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Towards a smoke-free 2030


Towards a smoke-free 2030

Almost six million people still smoke in England, according to an independent review by Dr Javed Khan OBE. His Making Smoking Obsolete review into the Government’s ambition to make England smokefree by 2030 was published in June this year, and it underlined the effects that smoking-related illness has on already stretched NHS resources. 

Smokers are more likely to be admitted to hospital than non-smokers; in 2015-16 alone, 474,000 hospital admissions and 79,000 deaths were attributed to smoking, and it’s estimated that the habit costs the NHS in England £2.6 billion a year. 

The Khan review sets out a case for comprehensive investment of an additional £125 million a year in tobacco control measures in order to deliver the Government’s smokefree 2030 ambition. It recommends that if the Government cannot fund this itself, it should either consider introducing a tobacco industry levy, or generate additional corporation tax.

Should ‘Big Tobacco’ pay?

The influential all party parliamentary group on smoking and health has called on the chancellor of the exchequer to make ‘Big Tobacco’ (the world’s largest tobacco companies) pay for the shortfall in funding for tobacco control and public health. Economists estimate that an immediate windfall tax on the tobacco transnationals could raise £74m a year. 

Deborah Arnott, chief executive of the anti-smoking charity Action on Smoking and Health (ASH) says: “Cutting smoking is not just vital for our health, but good for smokers’ pockets, the economy and the financial wellbeing of the UK. Driving down smoking reduces pressure on the health and social care system and will allow the Government to deliver on its levelling up mission for health and wellbeing.”

ASH suggests that around three quarters of adults (76 per cent) and the vast majority of tobacco retailers (73 per cent) in England support a levy on manufacturers to pay for tobacco control measures.

“Economists estimate that an immediate windfall tax on the tobacco transnationals could raise £74m a year”

The Government has previously committed several times to publishing a tobacco control plan in 2022. The plan had been due for publication before the end of the year, with the encouragement of the then public health minister, but plans were thrown into disarray following the recent spate of governmental changes. 

Officials with knowledge of her intentions said in October that previous secretary of state for health and social care Thérèse Coffey was reluctant to honour tobacco-related promises made by her predecessor, Sajid Javid. 

There has been speculation since then that proposals that had been due to feature in the plan could still appear in some other form, and NHS Digital confirmed to us that it has recently completed a user consultation around its suite of lifestyle publications. Senior Press Officer Karen Faughey says that at the moment: “The plan is to move to a combined compendia report annually, covering obesity, alcohol, smoking and drug misuse. Current publications have been paused until this is all redeveloped, but we are aiming to release a report by the end of 22/23, with all the latest data.”

The Department of Health and Social Care (DHSC) has said that some of Dr Khan’s suggestions may still be progressed. The NHS Long Term Plan committed to offering NHS-funded tobacco treatment to people admitted to hospital and to pregnant women by 2023/24, building on the findings of the Pharmacy Integration Fund community pharmacy NHS Smoking Cessation Transfer of Care (SCTC) pilot. 

In 2020/21, the pilot on smoking cessation started testing a new model of working in which community pharmacies managed the continuing of provision following patient discharge from hospital.  

The early findings indicated that a consistent national offer was possible through community pharmacy. Smoking cessation services were added to the NHS Community Pharmacy Contractual Framework (CPCF) as part of year three (2021/22) of the five-year CPCF deal. Hospital tobacco dependence teams (TDTs) and hospital pharmacy teams have now been issued with guidance about how to discharge patients into the care of community pharmacies. This is available on the NHS England website.

According to the Khan review: “The Government must do more to support the most deprived areas and groups who are disproportionately impacted by smoking. In particular, pregnant women and people with mental health conditions, who show substantially higher negative health impacts of smoking. I am calling on integrated care systems (ICSs) across the country to lead on meeting smoking cessation targets.”

Community pharmacy has a proven track record in delivering successful tobacco dependency services. Making them easier to access and providing a ‘way in’ for smokers who want to quit can only be a good thing.  

Faster pathway to vaping on the NHS?

In his review, Dr Khan recommends that the path to prescribed vapes should be accelerated, along with free ‘swap to stop’ packs in deprived communities. He also underlined the need to prevent children and young people from starting vaping, as well as banning child friendly packaging and descriptions. 

One of his recommendations was to consider producing a medicinally licensed vape product, although it was considered a high cost option that could face significant barriers. Currently, the MHRA is keen to work with Government to address this as quickly as possible. Dr Khan describes accelerating the promotion of vaping as a substitute for smoking, alongside accurate information on the benefits of switching – including to healthcare professionals – as a critical intervention. There are now 4.3 million people who vape in the UK and while the category is undergoing continued growth, there are a number of challenges facing the industry. 

“All adult smokers who don’t quit deserve access to – and information about – the full range of smoke-free alternatives”

Juul has launched its new JUULpod ID feature to address one of these challenges – fake products. Significantly improving the company’s ability to identify unauthenticated products and prevent their use, the JUUL2 device will only work with authentic JUUL2 pods. 

The brand is keen to dissuade non-nicotine users, especially those who are underage, from trying its products too, reiterating that their purpose is to transition, and completely switch, adult smokers from combustible cigarettes. To this end, Juul has created a ‘retailer resource centre’ designed to better inform retailers about ways to help keep their communities safe and uphold their reputation as responsible sellers.

The company believes that underage use prevention is imperative to building consumer, regulatory and stakeholder confidence in the industry, and mandates its Challenge 25 and mystery shopper programmes across all stockists. “We ask all of our retail partners to join us in combating underage use and we have been encouraged by the feedback the new website has received so far,” says John Patterson, country lead at Juul Labs UK. “The dedicated retailer website offers retailers advice and guidance on the legal sale of vaping products, best practice testimonials from retailers as well as outlining our commitment and our initiatives to combat underage access.”

Juul’s new JUUL2 System has been completely updated too. New features include a larger, longer-lasting battery, a smart light system to communicate e-liquid level and battery life, and a range of new JUUL2 pods (18 mg/mL nicotine strength). 

According to Hannah Rubery of vape manufacturer Pod Salt, zero nicotine disposables can offer a final stepping stone for vapers to quit their nicotine habit. She adds that nicotine-free cannabidiol (CBD) e-liquids are gaining in popularity. “They are the most bioavailable way for users to take CBD, giving quicker and stronger CBD effects than other methods,” she says. “There’s also a growing movement for using CBD vapes instead of nicotine as they can provide the same feeling of satisfaction without the addiction. CBD is a well-tolerated compound that has been found to be non-addictive – a strong plus in comparison to nicotine.”

Heated tobacco 

At Philip Morris UK, heated tobacco is advocated as the most suitable substitute for traditional cigarettes. The company’s head of scientific and medical engagement Maria Mantzourani agrees that while the best thing smokers can do is quit smoking altogether, the reality is that many don’t. She suggests a pragmatic approach and a ‘sensible solution’ that moves smokers away from cigarettes.  

The company’s research shows that while 68 per cent of current adult smokers in Great Britain say that they have tried e-cigarettes, only 17 per cent have continued with them. This, says Philip Morris, demonstrates that while vaping is helpful for some smokers and has a role to play in harm reduction, it doesn’t work for everybody. 

“The Government must do more to support the most deprived areas and groups who are disproportionately impacted by smoking”

“No one product will meet all adult smokers’ preferences or solve the smoking issue,” says Ms Mantzourani. “People smoke for different reasons – not just nicotine, but also taste, sensory experience, and ritual. All adult smokers who don’t quit deserve access to – and information about – the full range of smoke-free alternatives available, including vaping, heated tobacco and nicotine pouches, alongside NRTs [nicotine replacement therapies].

“Harnessing science and technological innovation is a great public health opportunity. We believe that pharmacists have an important role to play by supporting their adult smoking customers who don’t quit in their journey away from cigarettes, through education and providing a full range of effective smoke-free solutions.”

Philip Morris is currently the only major tobacco manufacturer committed to replacing cigarettes completely. Ms Mantzourani emphasises that the company goes to great lengths to have its science debated, published, and peer-reviewed transparently. “Our studies to date have found that our heated tobacco product, IQOS, generates no combustion and no smoke and emits, on average, a 90-95 per cent reduction in the levels of HPHCs [harmful and potentially harmful constituents] compared with cigarettes.”

Unlike a vape product, which uses liquid, IQOS uses sophisticated electronics to heat specially prepared and blended tobacco. “Our research programme is inspired by long-held practices of the pharmaceutical industry, and the totality of evidence – comprising Philip Morris International’s clinical data, aerosol chemistry, and nonclinical data – demonstrates that switching to IQOS completely, while not risk-free, is a better choice for adults who would otherwise continue smoking. 

“There is an opportunity in the UK to build on the success of vaping and introduce a multi-category approach, which should be underpinned with appropriate post-market surveillance and youth access prevention measures to ensure that products are not getting to unintended audiences.”

Smoking Cessation Transfer of Care: how it works

Under the Smoking Cessation Transfer of Care (SCTS) service, people who decide that they want to quit smoking while they are in hospital can ask to be referred to a community pharmacy for support once they have been discharged. They can choose a pharmacy that’s local and convenient to them. Referrals will be made electronically wherever possible. 

If a patient can’t attend a pharmacy in person, pharmacists also have the option of carrying out consultations over the phone to discuss their progress. After 12 weeks, pharmacists should review any nicotine replacement therapy (NRT) prescribed by the hospital team and adjust levels of support for the continued quit attempt. They will also be able to provide ongoing supplies free of charge if needed.

Who’s eligible?

The service is designed to help people over the age of 18 who have started treatment for tobacco dependence in hospital and have decided to continue treatment in community pharmacy after their discharge. The service doesn’t exclude pregnant women, or people with non-complex mental health problems specifically, although local arrangements may already be in place to support them separately.

People who have complex mental health problems will be encouraged to receive follow-up care from specialist tobacco dependency advisors in the community. The service is also unsuitable for under-18s, anyone who is deemed to be unable to consent, and people who have been in hospital for a long period of time and have already completed a 12-week tobacco dependency programme.

How to get involved

Pharmacy managers who want to offer this service first need to think about whether they are likely to receive enough referrals to make it worthwhile. To help you decide, you may want to determine whether your local NHS trusts are already making referrals to pharmacies – this is easy to check by looking at the national dashboard or asking your local pharmaceutical committee (LPC). 

Pharmacies wanting to offer the service also need to have a dedicated consultation room available with suitable IT equipment accessible within the room to allow simultaneous recording of all consultations provided. Video and telephone consultations can be used in circumstances where both the pharmacist and patient are happy for the service to be carried out remotely – this could be on an individual or ongoing basis (for example because the patient is housebound while recovering from illness or surgery). If sessions are carried out by phone or video call, they need to take place in a private place where conversations can’t be overheard (except by someone who needs to be able to listen in, such as a carer).

At the moment, the service can only be carried out by a pharmacist due to VAT regulations – the DHSC is working with HM Revenue & Customs to explore whether support staff will be able to provide the service at some point. Until then, it’s still important to make sure that the wider pharmacy team is aware of the service and how it works.

Views of the P3pharmacy category panel

This has slowed in the last couple of years. Remaining smokers are the hardest to reach and the most reluctant to give up. There used to be an NHS campaign and we had to achieve certain figures each year. None of this happens now. Our stock area has shrunk massively. We do get asked if it’s okay to smoke while using nicotine replacement therapy or vaping, so we can play an important role in educating customers about the best ways to quit and support them during the process. Niquitin and Nicorette are our best sellers.

We’ve almost lost this category in the last year or two. We stock Nicotinell, but some of it is going out of date and I’m seriously considering whether it’s worth restocking next year. Since the pandemic, demand for advice has dropped right off and there seems to be a lack of public health campaigns and messages this year, even for Stoptober. I used to run regular smoking cessation clinics, but this year I’ve done barely any. We often discussed quitting during MURs as smoking was something we picked up – another opportunity gone.

This is a small section in our pharmacy, with most patients who need NRT getting it through our stop smoking service. We have historically shied away from vapes, but with more evidence pointing to their benefit for many people it seems the time is right to offer this as an option in order to provide professional advice to our local community. We stock a small range of Niquitin patches and sprays, but with wholesalers struggling thanks to the Champix issue, we tend to keep these in the dispensary so we can support our service first.

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