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If you don’t smoke, you undoubtedly know someone who does – a friend, a customer, a colleague – and while society has made progress in curbing smoking over the last few decades in public places like aeroplanes or in offices, there are still around six million people across the UK who smoke, according to the Office for National Statistics, despite known adverse health effects.
This means there are plenty of opportunities for pharmacy teams to raise the health implications of smoking with customers and support them on their journey to quit.
What’s the damage?
When a person smokes, several things happen straight away. Nicotine, a highly addictive substance found in tobacco products (see boxout), reaches the brain in 10 seconds, and smokers may feel a sense of decreased stress and improved mood. However, these effects are short-lived. Blood pressure increases, blood flow to the hands and feet decreases and the brain and nervous system are stimulated, leading to a ‘jittery’ feeling. In the long-term, smoking has even worse physical and mental health implications. “Smoking is the leading preventable cause of ill health and premature death,” says Nick Hopkinson, medical director at Asthma + Lung UK and a professor of respiratory medicine at Imperial College London. “This includes respiratory and cardiovascular disease as well as lung cancer and many other cancers. People who smoke are more likely to get respiratory infections, be hospitalised with flu and pneumonia, develop complications after surgery, experience erectile dysfunction, and develop premature skin ageing.”
Smoking affects the tiny, hair-like structures in the trachea and bronchi, which usually remove mucus and other particles up and away from the lungs. Combined with increased inflammation caused by smoking throughout the body, smokers have a weakened immune system, making them more susceptible to infection and likely to suffer from respiratory conditions. This can lead to a myriad of health complications, use of healthcare resources and economic strain – on the system and the individual. “Two out of three long term users will die from a smoking-related disease. Smokers need social care support on average 10 years earlier,” says Nick.
Other impacts of smoking on physical health include:
- Fertility problems – smoking can lower sex hormone levels in males and females and contribute to fertility issues
- Vision – smokers often have higher eye pressure. Glaucoma, which results from pressure in the eye increasing, causes damage, loss of sight and cataracts
- Vaginal discomfort – menopause may also occur earlier in smokers and decrease lubrication.
Smoking has many health implications, including physical ones like staining the teeth.
“Smokers have a weakened immune system, making them more likely to suffer from respiratory conditions”
The mental health impact
The implications of smoking are not just physical. Smoking rates for adults with depression are double those for adults without depression, according to Action on Smoking and Health (ASH).
The NHS spends approximately £720 million every year in primary and secondary care treating smoking-related disease in people with mental health conditions, adds ASH.
“Although people often describe smoking as a way to reduce anxiety, for most people this is tied up with smoking cravings and withdrawal symptoms,” says Nick. “There is clear evidence that quitting smoking actually improves mental health.” The initial release of dopamine triggered by nicotine promotes positive feelings, but down the line “smoking encourages the brain to switch off its mechanism for making dopamine, so in the long-term, the supply decreases”, according to the Mental Health Foundation. Using smoking to relieve feelings of stress, may in fact contribute to them down the line. This is a crucial point to push home to pharmacy customers.
Reaping the benefits
Pharmacy teams can also rebuff the myth that giving up after so many years of smoking will make no difference to health. “Smoking cessation improves both physical and mental health, even in the short term and reduces the risk of premature death,” according to the NHS. In terms of physical health, quitting decreases the risks of cancers like mouth, throat, bladder, pancreatic and lung (see boxout). It also reduces shortness of breath, the risk of a heart attack and leads to an improved appearance – skin becomes brighter and teeth are no longer repeatedly stained by tar. For mental health, “stopping smoking can be as effective as antidepressants” says the Public Health England Guidance on Health Matters: Smoking and Mental Health 2020 report. It may be worth pointing out to customers the link between physical health and mental health. Smoking damages one’s physical health, and if the body is suffering, this is almost always reflected in the person’s mental wellbeing. Stopping smoking, therefore, provides a way to improve both physical and mental health.
Aside from the benefits to the individual, family and friends will also no longer be breathing in secondhand smoke. “Passive smoking is harmful, it increases the risk of lung cancer and is particularly dangerous for children,” says Amy Hirst, health information manager at Cancer Research UK. “Stopping smoking completely is the best thing someone can do to protect the people around them and benefit their own health.” If these reasons aren’t enough to persuade customers to give quitting a go, they may be swayed by the potential thousands of pounds they would be saving if they quit. “The average 10-a-day smoker spends around £40 a week on tobacco. That’s over £2,000 a year,” according to the Make Smoking History organisation. Customers can figure out how much they could save individually with the smoke free calculator at: smokefree.gov.
“Passive smoking is harmful, it increases the risk of lung cancer and is particularly dangerous for children”
Lung cancer red flags
Smoking is the leading cause of lung cancer, responsible for nearly nine out of 10 lung cancer deaths. Early diagnosis can be key to overcoming the condition so making customers aware of symptoms is vital. “Lung cancer takes more lives than any other cancer in the UK, but diagnosis at an early stage can significantly improve the chances of survival,” says Amy Hirst, health information manager at Cancer Research UK. “Symptoms of lung cancer include feeling breathless, a long-lasting cough or change to an existing cough, a chest infection that doesn’t get better or comes back, and coughing up blood. There are more general symptoms too, such as feeling tired for no reason, losing weight without trying to, pain in your chest or shoulder, and loss of appetite.” While many of these symptoms may not seem like they would be linked to a cancer, it is always safer to consult a GP. “Pharmacy staff can play an important role in supporting people and breaking down barriers to making a GP appointment. By offering guidance on next steps, they can give people the confidence and support to talk to their doctor about possible signs of lung cancer,” Amy continues. “If people are struggling to get an appointment with a doctor, it’s important that they keep trying, even though this can feel frustrating. Doctors want to hear from them.”
Help from the pharmacy
Luckily, those wanting to quit do not have to do it alone. “Pharmacy teams are well-positioned to provide encouragement and accurate information about stopping smoking and are a trusted and valued part of the community,” says Louise Ross, clinical consultant at the National Centre for Smoking Cessation and Training. “If not commissioned to provide an in-house stop smoking service, pharmacies can make sure they have details of the local service to signpost people to. They can also talk to people who smoke about digital help to stop smoking, as apps can be a great way of getting support without having to make appointments.”
Whether the pharmacy runs a stop smoking service or not, pharmacy teams are well placed to recommend over-the-counter stop smoking solutions, including nicotine replacement therapy (NRT) or e-cigarettes. Customers can also be signposted to their GP for prescription medicines – unless the pharmacy is home to an NHS stop smoking service, in which case, customers can get their prescription medication through this service.
Stop smoking aids help manage nicotine cravings and withdrawal symptoms to make quitting easier. “These products are like an anaesthetic for stopping smoking; we ask people ‘Would you have a tooth taken out without an anaesthetic? Think of your aid like that, it will help you successfully quit while taking away the pain in those early days,” adds Louise.
Below are the available options explained in further detail.
NRT
NRT is one of the most effective OTC stop smoking aids available from the pharmacy. It provides one with a low level of nicotine, without the tar, carbon monoxide and other harmful chemicals present in tobacco smoke. It helps to reduce withdrawal effects, like bad moods and cravings, and usually lasts eight to 12 weeks, gradually reducing the dose to eventually stop altogether. Suitable for pregnant and breastfeeding people with advice from a doctor, and people over 12 years old, NRT comes in various forms:
- Skin patches, which release nicotine slowly. Some are worn constantly, other should be taken off at night
- Inhalator
- Gum
- Tablets, oral strips and lozenges (lozenges are not suitable for anyone under 18 years)
- Nasal and mouth spray.
Each form has their own set of benefits; chewing gum may distract people from their cravings, sprays and inhalators act quicker and may help with urges, while patches are longer lasting. Using a combination of NRT has shown to be more effective than using a single product, according to a 2019 Cochrane Library review. Take a look at the review here: bit.ly/3Bk1wbY.
Nicotine replacement gum is a popular choice for smokers to curb cravings throughout the day.
“The average 10-a-day smoker spends around £40 a week on tobacco”
E-cigarettes
“Non-smoked nicotine products, such as vapes [or e-cigarettes] present only a tiny fraction of the risk of a smoked cigarette and are a popular and effective way of stopping smoking,” says Louise. E-cigarettes are electronic devices that deliver nicotine in a vapour, which contains no tar or carbon monoxide, however, it is not harmless and long-term effects are still being research. Though the ultimate goal is to be weaned off of nicotine completely, e-cigarettes are considered a safer and improved option than smoking cigarettes. E-cigarettes can be sold without prescription to people over 18 years.
Remember that e-cigarettes cannot be sold to anyone under 18 years old.
Prescription medication
There are various prescription medicines customers may opt for such as bupropion (Zyban). Pharmacy team members can signpost anyone interested in these aids to visit their GP, or if the pharmacy runs an NHS stop smoking service, can refer them to this service within the pharmacy. Available in tablet form, these medications help to limit cravings by attaching to some of the same neuronal receptors in the brain that nicotine does. These medicines do have side-effects which customers should be made aware of, like dizziness, difficulty sleeping and drowsiness and generally are not suitable for everyone – people with underlying health conditions should check with their GP.
Nicotine dependence
Nicotine is a highly addictive substance. By causing the release of dopamine, the body’s ‘happy’ chemical, nicotine stimulates a positive change in mood. On top of this, nicotine’s selling point is that this good feeling is felt almost instantly after inhaling – a huge part of the pull. As this process is repeated over a long period of time, nicotine dependence is likely to develop, which involves physical and psychological factors that make it difficult to give up, even if a person wants to quit. “In public health, we’re trying to move away from the term [nicotine] addiction, as it’s stigmatising, inaccurate and not helpful. We’re much more inclined these days to talk about dependence,” says Louis Ross, clinical consultant at the National Centre for Smoking Cessation and Training.
Having the urge to smoke within 30 minutes of waking, ranking the first cigarette of the day as the most important, and smoking at regular intervals throughout the day are all signs of physical nicotine dependence.
It is important to distinguish that nicotine is not solely to blame for the harm caused by smoking. “It is the smoke, not the nicotine, that presents such a significant danger,” says Louise. “The smoke from a cigarette is what causes the cancers, the heart disease and respiratory illness, not the nicotine. Nicotine, if a lot is used in one go, is likely to cause headaches, jitteriness and nausea.” However, in younger people, nicotine use is problematic as it is heavily associated with long-term nicotine dependence and smoking. This is because it affects key brain receptors and can disrupt the formation of brain circuits that control attention, learning and susceptibility to addiction – which may prime adolescents to be susceptible to other addictions in the future.
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