Guidance on Public Health Service (PHS)

The Public Health Service (PMS) supports pharmacists and their staff in promoting self-care towards patients.

NHS smoking cessation

Smoking cessation aims to provide extended access through the NHS to smoking cessation support, including the provision of patient-centred behavioural support.

Smoking cessation risk assessment

There are a number of circumstances whereby you are required to fill out a risk assessment form before treating your customer or patient.

In this instance, our risk assessment form must be completed.

E-learning for smoking cessation

NHS Education for Scotland (NES) provide online e-learning modules around smoking cessation via their online portal. Visit their website to find out more.

National Patient Group Direction

Individual boards can download and use this template to create a localised Patient Group Direction (PGD), supporting the use of Varenicline.

Varenicline may be supplied as part of the National Public Health Service (PHS) element of the community pharmacy contractual arrangements to support smoking cessation attempts.

Explore smoking cessation services

If you are looking for further information on the provision of smoking cessation services, more information is also below.

How should NRT patches be applied?

Apply to non-hairy, non-sensitive, dry skin. Do not apply after rubbing in lotion.

If a person presents at the pharmacy who has already stopped smoking but wants to come onto the programme what should you do/say?

This person is NOT suitable for our programme as they are a non-smoker. We could suggest that the person buys a packet of mini-lozenges, gum etc and keep in their pocket for the difficult times only (packet should last quite a while) – using NRT (nicotine replacement therapy) in this way is preferable to relapsing to smoking.

Person presents asking to join the service and has had a previous quit attempt. They advise that previously they used patches and had a side effect of tingling down one of their arms. What should you advise?

The pharmacist should speak to the client and/or the client's GP with regards to the side effect as this may be due to something else other than the patch. Once this is established, then an alternative form of NRT may be considered more appropriate or the patch could be re-considered but each day’s patch could be sited on a different part of the body rather than always on the same arm or location on the arm.

With any effect resulting from nicotine replacement therapy use, the pharmacist should make a professional judgement as to whether an alternative form of NRT would be more appropriate, an alternative mode of use (in the case of the patch which has more flexibility in terms of its location of placement on the body), or whether the side effect appears to be potentially more concerning and may indicate the need to speak to the client’s GP.

You have a client who has been on the service several times in quick succession and you feel that they are not motivated to quit, even though they keep telling you they are. What should you do?

The Pharmacist should use their discretion as to the best course of action. It may be more appropriate for referral on to the non-pharmacy specialist smoking cessation services where more time can be spent exploring the client’s motivation through the provision of intensive, behavioural support via health behaviour change and motivational interviewing techniques. (Shared care opportunities may also be available whereby such support is offered by non-pharmacy services but follow-on support or pharmacotherapy provision is provided by pharmacies.) Alternatively, they might be better to come back at a point when they have had a break to re-assess and re-evaluate their decision to quit and are more prepared and ready to give it a concerted effort to do so.

A client wants to try mini lozenges but has throat cancer?

Minis would be better than smoking so the patient could try them. Likewise, with any condition, use of nicotine replacement therapy is better than continuing to smoke. However, it would be good practice to inform the client’s GP. You should have a discussion with the patient about the intention to inform his or her GP.

What if the CO reading is high yet the smoking status has been recorded as a 'non-smoker'?

If this is higher than expected, repeat the CO reading and if it still remains high, test the CO monitor on staff members. Check if there is another smoker living in the house as this could raise the levels through second-hand smoke; this would be an appropriate opportunity to refer on to non-pharmacy specialist smoking cessation services where family-based smoking cessation support may be available including how to address the second-hand smoke issues. If the monitor is not faulty, it is possible that there is some under-reporting of cigarette use. However, in the first instance, remember that CO can be inhaled from faulty gas appliances in the home or car – given the potentially life-threatening situation this imposes, this should be investigated immediately (ensure client phones free Health and Safety Executive gas safety advice line on 0800 300 363). Finally, further avenues may need to be explored other than tobacco smoking (e.g. higher CO readings can occur as a result of lactose intolerance or alcohol on the breath or possibly some novel forms of devices e.g. e-shisha).

During the initial assessment, you check if a female client is pregnant but should you continue to ask that question throughout the programme?

Yes, as it may be necessary to change the client’s medicines etc after their quit attempt has started. Alternatively, you could state at the outset that, if they are planning a pregnancy or, if at any point during the programme they may have become pregnant, then it may be more appropriate to change their medicines.

It is recorded that a client is to receive dual NRT. Should they just be given the second product automatically? You should discuss the client’s progress each week and make a decision with regards to the second product. Do not dispense this if it is not necessary but, equally, do not withdraw the second NRT product if the client is in danger of relapse to smoking.

Can a client be given a second product when taking varenicline (Champix)?

No they can’t. Champix acts by partially blocking nicotine receptors in the brain hence giving nicotine will not help. You could suggest a non-nicotine plastic cigarette (costs about £2) if the patient is missing the hand to mouth action.

How long between quit attempts should a client wait before trying with Champix again?

There is no fixed waiting time between quit attempts. It is at the discretion of Pharmacist/GP, as long as the client is motivated. However, a break between quit attempts can be particularly useful in order to ensure that the client renews their motivation and determination to quit and to stay quit, and has time to prepare for it.

Note that a new quit attempt cannot be undertaken at a community pharmacy if a quit attempt with confirmed quit date has been undertaken at another community pharmacy in the last 12 weeks. (This is irrespective of the status of the existing quit attempt.)

A patient who smokes has entered a nursing home. He is not allowed to smoke in the home. Nursing home staff ask for advice on whether e-cigarettes are available on prescription, and of any associated risks if he were to use one e.g. environmental risk factors to patients in the home. No, e cigarettes are not available on prescription, and there is currently not enough evidence re their safety, quality and efficacy; it is possible that some products may become available on prescription later in 2014, however. It is always best that licensed products are used which ensure quality, safety and efficacy. Nicotine replacement therapy may be an option for the patient – it is safe and effective in helping people to quit and deal with nicotine cravings, and there are a variety of product types including an inhalator, patch, gum, nasal spray, oral spray, lozenge, and micro/sublingual tablet. There are also some non-nicotine plastic cigarette-like devices that can be bought (cost about £2) and some patients find them useful as they help alleviate the craving of the hand-to-mouth action that many smokers miss - as there are no drugs etc in it, it can be used along-side the NRT patch without a problem.

Is there any ethanol in the strips? How does this affect people who do not drink alcohol for religious reasons?

Alcohol content of the Strips is between 0.005% and 0.01% which evaporates on opening the foil wrapper. However, it is better to avoid them being used in patients who do not drink alcohol for either health or religious reasons.

Does the alcohol contained in NiQuitin Oral Strips interact with Antabuse?

Each NiQuitin strip contains only 4mg of ethanol. The disulfiram-alcohol reaction has been characterised as “unpredictable” and some patients experience a mild disulfiram-alcohol reaction with a Blood Alcohol Content (BAC) as low as 5-10mg/ml. There are other Nicotine Replacement Therapy (NRT) options that do not contain alcohol (patch, gum or lozenge) that could be recommended as alternatives.

Is there any gelatine in the strips?

The Strips are water based, so do not contain gelatine.

Can patients on e-Cigarettes join the service?

Like tobacco users, e-cigarette users should be encouraged to quit tobacco, nicotine and e-cigarette use entirely in order to maximise their health outcomes.

Some e cigarettes are nicotine products but have not been licensed by the MHRA for quality, safety and efficacy for smoking cessation; it is possible that some products may become available later in 2014 once they have passed quality and safety standards. Clients are best to use licensed products (currently NRT, bupropion or varenicline) for smoking cessation.

Many e-cigarette products do contain nicotine and therefore, switching to NRT may pose an issue for titrating nicotine dosage if the client is unable to quit e-cigarette use, while re-introducing nicotine through NRT if the client was using a non-nicotine e-cigarette product may pose additional issues. It would be more appropriate for e-cigarette users to be referred on to the non-pharmacy specialist smoking cessation services for the provision of intensive, behavioural support via health behaviour change and motivational interviewing techniques to help them quit their tobacco, nicotine and e-cigarette use entirely.

Should a pregnant woman use a 24 hour NRT patch?

No, a short acting product is best but if a patch is used, ensure it is removed at bedtime.

Has the number of pharmacy based quit attempts increased over the last few years?

In Scotland, in 2009 there were 42,631 pharmacy based quit attempts, in 2012 there were 90,221 recorded (most up to date figures available).

Quit attempts overall in Scotland (pharmacy based and non-pharmacy based) have increased – from 74,038 in 2009 to 119,428 in 2012.

How does this compare to non-pharmacy based quit attempts?

In Scotland, in 2009 there were 31,407 non-pharmacy based quit attempts, in 2012 there were 29,207 recorded (most up to date figures available).

To deliver the new Pharmacy Smoking Cessation Service, where would I source the varenicline clinical risk assessment form? The Varenicline clinical risk assessment form is available to download.

How long must I keep the smoking cessation service clinical paperwork?

You must keep these clinical documents for 3 years.

If the patient CHI number is not available, what should you?

First you should confirm with the patient you have the correct name, DOB and postcode. Also check that the patient is registered with a GP in Scotland. If this information is correct, contact the GP surgery or health board for assistance.

What do you do if a client fails to return to the pharmacy?

If the client does not make contact with the pharmacy, the pharmacy staff have the opportunity to record contact attempts. E.g. a staff member may try to text or ‘phone the client. At least 3 attempts should be made to contact the client. These should be recorded in the smoking cessation support tool within PCR. If a client is not successfully contacted for the 4 week or 12 week post quit date follow up they should be recorded as 'lost to follow up' and the MDS should be submitted from the smoking cessation support tool in PCR.

If the client is lost to follow up at 12 weeks the Health Board should be informed through locally agreed protocols. Boards have until week 16 post quit date to achieve and record a successful follow up directly on the national smoking cessation database.