Smoking is still the largest cause of preventable death in England. It costs communities an estimated £12.6 billion annually with an additional annual cost of £2.5 billion to the National Health Service (NHS)(1). Public Health England is aiming for a “smoke-free society by 2030 with adult prevalence of five per cent or less”(2).
Patients with a severe mental health illness smoke one-third of all cigarettes smoked in total(1). It is therefore important to focus on this group to be able to achieve this aim and give this group better patient outcomes.
Since the NHS long-term plan is committed to offering funding towards tobacco treatment services to all inpatients, including the option of switching to e-cigarettes while in the inpatient setting(2), it is important to use these products to maximum efficacy. NICE guidance states that for these patients a long-acting and a short-acting nicotine replacement therapy (NRT) should be used and that bupropion and varenicline should be made available for use(3). However, the data shows that only 47 per cent of mental health trusts offer the choice of combination NRT or varenicline(2).
Varenicline was a black triangle medicine until 2016 as additional monitoring was required for people with a mental health condition(4). However, the Evaluating Adverse Events in a Global Smoking Cessation study (EAGLES) found that neither varenicline nor bupropion increased the risk of neuropsychiatric adverse events. It also found that varenicline was more effective than an NRT patch, placebo and bupropion(5). Pharmacists can highlight these findings to encourage prescribers to prescribe according to the NICE guidelines and use varenicline and bupropion if necessary.
Harm reduction can be pursued with the use of e-cigarettes which are safer to use than smoking as “vaping is at least 95 per cent less harmful than smoking”(6). E-cigarettes can be used safely at the same time as NRTs(7). The risk of nicotine poisoning when using an e-cigarette is zero as the maximum strength of nicotine sold for use in e-cigarettes is 20mg/ml(8). According to Toxbase, a fatal dose of nicotine is estimated to be 0.5-1gram in an adult(9), which demonstrates the unlikeliness of overdose when using products in combination. Pharmacists can therefore encourage the use of NRTs with e-cigarettes to help with harm reduction.
A survey has found that 59 per cent of psychiatrists and 76 per cent of nurses have never prescribed stop smoking medicines since being qualified to do so(2). Pharmacists can help with this by educating and supporting those involved in smoking cessation or harm reduction and can also encourage the prescribing according to the NICE guidelines to gain the maximum benefit from these products.
As NICE have recommended frontline staff to be trained in smoking cessation on a yearly basis(2), pharmacists can support this by providing smoking cessation training and/or referring staff to online training platforms such as the National Centre for Smoking Cessation and Training (NCSCT)(7). To help with this, Ashtons has released a new training seminar on smoking cessation in mental health which covers the prevalence of smoking, why smoking cessation is important in mental health, why smoking rates are high in mental health patients, the difference between smokers with mental health illness and the general population, how nicotine affects the body, different types of products to aid smoking cessation, how to tailor treatment for mental health patients and how psychiatric medicines are affected by smoking.
- Action on smoking and health (ASH). True cost of smoking revealed in advance of World No Tobacco Day [Internet]. ASH; [Updated 30/05/18; Accessed 08/05/2021]. Available from: https://bit.ly/3qqEtUA
- Public Health England (PHE). Health matters: smoking and mental health [Internet]. PHE; [Updated 01/05/2020; Accessed 01/05/2021]. Available from: https://bit.ly/3tmfMdY
- NICE. Stop smoking interventions and services NG92 [Internet]. NICE; [Updated 28/03/2018; Accessed 01/05/2021]. Available from: https://bit.ly/3I65ItK
- Taylor D, Barnes T, Young A. The Maudsley Prescribing Guidelines in Psychiatry. 13th ed. GraphyCems. Spain. 2019.
- Anthenelli RM, Benowitz NL, West R, St Aubin L, McRae T, Lawrence D, Ascher J, Russ C, Krishen A, Evins AE. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. Lancet. 2016 [Accessed 02/05/2021]; 387(10037):2507-20. Available from: doi: 10.1016/S0140-6736(16)30272-0. Epub 2016 Apr 22. PMID: 27116918.
- Public Health England (PHE). Evidence review of e-cigarettes and heated tobacco products 2018: executive summary [Internet]. PHE. [Updated 02/03/2018; Accessed 02/05/2021]. Available from: Evidence review of e-cigarettes and heated tobacco products 2018: executive summary – GOV.UK (www.gov.uk)
- National centre for smoking cessation and training (NCSCT) [Internet]. NCSCT. [Accessed 02/05/21]. Available from: https://www.ncsct.co.uk