Award-winning pharmacist Ade Williams talks about how his pharmacy in Bristol has made important smoking cessation strides…although he fears pharmacy’s role as the number one stop-smoking service could be greatly diminished in future…

 

Stoptober, the month-long stop smoking campaign that runs every October, is one Bedminster Pharmacy passionately embraces. Smoking is still the biggest cause of preventable deaths in England and the health risks associated with smoking are well documented.

This not only puts a heavy burden on the healthcare system but also has a huge social impact. According to National Statistics in 2016 in the UK 15.8% of UK adults smoke which equates to around 7.6 million of the population. Reducing the prevalence of cigarette smoking is remains a main objective for the government and devolved administrations.

In spite of the fact that some local authorities have recently stopped providing locally commissioned NHS stop smoking service citing funding constraints, we are happy to still be able to provide the service, knowing it increases accessibility and our patients’ chances of quitting.

Combined with the Healthy Living Pharmacy ethos of our pharmacy, the service provided in our proactive way is able to engage more patients and deliver many successful outcomes locally. A narrative that demonstrates the unique potential of community pharmacy to deliver healthy living interventions and support behavioural change.

In community pharmacies smokers receive skilled behavioural support with or without a combination of pharmacotherapy. Community pharmacies’ ability to play a key important role is well established as such patients are up to four times as likely to quit.

The pharmacotherapy that pharmacies usually provide is the nicotine replacement therapy products. Some are also able to provide or refer on to facilitate access to Champix or Zyban, both prescription-only.

Over the last decade nicotine replacement therapy has been the most popular option for smokers who want to stop smoking. The effectiveness of using this method to quit smoking is long established. Nicotine replacement products come in different formulations such as patch, chewing gum, inhalator etc.

They are available on prescription or to purchase in pharmacies and some shops. They, like licensed products, are subject to all the usual legal and quality processes applicable in the UK.

Whilst the consensus on the merits of pharmacies supporting patients to quit is unequivocal much more contentious is the use of electronic or e-cigarettes as part of this. Stoptober usually brings this to a head, so no surprise that during the month MPs on the Cross Party Science and Technology Committee announced they were to launch an inquiry to look at all aspects of e-cigarettes and requested representations from various bodies.

Electronic or e-cigarette, handheld devices that allow you inhale nicotine without producing as many dangerous chemicals produced by smoking tobacco, have become more and more popular. In 2016, approximately 2.9 million people in the UK used e-cigarettes.

They do not produce tar or carbon monoxide, two of the most poisonous substances present in tobacco smoke, and using it is considered less harmful than smoking. Although e-cigarettes only carry a small fraction of the risk of cigarettes, they are still fairly new and their long-term safety profile is unclear. The evidence continues to develop on this with nothing of significant concern yet.

In the face of growing evidence showing that electronic cigarettes can be an effective stop smoking aid, many pharmacies not only recommend them but also stock them. That said, the absence of a licensing framework and the proliferation of multiple suppliers and manufactures makes for great unease amongst many other colleagues.

The Royal Pharmaceutical Society has a very risk adverse policy on e-cigarettes, rightly addressing patient safety concerns by calling for rigorous regulation and restrictions on public use of such products whilst acknowledging that e-cigs have a potential role to play in helping smokers reduce and stop smoking in the short term or as a pathway to other nicotine replacement therapies (NRTs).

In its latest draft guideline, the National Institute for Health and Care Excellence (NICE) acknowledges they may have a role in helping smokers reduce or stop smoking but cites the evidence gap as a reason for not explicitly recommending them.

Unlike many other bodies, Public Health England (PHE) unambiguously recommends that patients should be supported to use e-cigarettes to cut down. It laid its stall in a comprehensive review of evidence and an accompanying document highlighting the implications of this evidence for policy and practice of evidence on e-cigarettes published in August 2014. This position is subject to review based on emerging information on effects of long-term use.

The document Electronic cigarettes: A briefing for stop smoking services, produced by the National Centre for Smoking Cessation and Training (NCSCT) in partnership with Public Health England, is a great resource for anyone trying to access the research evidence and learn the best practice guidance around e-cigarette use.

One of the things that causes most anxiety for pharmacy practitioners is the absence of a clear-cut licensing framework we are familiar with. In community pharmacy our reputation is everything and to risk that for commercial interest or be seen to be complicit in compromising patient safety or health is unthinkable. Distinguishing in a very crowded market which products are of the highest quality does look daunting.

It is certainly worth knowing though that the regulatory framework does now exist. The Medicines and Healthcare products Regulatory Agency (MHRA) is responsible for the regulation of electronic cigarettes.

It licenses those that can be called medicinal products whilst for non-licensed products oversees the notification regulatory scheme, setting minimum standards for the safety and quality of all e-cigarettes and refill containers (e-liquids) before they can be sold to the public.

Bristol Council has adopted and funds the PHE-advocated harm reduction approach with its acceptance of the role of e-cigarettes to help people. The Bedminster Pharmacy team is proud to have helped design our local service pathway. We also work with local e-cigarette outlets to educate and set up a referral pathway to support patients.

Nevertheless, we remain aware that all of community pharmacy must keep up to date with guidelines and evidence in order to provide the most helpful and accurate information to our patients.

Working with manufacturers and distributors, we must ensure that evidence-led best practice is the gold standard – person-centered carefully embraced above commercial interest.

Last year over half of those who took part in Stoptober used an e-cigarette without community pharmacies’ engagement in how these products are used as quitting tools. The concern is our role as the go-to stop smoking service provided by commissioners will be greatly diminished.

 

Ade Williams runs Bedminster Pharmacy in Bristol – winners of this year’s Pharmacy Business innovation award.

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