As we draw closer to the deadline of a smoke-free England by 2030 and the ambition to achieve the first smoke-free generation, is enough being done to realise these goals and is community pharmacy being used to its full potential? 

Despite the limited scope of the commissioned pharmacy smoking cessation service in England, community pharmacy has seen a 10 per cent increase in the number of smokers using the service to quit, according to the latest data. Community pharmacies were the third most popular intervention setting to start the quit process in the last quarter of 2023 and achieved a 38 per cent success rate.

Alistair Buxton, director of NHS services at Community Pharmacy England, says: “Community pharmacies are well placed to provide easily accessible support to help smokers and vape users to stop, but any expansion of pharmacy services must be fairly funded with additional funding over and above the global sum. Pharmacy teams have always been a key part of local smoking cessation efforts, but local commissioning has previously been impacted by reductions in public health budgets.”

A smoke-free future?

Back in 2019, the Government announced its ambition for England to become smoke-free by 2030. In 2022, The Khan review: making smoking obsolete found that without further action, England would miss this target by at least seven years.

The review set out 15 recommendations to support the 2030 ambition, including increasing the age of sale of tobacco by one year every year, promoting vaping as a smoking cessation tool and offering smokers advice and support to quit at every NHS interaction.

In October 2023, the Government set out plans to introduce legislation to stop children born after January 2009 from ever legally buying cigarettes in England and to create the first ever smoke-free generation.

The Government committed an additional £70 million annually to support local authority led smoking cessation services and £45m over two years to roll out the new ‘swap to stop’ scheme, helping one million smokers to quit by providing them with a vape kit and behavioural support.

However, there is much work still to be done. “The country is currently not on track to achieve the smoke-free 2030 ambition and will miss this by nine years, and double that for the most disadvantaged groups,” says John Waldron, policy and public affairs manager at ASH (Action on Smoking and Health).

Smoking trends and hard to reach groups

In the UK, 12.9 per cent of people smoke. While the biggest fall in numbers has been among 18 to 24-year-olds, with just 11.6 per cent smoking now compared with 25 per cent in 2011, most smokers start in their teens.

Smoking remains the leading cause of preventable illness and death in this country. About half of all lifelong smokers will die early – most from lung cancer, COPD or CHD.

Those who are unemployed or on low income are more likely to smoke, and mortality rates are 2.1 times higher in the most deprived local authority areas. People with mental health conditions are 50 per cent more likely to smoke and many believe that smoking helps their symptoms, so are resistant to quitting.

“Approaching hard to reach groups tactfully requires understanding, empathy and a tailored approach,” says Kenny Chan, Numark’s lead information services pharmacist. “Emphasise it’s never to late to quit and every step towards quitting is a positive one. Encourage small, achievable steps.”

Since 2022, the only commissioned NHS community pharmacy smoking cessation service available in England is via the community pharmacy contractual framework, where if a smoker is started on a quit programme in hospital, the support is continued through community pharmacy. Pharmacies provide medication and support for the quitter. From March 2024, everyone admitted to hospital who smokes has been offered this service.

“Uptake of this service has increased significantly since implementation, with data showing 752 patients accessed the service during Q1 of 2023/24 – 12 months since launching. While it is encouraging that numbers are rising, it’s important that all patients discharged from hospitals are made aware of the benefits of this service and its convenient access and are initiated onto the programme,” says RPS English Pharmacy Board chair Tase Oputu.

However, many believe the service is not enough. Buxton says: “The national NHS smoking cessation service has been beneficial for patients, but referral numbers have been low. We’d like to see the service better utilised and expanded in line with the recommendations in Nuffield Trust and the King’s Fund’s Vision for Community Pharmacy. This would widen the scope of the service to cover all smokers, as well as users of vapes, as part of a package of public health services helping to position pharmacies as local health and wellbeing hubs.”

In Wales, there is the ‘Help me Quit’ service, which includes level 2 and level 3 options. The level 3 service allows patients to receive free NRT products as well as support via consultations. It includes an initial consultation to assess their needs, set a quit date and take a CO reading, followed by further consultations until week 12. They receive free NRT at each consultation.

Ellis Nugent, pharmacist at Davies Chemist in Gurnos, Swansea, provides both service levels. “Level 2 involves a third party – Help me Quit in Wales. Counselling is undertaken by the third party and the pharmacy provides the NRT products if suitable. Level 3 involves us providing both counselling and NRT over a number of weeks. I believe opening these services to a wider cohort in England would provide more patients with the opportunity to quit.”

Community Pharmacy Scotland provides the NHS service ‘Quit Your Way’. This includes support for patients supplied with NRT or Varenicline and also for those who wish to quit using behavioural techniques and CO monitoring only.

E-cigarettes update

It is thought that the use of e-cigarettes has helped an additional 30,00 to 50,000 smokers to successfully quit each year in England since 2013. However, according to ASH, a quarter of smokers have never tried vaping. “The provision of accurate information about vaping is vital,” it says. “Currently, 43 per cent of smokers who haven’t tried vaping think it is as or more harmful than smoking – up from 27 per cent in 2019.”

If smokers are using vaping as a quit method, it’s important that they don’t continue to smoke. “Every cigarette is harmful, so it is vital that smokers who are also vaping are encouraged to stop smoking completely,” says Waldron. “Pharmacists should inform smokers about all evidence-based smoking cessation products, including NRT and vapes, so they can make an informed choice.”

Last year, 9.1 per cent of the population used e-cigarettes (that’s 4.7m adults). This includes 2.7m ex-smokers, 1.7m current smokers and 320,000 never smokers.

NRT update

“NICE recommends advising smokers that they are more likely to successfully quit if they combine NRT or nicotine-containing vapes with behavioural support,” says Waldron.

Nugent agrees: “Combination therapy tends to be the most effective method and has the most success. However, a lot of success comes from the patient’s motivation to quit.”

Evidence shows that smokers are more likely to quit using a nicotine patch with another fast-acting type of NRT (lozenges/gum/spray). Chan advises: “NRT is designed to gradually reduce nicotine dependence. Customers should be advised to slowly decrease their use over time.”