Smoking cessation: shifting the research focus to community pharmacy

Community pharmacy is a cornerstone of primary healthcare. It is valued by patients and increasingly recognised by government as an effective platform for delivering a wide range of healthcare services. These diverse services substantially extend the traditional role of pharmacists and play to their strong, unique position as respected healthcare professionals who are easily accessible to the general public.

But infrastructure for research in pharmacies is poorly developed, and opportunities for pharmacists to train in research are few and far between. Consequently, rigorous published evaluations of the benefits of recent changes in pharmacy practice are rare; commissioning of new initiatives is fragmented and there is no cohesive framework for fulfilling the remarkable potential for healthcare delivery in community pharmacies.

One in five adults in the UK continue to smoke, despite the establishment of NHS smoking cessation services in 2000 and further policy initiatives that led to smoking being banned in public places in 2007. Evidence suggests that smoking cessation interventions can be effective in UK pharmacies but there are few trials with validated endpoints.

Research programme

Funding from the National Institute for Health Research (NIHR) allowed us to begin to address these shortfalls with a five-year programme of research into interactions between pharmacy staff and their clients in the NHS smoking cessation service.

Our plan was to look for examples of best practice and to study the barriers and facilitators to delivering an excellent service. Our studies comparing the communication strategies employed by smoking cessation advisers in counselling successful and unsuccessful quitters were published in BMJ Open in October 2017^[1]
. The work emphasised the importance of an adviser engaging in conversation about a person’s experience of life, with all its contextual and situational nuances, alongside medical talk, in quitting success. We highlighted the unique position of pharmacy staff to engage in this therapeutic dialogue.

To get to a point where we could test these strategies, we had previously interviewed the advisers themselves to find out their views on the best way to recruit and retain smokers in the service^[2]
. This work gave us an understanding of the training requirements for advisers providing a smoking cessation service. We used the results of these studies to construct and test educational sessions for pharmacy staff, and took into account a range of psychological and organisational theories^[3]
,[4]
. Through this preparatory work we were unable to find previous trials that suggested how best to develop smoking cessation services in pharmacies nationally, which highlighted the need for further research.

Developing the services is an important aim of the large-scale randomised controlled trial that we have under way in community pharmacies in London and Coventry, England, and Cwm Taf, Wales. Following a successful pilot, we are exploring whether brief additional training based on the findings from our earlier studies can increase the effectiveness of the smoking cessation service in pharmacies in these areas^[5]
.

We have found pharmacists ready and willing to participate in the research studies despite the severe demands of running a small business in challenging times. Tapping into local management structures, which we found to be highly developed, enabled us to recruit practice staff for the educational sessions that we run in the evenings and weekends for maximum convenience.

We have adapted our study protocols to use information already being collected in pharmacies, therefore avoiding duplication of data entry. It is essential that developments in pharmacy services take into account commercial imperatives and address the need for secure revenue streams on which to build the business.

Positive feedback

Feedback from staff attending sessions has been excellent — particularly from the counter staff, many of whom were attending their first ever training course. Helping counter staff to adopt a client-centred approach to engaging with smokers is crucial to increasing uptake of the service.

The evaluation of the current programme will be completed in 2018, and if it is successful in achieving its aims, we plan to roll out the additional training programme in pharmacies that did not have the opportunity to take part and in other areas of the country. Our programme involves complex mathematical modelling of all aspects of the pharmacy system. We plan to use these models to optimise the training and education programme during the roll-out to make the process as efficient as possible.

In the future, there will be further studies on the extended role of the pharmacist in more complex tasks. We are currently studying the delivery of sexual health services in community pharmacies, possibly a more challenging task newly adopted by pharmacists. However, the approach that we have developed can be easily adapted to any of the new tasks, such as supporting self care of minor illness or optimising management of medicines in the community.

Pharmacies taking part in these studies are upskilled in research practices, and we hope that this study will be the first of many to investigate effective ways of delivering a broad range of primary care services in this setting. Our work ties in well with the Royal Pharmaceutical Society’s Research Ready scheme for pharmacies, which is supported by the NIHR Clinical Research Network. These initiatives will help to shift the research focus from hospitals and universities to primary care in the community — an adjustment that is long overdue. High-quality applied health research should be conducted in settings where most contact with the NHS take place.

There is a bright future for research in community pharmacy — a highly skilled, able and motivated workforce is a tremendous asset. Delivery of new and enhanced community pharmacy services should go hand in hand with high-quality research and evaluation. This will enable increasingly more effective and cost-effective delivery of primary healthcare.