Smoking cessation - Module 152
Smoking is a major health risk, but with seven different quit options available in your pharmacy, you're in the perfect placeto help people stop
• the effects of smoking on health and wellbeing
• advice to give customers looking to stop smoking
• details of the different types of nicotine replacement therapy available.
Download a pdf version of this module here
Download the Test Your Knowledge questions here
Around 10 million adults in the UK smoke cigarettes. A recent survey showed that 22 per cent of men and 20 per cent of women aged 16 or over in England were smokers, smoking an average of 13 cigarettes a day. Smoking is most common in areas of deprivation. Rates are highest in the 20-24 age group, and gradually decline with age.
Support and encouragement from the community pharmacy team is vitally important in helping smokers to quit. But identifying smokers who visit your pharmacy and engaging them in a conversation about quitting is just the first step.
Why stop smoking?
Smoking can cause serious harm to a person's health, but it's also important to warn of the dangers of environmental (passive) smoking; thinking about others can give the person who is attempting to quit extra strength to see it through.
Giving up smoking can also boost a person's feelings of confidence and personal attractiveness as it gives them healthy, glowing skin and no tobacco stains on their teeth or fingers. They may also be able to enjoy the taste of food more. Saving money is also an important motivating factor: by quitting smoking a person who smoked 20 cigarettes each day will save more than £2,000 in just one year.
Help quitting
In a recent survey, 54 per cent of smokers said they needed help to manage their cravings; one third wanted advice on how to strengthen their willpower; and 32 per cent said they simply needed something to keep their hands busy. It's therefore important to make sure you meet these needs.
Any customer making a quit attempt should be offered advice on how to manage cravings, for example by using nicotine replacement therapy (NRT), which is twice as successful in helping a person quit compared with willpower alone. NHS Quit Kits, which will be provided to your pharmacy between January and March, will provide information, access to relaxation techniques and tools to keep quitters' hands occupied.
Reducing smoking gradually while using NRT can be effective for people unwilling or unable to stop abruptly, and most products are licensed to cut down smoking as a ‘stepping stone' to stopping completely. However, this approach is not as effective as stopping at once.
The seven NRT types
Seven formulations of NRT are currently licensed in the UK – transdermal patch, chewing gum, inhalator cartridges, lozenge, sublingual tablet (microtab), nasal spray and oral spray. All are licensed for use from 12 years of age. NRT products contain nicotine, which is harmful and addictive, but they deliver smaller amounts than cigarettes without any of the other harmful substances in tobacco, such as tar and carbon monoxide.
The strength of NRT used initially is determined by the number of cigarettes the person smokes each day and when the first cigarette is smoked. The suggested duration of use before attempting to reduce the dose depends on the product, so make sure you are familiar with the range you offer (the C+D Guide to OTC contains more information).
Always ask a customer what type of method they will prefer, as the person is more likely to comply with and complete the course of treatment if the product fits with their lifestyle. Using more than one product can be effective for people who have strong cravings.
1 Transdermal patches deliver a regular dose of nicotine across the skin over 16 or 24 hours. The sustained action means the patch can prevent cravings. A 24-hour patch may be best for people who get strong cravings to smoke as soon as they wake up. Some people develop irritation at the site of application and find the patch unsuitable.
2 Nicotine chewing gum comes in two strengths, 2mg and 4mg, and in a choice of flavours. People who smoke more than 20 cigarettes each day or who require more than 15 pieces of the 2mg gum each day should use the 4mg strength. The product is chewed until the taste becomes strong, and is then rested between the cheek and the gum. This process is repeated when the taste begins to fade.
3 Nicotine cartridges are placed in a holder with a mouthpiece. Sucking on the inhalator allows nicotine vapour to be drawn into the mouth, where
it is absorbed into the blood. Each cartridge is used for 20 minutes, and initially six to 12 cartridges are used daily.
4 Lozenges slowly release nicotine and should be moved from one side of the mouth to the other during use. They can take up to 30 minutes to dissolve. Customers should start with one lozenge every one to two hours; people who were unable to quit smoking with the lower strength lozenge can switch to the higher strength.
5 The microtab is a sublingual tablet that dissolves under the tongue. Microtabs can be more discreet than lozenges. People who smoked less than 20 cigarettes each day should initially use one sublingual tablet each hour. Heavy smokers may use two tablets each hour.
6 Nicotine nasal spray is targeted at people who are highly dependent on nicotine, and is used to give rapid relief from cravings. It delivers nicotine more quickly than the other NRT products. The spray may irritate the nose at first, but this passes quickly.
7 The oral pump spray is sprayed directly into the mouth. The spray must be primed at the time of first use, or if it has not been used for two days. Customers use one or two sprays up to twice an hour to relieve cravings. If two sprays are required, future doses may be delivered as two consecutive sprays. Customers should not inhale when spraying the device.
Counselling tips
• Many of the people visiting your pharmacy may not use their local GP surgery or other venues to look for support when they plan to stop smoking.
• Listen carefully to what all customers tell you about their lifestyle, health behaviours or concerns; if you identify that the customer smokes, assess their willingness to consider products to help them stop, and give them information about preparing to quit or cut down.
• Tell people who are planning a family or who already have children about the effects that cigarette smoke has on child health.
• The easiest time to intervene is if a person wants to purchase NRT, but many customers, such of those who have chest infections, or who have been recently diagnosed with a medical condition such as asthma, COPD, high blood pressure or diabetes, will be reassessing the effects of their smoking.
• Always support patients who are making a quit attempt. Encourage them to share their successes and challenges with you when they return to purchase NRT supplies, as your ongoing support and encouragement will influence their success.
The effect of smoking on health
• More than a third of all deaths from respiratory disease are due to smoking.
• Almost three in 10 deaths from cancers in people over 35 years of age are estimated to be caused by smoking.
• Smoking increases the risk of developing chronic health problems, including angina, hypertension, peripheral vascular disease, macular degeneration (causing loss of sight), impotence, infertility, skin wrinkling and osteoporosis.
• Around one in 20 hospital admissions among adults aged 35 and over are estimated to be attributable to smoking.
• People exposed to environmental tobacco smoke have an increased risk of smoking-related diseases, particularly lung disease and heart disease.
• Foetal exposure to maternal smoking increases the risk
of miscarriage, early birth, low birth weight and still birth.
• Children exposed to environmental or second-hand tobacco smoke are at increased risk of cot death, asthma, middle ear infection, chest infections and diabetes.
Who should see the pharmacist?
Women who are pregnant should only use NRT on the advice of their doctor or midwife, and if attempts to stop smoking without NRT have failed. You should refer any customer who mentions that they are pregnant, have diabetes, or who has kidney or liver disease to the pharmacist.
The components of tobacco smoke can also affect how other medicines work. Refer any patients who report side effects of their medicines or any symptoms since starting NRT to the pharmacist.
Symptoms such as a cough that has persisted for more than three weeks, coughing up blood, or chest pain may be related to an underlying disease
and these all require further investigation.
Key points
• Smoking doesn't just affect the patient: environmental smoking also impacts on family members, especially children.
• There are seven different types of nicotine replacement therapy available. You should give the patient a range of options and let them choose the one that best fits with their lifestyle.
• Always ask customers newly diagnosed with a long-term condition, such as COPD or diabetes, if they smoke. If they do, offer to give them help and support as they may be considering quitting.
Evaluation
• How would you find out if someone is smoking and would like help quitting? Practice asking with a colleague to hone your skills.
• Find out what the different NRT products do, and their different costs. Are you able to help patients make informed choices on the different products?
• Pull out the OTC wall chart and put it in your dispensary. What other visual aids and tools could you use to help people stop smoking?
Information
smokefree.nhs.uk
Free advice and support
quit.org.uk
UK charity that helps people quit
nice.org.uk/PH10
Smoking cessation services in primary care, pharmacies, local authorities and workplaces
C+D Guide to OTC
Information on the different stop smoking products
