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England will be smokefree by 2030, was the objective set by the Government in 2019, defining smoke free as only five per cent of the population smoking at that time.
Published in June 2022 by the Office for Health Improvement and Disparities (OHID), The Khan Review: Making Smoking Obsolete, however, found that without further action, England will miss the smokefree 2030 target by at least seven years, and the poorest areas in society won’t meet it until 2044. In fact, to have any chance of hitting the smokefree 2030 target, the Government needs to accelerate the rate of decline of people who smoke, by 40 per cent.
Despite smoking rates declining each year, and the proportion of people smoking now being the lowest recorded, there are still over six million smokers in England, more than one in seven adults. Smoking remains the leading cause of premature death, annually accounting for almost 75,000 deaths in England and costing the NHS approximately £2.4 billion. It’s also the leading cause of the 10-year difference in life expectancy between the richest and the poorest members of society. For every death caused by smoking, it’s estimated that another 30 people are suffering from serious smoking-related illnesses.
According to The Khan Review, the NHS needs to prioritise stopping people from smoking, providing support and treatment across all of its services, including primary care. This includes recommending vaping as a substitute for smoking, alongside providing accurate information on the benefits of switching from cigarettes to e-cigarettes.
In July 2023, data published by Action on Smoking and Health (ASH) showed that the public also believes that further action is needed to tackle smoking, with 49 per cent of adults in England thinking the Government is not doing enough. Further action could include increasing Government investment in public education campaigns and using pack inserts to motivate quitting, recommendations which were also included in The Khan Review.
“Reaching a smokefree 2030 is achievable but it requires more action than the Government has currently committed to,” says Dr Khan. “My 2022 review called for a holistic response that will make smoking obsolete in this country. Without doubt, sustainable and increased funding is needed to support those with the highest rates of smoking, something which could be levied from the tobacco industry. Anything less risks leaving some groups behind and widening the already substantial inequalities caused by smoking.”
The impact of smoking
According to Smokefree Action, two-thirds of smokers started smoking as children before realising how difficult it would be to quit. Smoking harms nearly every organ of the body and affects a person’s appearance and overall health. It contributes to health and social inequalities and can also have a negative impact on people’s finances. A survey by Niquitin to mark Stoptober (see page 14) in October 2022 found that nearly half of all smokers in the UK admitted to smoking more cigarettes since the start of the cost-of-living crisis, with financial stress as a key cause of the rise.
“Financial stresses and concerns about the cost-of-living crisis are clearly having a troubling impact on smoking levels,” says Farah Ali, superintendent pharmacist and NiQuitin spokesperson. “Stress is a known trigger for smoking, but our study reveals money worries are currently having a direct impact on people reaching for cigarettes. Even worse, this is likely to become a vicious cycle, as cigarettes are an expensive habit.”
Highlighting the health, financial and social implications of smoking may provide encouragement for some people to quit the habit. In October 2022, a UK-wide study led by the University of Stirling found that offering a shopping voucher incentive scheme alongside regular Stop Smoking Services more than doubled the number of women who stopped smoking during pregnancy.
Furthermore, a new research study has launched in Lanarkshire to tackle the number of children breathing in second-hand smoke at home. The study, which is being led by researchers at the University of Stirling in partnership with NHS Lanarkshire and the University of Glasgow, will offer free NRT to parents and carers (of at least one child aged five years and over) for 12 weeks.
“Smoking is highly addictive, and we know that people often want to quit but aren’t quite ready to completely give it up,” says Rachel O’Donnell, of the University of Stirling’s Institute for Social Marketing and Health. “We hope that this research study will take the pressure off participants and take those who smoke closer to thinking about quitting – supporting them to take that first, important step on the journey to a smoke-free home.”
“Reaching a smokefree 2030 is achievable but it requires more action”
Quitting services
Many people try to quit smoking with willpower alone, but it’s much easier to go smoke free with the right help. Smokers given nicotine replacement therapy (NRT) and behavioural support and advice are much more likely to succeed. Many pharmacies offer smoking cessation programmes to customers, either nationally funded programmes, locally commissioned services or private services.
“The most important thing that healthcare professionals can do is advise smokers on how to quit most effectively,” says Jim Pattison, policy assistant at ASH. “It is well established that most smokers want to quit and expect to have smoking raised by healthcare professionals. Studies have shown that focusing not on the case for quitting but how to quit increases the likelihood that people stop.”
According to The Nuffield Trust, the number of people using NHS Stop Smoking Services has fallen for eight consecutive years. This may partly be due to the reduced prevalence of smoking in the population but may also be due to the increased use of e-cigarettes, which are widely available outside of Stop Smoking Services. The percentage of people using NHS Stop Smoking Services who self-report that they were successful in quitting at four weeks has remained fairly steady over the last 12 years, at around 50 per cent.
Community pharmacy’s Smoking Cessation Service (SCS), which was commissioned as an advance service from March 2022, enables patients who start their smoking cessation treatment in hospital to then be referred to a pharmacy of their choice so they can continue to receive treatment, advice and support once they’re discharged.
In April 2023, the Government announced a new ‘swap to stop’ scheme to distribute one million vape kits to help adults to quit, and a financial incentive scheme for pregnant smokers. The Government is also holding a consultation about authorising quit-themed information messages and advice (pack inserts) inside tobacco packets to help more smokers quit. These inserts could focus on a variety of messages, including physical or mental health, financial benefits and stop-smoking aids (including vapes).
Case study
Ana Pazeiro at PharmacyExprezz in Great Yarmouth works as a pharmacy-based smoking cessation advisor. Patients can self-refer or are referred through GP surgeries or Smokefree Norfolk. Ana has these 10 tips for other stop smoking advisors, and those thinking about becoming one:
- Sometimes patients are smoking illegal substances such as cannabis as well as cigarettes. We tell them that they can’t use our programme to quit cigarettes unless they quit all of their dependencies
- Sometimes patients don’t speak English. Among the pharmacy team, we speak three other languages so we try to help them as much as we can. If we can’t help, we ask if they can bring someone with them to translate, or we have to rely on Google Translate
- I quit smoking five or six years ago, so I use this as an example when I speak to patients. I think it helps if they hear real stories of success. But I also explain that quitting can be a struggle
- At the moment, treatment through our NHS Stop Smoking programme involves a combination of NRT patches (which are mandatory and are the main source of nicotine) and then a choice of six or so other NRT products
- Every time a patient comes into the pharmacy for an appointment, we step down the treatment so that the NRT products contain less nicotine than the ones the patient has been using
- The choice of the second NRT product will depend on a patients’ preferences, such as their profession, lifestyle or background. We often start them on a patch with gum, but if they don’t like gum we can change this. If they miss the feeling of smoking, they could use an inhalator, which looks like a cigarette. If they are in a job where they can’t get a break easily, they may prefer a gum or lozenge to keep in their mouth while they work
- We don’t recommend vaping as part of our NHS programme as e-cigarettes are still nicotine-based and can be addictive. The idea is to take patients off nicotine completely
- It’s important to be firm with patients, although this isn’t always what they want to hear. If their GP has recommended that they quit for health reasons, we explain that this is why they need to quit smoking
- Around 50 per cent of the patients will leave the programme. If they don’t turn up, we chase them to see if they want to continue. We have learnt to be patient, and may have to ring them every day, sometimes even twice a day, to encourage them to come back
- If patients relapse during the programme, we discuss why they may have relapsed and give them appropriate support. But if they relapse and come back after a longer period, we add them as a new patient and start again. Starting afresh helps them refocus on their quitting journey, rather than dwelling on what went wrong in the past.
Pharmacy support
According to Farah, the first thing to do before starting a stop smoking journey is list the reasons for quitting, such as saving money or getting healthier. The next step is to set a quit date and stick to it.
NHS Stop Smoking Advisors will only recommend evidence-based support during the service. In the initial meeting, they will listen to why the patient smokes and carbon monoxide gas in the previous 24-48 hours; a high level is usually caused by exposure to cigarette smoke and provides visible proof of the harm caused by smoking.
If the patient decides to go ahead, the advisor will help them form an action plan and discuss NHS-endorsed stop smoking treatments, such as NRT patches, gum, lozenges, inhalators and mouth or nasal sprays. The NHS Quit Smoking app can help people to track their progress, see how much money they’re saving by not smoking and get daily support.
E-cigarettes (vapes) aren’t currently available on prescription, but the National Institute for Health and Care Excellence (NICE), ASH and other organisations recommend them as a quitting aid. Increasing numbers of pharmacies are stocking them to offer to customers as an alternative to NRT.
“Vaping is more effective at helping smokers stop than NRT,” says Jim. “Although it’s not risk-free, it poses a fraction of the health risks of smoking. It may be particularly helpful for those who have struggled to quit before using other methods, and those who are more nicotine dependent. E-cigarettes also tend to be cheaper than NRT so may be more practical for more disadvantaged smokers. Ultimately, different methods work best for different people so customers should be advised of all the options and encouraged to use what works for them.”
“The UK decline in smoking prevalence, while impressive, has hit a plateau, and the challenge of eradicating smoking persists,” adds Maria Mantzourani, head of Scientific and Medical Engagement at Philip Morris Limited UK.
“We know that no one product will meet all adult smokers’ preferences or solve the smoking issue. People smoke for different reasons – not just nicotine, but also taste, sensory experience, and ritual.
“To truly enable smokers to break free from cigarettes and accelerate our move towards a smoke-free England, policies must align with scientific evidence and a diverse range of smoke free alternatives should be embraced, including vaping, heated tobacco, and nicotine pouches. Smokers need a choice if they’re to have a chance in moving away from smoking.”
Disposable vape concerns
With 1.3 million disposable (single use) vapes thrown away every week, these have become a regular item of litter on the streets. In July 2023, the local Government Association called for the Government to ban the sale and manufacture of disposable vapes by 2024. The EU is proposing a ban in 2026 and France is rolling out a ban in December 2023.
Disposable vapes are designed as one unit, which means the battery can’t be separated from the plastic. The lithium batteries can sharply increase in temperature if they are crushed. This means that the products are a hazard for waste and litter collection and can cause fires in bin lorries.
Councils are also concerned about the impact vaping is having on children and young people, with more and more children (who have never smoked) starting vaping. The bright colours and packaging, flavours and relatively inexpensive price means these products tend to appeal to younger age groups. Strict new measures are needed to regulate the display and marketing of regular vaping products in the same way as tobacco.
“Councils are not anti-vapes, which are shown to be less harmful than smoking and have a place as a tool to use in smoking cessation,” says councillor David Fothergill, chairman of the LGA’s Community Wellbeing Board.
“However, disposable vapes are fundamentally flawed in their design and inherently unsustainable products, meaning an outright ban will prove more effective than attempts to recycle more vapes… Councils urge the Government to take this action to protect our planet, keep children safe and save taxpayers money.”
ASH supports putting an excise tax on disposable vapes, which could make them much less affordable, while giving much greater powers to Border Force, HMRC and trading standards to control their import, distribution and sale, and to force vape companies to ensure they are properly recycled.
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