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According to National Statistics, in 2016,15.5% of UK adults smoke which equates to around 6.1 million in the population. Reducing the prevalence of cigarette smoking remains the primary objective for the government and all devolved administrations.

Smoking is the most significant cause of preventable deaths in England and the health risks associated with smoking well-documented. This not only puts a heavy burden on the healthcare system but also has a substantial social impact.

Worrying, we know smoking is more prevalent amongst the most vulnerable in our society,  those with low educational attainment and poor socioeconomic status.

Even as smoking rates have progressively reduced, these group of patients still remain the most difficult to reach with cessation services.

Recent years has seen some local authorities stop providing locally commissioned NHS stop smoking service citing funding constraints.

Thankfully, in Bristol, Bedminster Pharmacy continues to provide the commissioned service. We know it increases access and offers our patients’ the best chance of quitting. The evidence supports this approach primarily for that hard to reach vulnerable group.

Combined with the Healthy Living pharmacy ethos of our pharmacy team, proactively offering the service and engaging patients delivers many successful outcomes locally. Our own experience demonstrating the unique potential of community pharmacy to provide healthy living interventions and support behavioural change expertly tailored to our localities.

The skilled behavioural support with or without a combination of pharmacotherapy evidence is the most effective way to help someone quit. The whole team plays a role, all colleagues are trained stop smoking advisors and can confidently deliver a personalised service. Such patients are up to four times as likely to quit.

While over the last decades, nicotine replacement therapy is the most popular option for smokers who want to stop smoking we also support patients choosing to use other pharmacotherapy options including Champix or Zyban, both prescriptions only.

Nicotine replacement products come in different formulations such as patch, chewing gum, inhalator etc. The team helps our patients to select the best product that caters for their needs. It is always worth noting that patients sometimes have unfounded concerns with regards taking too much nicotine or becoming addicted to nicotine products. Not using enough of the nicotine replacement products is actually the more significant risk and contributes significantly to quit attempt failures. Driving that message across is vital.

While 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.

Electronic or e-cigarette, handheld devices that allow you to 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 Great Britain currently use e-cigarettes. They do not produce tar or carbon monoxide, two of the most poisonous substances present in tobacco smoke, using it is considered less harmful than smoking. Although E-cigarettes only carry a small fraction of the risk of cigarettes, they are still reasonably new hence 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 cigarette can be a useful stop smoking aid. Bristol Council has adopted and funds the PHE advocated harm reduction approach with its acceptance of the role of e-cigarettes to help people. I helped the commissioners to design our local smoking cessation pathway, so I know this approach is supported by Public Health England and offers a practical but safe option underpinned by emerging evidence.

We also work with local e-cigarette outlets to educate and set up a referral pathway to support patients Bedminster pharmacy recommend them as part of our harm reduction approach.

In its latest guideline, the National Institute for Health and Care Excellence (NICE) acknowledges that 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, PHE unambiguously recommends that patients should be supported to use e-cigarettes to cut down, called the harm reduction approach or to stop smoking altogether. It lays 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 early  2018. This was their fourth report to review e-cigarettes based on emerging information on the 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 has been an excellent resource for our team. I would recommend it to anyone trying to assess the research evidence and learn the best practice guidance around e-cigarette use. The smoking cessation training modules by the NCSCT likewise offer excellent resources to empower and embed best practice.

One of the things that cause most anxiety for pharmacy practitioners is the absence of the clear-cut licensing framework we are hitherto 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 can look daunting.

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 while for non-licensed products it oversees the regulatory notification 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.

Our team built work with a variety of local contacts in the community. Local midwives know that we offer the service and are happy to refer pregnant patients and their partners to us. Around one in 10 pregnant women still, smoke and locally our prevalence are higher than the national rate. We run smoking cessation outreach in the local pubs and supermarket.

We embrace the Making Every contact count ethos (MECC). Linking every patient contact as an opportunity to engage in a conversation that can influence appropriate behavioural change. MUR, NMS, Flu vaccinations, minor ailments especially coughs, sore throat and indigestion in this smoking context. We also use very engaging displays as conversation starters and educational tools. Investing in motivation interviewing training has undoubtedly helped the team become more competent in providing care that delivers the quit outcome.

There is now an ambition to achieve a smoke-free nation. Community Pharmacy is best placed to champion and deliver this, working in partnership with other organisation. As the social impact alongside the health implications of smoking is better appreciated, we are the bridge and our offer of a personalised locally suited service a significant selling point.

Ade Williams

Ade Williams is a pharmacist at Bedminster Pharmacy, Bristol

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