1. Smoking cessation Supporting customers to quit

2. What you need to know PSA Presentation text 2 Discuss the health risks associated with smoking, and the benefits of quitting Apply the 5A principles of smoking cessation to support customers to quit Advise customers on the use of nicotine replacement therapy (NRT)

3. PSA Presentation text 3 Impact of smoking Brain  risk of stroke Lungs Lung cancer Emphysema Heart Clogged arteries Heart disease Eyes  risk of blindness Mouth/Throat Cancer Bad breath Stained/lost teeth Reproduction Erectile dysfunction(males)  Fertility

4. Benefits of quitting 12- 24 hours Almost all nicotine out of your body  oxygen in blood 1 week Improved sense of smell and taste 1-2 months Blood pressure returned to normal Improved immune and lung function 1 year Risk of dying of heart disease is halved Progression of lung disease reduced 10-15 years Risk of lung cancer halved Risk of heart attack and stroke same as never smoked

5. 5As of smoking cessation 1.ASK about smoking 2.ASSESS readiness to quit and nicotine dependence 3.ADVISE about quitting 4.ASSIST to quit 5.ARRANGE follow-up Edit name of Presentation 5

6. ASK about smoking Ask all customers about smoking status when receiving a prescription Link questions about smoking status to promotion of the new smoking cessation service Run an anti-smoking health promotion campaign in store, and provide a questionnaire for consumers to identify smoking related risk Edit name of Presentation 6

7. ASSESS readiness to quit (1) Edit name of Presentation 7 Pre-contemplation Unconcerned about smoking,not seriously thinking of quitting Contemplation Aware of the need to quit and considering quitting in the next six months Preparation Planning to quit within the next 30 days Action Quit smoking within the last six months, high risk of relapse Maintenance Non-smoking behaviour established and the threat of smoking diminishing Relapse Recently starting smoking following a previous quit attempt

8. ASSESS readiness to quit (2) How do you feel about smoking at the moment? I am sure that you know the health risks of smoking, do they concern you? What do you like about smoking? What don’t you like? Does smoking stop you from doing things you would like? How do the people in your life feel about you smoking? Edit name of Presentation 8

9. ASSESS nicotine dependence (1) When do you have your first cigarette of the day? How many cigarettes do you smoke a day? Have you experienced withdrawal symptoms when you have stopped smoking in the past? Edit name of Presentation 9

10. ASSESS nicotine dependence (2) High dependence smoking within first five minutes of waking usually >30 cigarettes/day Moderate dependence smoking within first 30 minutes of waking usually 20-30 cigarettes/day Low-moderate dependence smoking within first 30 minutes of waking usually 10-20 cigarettes/day Low dependence no need to smoke within first hour of waking Usually <10 cigarettes/day Edit name of Presentation 10

11. ADVISE about quitting Establish rapport and ask permission to discuss smoking Raise the risks of smoking and the benefits associated with smoking cessation Personalise the advice and the benefits of quitting Edit name of Presentation 11

12. ASSIST to quit (1) Pre-contemplation (not ready) Give clear, non-confrontational advice Reassure that help is available when ready Contemplation (unsure) Discuss pros and cons of quitting Explore beliefs and barriers to quitting Preparation (ready) Provide encouragement Discuss QUIT plan and pharmacotherapy Edit name of Presentation 12

13. ASSIST to quit (2) Action (recent quitter) Congratulate on quitting Review pharmacotherapy and provide advice on relapse prevention strategies Maintenance (non-smoker >6 months) Reinforce benefits of not smoking and relapse prevention Relapse Encourage and motivate to try again Discuss reasons for relapse Edit name of Presentation 13

14. Beliefs and barriers to quitting Edit name of Presentation 14 Belief/Barrier to quittingResponse I can quit at any time, I’m not addicted. Ask about previous quit attempts and success rates. Use of cessation assistance is a sign of weakness, I don’t need help to quit. Reframe assistance, and highlight unassisted quit rate is 3–5%. I am too addicted, it is too hard to quit. Explore pharmacotherapy used and offer options. I’ve smoked for so long, its too late now. Benefits evident at all ages, and are greater the earlier you quit. Provide evidence/feedback e.g. Discuss impact of quitting on absolute cardiovascular risk score. You have to die of something, I know a heavy smoker who has lived a long time. Reframe by discussing impact of smoking related diseases e.g. COPD on quality of life. I don’t have enough willpower to quit Explore motivation and confidence. Explore and encourage use of effective strategies, e.g. Quitline, Pharmacotherapy.

15. QUIT action plan Pick a QUIT date –Ideally within two weeks Obtain pharmacotherapy if required –NRT or referral to GP for prescription smoking cessation medicine Plan behavioural strategies –Avoid triggers; coffee, alcohol etc –Dispose of ALL cigarettes –Ask friends and family to support by not smoking around you Edit name of Presentation 15

16. ARRANGE follow up Contact customer in first week of quit attempt –Provide ongoing encouragement –Discuss and attempt to resolve any problems Arrange appointment for one month after quit date –Check progress- are they still smoke free? –Identify any problems or barriers –Provide more NRT if required –Reinforce support of pharmacy and Quitline etc. –Offer service again if they relapse Edit name of Presentation 16

17. Nicotine replacement therapy (NRT) NRT doubles quit rates at 12 months Recommend for all smokers with nicotine dependence if no contraindications Several different formulations – all equally effective –Gum –Patch –Inhaler –Lozenge –Microtab Dose/strength depends on level of nicotine dependence Edit name of Presentation 17

18. Nicotine gum Available as 2 mg or 4 mg 4 mg more effective if > 20 cigarettes/day Max dose is 40 mg/day Use for at least 12 weeks before weaning gradually Chew gum slowly until tingling sensation then “park” in cheek or under tongue Repeat for 30 minutes Not suitable for customers with dentures

19. Nicotine transdermal patches Available as 16 or 24 hour patches, at various strengths –Step 1: 21 mg/24 hours or 15 mg/16 hours –Step 2: 14 mg/24 hours or 10 mg/16 hours –Step 3: 7 mg/24 hours or 5 mg/ 16 hours >10 cigarettes/day start at step 1, <10 cigarettes/day start at step 2 Use for 8-12 weeks, with staged “step down” 24 hour patch may cause vivid dreams and nightmares May not be suitable for customers with skin disorders Edit name of Presentation 19

20. Nicotine inhaler Useful for patients who miss the hand to mouth action of smoking Take shallow puffs every 2 seconds or 4 deep inhalations per minute for up to 20 minutes Dose can be titrated easily according to withdrawal symptoms –Usually 6-12 cartridges/day for 3 months then reduce over 6-8 weeks –Maximum recommended duration is 6 months May not be suitable in asthma or chronic throat disease Edit name of Presentation 20

21. Nicotine lozenges Available as 1.5 mg, 2 mg or 4 mg Dose should be titrated –Week 1-7: 1 Q1-2H, minimum of 9/day –Week 7-9: 1 Q2-4H –Week 10-12: 1 Q4-8H –Week 12-24: 1 when tempted to smoke Lozenge placed in mouth and allowed to dissolve May not be suitable in GORD Edit name of Presentation 21

22. Nicotine micro-tabs Available as 2 mg only Dose according to level of dependence –Low dependence: 1 Q1-2H –High dependence: 2 Q1-2H –Maximum of 40 tablets per day Allow tab to dissolve under tongue over 30 minutes Use for at least 2-3 months before weaning dose May not be suitable in GORD

23. Combination NRT Patch + low strength gum/lozenge Used when withdrawal symptoms persist despite one form of NRT Increases chances of quitting Edit name of Presentation 23

24. Cut down to quit NRT can be used to reduce the number of cigarettes Aim is to progress to full quit attempt Refer customers who have not cut down after 6 weeks to the pharmacist Edit name of Presentation 24

25. Prescription medicines Available on prescription from doctor Refer customers to pharmacist for further information Edit name of Presentation 25

26. When to refer to the pharmacist Existing medical condition Taking other medicines Pregnant or breastfeeding < 18 years of age NRT causing side effects NRT not effective and/or wishes to try prescription therapy Edit name of Presentation 26

27. Any questions? Edit name of Presentation 27

28. Summary The health benefits of smoking cessation are immediate and increase with long term abstinence The 5A principles provide a structured way to support customers to quit All customers should be asked about smoking and advised and assisted to quit in a way suitable to their stage of change NRT is an effective treatment to assist nicotine dependent customers to quit Edit name of Presentation 28