Internationally, tobacco smoking is responsible for more than eight million deaths per year.1 Around seven million of these deaths are directly due to individuals smoking, while around one million are due to second-hand smoke.1 In England, around 78,000 people die each year from smoking-related illnesses, and around 490,000 are admitted to hospital due to smoking.2 Tobacco smoking not only contributes to death and mortality, but is a considerable financial cost to smokers, leading to financial difficulties and stress.3 Smoking cessation has been described as potentially the most important public health intervention globally, if effective.4 It can offer several health and financial benefits to smokers and their families,3, 5 including the reduction of second-hand smoke exposure.5 However, despite many smokers reporting a desire to stop smoking,6 successful, long-term cessation is challenging. Barriers include: stress and smoking as stress management; the social acceptability of smoking especially in low-income and marginalised communities; and a lack of effective interventions, especially those involving contact with healthcare professionals7. Due in part to such barriers, rates of quitting smoking may be as low as 3%, and rates of relapse may be as high as 80%.8
There may be a cyclical relationship between smoking and stress, whereby higher levels of stress in smokers becomes a barrier to quitting or a cause of relapsing, and the expense of smoking cigarettes creates financial stress.3 This has been found to be particularly harmful in people from lower-income backgrounds who have less disposable income and may be at risk of financial problems caused by continued spending on cigarettes.9 In the UK, likelihood of being a smoker tends to correlate with socioeconomic status; around 9.3% of people in managerial and professional occupations were smokers in 2019, while the proportion in intermediate occupations was 14.1% and in manual and routine occupations the figure was 23.4%.10 Smokers from disadvantaged areas of society including lower income groups could benefit from short-term, individual-level interventions.7, 11
Individual-level interventions to promote smoking cessation include brief interventions, behavioural interventions, nicotine replacement therapy (NRT), pharmaceutical therapies, and combinations of these such as a behavioural intervention combined with pharmaceutical treatment.4, 12, 13 Brief interventions take the form of a short conversation between a healthcare practitioner and their patient or client, often lasting only a few seconds or minutes.12 There is evidence of their effectiveness, albeit at fairly low levels, but this is seen as an efficient use of time.14 Behavioral interventions typically consist of regular support meetings with a healthcare professional, and will often be combined with another form of intervention such as NRT. They can be delivered to individuals or groups over a number of weeks and may involve some form of recognised therapy such as cognitive behavioural therapy.12 Their efficacy has been difficult to assess however, because they are typically delivered alongside other interventions. A recent systematic review found stronger evidence of efficacy for brief interventions compared to longer-term behavioural interventions.15 NRT and other pharmaceutical treatments can reduce the urge to smoke by either delivering nicotine without the use of tobacco (in the case of NRT), by delivering a psychoactive compound which blocks the brain’s nicotine receptors (Varenicline), or by using an antidepressant to suppress the negative emotions associated with nicotine withdrawal (Bupropion and similar drugs).12 A review of trials showed that Varenicline performs better than placebo and better than Bupropion as an aid to smoking cessation16. These and other methods of aiding smoking cessation are generally seen as a useful range of tools from which practitioners and public health bodies can choose alongside broader strategies such as bans on advertising and increased taxes on cigarettes.17 Aside from the tools used to aid smoking cessation, the use of local pharmacies in smoking cessation efforts has been shown to increase the efficacy of programmes.18 Pharmacies represent a cost-effective and efficient system of delivering evidence-based interventions alongside practitioner advice and support.18
Recently, another tool has emerged as a potentially useful and effective option to aid smoking cessation. Electronic cigarettes (e-cigarettes) are small, hand-held, battery-operated devices that resemble cigarettes. They work by heating a solution containing nicotine which is then inhaled as an aerosol into the lungs of the user (known as vaping).19 As well as representing an effective method of nicotine delivery, they may also be beneficial as an aid to smoking cessation due to their hand-to-mouth and inhalation actions, and the presence of a visible vapour released upon exhalation, resembling the experience of smoking.4 E-cigarette users (known as vapers) in the UK have reported enjoying the experience of using their e- cigarettes, and were able to switch easily from conventional cigarettes, especially due to their effective nicotine delivery and the action of vaping as similar to that of cigarette smoking.20 Studies into the efficacy of e- cigarettes as aids to smoking cessation have tended to use observational methods rather than trials, and have tended not to find that vaping leads to long-term cessation.19 Some studies have found that, rather than being useful as an aid to cessation, vapers often switch between conventional cigarettes and e-cigarettes and adopt e-cigarettes as part of their smoking routine20. However, one recent randomised trial found that e-cigarettes were more effective as an aid to smoking cessation than NRT, when each were provided alongside behavioural support.21 E-cigarettes are not without their risks however. As well as containing nicotine, e-cigarette vapour contains other substances that are known to be harmful upon inhalation, some of which may be carcinogenic.22 There is some debate around the safety of e-cigarettes and long-term data are still needed,23 but some studies have concluded that the risks associated with vaping are minimal when compared to the well-known health risks associated with smoking conventional cigarettes, and that e-cigarettes are preferable.24–26 The UK Royal College of Physicians has endorsed the use of e-cigarettes as an aid to smoking cessation, and Public Health England have reported that e-cigarettes are around 95% less harmful than conventional cigarettes.23 Others have been more critical however,27 and some public health bodies have been less positive. For example, the US Preventive Services Task Force has reported that there is not sufficient evidence to recommend e-cigarettes as an aid to smoking cessation.23
To summarise: E-cigarettes have been shown to be a promising intervention for smoking cessation and are generally viewed as positive in the UK. Healthcare professional-assisted interventions, especially those conducted via pharmacies, have been shown to increase intervention efficacy at a relatively low cost. Smoking cigarettes is harmful to the health and finances of smokers, their families and the people around them, particularly for lower income groups such as manual and routine workers. Smokers are often motivated to stop smoking but find it difficult and interventions can increase the chance of successful quitting.
In 2017, the Greater Manchester Health and Social Care Partnership (GMHSCP)28 published a strategy to reduce adult smoking in the region to 13%, or by 115,000 smokers. As part of that plan, two local authorities in Greater Manchester introduced e-cigarette interventions delivered by pharmacies. In 2018, the first intervention29 recruited 1,022 smokers, 383 (37%) of whom had quit smoking tobacco after four weeks. Among those still smoking tobacco, the average number of cigarettes smoked per day had dropped from 19.1 to 8.7. People in less deprived areas and working in higher-paid jobs were more likely to have quit tobacco. The study concluded that such schemes appear to be effective, but more work was needed on targeting smokers from lower income backgrounds, and interventions needed to be followed up over a longer period. Here we report on the second intervention, which used similar methods to the first programme: a pharmacy-supported smoking cessation intervention using e-cigarettes, which targeted smokers in manual and routine occupations. This study additionally included a 12 month follow up.