best estimate, we still don’t know the long-term risks and the hard evidence needed to reach a firm conclusion about harm will probably take decades to emerge. Indeed, The Lancet (2015;386:829) strongly criticised PHE’s figure, noting that the 95 per cent derives from “the opinions of a small group of individuals” who attended a workshop and “an extraordinarily believe they should not be sold or advertised from pharmacies,” says RPS director for England Howard Duff.

“We echo the views of PHE and support the original intention of The Medicines and Healthcare products Regulatory Agency to regulate e-cigarettes as medicinal products as an aid to smoking cessation. The licensing process would align e-cigarettes with other nicotine reduction therapies and ensure quality control and standardisation of products.”

“E-cigarettes contain less harmful toxins than tobacco, but still contain nicotine, which is an addictive substance. As they are a very new product, no-one can be sure of the consequences of long-term use on health and further research is needed.”

Legal changes

No single approach can tackle the smoking epidemic. Legislation, in particular, needs to support innovations in technology and improved services. For example, there’s no doubt that the 2007 ban on smoking in public places in England improved the nation’s health – and not just among smokers.

For instance, smoking in the home by adult smokers dropped from 65 per cent to 55 per cent within six months of the ban on smoking in public places in England. And the number of smoke-free homes lived in by children whose parents smoked increased from 34 per cent to 41 per cent within a year of the ban. So, the ban helped reduce the risk of passive smoking by other members of the family.

Second-hand smoke, for instance, increases the risk that children will develop respiratory tract infections (RTIs), such as bronchitis, bronchiolitis and middle ear infections. Indeed, research published in September suggests that the ban seems to have reduced hospitalisations for RTIs in children less than 15 years of age by about 11,000 a year.

“Our results add to the growing body of evidence demonstrating the benefits of smoke-free legislation,” remarks lead author Jasper Been, honorary research fellow at the University of Edinburgh’s Centre for Population Health Sciences. “Although our results cannot definitively establish a cause and effect, the rigorous analysis clearly shows that the introduction of smoke-free legislation was associated with significant reductions in hospital admissions among children.”

Many other legislative changes are underway to create smokefree environments. As of 1 October this year, smoking in cars carrying children will be illegal, and some councils are considering banning smoking in outdoor public spaces. Meanwhile, a proposed Welsh Government Bill suggests: “Restricting the use of nicotine inhaling devices such as electronic cigarettes in enclosed and substantially enclosed public and work places, bringing the use of these devices into line with existing provisions on smoking”.

The 2007 smoking ban has had a significant impact on cigarette use

 

It doesn’t add up…

Meeting the challenging vision in the Smoking Still Kills report depends on increased investment, focused especially on tackling inequalities. Yet the report comments that in some areas, funding for tobacco control and stop smoking services are declining.

This doesn’t add up. In England alone, smoking probably costs at least £13.8 billion annually, including health and social care costs arising from smoking-related illness, lost productivity and smokingrelated fires. ASH notes that in 2013-14, the Government received £9.5 billion from tobacco tax (excluding VAT). Yet in 2012-13, the Government spent just £87.7 million on smoking cessation services and a further £58.1 million on stop smoking medications.

The vision laid out in Smoking Still Kills is challenging, but based on historical trends it’s certainly attainable. However, there is still a long way to go and everyone, including policy makers, politicians and pharmacy teams, needs to maintain the momentum to ensure it is achieved. After all, by this time tomorrow, another 200 people will have died from smoking-related disease – or, to look at it another way, tobacco will have taken yet another life since you started reading this article.

Find out about how pharmacies can get involved in tackling the smoking epidemic through this year's Stoptober campaign, which begins on 1 October.

Scientists have known for many years that it’s the smoke in cigarettes that’s deadly, not the nicotine.