OSPAP Programme: Smoking Cessation

OSPAP Programme

• Programme name: OSPAP Programme
• Presenter: Smoki Rebecca Waton
• Contact: [email protected]

Learning Outcomes

• Describe the current status of tobacco use in England
• Understand the harm associated with tobacco use
• Know the strategies employed in the UK to tackle tobacco use
• Describe the role of pharmacy in supporting harm reduction for tobacco
• Conduct a smoking cessation consultation with a patient

Role of Pharmacy in Smoking Cessation

• Community pharmacists trained in behaviour-change methods are effective in helping clients stop smoking (B1)
• Community pharmacy-based stop smoking services are cost-effective (B1)
• Abstinence rates from one-to-one treatment by community pharmacists and primary care nurses are similar to rates with specialist behavioural support. Rates are lower for specialist one-to-one advice compared to group interventions with specialist behavioural support (B3)
• Training increases pharmacists' knowledge, self-confidence, and positive attitude towards smoking cessation (B1)
• B1 indicates randomised controlled trials, and B3 refers to individual studies or observational studies.

Name the Tobacco...

• Images of various tobacco products are shown (e.g. cigarettes, cigars, hookah, vaping devices, chewing tobacco)

Tobacco in Images - Glamorous

• Images depict instances of smoking with an apparent glamorous presentation.

Tobacco in Images - Safe

• Images include vintage advertisement featuring doctors smoking Camels suggesting smoking as safe or common

Tobacco in Images - Deal

• Image of a crying child surrounded by images of smoke, showing a negative connotation to smoking, with the slogan, "Smoking isn't just suicide, it's murder"

Hazardous Contents of Tobacco (WHO 2006)

• Cigarettes contain over 4,000 toxic compounds causing damage to healthy tissue
• Tar, mostly deposited in the lungs, is a combination of chemicals, many known as carcinogens
• Nicotine is the psychoactive drug in cigarettes that affects the cardiovascular system
• Carbon monoxide is a poisonous gas that impacts health

The Scale of the Problem

• In 2022, 12.9% of people aged 18 and above smoked cigarettes, equating approximately to 6.4 million people in the UK
• The proportion of current smokers in the UK has decreased significantly from 14.1% in 2019
• 14.6% of men smoked compared to 11.2% of women
• Those aged 25 to 34 years had the highest proportion of current smokers (16.3%)
• E-cigarette use has risen from 7.7% in 2021 to 8.7% in 2022

The Scale of the Problem (OFNS 2022)

• In the UK, around 22.8% of people in routine and manual occupations smoked
• Unemployed people were more likely to be smokers than those who were employed
• 45.4% of smokers in Great Britain wanted to quit

Health Burden of Smoking (NHS digital 2020)

• 506,100 hospital admissions (2019/20) were attributable to smoking – 10% higher than 2009/10
• 74,600 deaths (2019/20) were attributable to smoking
• 710,000 prescription items to help people stop smoking (2018/19)

The Cost of Smoking to Society

• Total cost to society in England was estimated to be £17.3 billion a year (2021)
• Includes NHS costs of treating smoking-related diseases (£2.5 billion), productivity loss (£14.1 billion), social care costs for older smokers (£1.2 billion), and costs of fires caused by smokers' materials (£328 million)
• £10 billion in treasury revenue from tax (2022-2023) was gained

How Does Smoking Cause Cancer?

• Cigarette smoke contains over 5,000 chemicals, with at least 70 known to cause cancer.
• Harmful chemicals enter the lungs and body, damaging DNA (including parts that protect against cancer).
• Some chemicals make it harder for cells to repair DNA damage
• This damage can build up and lead to cancer

Smoking is an Addiction

• Up-regulation of nicotinic receptors in smokers leads to withdrawal symptoms when nicotine intake is reduced
• Nicotine stimulates dopamine production, causing feelings of satisfaction and reward
• It’s a physical and psychological addiction

Physical Addiction

• Reducing nicotine intake causes withdrawal symptoms in smokers
• Short-term symptoms include light-headedness, difficulty concentrating, sleep disturbances, depressed mood, and irritability
• Longer-term effects may include increased appetite, weight gain, constipation, and mouth ulcers
• Withdrawal symptoms typically last up to 4 weeks, but cravings can persist for over 10 weeks

Renormalisation of the Body

• After quitting, the body starts to recover
• Heart rate and blood pressure return to normal within 20 minutes
• Carbon monoxide levels in the lungs decrease after 12 hours
• Oxygen levels return to normal
• Lung function improves; coughing and breathing become easier
• Risk of heart attacks and strokes decreases significantly within 30 days

Psychological Addiction

• Assessing patient readiness and motivation to quit is crucial.
• Setting a quit date is a critical step.
• Removing smoking triggers (e.g. ashtrays, lighters) is helpful
• Coping strategies for urges and distractions from cravings are important

NHS Stop Smoking Services

• Provides various intervention types, including closed groups, couples/family programs, drop-in clinics, one-to-one support, open groups, and therapy.
• Services are available in multiple settings, such as children's centres, community centres, community psychiatric settings, dental practices, general practices, hospitals, maternity units, military bases, pharmacies, prisons, psychiatric hospitals, schools, and workplaces.

Helping People to Quit (BMA and RPS 2014)

• Nicotine Replacement Therapy (NRT) facilitates gradual nicotine withdrawal
• Available in various formulations and dosage routes
• Combinations can help provide a baseline of nicotine
• Chosen based on patient preference
• Counselling on dependence level, and expectations is crucial

Helping People to Quit (Zyban/Bupropion (Consilient Health))

• Noradrenaline and dopamine (reuptake inhibition)
• Reduces withdrawal symptoms, lowers cravings
• Commonly taken 1-2 weeks before quitting
• Side effects: dry mouth, GI disturbances, taste disturbances, agitation, anxiety, dizziness, depression, headache, impaired concentration, insomnia, tremor, fever

Helping People to Quit (Champix/Varenicline (Pfizer, Thistle Pharma))

• Partial agonist at nicotinic receptors
• Reduces withdrawal symptoms and nicotine cravings
• Common side effects: GI problems, appetite changes, dry mouth, taste disturbances, headache, drowsiness, dizziness, sleep disorders, unusual dreams
• Can cause suicidal behaviour (rarely)

Helping People to Quit (Cytisine (Consilient Health))

• Similar mechanism to Champix (binding at nicotinic receptors)
• Similar side effects
• Standard course is 25 days but potentially effective up to 12 weeks.
• Not recommended for those under 18 or over 65.

Behavioural Support (Croghan 2011)

• Essential in combination with pharmaceutical treatments
• Structured program, usually up to 12 weeks
• Regular consultations with a smoking cessation advisor (every 1-2 weeks)
• Covers information about smoking consequences, withdrawal symptoms, past quit attempts, nicotine dependence, and coping mechanisms.
• Includes carbon monoxide or cotinine testing, and addressing any potential lapses.

Heaviness of Smoking Index (Heatherington et al., 1991)

• Questionnaire to assess smoking dependence.
• Two questions: time until first cigarette, and number of cigarettes smoked per day.
• Scores range from 0 to 6; 0-2 low dependence, 3-4 moderate and 5-6 high dependence
• Useful for understanding the level of dependence to tailor interventions

Alternative to Fagerström test for Nicotine Dependence (FTND)

• Provides quantitative measure for nicotine dependence.
• Measures several factors contributing to addiction.

Carbon Monoxide Testing (Crogan 2011)

• Measures carbon monoxide in exhaled air
• Assesses nicotine dependence objectively
• Used as baseline assessment to determine a smoker's quit status 4-6 weeks after stopping smoking
• Non-smokers usually have a CO level lower than 10 ppm

Electronic Cigarettes/Vapes (NCSCT)

• Newer development becoming addictive
• Two components (reusable device with a heating element, and liquid containing nicotine and chemicals)
• Considered a medicinal device when refillable
• Has restrictions on product capacity and nicotine strength
• Licensed NRT products are usually preferred.
• Pharmacists should use their professional judgment when assisting those wishing to quit vaping

Electronic Cigarette Evidence Update

• Recent reviews have shown regulated e-cigarettes are safer than regular smoking.
• Government's evidence update and tobacco control plan provide further information

Breaking News

• E-cigarettes potentially to be prescribed on the NHS to help reduce smoking prevalence.

The Pharmacist's Role

• Pharmacists play an essential role in public health through various interventions, primarily focusing on prevention-focused promotion of healthy lifestyles, signposting to smoking cessation services, OTC nicotine replacement therapy (NRT) provision, and participation in NHS-commissioned smoking cessation programs.
• Additional roles include consultations within GP practices, the management of in-patient smokers in hospitals, transfer arrangements for smokers transitioning from hospital to community pharmacy for smoking cessation intervention, and participation in smoking cessation clinics or offering prescribing advice to local NHS physicians.

The New Image of Smoking

• Advertisements present a new image promoting vaping products over cigarettes.

30 Seconds to Save a Life

• An informational campaign from the National Centre for Smoking Cessation and Training (NCSCT) to highlight the value of immediate interventions.

Very Brief Advice Model

• A simplified 3-step model for providing advice on smoking cessation: ask, advise, act; referring people to stop smoking services