Access to vital stop smoking services could be in jeopardy. This was the stark warning from the PAGB following last year’s Autumn Statement, which cut local government spending.
Access to these services – which are proven to be the most effective means of stopping smoking – has already declined by 48 per cent in the last three years and, despite smoking prevalence overall decreasing, PAGB chief executive John Smith remains concerned. “We must ensure that smokers continue to have access to the most effective interventions to support their quit attempt: licensed smoking cessation medicines such as nicotine replacement therapy (NRT) delivered in conjunction with behavioural support through stop smoking services,” he says.
PAGB believes that with appropriate investment and ambitious targets, the Government could accelerate the reduction in smoking rates, saving more smokers’ lives and reducing the burden on NHS services and budgets.
However, the proposed funding cuts form another layer on top of significant cuts to local authority public health budgets, which have impacted service provision. And a reduction in budgets available for local services to market and promote themselves means smokers are less aware of the support available to help them quit.
We must ensure that smokers continue to have access to the most effective interventions to support their quit attempt
So what else is behind this decline in use? George Butterworth is tobacco control manager at Cancer Research UK and was one of the signatories on the PAGB’s Agreed Principles, which it wants the Government to take into account in developing a new Tobacco Control Plan for England to help improve the health of smokers in need of support. He believes “the truth is that nobody knows for sure why it has declined”.
He says e-cigarettes are “often cited as a reason and they may have had an effect”, but that it is “equally likely that it’s because the funding for mass media campaigns – Stoptober, etc – has been cut back to a quarter of what it was in 2010, and we know the regional organisations have had their funding reduced. For example, Smokefree South West just had its funding cut entirely and will be wound up by June of this year.”
Alice (not her real name) is a pharmacy technician and smoking cessation advisor. She says her personal opinion is that the decline in people taking up the service is because “we, with our proactive approach in healthy living pharmacies, have already introduced the service to most of our customers, [and] many have already quit. Most remain quit, leaving us only the new people to the area to introduce our service to – a smaller quantity.
“However, we do have the word-of-mouth referrals within town due to our great customer service, so still have new customers coming to us, [and] we work with the school nurse and other local service suppliers so if they have pupils or clients wishing to quit they will refer to us also.” Alice says they are also “very lucky” to have had Live Well Suffolk, who are “very helpful and knowledgeable”, supporting the pharmacy service.
Henry Tapp is team lead for stop smoking services at Live Well Suffolk. He cites the decline in the use of stop smoking services as “predominantly due to e-cigarettes, their popularity and the fact that stop smoking services cannot provide them. Then there are hardened smokers who are reluctant to access the service, and the fact that people may have a lack of knowledge of the service available and the flexibility of appointments.”
Henry also thinks e-cigarettes are perceived by some users as “cool and trendy, with a huge subculture attached now.” He adds: “Traditional NRT and smoking cessation services have to try and compete with this, especially as there is now a proliferation of e-cig stores and products, which can also be highly personalised – another attraction for users.”
For Annie Clarke, pharmacy technician and smoking cessation advisor at City Pharmacy, a Numark pharmacy in Portsmouth, it’s the “prescribing of Champix” that she thinks has contributed to what she has noticed is “a small decline in the use of the stop smoking service in the pharmacy”. She says this does seem to have influenced potential service users who, at first glance, may view it as a more easily managed solution than a course of NRT.
“It is also possible that the availability and widespread use of e-cigarettes may have affected the take-up of the service, with potential clients maybe seeing these products as an off-the-shelf solution,” says Annie. “However, in some cases, it appears that people may have come to the conclusion that they were, in fact, using the e-cigarettes in exactly the same magnitude as tobacco products and, as such, did not appear to be working towards successfully stopping smoking.”
Naeem Shad, a Day Lewis pharmacy technician, healthy living champion and stop smoking advisor who has done courses with the National Centre for Smoking Cessation Training, says it is a lack of smoking cessation expertise that is derailing the service. “There are not many trained stop smoking advisors in GP surgeries but, on the other side, not many referrals as well to pharmacies where people can use these services. There should be a proper referral system in place.”
Naeem says: “I remember we used to have regular stop smoking network meetings in Croydon borough, where numerous advisors could discuss their views and share ideas and plans to improve these services. Due to funding cuts, unfortunately, these meetings are not held regularly, which also does not help to improve the stop smoking service because they could provide the refreshed knowledge and skills to stop smoking advisors.”
According to Naeem, there is also “not much motivation for stop smoking advisors to increase the use of services from service commissioners or employers. I think this has also led to decline in use of these services over the years, and the recent funding cuts by the Government are going to make it even harder for pharmacies to deliver these services.” His solution: “It might be a great idea to engage all the stop smoking advisors to motivate them and also monitor their performance more often.”
As of 2016, all e-cigarettes containing more than 20mg/ml nicotine will require medicines licensing through the MHRA. E-cigarettes containing less than 20mg/ml of nicotine will be classified as tobacco containing products and regulated under the European Tobacco Products Directive.
In a move that is dividing opinions of smoking cessation practitioners, the MHRA has recently licensed British American Tobacco’s e-Voke as the first e-cigarette that can be prescribed.
Tobacco harm reduction within a regulated framework and encouraging smokers to use non-tobacco nicotine-containing products is supported by the UK Government, most of the public health community, the MHRA and NICE. But how have smoking cessation experts and service providers reacted to the news?
Prior to this development, the Royal Pharmaceutical Society’s stance was that pharmacies should not sell or advertise e-cigarettes, but following the granting of this licence, president Ash Soni said that pharmacists now have an “additional piece to [their] armoury”.
PAGB says it is “committed to supporting the public health community on the journey to a society free from tobacco use and nicotine addiction and recognises that licensed medicines and licensed nicotine-containing products, including the first licensed e-cigarette, all play a part in this.” But some expert groups – including The British Medical Association and The Royal College of GPs – still have reservations, particularly around the possibility of the devices being prescribed as medicines on the NHS.
George Butterworth, tobacco control manager at Cancer Research UK, says a further concern lies with the question of who would profit from the wide-scale take-up of prescribed e-cigarettes. “It’s concerning that all of the currently licensed e-cigarettes are owned by tobacco companies, an industry responsible for a product which kills more than 100,000 people in the UK every year,” he says. “We hope that independent e-cigarette companies apply to the licensing process so it isn’t ‘Big Tobacco’ profiting from a solution to a problem it has caused.”
Meanwhile, Dr Penny Woods, chief executive of The British Lung Foundation, says: “We know that many people have used e-cigarettes to help them quit the much more harmful practice of smoking. Having a brand officially regulated for this purpose should give more smokers, and people working in smoking cessation services, more confidence to use them as such.”
Numark also welcomes the news, saying: “It’s clear that Public Health England has done the maths and assumes that the £20 cost for a starter kit plus £10 a week for cartridges will easily outweigh the savings in treating people for smoking-related diseases. We can only assume that this will lead to a reduction in deaths – let’s hope so.”
So with the odds seemingly stacking up against them, how can pharmacies still run a successful stop smoking service and help people quit?
Gemma Richardson is a dispensing assistant at Avicenna Pharmacy at The Green, Luton – a deprived area with a high level of smokers – where she has been running a smoking cessation service since March last year and seen impressive results.
She says: “My pharmacist manager, Simur Rahman, thought it would be good to have this service available, especially as smoking is quite high in this area. He enrolled me on a two-day course with Live Well Luton where you go through all of the products and what you do in the meetings with the customers, and you can also take refresher courses once a year to give you extra knowledge.”
“Usually I meet with clients once a week but if they live further away it can be once a fortnight. At the first meeting we’ll talk about why they smoke and why they want to quit. I’ll also establish whether they actually do want to quit – I believe the first step in quitting is wanting to quit, not that you’ve just been told you have to. I also ask if they have ever quit in the past, if they used any products before, what products can help, and then we’ll set a quit date.”
“Normally people choose to use the NRT patches and this is what I recommend as you get a constant supply of nicotine during the day. I also recommend the fast-acting mouth spray to deal with the cravings, and then we look at behavioural changes they can make, such as how to get out of the habit of having a cigarette with their morning coffee, perhaps by switching their morning routine around and having a shower first, for example.”
The whole service lasts 12 weeks and Gemma says it has helped about one in three people quit so far. The ones who don’t manage it can enrol on the course as many times as they wish. She adds: “I only began working in the pharmacy in October 2014 and it was my first job after A-levels. Smoking cessation is the first service that I got involved with.”
“Doing this has built my confidence massively, as I get to talk to patients one on one. If anyone else out there is considering setting up a stop smoking service in their pharmacy, I’d say ‘go for it’. If you can help someone to stop it has a huge impact on their life and can have a catalytic effect on the rest of their household.”
Laura Reed, Numark’s service development manager, agrees that one of the most important factors in the delivery of successful services is the staff. “This is especially important in stop smoking services, where the relationship built with the client and the quality of the support given improves their chances of success,” she says. “Evidence clearly shows the addition of behavioural support to a quit attempt increases the success rate, therefore selecting the right staff to deliver the support is key.”
And while – like Gemma – many staff who deliver stop smoking services find it rewarding, Laura says it is important that “all staff in the pharmacy get behind the service, not just the ones delivering it.”
It is going to be tough for pharmacies under the Government’s impending cuts over the coming years, but as George Butterworth says: “I can’t think of any better intervention pharmacy staff can make than to help someone stop smoking, in terms of their health choices, so local action is vital.”