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Background
The Minister for Health and Children intended to make all workplaces, including pubs and restaurants, smoke free zones. This had led to considerable media attention to smoking habits and awareness of the damage caused by smoking and passive smoking.

Aim
To investigate the potential for smoking cessation clinics in a community pharmacy and assess their success rates.

Method
Seventeen smokers who presented in a community pharmacy were identified as prospective subjects for the clinic. The smokers were selected at random, but all were at some stage of the "cycle of change" conceptual model as described by Prochaska and DiClemente (1).

Background reading involved Ways to Change Behaviour by Terry Maguire (2) and Smoking Cessation for Community Pharmacists by Idis (3).

The subjects were invited to attend a smoking cessation clinic in the community pharmacy. Each patient was allocated an appointment card for a 30 minute session with Declan Brehony RGN.

Each of our local GPs was informed of our Smoking Cessation Clinic and were invited to submit patients whom they felt would benefit from it. Each GP was aware of Nicotine Replacement Therapy (NRT) being available on the GMS. They were appreciative of their patients being referred back to them for prescribing of NRT where it was considered appropriate.

A screened area was created in the pharmacy to allow a private consultation area for the smoker to discuss their smoking habits and give their personal details, including contact details in order to allow for follow up contacts. Details noted included age, number of cigarettes smoked per day, smoking history, details of previous quit attempts, so that a profile of each smoker could be established and their motivational level assessed.

This was followed by an analysis of each smoker's exhaled breath using a Micro Monitor Smoke Check Monitor SC01 which analysed the level of carbon monoxide (CO) in the exhaled breath of the smoker. From this, it was possible to estimate how many cigarettes were still in the patient's respiratory system and their associated level of carbonmonoxyhaemoglobin (COHb). This haemoglobin (Hb) is saturated with carbon monoxide and is unavailable to combine with oxygen. Carbonmonoxyhaemoglobin dissociates from the carbon monoxide very slowly. Each patient was given the result of their Smoke Check. Results varied from carbon monoxide levels of 0.7ppm CO (equivalent to five cigarettes in the person's respiratory system) to 9.1ppm CO (equivalent to fifty six cigarettes in the person's respiratory system) with an average of 3.2ppm CO (equivalent to twenty cigarettes in the respiratory system).

This was then used to create an individual smoker profile and the smoker was then counselled on various health issues including the potential benefits of smoking cessation and the hazards associated with continued smoking. Each patient was advised of various techniques and motivational aids available to assist with smoking cessation. Where appropriate, a smoking cessation programme was created and advised to the various smokers. Some patients commenced immediately on nicotine replacement therapy (NRT), others waited until after to weekend to have a final "blow out". Where patients could avail of NRT on the GMS, they consulted with their GPs, who had been previously advised of the proposed smoking cessation clinic.

Contact was made with each patient at 4 weeks, 12 weeks and 26 weeks after the clinic to monitor and record their progress and provide advice and motivation as was appropriate. Success and failure rates were noted as were any adverse or withdrawal effects.

Results
Seventeen smokers were assessed during the clinic. They were at various stages of the cycle of change including relapse, precontemplation, contemplation, planning and now action.

Of the seventeen smokers who presented for the clinic, only sixteen attempted to stop smoking. At the four-week stage, two others had relapsed, although three others admitted to "sneaking" an occasional cigarette - usually while in a social environment. This didn't bode well for these individuals as two of those three were back smoking at the twelve-week stage. At the twenty-six-week stage, the number of non-smokers had fallen to ten, giving a 59% success rate.

This is outlined in the table below.

Table of number of non-smokers against progression in time

Time lapse clinic 4 week 12 weeks 26 weeks

No. of smokers 17 3 (18%) 5 (29%) 7 (41%)

No. of non-
smokers 0 14 (82%) 12 (71%) 10 (59%)


This compares favourable with the success rates of 13 % to 19% quoted in the Irish Pharmacy Journal (January 2004, 26-30).

The successful participants tended to include those who smoked a lower number of cigarettes daily, who, when assessed, had lower levels of CO in their exhaled breath. The relapsing smokers tended to be those who smoker higher numbers of cigarettes daily and, when assessed, had this confirmed by the higher levels of CO in their exhaled breath. The latter group of heavier smokers may have benefited from more regular intervention and counselling during their progression from the clinic to the twelve-week interval.

Conclusion
Pharmacy-based smoking cessation clinics have a major role to play in assisting smokers to stop smoking, thereby promoting a healthier lifestyle for smokers and those in their environment. Community pharmacists, during their daily routine, can identify potential participants and, with intervention, counselling and advice, can greatly enhance their prospects of stopping smoking. For heavy smokers, or those with a long term addiction, repeated advice and counselling at appropriate intervals may be of assistance as they appear to be most liable to relapse.

The direct counselling and advice given in a screened area yielded better results than when attempted in an over-the-counter situation. The subjects were more at ease and preferred the privacy. For the health professional, it allowed for less interruption by other routine matters, patients, telephone, etc. Cost of establishing a smoking cessation clinic is small, however, it requires a trained professional, either a pharmacist or nurse, to give the appropriate intervention, counselling and advice to maximise the opportunity presented by the patient. Perhaps Health Board funding will become available. Nicotine Replacement (NRT) is available on the GMS and is deemed "Budget Neutral". Unfortunately, it is not available on the Drug Payment Scheme. Perhaps, this is an area of potential for pharmacist prescribing.

References
1. Prochaska, J, Ciclemente C.C., The Tran Theoretical Approach: Crossing Traditional Boundaries of Therapy. Homewood, Illionois: Dow Jones-Irwin; 1984.

2. Maguire, T, Ways to Help Change Behaviour. Pharmaceutical Journal 2003; 271; 813-815

3. Idis. Smoking Cessation for Community Pharmacists. Irish Pharmacy Journal 2004; 82; 26-32.