Smoking rates have more than halved in Britain since 1974, when 51 per cent of men and 41 per cent of women smoked. Around 20 per cent of people now smoke (20 per cent of men and 17 per cent of women), representing 9.6 million people.
However, one thing hasn’t changed and that’s the damage that smoking can do to a person’s health. Smoking still causes 17 per cent of all deaths among people over 35 years of age, which equates to around 78,000 deaths every year. Moreover, 33 per cent of deaths are from conditions that could be caused by smoking. To put that into perspective, 55 per cent of cancer deaths and 37 per cent of all deaths from respiratory diseases are estimated to be attributable to smoking.
Equally worrying are the inequalities that exist among different population and socio-economic groups. For instance, smoking rates are much higher among poorer people. In 2014, 13 per cent of adults in managerial and professional occupations smoked compared with 30 per cent of people in routine and manual occupations. And in Scotland, smoking prevalence in the most deprived areas remains disproportionately high at 40 per cent compared with 11 per cent in the least deprived areas.
There is also a noticeable difference in smoking prevalence when it comes to age. Many would think that today’s youth are immune to the lure of tobacco, since they live in an age when advertising cigarettes has long been banned, smoking in pubs and restaurants is a distant memory and the dangers of smoking are well documented. However, while older people are more likely to have smoked at some point in their lives, most of them have given up, and smoking prevalence is actually highest in those aged 25-34 years, with two-thirds of smokers starting before the age of 18. Evidence shows that the younger an individual starts to smoke, the more likely they are to be an adult smoker, the more heavily they are likely to smoke during adulthood and the more likely they are to fall ill and die early as a result of smoking.
So what can be done to encourage younger smokers to use smoking cessation services and, importantly, dissuade them from lighting up in the first place?
“Middle-aged and older smokers are more likely to use stop smoking services, but obviously the whole age range is represented and catered for,” says Amanda Sandford from public health charity Action on Smoking and Health (ASH). “Being dependent upon tobacco means that an individual’s motivation to quit fluctuates, but when it is strong and someone wants to quit, we need to ensure that they have the best possible chance of quitting successfully.”
Amanda adds that figures show year-on-year falls in the prevalence of smoking among young people, which suggests that tobacco control policies are having an impact.
Importantly, however, young people are influenced by the smoking habits of adults: “We know that one of the best ways of preventing young people from taking up smoking is to have fewer adults smoking,” says Amanda. “So, when the stop smoking service helps a parent or carer to quit, they are also contributing to preventing the young people these clients care for becoming smokers.”
Reducing the number of people who smoke isn’t just about one approach however – it’s about a series of tobacco control measures. For example, the UK Government’s strategy is a three-pronged approach: prevention, protection, cessation. This includes a ban on smoking in public places, plain packaging, increasing the age at which tobacco can be purchased, point-of-sale display bans, increased taxation, public health campaigns and smoking cessation services in pharmacies.
In Scotland, the national smoking cessation service is part of the Public Health Service element of the community pharmacy contract. It’s a free 12-week programme of support, where people are provided with nicotine replacement therapy (NRT) or varenicline under a patient group direction (PGD) where appropriate, and provided with support and encouragement from the pharmacy team. In England, while there is no nationally commissioned smoking cessation service, these are widely commissioned locally, with 93 stop smoking services available across the different local pharmaceutical committee (LPC) areas. This means that at least 76 per cent of LPCs have a stop smoking service, and at least 31 per cent of LPCs have an NRT and/or varenicline voucher scheme service in their area.
The question is: are campaigns and services working? “To be successful, campaigns need to be clear in their aims: to educate, raise awareness, prompt action,” says Amanda. ”Stop smoking campaigns usually do a combination of these, but they are most effective when they prompt action to quit and where they signpost help – quit with your local stop smoking service.”
In 2014/15, there were 66,756 quit attempts made with the help of NHS Scotland smoking cessation services, with one in five (12,692) people remaining smoke free at three months – a quit rate of 19 per cent. Of all these quit attempts, 60 per cent were made in the most deprived areas in Scotland.
In England, the number of people using stop smoking services continued to decline in 2015/16, with 382,500 people setting a quit date through the NHS Stop Smoking services – down 15 per cent compared to the previous year. In fact, this is lower than the number of people setting a quit date 10 years ago when it was 529,567. This follows a trend of recent years, which may be partially explained by the uptake of e-cigarettes, which as yet are not being used for NHS stop smoking services. According to NHS statistics, self-reported quit rates at four weeks were 51 per cent, with the success rate increasing with age – 43 per cent for those aged under 18 successfully quitting compared to 57 per cent of those aged 60 and over.
“The English stop smoking services have been shown to be very effective, particularly in helping people from more disadvantaged backgrounds,” says Amanda. “For this reason, ASH is particularly concerned about local authorities reducing, or in some cases cutting, their smoking cessation services altogether. Some have cited falling attendance to justify the reduction in service, but we believe this is a false economy, based on a false premise.
“Stop smoking services provide a clinical service for people who are tobacco dependent, and they should really be evaluated on the quality of this clinical service and not by how many people they see.
“Pharmacists have a key role to play as they have direct contact with the public, particularly those who may not have received advice from other healthcare professionals,” adds Amanda.
NRT – nicotine replacement therapy (NRT) has been the mainstay of smoking cessation treatment for many years. Available in a variety of formats: patches, tablets, lozenges, sprays, and inhalators, to suit people’s different needs, it replaces the addictive nicotine in tobacco without producing the harmful effects, reducing cravings when people stop smoking. Normally, a course lasts for around 12 weeks, and the dose of nicotine is gradually reduced over this time.
Varenicline (Champix) – working differently from NRT, Champix reduces cravings and the enjoyment felt when smoking, making it less desirable. Available only on prescription, or by patient group direction (PGD), patients normally set a quit date and start taking the tablets one to two weeks before that and for a further 10 weeks. It has more potential for adverse effects and drug interactions than NRT.
Buproprion (Zyban) – available only on prescription, it is not known exactly how buproprion reduces cravings. Like varenicline, patients set a quit date and start taking the drug one to two weeks before that. Treatment normally lasts for a couple of months.
E-cigarettes – these electronic devices deliver a vapour of nicotine, but without the harmful chemicals in tobacco. There are currently no devices available on prescription, but there is evidence that they are effective at helping people to stop smoking.
E-cigarettes are a relatively new option, and some questions about their long-term safety remain, so should pharmacies sell them? “E-cigarettes are used almost exclusively by smokers and ex-smokers to help them cut down, quit smoking and, in the case of ex-smokers to prevent relapse to smoking. With an estimated 2.8 million users in the UK, it’s important that the healthcare sector builds on this popularity to improve public health. This means taking an evidence-based approach to e-cigarettes and not discouraging their use,” says Amanda Sandford from Action on Smoking and Health.
Community pharmacies already play an important role by providing access to stop smoking services, information and advice, as well as encouragement and support for people wanting to quit. Moreover, we know that smoking is most prevalent in the least deprived areas, which are usually well served by community pharmacies. Encouragingly, a Royal Society of Public Health survey of more than 2,100 adults also showed that 67 per cent of people were comfortable accessing stop smoking services from their local community pharmacy.
But there is still a lot of work to be done to reverse the decline in use of NHS smoking cessation services. There’s no denying that quitting smoking is the best thing people can do for their health. It will also help to reduce the huge burden on the NHS, so perhaps it’s time to look at how community pharmacy can help people who have turned their backs on NRT and prefer to use e-cigarettes instead.
Leanne Beverley, pharmacy technician at Monarch Pharmacy in Coventry, shares her experiences of how to reach young people to help them stop smoking
Pharmacy is in an ideal place to be able to help most young people stop smoking or prevent them from starting. We change our style of conversation when the patient is younger and we make them feel completely at ease – as if they are talking to a friend. We also tailor the questions of the nicotine dependence questionnaire to their age – for example, asking them what kind of job they want to do when they leave school, and how smoking would affect this in the long term; how they feel when doing PE lessons or when playing football/rugby, and how smoking could be playing a massive part in them feeling unfit or why they get out of breath.
We use text messages and emails to support the young person in between appointments too. Ease of access is a massive issue for young people, so we must make sure we use avenues they can relate to and connect with.
Going to the source
As a lot of funding has been cut around youth clubs, youth services and even school nurses, pharmacy has to step up to help this next generation become a generation of non-smokers. At Monarch, we pride ourselves on going the extra mile, so we don’t just rely on young people coming to see us, or even the good rapport we have with the student liaison officer at the local school, who will bring students to see us. We go out to see them.
A few years ago, I was approached by Coventry Healthy Lifestyle Services (part of the NHS) to run a 12-week programme at a local school. I was given broad guidelines for what to cover – for example, the dangers of smoking and shisha, e-cigarettes, the benefits of stopping smoking and the products and services available to help them do so.
Each week I attended these after-school sessions once I’d finished work at the pharmacy. I used messages and powerful images through presentations and talks that led to a strong emotional reaction and portrayed tobacco as a deadly product, in line with NICE guidance. I concentrated on a different topic each week and included practical demonstrations, including getting the young people to do carbon monoxide tests to see the effect smoking had. In the last two sessions, I helped them design and draw posters to encourage other young people to stop smoking. I found that even though some of the young people were loud and acted a little uninterested, they had learnt something. Others told me how they explained what they had learnt to family members who smoked and had encouraged them to book appointments at a pharmacy. Unfortunately, no more funding has been available for similar programmes to be set up.
Once a week, I also used to visit a local school at lunchtime. I would sit in the communal area with a display of products, some ‘jars of tar’ and other promotional materials. I would sign young people up to the stop smoking service and do a follow up each week at the school. I also dropped leaflets and promotional material to another school to encourage conversations about smoking.
Most recently myself, Sue – another stop smoking advisor at Monarch Pharmacy – and our pre-registration pharmacist Justin visited a local engineering college. We managed to get a cigarette costume from Coventry Healthy Lifestyles and had a couple of tables in the foyer where we spread out leaflets and products. It was a very lively session: we let the young people do carbon monoxide tests and were really able to engage them in conversations about the dangers of smoking and the effects it is having on their health. A couple of them started a stop smoking programme with us and we’re hoping to work together with the college in the future to provide these services to as many young people as possible.
I think schools, training colleges and universities should be utilised to attract young people. I feel media campaigns are very much aimed at adults – in particular TV adverts – and do not appeal to young people. And while we do go the extra mile, it could be difficult for other pharmacies to do the same. Funding is a massive issue.
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