As the target of achieving a smoke-free England by 2030 draws closer, steps are being taken to reach stubborn smokers and make quitting easier. In a world first, updated MHRA guidelines point to the prescribing of e-cigarettes on the NHS. From January, hospital patients identified as smokers will be encouraged to start a quit attempt and on discharge can be referred to their local pharmacy for a continuing support plan. A consultation to raise the minimum age for tobacco sale to 21 has also been proposed.

All of these measures are positive, but will it enable us to meet the ‘Smokefree by 2030’ goal, given that there are still 6.1 million smokers in England?

“The goal of a Smokefree England by 2030 (less than 5 per cent of the population smoking) looks unlikely to be met. That is particularly the case in the most disadvantaged parts of the country, where smoking rates are highest,” says Hazel Cheeseman, deputy chief executive at Action on Smoking and Health (ASH). “Pharmacists have long played a key role in encouraging smokers to give quitting a try and directing them to the support that will be best to successfully quit. Often, pharmacists will reach parts of the population that other parts of the health system don’t. As rates fall, this role is more important than ever to make sure that disadvantaged smokers are not left behind.”

Numark OTC business development executive Cathy Crossthwaite adds: “Smoking cessation is a key priority for community pharmacies in the current climate, as it is a support-driven category. Whilst products may be cheaper and more accessible in a supermarket, customers aren’t able to access the valuable advice available in a pharmacy. One-to-one support can go a long way, particularly with those just starting out on their smoking cessation journey.”

A Nicorette spokesperson adds: “With more and more smokers trying to quit, pharmacists have a vital role to play. Personalised healthcare is going to be increasingly prevalent in the smoking cessation space as consumers continue to expect individualised solutions. According to Johnson & Johnson research, more than eight out of 10 pharmacists are interested in the management and treatment of smokers looking to quit.”

Vaping on the NHS?

The MHRA is working with manufacturers to assess the safety and effectiveness of e-cigarette products to support the target of Smokefree by 2030. Medically licensed vaping products could then be prescribed on the NHS for smokers who want to quit. E-cigarettes would go through the same regulatory procedure as other medicines.

According to Health & Social Care secretary Sajid Javid: “Opening the door to a licensed e-cigarette prescribed on the NHS has the potential to tackle the stark disparities in smoking rates across the country, helping people stop smoking wherever they live and whatever their background.”

pharmacists will reach parts of the population that other parts of the health system don’t

E-cigarettes were the most popular quit aid in 2020 in England, with 27.2 per cent of smokers using them versus 18.2 per cent using nicotine replacement therapy (NRT). The highest quit rates are for smokers who use e-cigarettes with local stop smoking services, with up to 68 per cent successfully quitting in 2020-21.

Dan Marchant, managing director of online vaping store Vape Club, says: “We fully support this move. For some very heavy smokers, the current legal limitations on nicotine strength may be hampering their ability to switch. But more so, as part of the UK’s levelling up scheme, making the products available to smokers in the lowest income bracket could be exactly the help they need to switch away from smoking.”

Sairah Salim-Sartoni, head of scientific partnerships and specialist support for training at e-cigarette maker Juul UK, says: “We support the Government’s 2030 Smokefree target as our mission is to help transition the world’s billion adult smokers away from combustible cigarettes. We respect and welcome the central role of regulators like the MHRA in devising science and evidence-based pathways towards achieving the UK’s smokefree ambitions, and the important role of alternatives like e-vapour products.”

A new pharmacy referral service

From January 2022, a new stop smoking advanced service which refers patients discharged from hospital to local pharmacies is being commissioned. A pilot for thescheme began in September 2020 in Oldham, Southwark and Lambeth. “Details are still being finalised, but we are working with the Government and NHS officials towards the scheduled start in January and hope to have more information to share soon,” says Alastair Buxton, PSNC director of NHS services. 

“The service forms an important part of wider efforts to increase clinical service provision in pharmacy and to further cement the sector’s role in public health. However, given that patients will need to be referred on discharge from hospital and volumes are therefore expected to be relatively low, it is likely the service will be of most interest to pharmacy contractors who are already providing a locally commissioned smoking cessation service.” The new service is based on the Ottawa model for smoking cessation, which has improved quit rates across Canada by 11 per cent.

The NPA’s Stephen Fishwick believes the service demonstrates the growing integration of community pharmacy with the wider healthcare system. “For patients,” he says, “this service would allow for a seamless transition between care settings and see them receive attention from a trusted healthcare professional close to home. Community pharmacies offer an accessible, non-stigmatising environment where behavioural support can be given in combination with products like nicotine patches or gum.”

English Pharmacy Board chair Thorrun Govind also welcomes the move: “Many community pharmacists have run smoking cessation services, so we don’t foresee any problems with them providing this service,” she says. “The digital systems between hospitals and community pharmacies need to ensure that data can be transferred easily between the two providers so people can easily be referred on to the service and everyone providing care has up to date and accurate information. There must also be additional NHS investment in local project management that supports the implementation of these services.”

Numark patient services manager Lucy Morris says the pharmacy membership group is paying particular attention to the launch of this service. “It will help to support awareness around the role of community pharmacy in assisting patients with smoking cessation,” she says.

Ms Cheeseman adds that while smokers are more likely to quit with support, it is vital that this support is evidence-based. “Pharmacists have a mixed history of providing cessation support,” she says. “Some have excelled, but, overall, pharmacy-delivered support tends to perform less well than dedicated stop smoking services, as they don’t have the depth of expertise that a dedicated service does. Those who are seeing more smokers should ensure their training is current. The National Centre for Smoking Cessation and Training runs great online courses.”

There are 6.9m adult smokers in the UK, according to ASH. The highest prevalence is among 25-34 year olds (21.8 per cent). Annually, smoking accounts for 74,600 deaths in England, and the cost of smoking to the NHS is £2.5bn.

While one million smokers were inspired to quit during the first lockdown, the effects of prolonged stress due to the pandemic has led to increased smoking among many. Mintel research found that this has especially affected young people, with 39 per cent of smokers aged 18-34 saying they smoke more regularly and a further 10 per cent of all smokers saying they had restarted smoking after quitting. Some 30 per cent of all smokers said they were smoking more regularly since the start of the pandemic.

Not quite on target

“Smoking rates have been turbulent through the pandemic,” says Ms Cheeseman. “There is reasonable evidence that older smokers did quit in greater numbers, but younger smokers’ response has been more chaotic, with many more smoking, but lots of them trying and succeeding in quitting. What’s important is for smokers to know that any bad habits picked up during Covid can be addressed now.” 

During the pandemic, smoking rates in pregnancy fell below 10 per cent for the first time, but the Government is still not on track to reach its goal of six per cent or less in this group by 2022.

A new ‘tobacco control plan’ is due to be published by the end of this year, to set out a roadmap for achieving the target of a Smokefree England by 2030. The All Party Parliamentary Group on Smoking and Health has produced a report. Its recommendations include:

• Funding for tobacco control programmes to be secured
  by a ‘polluter pays’ amendment to the Health & Social Care bill
• Targeted investment to provide additional support to help smokers quit in regions and communities where smoking does most harm
• Tough tobacco regulations to protect children and young people from becoming smokers and helping smokers to quit, including consulting on raising the age of sale to 21.

At the current rate, the report says we will miss the 2030 target by seven years, and double that for the most deprived in society.

Views of the P3pharmacy category panel

“This is a fairly important category for our pharmacy and demand for products increased when we reopened after lockdown. We show customers who ask for nicotine replacement therapy a variety of brands. We always keep the spray, inhalator and gum, as well as patches, to give choice. Best sellers are Nicorette and Niquitin. Keep educational leaflets on show. Explain to customers how to use the patch – it’s important to educate them on how to use one correctly. We get asked frequently about e-cigarettes. We sell nicotine-free vapes with essential oils, but that’s all.”

Sarina Mughal, Day Lewis, Knightsbridge

“This is not as important a category as it used to be because there are now far fewer smokers in our area. We’ve cut the amount of space we dedicate to smoking cessation as a result. Those that still smoke don’t want to give up – a difficult to reach group. The most common questions we get about nicotine replacement are: can I use NRT to help reduce the number of cigarettes I smoke, and what different types of NRT are available? Nicorette is our top seller. Many of the NRT products are P lines, so make them visible to customers from behind the counter.”

Lila Thakerar, Shaftesbury Pharmacy, Harrow

 “Smoking services have dropped off for us due to funding cuts, although the new service for hospital discharge patients may reverse this. We used to offer a full consultation service, but now people tend to ask for specific cessation aids. Nicorette Quick Mist is popular; patches are used much less now. People who have tried everything will ask for Champix, but this is still on manufacturer recall. More people are using vaping to give up, so unless we stock vape products, our market share will decrease. January is a key time for quit attempts, so use social media to promote your offer.”

Lindsey Fairbrother, Goodlife Pharmacy, Hatton, Derbyshire