From this module you will learn:
- How to support health behaviour change
- The barriers that smokers face when trying to quit
- Identifying triggers that cause smokers to relapse
- Continued support to offer smokers after they have quit
Download this module - this includes the 5 minute test - here.
While the number of smokers has more than halved in the past 40 years – 46% of adults smoked in 1974 compared with 19% in 2016 – there are still more than 9.6 million across the UK.
Treating smoking-related diseases cost the NHS upwards of £50 million every week in 2008. These conditions also have an indirect economic impact, as smokers take more days off work due to illness, and face a higher risk of dying earlier than they would have if they quit smoking.
The Department of Health (DH) has worked hard to reduce these figures, adopting strategies such as:
- banning tobacco advertising in 2003
- banning smoking in workplaces and public spaces in 2007
- banning “eye-catching” displays in all shops in 2015
- ongoing increases to tobacco taxes to make smoking less affordable
- regular anti-smoking campaigns, such as Stoptober
- commissioning smoking cessation services from a range of providers, including pharmacies, to offer smokers a choice of where they can go for support.
In addition to its aim of reducing overall smoking prevalence, the DH has put particular emphasis on reducing smoking during pregnancy, as well as among young people.
But despite these admirable efforts, the number of smokers appears to have plateaued, remaining at 19% of the adult population for the past three years.
Supporting quit attempts
A report published by the NHS in 2009 noted that the support of a healthcare professional dramatically increases the chances of quit success, specifically:
- one-to-one support alongside nicotine replacement therapy (NRT) resulted in four-week quit rates of 37% compared with 25% when NRT was used alone; when NRT was replaced with varenicline (Champix), quit rates increased to 52% and 37% respectively
- group behaviour support alongside NRT resulted in exactly half of smokers quitting. This increased to nearly three-quarters (74%) when NRT was replaced with varenicline.
More recent findings from 2014-15 show that nearly 152,000 people in England managed to quit smoking cigarettes through the use of unlicensed nicotine-containing products (NCPs). This term refers mainly to e-cigarettes – an increasingly popular option – and accounted for 65% of all those who quit smoking during this period.
Looking specifically at community pharmacy smoking cessation services, more than 51,500 smokers in the UK set a quit date through a pharmacy from April-December 2015.
This represented 19% of all smokers who set a quit date through an NHS stop smoking service during this period. Of the smokers who chose pharmacy, 40% had successfully quit at a four-week follow-up.
Despite the fact that pharmacy has demonstrated that it provides cost-effective smoking interventions for the NHS, more than 80% of smokers do not use the sector to help them quit.
There is, therefore, much you can do to enhance your chances of supporting smokers to kick their habit for good, as well as help smokers who currently fail to quit successfully through the pharmacy.
Supporting behaviour change
Two-thirds of smokers have stated that they want to quit, but only 30% actually make the attempt. There may be various reasons for this discrepancy, but one point to remember is that smokers are living with an addiction.
Addiction can grip people to such an extent that they feel they can never break away from it. In these instances, it is important to emphasise the vital supportive role you and your team can play in helping them quit for good.
An important aspect of any health service that requires a change in behaviour is the incorporation of a health behaviour change theory into the strategy for dealing with patients. These theories are evidence-based recommendations for approaches to help people improve their own health.
One such model, which is often incorporated into stop smoking services, is the ‘stage of change’ model. This model addresses the process of change as a cycle involving six stages:
Smokers at this stage have not considered quitting. It is unlikely that they will be receptive to your attempts to persuade them to stop. The best way to support smokers at this stage is to provide them with information leaflets that highlight the benefits of quitting smoking.
It is particularly important to avoid appearing patronising, as this could deter the smoker from coming back to your pharmacy for cessation advice in the future.
During the contemplation stage, the smoker is thinking about quitting but has not taken active steps to do so. They are usually open to discussing this, so it is a good opportunity to suggest ways they can quit.
It might be worth discussing their motivation for wanting to quit (see Motivations, on the following page). Listen carefully and explain how quitting smoking, with your support, is achievable and has many benefits.
At this stage, the patient has made a decision to quit smoking and your support will be extremely valuable. So how can you help? As part of the planning process, there are a few things you need to consider:
- Agree a quit date – it is important that this is a day when the patient is likely to be relaxed. A day when they are off work may be most suitable.
- Give the patient realistic expectations of the withdrawal symptoms they may experience after they quit. These symptoms can be upsetting for some people, and may force them to abandon their quit attempt before it has really started.
- Explain the product support options available and discuss which might work best for them. For some smokers, a combination of a couple of NRT products may be the most suitable choice.
- Discuss how your patient will deal with scenarios in which they would normally have smoked. Ask how they will cope with stressful situations after quitting smoking, and how they will resist peer pressure to smoke. Addressing these possibilities before they arise will help set them up for a successful quit attempt.
Your patient has now stopped smoking, but your role does not stop here. They may be experiencing some difficult withdrawal symptoms and will need your reassurance that these symptoms are common and will pass.
In addition, your patient may be experiencing weight gain, which may be an issue for them.
Encourage them to focus on their quit attempt for now and suggest that issues such as weight gain can be tackled further down the line.
Address any concerns as they arise and focus on the benefits of stopping smoking. Every day they have managed to not smoke is a day closer to quitting for good.
This stage can be a very tricky time for someone who has quit smoking. Most likely they will be feeling good about having quit, but they may be vulnerable to returning to smoking if they come into contact with another smoker, or if they face challenging or stressful situations.
The presence of alcohol, for example, may affect an ex-smoker’s willpower, causing them to smoke “just one cigarette”.
The maintenance stage should involve follow-up checks to ensure that the patient has refrained from smoking.
Regular check-ups with you can give a patient the feeling of being accountable to someone – this has been shown to be a motivator for continued health behaviour change.
During your discussions, you can ask at what points they have been tempted to smoke since they quit. This will help the two of you develop strategies to manage these situations when they arise in the future.
At this stage, an ex-smoker goes back to being a smoker. This can be a time of shame for someone, as they may feel they have failed or that they will never be able to quit smoking successfully. Patients now need your encouragement and support.
Reassure them that this is just a small blip in their journey to quitting; it is not the end of the road. Remind them that they have successfully quit smoking before and can do so again.
There are many motivations for those who want to quit smoking – such as getting healthier, saving money, or pleasing a family member. Find out what motivates your patient to quit and focus on this. Taking the time to get to know their wants and needs is the best way to successfully support them.
As pharmacists, we know the long-term consequences of smoking on health. For some patients, labouring this point will not always be a motivator to quit smoking. In fact, they may rebel when given this advice.
These individuals may be more motivated to quit by being made aware of the immediate positive effects of quitting smoking. The
NHS Smokefree website is a reliable, evidence-based source to direct patients to for more information on the short-term and long-term benefits of making this lifestyle change.
Involving your team
It is not just the pharmacist who can support smokers to quit. With the appropriate training, dispensers and healthcare assistants may be more than qualified to help. In fact, you may have a member of staff who is an ex-smoker themselves. This would be the ideal person to offer support, as they understand the challenges of quitting and can draw on their experiences as a source of encouragement.
Your main consideration when delegating any task to a member of your team is whether you are satisfied that they have the necessary skills and competence levels to support patients. You can check this through role play or observational activities. You should also ensure they have adequate time to carry out this enhanced role.
It is important to recognise that people smoke for a variety of reasons. For some, it may have become a tool to reduce stress levels;
for others, it may be a way to manage their weight. For the vast majority, it may simply be a habit they have become accustomed to.
There are some obvious opportunities for you to identify smokers who could be interested in quitting, for example:
Collecting a prescription or purchasing an over-the-counter product
Pay attention to when: a customer is asking to buy a cough medicine; a COPD or asthma patient is collecting their inhaler prescription; a customer is asking about NRT products or for your advice on e-cigarettes.
During public health campaigns
There are a number of smoking cessation campaigns during the year, including the NHS’s Stoptober initiative and the British Heart Foundation’s No Smoking Day – in October and March respectively. Use these events as opportunities to strike up conversations with your customers about their intentions to quit smoking.
There are certain times in a patient’s life when they may be more likely to consider a health behaviour change. These include around the New Year, on birthdays, or when they find out they are having a child.
There are lots of outreach opportunities for you and your team to participate in around your area. These include visiting schools to talk about smoking, as well as attending local community centres, sports teams and youth groups. These groups often appreciate an expert speaker coming to talk to them about health topics.
Supporting smokers to quit CPD
Reflect How successful are quit attempts supported by healthcare professionals? What is the ‘stage of change’ model of health behaviour? What are the main challenges to stopping smoking?
Plan This article contains information about smoking cessation, including the prevalence of smoking, how the Department of Health is working to reduce it and the success of health professional-supported quit attempts. How pharmacists can support behaviour changes of those wanting to quit, and common barriers to stopping smoking, are also discussed.
Act Find out about resources for helping patients make successful quit attempts. The Smokefree website has information about reasons for quitting and the Action on Smoking and Health (ASH) website has useful factsheets
Read the briefing on electronic cigarettes on the ASH website
Revise your knowledge of nicotine replacement therapy products from the C+D Guide to OTC Medicines and Diagnostics
Test how you would deliver a medicines use review to a smoker, by reading C+D’s practical approach article
Evaluate Are you now confident in your knowledge of smoking cessation? Could you give advice and support to patients making a quit attempt?