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Holy smokes!

Whilst smoking prevalence has fallen across the UK since 2011, there is still a long way to go to reach its 2030 ‘smokefree’ target.

Smoking rates in the UK continue to fall while the proportion of cigarette smokers who have quit continues to rise, according to data from the Opinions and Lifestyle Survey published by the Office for National Statistics (ONS) in December 2021.

In fact, in December 2020, ONS recorded that just 12.1 per cent of the English population were smokers, a figure much lower than the World Health Organization’s (WHO) global estimate of 22.3 per cent.

Although UK figures continue to fall, there is much pharmacy teams can do to support those who continue to smoke. In the UK, the highest proportion of smokers are aged between 25-34, with smoking prevalence continuing to be higher in men than women. Scotland has the highest proportion of UK cigarette smokers (14 per cent), followed by Wales and Northern Ireland (both 13.2 per cent).

Health impacts of smoking

Physical health

Smoking is a risk factor for many cancers – particularly lung cancer – as well as respiratory and cardiovascular diseases. The latest NHS data suggests that 35 per cent of all deaths from respiratory conditions can be attributed to smoking. Additionally, smokers are also at risk from type 2 diabetes, eye disease and dementia. Smoking leads to decreased bone mineral density and is associated with an increased risk of osteoporosis, bone fractures, back pain and degenerative disc disease.

Mental health

The effects of smoking on an individual’s mental health are also becoming increasingly apparent. Nicotine creates an immediate sense of relaxation, so initially people who smoke believe it reduces stress and anxiety. In fact, this sensation is temporary and soon gives way to withdrawal symptoms and cravings, both of which provoke anxious feelings, according to the Mental Health Foundation. 

Additionally, smoking causes the brain to “switch off its own mechanism” for producing dopamine, reducing supply and provoking feelings of depression. Moreover, adults with depression are twice as likely to smoke as adults without depression, the charity says.   

In addition, they add: “People with schizophrenia are three times more likely to smoke than other people and tend to smoke more heavily. It’s likely this is because people with schizophrenia use smoking to control or manage some of the symptoms associated with their illness. A recent study has shown smoking may increase the risk of developing schizophrenia. However, further research is needed to fully understand how the two are linked.” 

Secondary effects

Of course, it is not just the health of smokers themselves which is affected but also the people around them. Tobacco kills more than eight million people each year, according to WHO. Around 1.2 million of these deaths are the result of non-smokers being exposed to second-hand smoke. 

Children are particularly vulnerable to the harmful effects of passive smoking due to breathing more rapidly and having less developed airways, lungs and immune systems. Furthermore, as well as decreasing fertility, if an individual is pregnant, smoking increases the risk of miscarriage, stillbirth, premature birth and health problems in new-borns. 

Wider impacts

Even if smokers don’t notice any negative health effects from cigarettes, smoking may influence their lives in other ways. In February 2022, a new analysis of national data commissioned by charity Action on Smoking and Health (ASH) found that the average smoker is spending just under £2,000 a year on tobacco, meaning that a rough total of £12 billion is spent on smoking in England each year. 

“The financial burden is high now at £11 to £12 a pack, especially as the cost of living has increased rapidly,” says Robert Bradshaw, pharmacist manager and lead clinical pharmacist at Oxford Online Pharmacy. “For many, this is an avoidable expense.”

Smoking also harms the environment, and a recent YouGov survey commissioned by ASH found 82 per cent of people agreed that cigarette butts that contain plastic should be banned. “Cigarette filters are the single biggest source of global plastic pollution,” says Nick Hopkinson, professor of respiratory medicine at Imperial College London, and chair of ASH. “Growing and curing tobacco drives deforestation, damages the environment and contributes to food scarcity in low- and middle-income countries. Cigarettes are an unethical product, robbing smokers in the UK of their health and increasing their risk of premature death, while burning the resources of the developing world.”

Focus on the positives

The benefits of quitting smoking are well-publicised but not many people know they start within hours of putting out that last cigarette. After eight hours, harmful carbon monoxide levels in the blood will have reduced by half, with all carbon monoxide being flushed out within 48 hours. 

By 12 weeks, blood circulation will have improved and, after three to nine months, lung function increases by up to 10 per cent. After one year of being smoke-free, the risk of heart disease will have halved.

“It’s always better to focus on the benefits of giving up – fewer chest infections, feeling like you have more energy, improvements in hair, skin and nail appearance,” says Robert. “Also, the lower risk of heart attack, strokes, diabetes and multiple types of cancers. If patients have prescriptions for asthma/COPD treatments, add a note for the pharmacist to hand out and ask, ‘Are you a smoker?’ Then, if yes, ask if they would like to have a chat in the consultation room about some options.”

NHS smoking cessation services

Using a combination of smoking cessation medicines and behavioural support – in a group or one-to-one – provides the best chance of quitting successfully in the long-term. 

“Like anything worth doing, it can take practice to stop smoking – but there is lots of help out there,” says Deborah Arnott, chief executive of ASH. “Smokers are three times more likely to succeed in quitting with help from a trained professional than with willpower alone. Healthcare professionals can refer them to this support, but smokers can also find their local free service by searching ‘smokefree’ and entering their postcode.”

“Advising patients to stop smoking is important, as smoking remains the biggest preventable cause of illness and death,” adds Dr Shanika Sharma, a GP in London. “One in every two people who smoke will die of a smoking-related disease unless they quit.”

The latest figures from the NHS Stop Smoking Services in England (April 2021 to September 2021) revealed that of the 88,960 people setting a quit date, 48,676 (54.7 per cent) self-reported that they were successful. 

Of those successfully quitting, 5.3 per cent had their results confirmed by carbon monoxide verification. Self-reported quitting success increased with age: 47.6 per cent of those aged under 18, compared to 57.9 per cent of those aged 60 and over.

Despite NHS stop smoking services being the most effective way to quit, Government funding cuts mean that local authorities are finding it difficult to keep these services running. 

More must be done by “offering smokers advice and support to quit at every interaction they have with health services, whether that be through GPs, hospitals, psychiatrist, midwives, pharmacists, dentists or optometrists,” according to the independent Khan review ‘Making Smoking Obsolete’, published in June 2022. 

In particular, the Government should prioritise supporting the most deprived areas and groups who are disproportionately impacted by smoking, such as pregnant women and people with mental health conditions.

Using vaping as a tool

In recent years, e-cigarettes (vapes) have become a popular way to quit smoking. In fact in June 2021, 7.1 per cent of British adults use e-cigarettes, amounting to 3.6 million people, according to charity Action on Smoking and Health (ASH). Nearly two-thirds of current vapers are ex-smokers, while the proportion of people using both cigarettes and e-cigarettes fell to 30.5 per cent in 2021. 

Research shows that e-cigarettes can help smokers quit for good. They help manage nicotine cravings without exposure to other harmful toxins found in cigarettes (such as tar or carbon monoxide). The products are tightly regulated by the Medicines and Healthcare products Regulatory Agency (MHRA) for safety and quality. The organisation encourages the licensing of these products as medicines and, in the case of refillable and reusable e-cigarettes, as medical devices. 

According to the June 2022 Khan review ‘Making Smoking Obsolete’, some healthcare professionals are concerned about the safety of vaping, but much of this scepticism “is based on myths” and needs addressing. 

The report states: “The Government must embrace the promotion of vaping as an effective tool to help people to quit smoking tobacco. We know vapes are not a ‘silver bullet’ nor are they totally risk-free, but the alternative is far worse… Vapes can be cheaper and more effective than many quitting medicines yet, currently, only 10 per cent of those in stop smoking services use vaping as a cessation tool.” 

For more on this subject, see our report on young people and vaping

Pharmacy support 

The most popular smoking cessation tool in the pharmacy is nicotine replacement therapy (NRT) which helps to stop the cravings associated with nicotine withdrawal. It comes in many different forms (including patches, gum, sprays, lozenges and inhalators), so it’s important that pharmacy customers choose the right one to suit their needs. For most people, the best approach is to combine two types of NRT.

“To find the best NRT product, it’s important to talk to customers to see what has been tried already, how many they smoke a day, when they smoke and what the motivation is to stop,” says Robert. “Once you have done this, it’s best to discuss using a steady release NRT, like a patch, along with a quick release one, like gum, mouth spray or nasal spray, to deal with ‘emergency’ cravings. There are no prescription-only products available on the market at the moment that I would recommend so it’s very much down to fighting the cravings and encouraging/supporting customers to want to quit.”

The pharmacy team can also give advice on other smoking cessation aids, such as e-cigarettes, as well as signpost to other services. The NHS Quit Smoking app, for example, enables people to track their progress while they quit, see how much money they are saving, and get daily support.

“Some members of the pharmacy team have also done training to support people with smoking cessation by offering regular time to support and help with hints and tips as each week goes by,” adds Robert. “One great tool is a carbon monoxide (CO) meter. I have seen people with above 50ppm CO come down to less than 1ppm CO by stopping, and they have found this to be very motivational.”

Case study

Service Excellence winner at the Recognition of Excellence (RoE) Awards 2022, Lisa O’Neill, runs a successful pharmacy-based 12-week smoking cessation service in Scotland, offering personalised support to customers. The pharmacy has the highest quit rates in Lanarkshire.

“Most customers self-refer, which means they’ve already recognised that they should give up smoking,” says Lisa. “We also look for certain groups of customers, such as those with heart disease, COPD or asthma, and mention ‘we offer a smoking cessation service if it’s applicable to you’ when they pick up a prescription.”

After customers have filled in the necessary forms, the pharmacy team ask about their smoking habits. “This means we can tailor the service to the individual,” explains Lisa. “We ask how many cigarettes they smoke a day and when they need their first cigarette after waking. We also ask about their triggers, such as having a cigarette with a cup of tea, to help them change that behaviour. We explain that giving up smoking isn’t easy, but they have already taken their first step.”

The customers return on a weekly basis, or every two weeks if this is more convenient for them. “We want the service to be as practical as possible,” she says. “Each time, we ask them how their week has been and discuss whether we need to change anything, such as the type or dose of NRT. In general, most people find combination NRT works well, using gum or a microtab alongside patches. A lot of people also like the inhalators, as they miss that hand-to-mouth action of smoking.”

Stoptober campaign

This year’s Stoptober begins on 1 October. The annual event is based on research that if a smoker can make it to 28 days smoke-free, they are five times more likely to quit for good. The pharmacy team can encourage customers to take part. Staff can signpost customers to ‘Stoptober’ online and should be ready with smoking cessation information and advice within the pharmacy. 

Stoptober offers a range of quitting tools, including the NHS Quit Smoking app, Facebook messages, Facebook online communities, daily emails and text messages. There is also an online Personal Quit Plan to help people find the combination of support that’s right for them, including local Stop Smoking Services and stop smoking aids. For more details, visit the NHS website.

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