NIHR Signal Community pharmacies may be a useful place to deliver stop smoking services

Published on 26 April 2016

This NIHR review provides evidence that ‘stop smoking’ interventions delivered at a community pharmacy, are effective and probably cost-effective for stopping smoking among adults, especially when compared to usual care without nicotine replacement. These interventions often include such things as behavioural support and nicotine replacement therapy and were most effective when both were delivered together.

The review also looked at other community pharmacy-delivered interventions, like weight loss. But the evidence was less strong for the long term impact of these.

The review included 19 studies of mixed quality and study designs, eight of which were carried out in England.

Community pharmacies can be more accessible than GP services and have the potential to play a key role in delivering public health initiatives especially for hard to reach populations, but so far evidence of their effectiveness is limited to smoking cessation.

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Why was this study needed?

In England, community pharmacies are reported to be more accessible than GP services. A 2014 study found that in England, 89% of the population can walk to a community pharmacy within 20 minutes, with this figure increasing to almost 100% in areas of highest deprivation. They are often sited on high streets, in supermarkets or neighbourhood clinics.

Community pharmacies and their staff could play a key role in delivering public health initiatives, especially in priority areas such as those with high smoking rates. Community pharmacies could therefore be a way of engaging with hard-to-reach populations.

There are two main approaches for public health initiatives delivered by community pharmacy teams: pharmaceutical-related, such as nicotine-replacement therapy for stopping smoking, and non-pharmaceutical-related such as providing advice on behaviour change strategies. A combination of the two approaches can also be used.

According to the review, no other study has looked at evidence from community pharmacy-delivered smoking, weight management and alcohol interventions and directly compared it to other primary care and community healthcare settings.

What did this study do?

This systematic review included any type of community-based pharmacy-delivered intervention aimed at stopping smoking, weight management or alcohol reduction compared to another type of intervention. For smoking, these could be “active” e.g. NRT patches, or “non-active” such as usual care. Usual care varied but was generally an intervention such as ad hoc advice or a thank you letter.

It found 19 relevant studies (15 randomised controlled trials and four non-randomised studies) up to May 2014 with approximately 13,500 adult participants in total. Eight studies were carried out in the UK.

To be included, interventions had to be delivered by the pharmacy team (community pharmacist, pharmacy technician or medicines counter assistant). The number of pharmacies included in each study ranged from one to over 200. Follow-up in the studies ranged widely from short-term, five weeks, to long-term, just over a year.

It was only possible for meta-analyses to be carried out for the studies that looked at stopping smoking because of study differences. There was also a wide variety of interventions and levels of study quality which made comparing the studies difficult and reduces the reliability of the results.

What did it find?

Stopping smoking:

  • Seven studies of mixed quality found pharmacy delivered behavioural support and or nicotine replacement therapy were more than twice as effective for stopping smoking compared to usual care with a non-active comparator (pooled odds ratio [OR] 2.56, 95% confidence interval [CI] 1.45 to 4.53). This effect was smaller when only looking at studies with a high quality rating (pooled OR 1.65, 95% CI 1.13 to 2.42; five studies). There was no difference when compared with other active interventions i.e. those that included nicotine replacement therapy (pooled OR 1.21, 95% CI 0.86 to 1.71; four studies).The majority of studies measured the 6 month quit rate.
  • Four studies of mixed quality reported on cost-effectiveness; however, results were unable to be pooled. Three UK pharmacy-delivered interventions were found to be cost-effective across a range of quit rates and an Australian study showed it was cost-effective compared to usual advice.

Weight reduction:

  • Pharmacy-delivered interventions produced similar weight loss compared with active interventions in other primary care settings; however, weight loss was not sustained longer term in a range of primary care and commercial settings when compared with usual care (five studies of mixed quality).
  • Two UK-based studies found that pharmacy-delivered weight management interventions have similar provider costs to those delivered in other primary care settings, which are greater than those delivered by commercial organisations.

What does current guidance say on this issue?

There are no specific NICE recommendations for using community-pharmacy-delivered interventions for public health priorities such as alcohol reduction, stopping smoking or weight management. The review authors note a Cochrane review in progress that is evaluating the effectiveness of a wider variety of health promotion and behavioural interventions set in community pharmacies.

There is a strong drive in the NHS to strengthen the role of community pharmacy in health and healthcare. This includes initiatives like the 2013 Community Pharmacy Call to Action by NHS England. An example of a local community-pharmacy delivered intervention, is the Community Pharmacy Minor Ailment Scheme pilot project in Furness, Cumbria. Its aim is to enable pharmacies to treat minor ailments without the need for a GP, and if successful, could become a countrywide operation to improve patient access to medication for minor problems. Lead GP for Furness with the Cumbria Clinical Commissioning Group, Dr Geoff Jolliffe said: “The idea of this scheme is for eligible patients to have access to a range of basic medicines and helpful advice from their local pharmacist”.

What are the implications?

This review provides evidence that community pharmacy-delivered interventions are effective and probably cost-effective for delivering public health interventions such as stopping smoking for adults. Training requirements and whether the service can be provided confidentially in a community pharmacy setting are further considerations for commissioners.

Evidence was weaker as to the effectiveness of pharmacy-delivered weight management interventions and they did not appear to work in the long term. These results are not conclusive though as there were no large high quality trials and the included studies covered a wide range of dietary interventions, so the results could not be pooled.

Citation and Funding

Brown TJ, Todd A, O'Malley C, et al. Community pharmacy-delivered interventions for public health priorities: a systematic review of interventions for alcohol reduction, smoking cessation, and weight management, including meta-analysis for smoking cessation. BMJ Open. 2016;6(2):e009828.

This project was funded by the National Institute for Health Research Public Health Research Programme (project number: 12/153/52).

Bibliography

Healthwatch Cumbria. Community pharmacy minor ailment scheme [internet]. Healthwatch Cumbria.

NHS England. Pharmacy call to action [internet]. London; NHS England.

Todd A, Copeland A, Husband A, et al. The positive pharmacy care law: an area-level analysis of the relationship between community pharmacy distribution, urbanity and social deprivation in England. BMJ Open. 2014;4(8):e005764.

Why was this study needed?

In England, community pharmacies are reported to be more accessible than GP services. A 2014 study found that in England, 89% of the population can walk to a community pharmacy within 20 minutes, with this figure increasing to almost 100% in areas of highest deprivation. They are often sited on high streets, in supermarkets or neighbourhood clinics.

Community pharmacies and their staff could play a key role in delivering public health initiatives, especially in priority areas such as those with high smoking rates. Community pharmacies could therefore be a way of engaging with hard-to-reach populations.

There are two main approaches for public health initiatives delivered by community pharmacy teams: pharmaceutical-related, such as nicotine-replacement therapy for stopping smoking, and non-pharmaceutical-related such as providing advice on behaviour change strategies. A combination of the two approaches can also be used.

According to the review, no other study has looked at evidence from community pharmacy-delivered smoking, weight management and alcohol interventions and directly compared it to other primary care and community healthcare settings.

What did this study do?

This systematic review included any type of community-based pharmacy-delivered intervention aimed at stopping smoking, weight management or alcohol reduction compared to another type of intervention. For smoking, these could be “active” e.g. NRT patches, or “non-active” such as usual care. Usual care varied but was generally an intervention such as ad hoc advice or a thank you letter.

It found 19 relevant studies (15 randomised controlled trials and four non-randomised studies) up to May 2014 with approximately 13,500 adult participants in total. Eight studies were carried out in the UK.

To be included, interventions had to be delivered by the pharmacy team (community pharmacist, pharmacy technician or medicines counter assistant). The number of pharmacies included in each study ranged from one to over 200. Follow-up in the studies ranged widely from short-term, five weeks, to long-term, just over a year.

It was only possible for meta-analyses to be carried out for the studies that looked at stopping smoking because of study differences. There was also a wide variety of interventions and levels of study quality which made comparing the studies difficult and reduces the reliability of the results.

What did it find?

Stopping smoking:

  • Seven studies of mixed quality found pharmacy delivered behavioural support and or nicotine replacement therapy were more than twice as effective for stopping smoking compared to usual care with a non-active comparator (pooled odds ratio [OR] 2.56, 95% confidence interval [CI] 1.45 to 4.53). This effect was smaller when only looking at studies with a high quality rating (pooled OR 1.65, 95% CI 1.13 to 2.42; five studies). There was no difference when compared with other active interventions i.e. those that included nicotine replacement therapy (pooled OR 1.21, 95% CI 0.86 to 1.71; four studies).The majority of studies measured the 6 month quit rate.
  • Four studies of mixed quality reported on cost-effectiveness; however, results were unable to be pooled. Three UK pharmacy-delivered interventions were found to be cost-effective across a range of quit rates and an Australian study showed it was cost-effective compared to usual advice.

Weight reduction:

  • Pharmacy-delivered interventions produced similar weight loss compared with active interventions in other primary care settings; however, weight loss was not sustained longer term in a range of primary care and commercial settings when compared with usual care (five studies of mixed quality).
  • Two UK-based studies found that pharmacy-delivered weight management interventions have similar provider costs to those delivered in other primary care settings, which are greater than those delivered by commercial organisations.

What does current guidance say on this issue?

There are no specific NICE recommendations for using community-pharmacy-delivered interventions for public health priorities such as alcohol reduction, stopping smoking or weight management. The review authors note a Cochrane review in progress that is evaluating the effectiveness of a wider variety of health promotion and behavioural interventions set in community pharmacies.

There is a strong drive in the NHS to strengthen the role of community pharmacy in health and healthcare. This includes initiatives like the 2013 Community Pharmacy Call to Action by NHS England. An example of a local community-pharmacy delivered intervention, is the Community Pharmacy Minor Ailment Scheme pilot project in Furness, Cumbria. Its aim is to enable pharmacies to treat minor ailments without the need for a GP, and if successful, could become a countrywide operation to improve patient access to medication for minor problems. Lead GP for Furness with the Cumbria Clinical Commissioning Group, Dr Geoff Jolliffe said: “The idea of this scheme is for eligible patients to have access to a range of basic medicines and helpful advice from their local pharmacist”.

What are the implications?

This review provides evidence that community pharmacy-delivered interventions are effective and probably cost-effective for delivering public health interventions such as stopping smoking for adults. Training requirements and whether the service can be provided confidentially in a community pharmacy setting are further considerations for commissioners.

Evidence was weaker as to the effectiveness of pharmacy-delivered weight management interventions and they did not appear to work in the long term. These results are not conclusive though as there were no large high quality trials and the included studies covered a wide range of dietary interventions, so the results could not be pooled.

Citation and Funding

Brown TJ, Todd A, O'Malley C, et al. Community pharmacy-delivered interventions for public health priorities: a systematic review of interventions for alcohol reduction, smoking cessation, and weight management, including meta-analysis for smoking cessation. BMJ Open. 2016;6(2):e009828.

This project was funded by the National Institute for Health Research Public Health Research Programme (project number: 12/153/52).

Bibliography

Healthwatch Cumbria. Community pharmacy minor ailment scheme [internet]. Healthwatch Cumbria.

NHS England. Pharmacy call to action [internet]. London; NHS England.

Todd A, Copeland A, Husband A, et al. The positive pharmacy care law: an area-level analysis of the relationship between community pharmacy distribution, urbanity and social deprivation in England. BMJ Open. 2014;4(8):e005764.

Community pharmacy-delivered interventions for public health priorities: a systematic review of interventions for alcohol reduction, smoking cessation, and weight management, including meta-analysis for smoking cessation.

Published on 1 March 2016

Brown,TJ; Todd,A; O'Malley,C; Moore,HJ; Husband,AJ; Bambra,C; Kasim,A; Sniehotta,FF; Steed,L; Smith,S; Nield,L; Summerbell,CD.

BMJ Open , 2016

Objectives To systematically review the effectiveness of community pharmacy-delivered interventions for alcohol reduction, smoking cessation and weight management. Design Systematic review and meta-analyses. 10 electronic databases were searched from inception to May 2014. Eligibility criteria for selecting studies Study design: randomised and non-randomised controlled trials; controlled before/after studies, interrupted times series. Intervention: any relevant intervention set in a community pharmacy, delivered by the pharmacy team. No restrictions on duration, country, age, or language. Results 19 studies were included: 2 alcohol reduction, 12 smoking cessation and 5 weight management. Study quality rating: 6 ‘strong’, 4 ‘moderate’ and 9 ‘weak’. 8 studies were conducted in the UK, 4 in the USA, 2 in Australia, 1 each in 5 other countries. Evidence from 2 alcohol-reduction interventions was limited. Behavioural support and/or nicotine replacement therapy are effective and cost-effective for smoking cessation: pooled OR was 2.56 (95% CI 1.45 to 4.53) for active intervention vs usual care. Pharmacy-based interventions produced similar weight loss compared with active interventions in other primary care settings; however, weight loss was not sustained longer term in a range of primary care and commercial settings compared with control. Pharmacy-based weight management interventions have similar provider costs to those delivered in other primary care settings, which are greater than those delivered by commercial organisations. Very few studies explored if and how sociodemographic or socioeconomic variables moderated intervention effects. Insufficient information was available to examine relationships between effectiveness and behaviour change strategies, implementation factors, or organisation and delivery of interventions. Conclusions Community pharmacy-delivered interventions are effective for smoking cessation, and demonstrate that the pharmacy is a feasible option for weight management interventions. Given the potential reach, effectiveness and associated costs of these interventions, commissioners should consider using community pharmacies to help deliver public health services.

The review defined a community pharmacy as a pharmacy which is accessible to all and not based in a hospital, clinic or online, but set in the community.

For the studies that looked at stopping smoking, usual care was in general a minimal intervention such as observation only, ad hoc advice for stopping smoking or a thank you letter to act as a control for making contact with the participant.

Expert commentary

This systematic review is very useful and timely and will support commissioners of community pharmaceutical services by providing the evidence base for a number of the frequently commissioned services.

Published evidence that demonstrates both the effectiveness and cost-effectiveness of pharmacy based smoking cessation services is particularly welcome and this review therefore supports the commissioning of such services from community pharmacies.

The review highlights the need for more research and high quality studies to provide evidence for the effectiveness of community pharmacy public health services including any impact on health inequalities. Properly designed studies are needed to provide the evidence to support commissioning decisions.

Neil Hardy, Associate Director, Medicines Management, NHS West Hampshire Clinical Commissioning Group

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