Pharmacy support staff could offer advice and support to more smokers than ever, if pharmacy gets behind the tobacco harm reduction guidance recently published by NICE

Every day, smokers decide that they want to quit, and quite often the local pharmacy is their first port of call for advice and guidance. Reasons for this include knowing that judgement won’t be passed on their decision to smoke, and feeling that they will be given the time and space to explain their habit so someone with in-depth knowledge can make an appropriate and personalised recommendation.

The backdrop to this has always been clear: smoking is bad, and quitting is good. Yet in between these two extremes of happy smokers and healthy abstainers, there has always been a sliding scale. Within this grey area are those who know smoking is harmful but are not ready to give up, those who have tried and failed to quit the habit, and those who encounter situations when smoking isn’t permissible but who are keen to carry on otherwise. These groups have been tricky for pharmacy to handle. Until now, that is.

Last year, the National Institute for Health and Care Excellence – the body that produces independent and evidence-based guidance on providing high quality and cost effective health and social care services, more commonly known as NICE – issued a document that described how to help smokers who didn’t want, or were not ready, to give up smoking. The guidance explained several ‘harm reduction’ approaches:

• Stopping smoking, using one or more licensed nicotine containing products (NCPs) for as long as needed to prevent relapse
• Cutting down to quit, with or without the use of licensed NCPs, again for as long as needed
• Smoking reduction, either on its own or with the help of licensed NCPs for as long as required
• Temporary abstinence from smoking, either with or without the use of licensed NCPs – for example, while at work, or during a hospital stay or long haul flight.

At first glance, this seems a big change from the ‘abrupt quit’ model, which was previously the only way in which smokers could be supported. But Professor Robert West, who was part of the programme development group that worked on the NICE guidance, explains: “The vast majority of people want to stop smoking but not necessarily straight away. The main reason for encouraging them to cut down, even if they are not ready to stop altogether, is that research has shown that it is a potentially useful step towards their long-term goal of quitting.”

Nicotine products

Nicotine-containing products are helpful to reduce smoking, emphasises Professor West, who is director of tobacco studies at University College London’s department of epidemiology and public health: “Fifty per cent of smokers are trying to cut down, but with little obvious benefit unless they use a nicotine containing product. Don’t be worried about someone using several different products – for example, if a customer says that they are struggling on patches because they still crave a cigarette at certain times of the day, recommend they add in a faster-acting product such as gum to use at those moments.”

Professor West, who is also the author of a new book, The Smoke Free Formula, which tells smokers and health professionals about the best ways to stop smoking, including information on the recent NICE guidance, adds: “Pharmacy staff also shouldn’t worry about how long someone needs to use nicotine containing products for. They should be allowed to use them for as long as they feel they need to.” This is supported by the product licenses for NCPs, which do not place restrictions on duration of use.

Fifty per cent of smokers are trying to cut down, but with little obvious benefit unless they use an NCP

This last point – the safety of long-term nicotine – is hugely important. Because stop smoking services have traditionally focused on an individual first quitting cigarettes and then any medication that they are on after a few weeks or months; the implication has been that nicotine is harmful. But the truth is that there is a lack of evidence that medicinal nicotine causes cancer or poses a significant risk for cardiovascular events. Certainly, nicotine-containing products are safer and better for someone’s health than the thousands of chemicals in tobacco smoke.

One of the latest innovations in the nicotine-containing products market is the controversial electronic cigarette, which many pharmacies are struggling to decide whether or not to stock. On the one hand, the products are not licensed, but on the other hand, they are popular with many people who have found them a useful quit tool where other products have failed. In fact, it is believed that some 1.3 million people in Britain have switched from smoking cigarettes to using the electronic devices.

Professor West offers some advice on the matter: “As a professional, you should direct people towards licensed products, but if smokers are keen to try something else it is sensible to suggest e-cigarettes with the proviso that there is huge variation between products, and the person may need to try a few before they find one that works for them.

My advice is to use what is known as a second generation product. These feature a rechargeable battery and refillable e-liquid container. These tend to give better nicotine delivery and work out cheaper.” These products also offer flexibility, in that the user can choose the liquid strength, how hot the element gets and the flavour.

Prescriptions for steroid inhalers are an obvious opportunity to discuss smoking habits

Awkward questions

It is easy enough to talk about products and services to help smokers when they come in and ask for advice, but what about those customers who don’t? How can the topic be raised without the customer feeling awkward, put on the spot or, worse still, judged and defensive?

Darush Attar-Zadeh, pharmacist and national trainer specialising in smoking, suggests using product requests as a trigger: “If someone asks for a cough medicine or cold sore treatment, ask if the customer lives with a smoker, and then go on to explain that exposure to smoking can make these conditions worse or harder to treat.” This is a much more diplomatic approach than asking the customer directly if they smoke, he says, but will usually lead to them saying whether they do or not. “Once you have reached this point in the conversation, you can adopt the usual “ask, advise, act” approach by informing the customer that they are four times more likely to successfully quit smoking if they use an NHS programme,” he states.

Another way to bring up smoking is to look at the prescriptions that patients bring in for dispensing, says Darush: “Steroid inhalers for asthma are an obvious example of an opportunity to ask if anyone in the household smokes, explaining that reducing smoking exposure or consumption can make a big difference to symptoms. But there are also some drugs to look out for, such as insulin, warfarin, clozapine, olanzapine and theophylline. All these interact with smoking, and explaining that quitting may lead to the patient needing a lower dose and therefore put them at a lower risk of side effects can be very effective.”

Another group of patients who can be targeted to help are those with mental health conditions. Darush points out: “Many people with mental health issues smoke as a way of relieving tension and anxiety, and it does have that effect. But the body quickly starts to experience withdrawal from the nicotine, which makes the person irritable, their stress levels start to go up, and then their mood drops.” Describing this process can be a powerful motivator to cutting down or quitting, he adds.

Professor West highlights the important role pharmacy staff also have in assisting those already using nicotine-containing products. “Ask how the customer is getting on with the product, keeping in mind that they may need advice on how to use it. Products such as gums and inhalators seem simple, but in fact can be quite difficult to get to grips with, so compare them to other medicines such as antibiotics, which people understand have to be taken correctly and for long enough to get the maximum benefit.”

Personal service

The constant stream of people through pharmacies means that there are always potential recruits for stop smoking services and product recommendations, but the added extra is the familiarity that pharmacy staff enjoy with their customers.

Charlotte Dear, an accuracy checking technician, says the success of the service run at Victoria Park Pharmacy in Dorchester is the personal touch that they offer to customers: “Everyone is different and gives up smoking differently. We get to know the patients before getting into the rules of it all, otherwise they just get put off. Our customers feel like they know us, so they are comfortable being honest with us, even if it means they tell us they had a sneaky cigarette.” This tactic is clearly working, as illustrated by the pharmacy’s quit rate of over 60 per cent, and its excellent local reputation as numerous referrals from GP surgeries and others attest to.

Robin Mitchell, pharmacy manager at Victoria Park Pharmacy, is quick to praise his staff for their methods: “It’s all about engaging with smokers on their terms. Different people have different needs, with some asking to almost be bullied into quitting and others needing to be coached gently, while there is also a group that are not ready to give up yet and need space to figure it out. The approach whereby the whole team identifies candidates and our technician ‘champions’ lead the service with support from a pharmacist as necessary works best. We always leave the patient in control of their own quit attempt, providing a friendly and accessible service.”

Don't forget quits

The NICE guidance of last year has certainly put the focus onto tobacco harm reduction, but it is important not to forget about the traditional abrupt quit method, which remains the recommended option for smokers. Smoking trainer Darush says: “A good way to think of it is like a flick of a switch in your mind. Ask the smoker how much they want to give up on a scale of one to 10, and how confident they feel about it, using the same measure. If they are feeling ready and confident about their chances of success, put them on that path.”

Darush continues: “For those who say they are ready but are low in confidence, or are not ready, flick the switch in your head from quitting to harm reduction and explore what they feel they need to do to be more ready or confident.” Professor West agrees that harm reduction is about offering an alternative instead of replacing one strategy for smokers with another: “Rather than undermining quitting, the harm reduction approach means that now there is something on offer for everyone who smokes.”