Guidance Notes for Service Delivery Smokefree Pharmacy Services
Contents
1. NHS S Greater Glasgow and Clyde SERVICES Guidance Notes for Service Delivery Smokefree Pharmacy Services West House Gartnavel Hospitals Glasgow G12 0XH 0141 201 4945 Issued October 2008 Revised August 2014 Index Introduction Page 2 Health Efficiency Access and Treatment HEAT Targets Page 2 Aim of the Smokefree Pharmacy Service Page 3 Professional Objectives Service Support S o Smokefree Training for Pharmacists amp Assistants Client Journey through the Pharamcy Service with NRT Dual NRT Pharmacy Smokefree Enhanced Service Smokefree Young People Service 12 18 years Varenicline Champix Client Journey through the Pharmacy Service with Varenicline Champix Housebound Clients Carbon Monoxide CO Monitoring Product Information Dosage Regiment Per Product Cigarette Equivalents for Tobacco Users Contact Details Smoking Cessation Contacts in Greater Glasgow amp Clyde CHCPs Client Journey Pharmacy Role Weeks 0 10 12 Prescribing NRT Guidance Appendix 1 Smoking Cessation and Pharmacy Care Record PCR August 2014 1 INTRODUCTION Adult smoking rates in Scotland have remained consistently higher than in England and Wales Throughout the 1970 s and 1980 s the number of people smoking cigarettes fell sharply but this decline levelled out during the 1990s Smoking rates among young teenagers are also of concern for health pr2. Suggest client check motivation at NiQuitin QuickMasters Log on to www niquitin co uk Stop smoking programme not cutting down No cigarettes from quit date to be successful Smoking cessation details on Pharmacy Care Record PCR Agree on NRT product to be used NiQuitin Patch 1 line Client journey through week 0 1 i e preparation week 0 quit date must attend for 10 12 continuous weeks CO readings NRT dispensed weekly support from the pharmacy Setting a formal quit date BETWEEN 5 7 DAYS AFTER THIS INITIAL CONSULTATION if the client is deemed ready to quit Arrange an appointment for client to return for NRT the day before quit date Provide and encourage client to read and complete How to Stop Smoking booklet client to complete relevant pages of How to Stop Smoking and Stay Stopped booklet By developing a relationship with your client you will make them aware that you are there to support them throughout their quit attempt Relevant pages of How to Stop Smoking and Stay Stopped booklet ensuring client wants to stop smoking This will help to build a positive relationship between client and pharmacy staff Smoking cessation details on PCR Take the clients CO level and explain their reading to them Remove any temptations get support of family amp friends prepare for identified triggers going for drinks friends offering a cigarette etc change or avoid familiar routines keep your hand busy BE POSITIVE Use p
3. 21mg patch with the option of a second product if the patient has tried and failed with 21mg patch previously Otherwise review at week 2 If still smoking offer additional short acting NRT minis lozenge gum lozenge or strips product If patient very addicted to smoking two products may be considered at week one e Weeks 2 3 amp 4 Review use of second product and supply again if necessary After week 4 advise client to purchase second product if required b Pharmacy Smokefree Enhanced Service Enhanced Service A number of pharmacies in the more deprived areas of Greater Glasgow and Clyde are delivering the Enhanced Service This provides the option of dual NRT for the duration of the service Pharmacies located in these areas may be eligible to take part in the service Separate training and operating procedures apply here Further information is available by contacting Pharmacy Smokefree Service office on 0141 201 4945 c Smokefree Young People Service 12 18yrs Under revised guidance all forms of NRT can now be used by smokers aged 12 and over although there is limited evidence around the use of NRT in young people aged 12 to 17 If the pharmacist considers it appropriate i e the young person is a regular smoker and is motivated to stop they can be signed up to a Smokefree pharmacy in the usual manner Consequently we recommend that this group August 2014 8 should not use NRT unless they have access to a support
4. 3 CO levels should be monitored weekly but mandatory at 4 and 12 weeks post quit date 4 Cessation strategies are discussed and personalised advice and support provided by pharmacy staff Encourage the client to use the Smokeline freephone number 0800 84 84 84 for additional support and advice 5 The NRT will be dispensed weekly unless the client has a legitimate reason why this should not be so for a maximum of 12 continuous weeks together with support from a trained member of staff Dual NRT From J une 2010 patients who have accessed either the pharmacy or group service failed to stop smoking and match the inclusion criteria listed below have been offered the opportunity to use dual NRT therapy for the first four weeks Research shows that when combination NRT together with behavioral support is offered on an individual basis there is a 20 increase in four week quit rates from 37 to 50 and when in combination with group support from 50 to 71 NHS stop smoking services can help to improve quit rates Bauld L Guidelines in Practice December 2009 Vol 12 12 Criteria for dual NRT all the following criteria must be matched e Client smokes 20 or more cigarettes per day e Client must have previously tried NRT and attended an NHS Greater Glasgow and Clyde NHSGGC smoking cessation service pharmacy group or acute e Client is neither pregnant nor breastfeeding e Client is not allergic to NRT patch e Start on NiQuitin
5. Assess the patient s current smoking status and previous quit attempts Obtain consent to follow up the patient This includes times when the patient fails to attend the pre arranged appointment If patient does not consent they are ineligible to join the Service Record contact details for the patient including telephone numbers Check if the patient is motivated to stop smoking Ascertain if group sessions are preferable if so refer Discuss the advantages and disadvantages of stopping smoking Provide information on varenicline Discuss the Want to Stop Smoking leaflet Record the patient s details and motivation to quit in the smoking cessation support tool within PCR Discuss setting a formal quit date around 7 days after initial visit if the patient is deemed ready to quit Do not set the quit date in the smoking cessation support tool at this stage Arrange an appointment for the patient to return for varenicline Starter Pack and further support as near as possible to the quit date Provide the How to Stop and Stay Stopped booklet and encourage the patient to complete the relevant sections Show these to the patient Offer the patient the Smokefree Services diary If accepted help them complete the mission statement and show them how to use the diary Introduce the patient to the member of staff who will help support them through their journey and record their name on the support card DO NOT routinely provide varenicline at thi
6. Other chosen above please specify Tobacco use and quit attempts On average how many cigarettes does the client usually Please select Record the date on the referral or the smoke per day date of initial patient contact and tick How soon after waking does the client usually smoke their P lect first cigarette J gase seed w the box for the appropriate referral How many times has the client tried to quit smoking in the Please select source past year Referral and assessment context Date referred to service Referral source s Self referral Pharmacist Dentist Practice nurse go Select Pharma cy GP O Prison Health visitor Smokeline Oo HealthPoint 1 Stop smoking roadshow Hospital Midwife Other please specify Record date of first contact and select One to one If Other chosen above please specify Intervention setting s Primary care Workplace session or Hospital Inpatient O Educational establishment Group support closed Hospital Outpatient 1 Non NHS communi i p p Aa ty groups as appropriate Pharmacy Home Prison Other please specify If Other chosen above please specify Where Varenicline is Date of initial appointment E selected additional Intervention s used in this quit attempt One to one sessions Goumeramily based questions will be pre
7. o Post Code Please ensure this is entered correctly and in full or submission will be rejected o Home Phone Number Submission of data sets After each submission check that the Minimum dataset section Status is shown as Validated and the Release Status as Submitted Reimbursement ACPUS form should still be completed for reimbursement purposes e The patients CHI number should be included August 2014 25 e Initial Data Capture Pharmacy 9801 GGC1 N S User GGC1 Gary Glasgow Last login Wed Jun 18 2014 15 12 ws oe SCOTLAND Search Protocols Reports Change password Manage profile Yellow card Help Hospital Logout Born 06 Jun 1966 48y Gender Female CH No 6666666666 SHORTBREAD Sally f Patient Details Last Modified On 09 Jun 2014 By GGC1 Address Phone and email St Smoking cessation initial data capture Consent Does the client consent to follow up Please select By participating in the smoking cessation service the client has agreed to be contacted by NHS Scotland representatives in order to fo progress and smoking status and has agreed to provide a telephone number to facilitate follow up See note on Client information Pg 1 Gender Female v If female pregnant oge What is the client s ethnic group Please select If Other chosen above please specify What is the client s employment status Please select If
8. Ask how the patient got on during the past week Use the diary to help discussions Assess compliance with and suitability of product Reinforce the correct use of varenicline and discuss any concerns about side effects If patient is experiencing side effects consider reducing the dose to 0 5mg twice daily temporarily or permanently or alternatively stopping varenicline and commencing on a course of NRT Determine the patient s smoking status at each supply interval using the CO monitor Record on the CO Monitoring card Record the results of the CO reading in the smoking cessation support tool within PCR Make subsequent supplies of varenicline pharmacist only when necessary using the 28 day pack Arrange follow up appointments at weekly intervals Give encouragement to continue in the quit attempt Follow up patients who do not present as anticipated e g through a proactive telephone call or text message At least three attempts should be made to follow up with patients who have not presented according to local NHS Board procedures Dates and times of attempts to contact should be recorded within the smoking cessation support tool If no response after two missed visits and three attempts of contact then inform the office on 0141 201 4945 August 2014 11 If the patient is deemed to have ended their quit attempt then this should be recorded within PCR and the MDS submitted electronically e Four week post quit date f
9. If initial data capture has changed please edit the values using the following link Before sub ion it is necessary to update the Pharmaceutital usage and Pharmaceutical usage weeks fields in the initial data capture Use this link to access the Submit four week data fields Submit 12 Week Data The link to release the data will be made available in the Next Action section between 12 and 14 weeks It is not possible to submit the date if this submission window is missed and payment will not be made Submit twelve week minimum dataset Was the client successfully contacted for 3 month follow up Yes v Date follow up carried out 5 05 2014 7 Complete the details following the guidance given above for the 4 week submission Has the client smoked at all since the 1 month follow up CO reading confirms quit Reason CO reading not taken If initial data capture has changed please edit the values using the following link Initial data capture Submit twelve week data q return to Smoking Cessation Review Page Recording the Assessment Outcome If at any point the patient is no longer attending the pharmacy and is not contactable it should be recorded in the Assessment completion section as Client lost to follow up If the patient is found to have smoked in the 2 weeks prior to the 4 week submission or smoked more than five cigarettes since the last submission at week 12 an
10. NRT for up to a 12 week time period Explain to the patient that if they do not attend any arranged appointments they will be contacted to reschedule e Subsequent weeks prior to 4 week post quit date follow up appointment Ask how the patient got on during the past week Use the diary to help discussions Determine the patient s smoking status at each supply interval using the CO monitor Record on the CO Monitoring card Record the results of the CO reading in the smoking cessation support tool within PCR Assess compliance with and suitability of product Reinforce the correct use of NRT check strength and formulation are still appropriate Give encouragement to continue in the quit attempt Arrange follow up appointments Follow up patients who do not present as anticipated e g through a proactive telephone call or text message At least three attempts should be made to follow up with patients who have not presented according to local NHS Board procedures Dates and times of attempts to contact should be recorded within the smoking cessation support tool If no response after two missed visits and three attempts of contact then inform the office on 0141 201 4945 August 2014 5 If the patient is deemed to have ended their quit attempt then this should be recorded within PCR and the MDS submitted electronically e Four week post quit date follow up appointment Determine the patient s smoking status using the CO monit
11. This receptor modulates the release of dopamine in response to nicotine reinforcing its rewarding properties Varenicline releases less dopamine and releases it more slowly than nicotine theoretically reducing the craving and withdrawal symptoms of smoking cessation without producing its own dependence The most common side effect associated with varenicline is nausea Delaying the morning dose of the tablet until the client has had something to eat does help negate this side effect Dosing information Adult over 18 years Start 1 2 weeks before the target stop date 0 5mg daily on days 1 3 0 5mg twice daily on days 4 7 and 1mg twice daily thereafter for 11 weeks A support programme to help clients quit using varenicline can be found at www myliferewards co uk or by phoning 0800 3457905 for a paper copy of the support pack should the client prefer Support should be offered from either the Smokefree adviser or pharmacy The summary of the referral guidance sent to GPs and pharmacists that should be offered when varenicline is prescribed is detailed below If any adverse effects are experienced these must be recorded using the yellow card reporting system Yellow cards and guidance on their use are available at the back of the BNF or online at http yellowcard mhra gov uk August 2014 9 Client J ourney through the Pharmacy Service with Varenicline Champix e Pre quit attempt when the patient is initially identified
12. Unsuccessful result should be recorded If the patient has quit at week 12 then the assessment should be recorded as Successful August 2014 29 Assessment completion Assessment complete Assessment completed by Please select v Please select Successful Unsuccessful PCR DPCE3FCB 5DFA 49E0 808E 0682F6D1179A Client lost to follow up Ox least 3 separate attempts must be made to contact the patient at week 4 and 12 before recording that they have been lost to follow up 0 recording as lost to follow up the Health Board should be informed using the local protocol Smoking Cessation Reports Additional reports have been created to support the smoking cessation service It is recommended that you familiarise your self with these and in particular e Expiring within next 7 days IF A SUBMISSION IS MISSED IT IS NOT POSSIBLE TO PROCEED AND PAYMENT WILL NOT BE MADE e No interactions in last 7 days Owren viewing the reports please be aware that the Week counter is set Mon Sun This means that a patient could have their first contact on a Friday and show as week 1 and then on the following Monday show as week August 2014 30
13. at each defined supply interval Re assess NRT strength with the aim of discontinuing by the end of the 12 week period At eight weeks post quit date issue the silver certificate Complete a CPUS form for the appropriate supply quantities of NRT Do not endorse with a total quantity to be dispensed weekly August 2014 6 Continue to give encouragement and advice both written and verbal as required by the patient and according to national and local guidance in order to support the quit attempt Three attempts should be made to follow up with patients who have not presented according to local NHS Board procedures Dates and times of attempts to contact should be recorded within the smoking cessation support tool If no response after two missed visits and three attempts of contact then record as lost to follow up in the MDS within PCR and submit it electronically Details of patients who are lost to follow up should be relayed to the Pharmacy Office 0141 201 4945 e 12 week post quit date follow up appointment Determine the patient s smoking status using the CO monitor to provide feedback A reading of less than 10ppm verifies the client as a non smoker Record the results of the CO reading in the smoking cessation support tool within PCR Congratulate the patient and encourage them to stay quit Issue the gold certificate Electronically submit the MDS data from PCR immediately after the appointment but no later than 14 week
14. network to ensure that nicotine dependency and motivation to stop has been assessed Across NHS Greater Glasgow and Clyde there is a youth stop smoking service for young people aged 18 and under The stop smoking advisor will assess their motivation to quit and nicotine dependency and if suitable complete a NRT request form for the young person to bring to the Smokefree Pharmacy service If you think a young person would benefit from the Youth stop smoking service please provide the client with the Smokeline number 0800 84 84 84 or go to www w west org uk Where a young person is not accessing the Smokefree Youth Stop Smoking Service the pharmacist should if possible involve the parent carer in the quit attempt by asking them to accompany the youngster to the pharmacy on a weekly basis as this will aid success However consent of a parent or legal guardian is required if the patient is under 13 years of age Pharmacists should follow the advice of the Caldicott Guardian in their local health board on establishing and recording consent for patients without capacity d Varenicline Varenicline is a prescription only medicine POM and so can only be prescribed by a GP Nurse prescriber trained Independent Pharmacy Prescriber and pharmacists who have completed relevant training and signed the Patient Group Direction PGD for varenicline It is a selective nicotine acetylcholine partial agonist that binds to a specific nicotinic receptor subtype
15. side effects are localised reactions for example skin irritation with patches irritation of the nose throat and eyes with nasal spray but minor sleep disturbances occur commonly These side effects are unlikely to lead to discontinuation of therapy Effects of stopping smoking Smoking cessation with or without treatment is associated with various symptoms including depressed mood insomnia irritability frustration or anger anxiety difficulty concentrating restlessness decreased heart rate increased appetite and weight gain Physiological changes resulting from smoking cessation with or without treatment may alter the metabolism of some medicinal products for which dosage adjustment may be necessary Examples include theophylline warfarin and insulin As smoking induces enzyme CYP1A2 smoking cessation may result in an increase of plasma levels of CYP1A2 substrates including caffeine clozapine theophylline See factsheet from UK Medicines Information UKMi entitled Which medicines need dose adjustment when a patient stops smoking for further information August 2014 23 Pregnancy Pregnancy should no longer be a contraindication for the use of NRT although there is limited clinical data on NRT use in pregnancy However what is clearly understood is the impact of smoking towards maternal and foetal health Therefore pregnant women who cannot stop smoking on their own can use NRT only if smoking cessation without NRT fail
16. T are preferred to maximise the gap between dosage and breastfeeding first line product is NiQuitin mini lozenge If patches are preferred a 24 hour NiQuitin patch is used and should be removed before going to bed NRT beyond the 12 week treatment phase Under revised guidance NRT can now be used beyond the 12week treatment period We recommend all NHS Greater Glasgow amp Clyde services stay with the existing 12 week NRT supply For smokers who require additional NRT beyond this period they can purchase this There is limited evidence of the benefit of continued use of NRT August 2014 24 Appendix 1 Smoking Cessation and Pharmacy Care Record PCR Orci starting a new assessment check the following e Does the patient consent to Follow Up If No do not proceed as it is no longer permitted under the new rules e Is the patient pregnant If Yes do not proceed and refer to the Pregnancy Service Orce will check for other quit attempts at other community pharmacies recorded in the last 12 weeks If identified a new quit attempt cannot be started unless undertaken at the same pharmacy as the previous attempt Selecting the patient e t may be necessary to create a record for the patient e A CHI look up function is available CHI is mandatory e The mandatory patient information for smoking cessation patients differs from the normal PCR requirements It is necessary to record the following additional information o Address 1
17. ata from PCR immediately after the appointment but no later than 14 weeks after the quit date This will trigger the final payment of 20 Patients who do not attend the arranged appointment should be contacted to reschedule If no response after three attempts of contact then record as lost to follow up in the smoking cessation support tool within PCR and submit it electronically Details of patients who are lost to follow up should be relayed to the Pharmacy Office 0141 201 4945 If at the appointment the patient reports having more than five cigarettes since the 4 week follow up they are deemed a smoker Any further cessation support to the patient should be defined as a new quit attempt Under these circumstances a new quit attempt can be started at any point thereafter based on the professional judgement of the pharmacist Beyond Week 12 Where a patient requires advice beyond the 12 week period then they should be advised that they can also seek support from local specialist smoking cessation services and the national telephone support line Smokeline on 0800 848 484 The service is open every day from 8am 10pm and is supported by a website which offers interactive web chat with trained support staff http www canstopsmoking com August 2014 13 Notes 1 If a patient is lost to follow up or recorded as a smoker at week4 then the week 12 status cannot be recorded 2 All patients need to be followed up at we
18. ecord Quit date this should be within the next few days Quit date Co B Record the Contact date this can pre date E Record conac the Quit date to allow for supply of product Confirm quit date and record contact Contact date B in preparation of quitting Contact type Please select Has the patient smoked OYes ONo Where Varenicline is provided CO Reading Please select ppm follow up consultations must be Product 16h patch 24h patch Lozenge undertaken by the pharmacist Gum Nasal spray Inhalator Sub lingual tablet Bupropion Varenicline Product and contact notes The data will be electronically submitted when the Confirm quit date button is clicked Orias continue to follow local Formulary guidance when supplying products Tf appropriate e g patient is sufficiently prepared the quit date and contact can be recorded at the initial appointment August 2014 27 Recording a Contact Record a contact each week as current practice If this is not possible record the date and type under the Contact attempt section Contact Contact date ds CO monitoring is a requirement at Contact type Please select weeks 4 and 12 post quit Has the patient smoked OYes ONo CO Reading Please select ppm Product 16h patch 24h patch Lozenge Gum Nasal spy CZ In
19. ek 4 whether or not they are still attending the pharmacy If the patient is known to have defaulted from the programme smoker needs to be entered on the record between weeks 4 amp 6 after quit date to generate payment of 20 Pharmacy Office Contact Details 0141 201 4945 Stacy greer ggc scot nhs uk e Housebound Clients From time to time we are asked to support clients who wish to stop smoking but are unable to attend the pharmacy every week for their NRT and or support due to illness etc We wish to support these clients where possible and would ask that the clients are contacted by telephone each week as the support part of the quit This is often done by the Smoking Cessation Adviser but if not we would encourage you to offer this support Pharmacy Direct A week zero should still be completed and at this week the client should be contacted and relevant sections of the smoking cessation support tool on the PCR completed in the normal way Carbon Monoxide CO Monitoring What is CO Carbon monoxide is a toxic odourless colourless tasteless gas When a smoker inhales smoke from a cigarette CO is absorbed into their blood through their lungs CO is dangerous because it binds to the haemoglobin in the red blood cells about 200 times as readily as oxygen depriving the body of oxygen What does a CO breath test show A CO breath test shows the amount of carbon monoxide in parts per million ppm CO in the breath
20. ent to return to complete CO reading and record this on the PCR Record the AsSessisie t Gutcome and submit 22 CO level recorded weekly but mandatory at 4 and 12 weeks post quit date Prescribing of Nicotine Replacement Therapy Guidance Safety of NRT Any risks that may be associated with NRT are substantially outweighed by the well established dangers of continued smoking Contra indications e NRT should not be administered to patients with known hypersensitivity to the active ingredient or any component of the NRT product e Clients with temperomandibular joint disease should not use NRT gum e NRT nasal spray should not be used by patients with active gastric or duodenal ulcer Cautions Cardiovascular disease Where there has been a serious cardiac event or hospitalisation for a cardiovascular complaint in the previous four weeks including myocardial infarction unstable angina cardiac arrhythmia coronary artery bypass graft and angioplasty stroke TIA it is recommended to wait for the condition to stabilise before treating with NRT and involve the clinician looking after the patient in the decision to recommend NRT Other Cautions NRT should be used with caution for patients with diabetes mellitus hyperthyroidism peripheral vascular disease hypertension stable angina coronary heart disease renal or hepatic impairment phaeochromacytoma active peptic ulcer disease and epilepsy Adverse Effects The most common
21. halator Sub lingual tablet Bupropio Varenicline o Product and contact notes Please follow current Formulary guidelines and use the box to the right of the appropriate option Record contact Cancel Contact attempt Contact attempted on piisi Contact type Please select Record contact attempt ff Cancel Oz f no response after two missed visits and three attempts inform the board on 0141 201 4945 August 2014 28 Submit 4 Week Data The link to release the data will be made available in the Next Action section between 4 and 6 weeks Quit date 24 Jun 2014 Next action View submitted minimum data s Minimum dataset MDS Target date Status Release status Submitted by Submitted on Start Validated Submitted GGC1 24 Jun 2014 Four week 22 Jul 2014 05 Aug 2014 Open Not submitted Twelve week 02 Sep 2014 30 Sep 2014 Open Not submitted Submit four week minimum dataset Was the client successfully contacted for 1 month follow up Yes Vv If the patient was not Date follow up carried out poa jA successfully contacted at the 1 Client withdrawn from service at time of follow up OYes No month follow up or has Has the client smoked at all even a puff in the lasttwo weeks No IV smoked it will not possible to CO reading confirms quit vas progress to the 12 week Reason CO reading not taken Please select submission
22. hen increase to higher strength if required However decisions should be made on an individual client basis and pharmacist should prescribe the most appropriate strength product for the client 1 LINE e NiQuitin Clear Patch 10 cigarettes a day or more 21mg for 6 weeks 14mg for 2 weeks 7mg for 2 weeks Less than 10 cigarettes a day 14mg for 6 weeks 7mg for 2 weeks 2nd LINE CHOICE Please be aware of product price when making choice this list in order of price e NiQuitin Minis Lozenge Mint 1 5mg amp 4mg Orange 1 5mg over 20 cigarettes daily 4mg max 15 lozenges day less than 20 cigarettes daily 1 5mg max 15 lozenges day e NiQuitin Gum 2mg amp 4mg First cigarette within 30 minutes of wakening NiQuitin 4mg Mint Gum First cigarette more than 30 minutes after waking NiQuitin 2mg Mint Gum Max 15 pieces daily e NiQuitin Lozenge 2mg amp 4mg Original amp Mint First cigarette within 30 minutes of wakening NiQuitin 4mg Lozenge First cigarette more than 30 minutes of wakening NiQuitin 2mg Lozenges Max 15 Lozenges daily August 2014 17 NiQuitin Strips 2 5mg Oral Film Mint NiQuitin Strips are suitable for smokers who have their first cigarette of the day more than 30 minutes after waking up Abrupt cessation of smoking Recommended treatment schedule Step 1 Step 2 Step 3 Weeks 1 to 6 Weeks 7 to 9 Weeks 10 to 12 Initial treatment period Step down treatment period Ste
23. nces of tobacco they smoke per week then apply the following formula which has been seen to give a fairly accurate guide to cigarette equivalents smoked 25gms tobacco loz smoked per week S0 cigarettes divided by 7 days approx 7 cigarettes day 50gms tobacco 20z smoked per week 100 cigarettes divided by 7 days approx 14 cigarettes day 75gms tobacco 30z smoked per week 150 cigarettes divided by 7 days approx 21 cigarettes day 100gms tobacco 40z smoked per week 200 cigarettes divided by 7 days approx 28 cigarette day 125gms tobacco 50z smoked per week 250 cigarettes divided by 7 days approx 35 cigarettes day 150gms tobacco 60z smoked per week 300 cigarettes divided by 7 days approx 42 cigarettes day August 2014 19 Contact Details Liz Grant Public Health Pharmacist Tel 07711 01502 Pharmacy Project Assistants Annette Robb amp Stacey Greer Tel 0141 201 4945 4799 Fax 0141 201 4949 e mail annette robb gqc scot nhs uk stacy greer c scot nhs uk Community Pharmacy Public Health Facilitators CHP Contact Name E mail address Area Julie Smith juliesmithl1l nhs net East Renfrewshire Hilary Millar hilary millar nhs net South Katrina Henderson katrina henderson nhs net North West Norma Choat Fiona Moffat norma choat nhs net fiona moffat nhs net East Dunbartonshire North East Annette Robb annette robb nhs net West Dunbartonshire Christine Alford chri
24. ofessionals and policy makers and national targets have been set relating to these See www ashscotland org uk for further details A flavour of previous targets can be found at www scotland gov uk Smoking is the United Kingdom s single greatest cause of preventable illness and early death Currently about 13 million adults in the country smoke with more than 120 000 people in the United Kingdom dying from smoking related diseases annually In addition passive smoking kills hundreds every year while the totality of smoking attributable diseases costs the NHS up to 1 7 billion each year The Tobacco Strategy sets out a three year plan of action with a budget of 100 million allocated to support its implementation Three groups in particular are targeted under 16s who are smokers adults living in disadvantaged communities and pregnant women Community pharmacists are in the ideal position to help all of these groups Success will be measured by performance against the allocated targets set for Scotland On average each community pharmacy in Greater Glasgow and Clyde serves the needs of 1 500 2 000 smokers Community pharmacists and counter staff who have been trained as smoking cessation pharmacy advisers are ideally placed to directly supply Nicotine Replacement Therapy NRT to patients within the product licenses This has the support of the Local Medical Committee as this model cuts down the workload of GPs and also improves patien
25. ogan Garshake Road Adelle McGinn Dumbarton G82 3PU Claire Blair East Renfrewshire Agnes Rowland 0141 577 8688 Health Improvement Team Claire McCririck 0141 577 8302 Eastwood Park Roukenglen Road Secure Answering Machine Eastwood Park Roukenglen Road Thornliebank G46 6UG Renfrewshire Margaret Toal 01505 821316 Old Johnstone Clinic Smoking Cessation Dan Kershaw Ludovic Square Team Alan Curley Johnstone Bob Gibson PAS 8EE Inverclyde Alison King 01475 501226 Greenock Health Centre Donna Lang Answering Machine 20 Duncan Street Liz McArdle Greenock PA15 4LY Issued October 2008 Revised August 2014 Clients should always be offered a quiet or private area to discuss their quit attempt WEEK 0 clients Can be seen by either trained assistant or trained pharmacist approx 15 min Clients under 18 years pregnant breastfeeding on medication or have a medical condition REFER TO PHARMACIST Clients Referred from group secondary care or pregnancy services do not require to do week 0 please supply NRT from weeks 1 6 Support NRT to be given from weeks 7 10 12 Inform Check Stress Record NRT Explain Discuss Appointment Leaflets Relationship Discuss Record CO reading Give tips Appointment Option to go to Group Service give local Group phone No END SESSION Smoker is motivated to stop Reasons for wanting to quit easier with a plan Advantages disadvantages of smoking
26. ollow up appointment Determine the patient s smoking status using the CO monitor to provide feedback Record the results of the CO reading in the smoking cessation support tool within PCR Electronically submit the MDS data from PCR immediately after the four week post quit date appointment but no later than six week post quit date This will trigger the second payment of 15 If the patient is a non smoker issue the Four Week Bronze Certificate Patients who do not attend the arranged appointment should be contacted to reschedule If no response after three attempts of contact then record within PCR and submit it electronically If at the 4 week post quit date follow up the patient reports having smoked in the last two weeks then the pharmacist should record accordingly A new quit attempt can be started at any point thereafter as long as the new quit attempt is undertaken at the same community pharmacy However it is best to allow time to elapse for patients to renew motivation re prepare and have a better chance at a subsequent quit attempt e Subsequent weeks prior to the 12 week post quit date follow up appointment Ask how the patient got on during the past week and assess compliance with and Ongoing suitability of product Use the diary as a discussion point Determine the patient s smoking status at each supply interval using the CO monitor to provide feedback Record on the CO card Record the results of the CO
27. or to provide feedback Record the results of the CO reading in the smoking cessation support tool within PCR Electronically submit the MDS data from PCR immediately after the four week post quit date appointment but no later than six week post quit date This triggers the second payment of 15 If the patient is a non smoker issue the Four Week Bronze Certificate Patients who do not attend the arranged appointment should be contacted to reschedule If no response after three attempts of contact then record within PCR and submit it electronically If at the 4 week post quit date follow up the patient reports having smoked in the last two weeks then the pharmacist should record accordingly A new quit attempt can be started at any point thereafter as long as the new quit attempt is undertaken at the same community pharmacy However it is best to allow time to elapse for patients to renew motivation re prepare and have a better chance at a subsequent quit attempt e Subsequent weeks prior to the 12 week post quit date follow up appointment Ask how the patient got on during the past week and assess compliance with and Ongoing suitability of product Use the diary as a discussion point Determine the patient s smoking status at each supply interval using the CO monitor to provide feedback Record on the CO card Record the results of the CO reading in the smoking cessation support tool within PCR Make subsequent supplies
28. ou will be contacted annually regarding the calibration of the monitor If the monitor screen shows the image of a screwdriver switch off remove the batteries and leave for ten minutes approximately At the end of that time after replacing the batteries the machine should work perfectly If not please call 0141 201 4945 Extra cardboard tubes and D pieces are available from the Smokefree Pharmacy Service office August 2014 15 Product Information USUAL NO OF PACKS TO BE SUPPLIED EACH WEEK FOR UP TO 10 12 WEEKS PRODUCT DOSE 1 LINE PRODUCT NIQUITIN PATCHES 1 pack of 7 patches f 1 Line product unsuitable NiQuitin Clear Patch 21mg 24 hour patch Max one daily NiQuitin 14mg 7mg 24 hour patch Max one daily a enn ee A 2ND LINE PRODUCTS in order of cost GUM 1 pack of 96 pieces NiQuitin 4mg amp 2mg Max 15 pieces daily LOZENGE 1 x 72 1 x 36 Lozenges Check the patient needs 2 boxes on a weekly basis NiQuitin 2mg amp 4mo Mint or Original Max 15 lozenges daily MINIS LOZENGE 2 x 60 pack size Check if this amount is required by client ona weekly basis NiQuitin 1 5mg amp 4mg Mint 1 5mg Orange Max 15 minis lozenges daily STRIPS 2 x 60 pack size NiQuitin 2 5mg Check if this amount is Max 15 films daily required by client ona weekly basis Notes e these are the only products available fo
29. p down treatment period 1 nicotine film every 1 to 2 1 nicotine film every 2 to 4 1 nicotine film every 4 hours hours to 8 hours During weeks 1 to 6 it is recommended that users take a minimum of 9 films per day Users should not exceed 15 films per day Reference 1 Stapleton J Russell M Feyerbend C et al Dose Effects and predictors of outcome in a randomised trial of transdermal nicotine patches in general practice Addiction 1995 90 31 42 August 2014 18 Cigarette Equivalents for Tobacco Users Pipe Smokers One bowl of tobacco is roughly equivalent to 2 5 cigarettes Take the total number of bowls of tobacco smoked per day and multiply by 2 5 e If the cigarette equivalent is 20 or more day then they can start the course on TTS30 large patches e If the cigarette equivalent is between 10 and 19 they can start the course on TTS20 medium patches Cigar Smokers One Caf Cr me or similar small size cigar is equivalent to approximately 1 5 cigarettes One Hamlet or similar medium size cigar is equivalent to approximately 2 cigarettes One Havana or similar large size cigar is equivalent to approximately 4 cigarettes Roll Your Own Smokers In the absence of a smoker not being able to tell you how many roll ups they smoke per day the following may be of assistance Each 25gms loz of tobacco is approximately equivalent to 50 cigarettes The smoker needs to be asked how many ou
30. r the Dual NRT option described on page 6 section e e All NRT products supplied must be issued with a prescription label e NiQuitin 24hr Clear patch can be removed at bedtime if client prefers Information on SPCs can be found at http emc medicines org uk Guidance on quantities and strengths of second NRT product to supply Remember that the second NRT product is only used as a top up dose therefore small realistic pack size quantities should be prescribed initially eg e 1x36 pack size NiQuitin gum 2mg or 4mg e 1x36 pack size NiQuitin lozenge 2mg or 4mg e 1x60 pack size NiQuitin minis lozenge 1 5mg or 4mg August 2014 16 a NiQuitin Strips when used as a second product if possible initially give 1x15 pack size to client to try only if client can access pharmacy easily should they require additional supply that week It is fine to give 1x60 pack and review on a weekly basis but since this is a new product and people might not like the texture or taste it might be better to give the smallest pack size first just to try Client can always return for an interim supply later on in the week if necessary The quantity of the second NRT product to be given will be assessed on a weekly basis and if a larger pack size is required then this will be dispensed Assess the necessity for extra NRT to be supplied each week When prescribing second NRT products guidance would be to initially prescribe the lower strength and t
31. reading in the smoking cessation support tool within PCR Make subsequent supplies of varenicline when necessary at two weekly intervals Complete a CPUS form for the varenicline including CHI number At eight weeks post quit date issue the silver certificate Complete a CPUS form for the appropriate supply quantities Do not endorse with a total quantity to be dispensed weekly August 2014 12 Continue to give encouragement and advice both written and verbal as required by the patient and according to national and local guidance in order to support the quit attempt Three attempts should be made to follow up with patients who have not presented according to local NHS Board procedures Dates and times of attempts to contact should be recorded within the smoking cessation support tool If no response after two missed visits and three attempts of contact then record as lost to follow up in the MDS within PCR and submit it electronically Details of patients who are lost to follow up should be relayed to the Pharmacy Office 0141 201 4945 e 12 week post quit date follow up appointment Determine the patient s smoking status using the CO monitor to provide feedback A reading of less than 10ppm verifies the client as a non smoker Record the results of the CO reading in the smoking cessation support tool within PCR Congratulate the patient and encourage them to stay quit Issue the gold certificate Electronically submit the MDS d
32. rogress monitor Throw out smoking items drink plenty of water and eat fruit and vegetables and reward themselves Agree time to return one week later usually on the same day PHARMACIST must ensure WEEK 4 Complete Check NRT Enter details on PCR under smoking cessation support tool Assess for the use of NRT medical conditions medicines pregnant breastfeeding Prescribe NRT and ensure client has information on how to use NiQuitin patch 1 line If client does not return at week 4 try to contact them by phone try at least three times Document interventions and outcomes in the PCR amp submit If no response inform the Health Board 0141 201 4945 WEEKS 2 12 Trained assistant may provide support approximately 10 minutes Trained pharmacist sees client when change to NRT strength or if product unsuitable for client Ask Discuss Advice Diet advice Give NRT Record CO reading Appointment How did you get on this week Good points bad points coping strategies withdrawal symptoms refer to booklets Give practical advice and help in dealing with problems during their quit attempt Avoid sugary snacks between meals try fruit or vegetables instead Encouragement to continue in their quit attempt Check correct use of product and supply weekly Smoking cessation details on PCR Completed weekly but mandatory at week 4 and 12 post quit date Arrange follow up appointments up to week 10 12 Week 12 Arrange for cli
33. s It is recommended that all pregnant women who smoke should be referred to the Smokefree Pregnancy Service to be seen by a Smokefree Pregnancy Service Advisor This is to ensure that a risk benefit analysis has been completed and understood by the mother which is retained in the mother s medical records If this client group expresses a clear wish to receive NRT use professional judgment when recommending or prescribing NRT If unable to stop without NRT intermittent therapy is the preferred option first line product is NiQuitin mini lozenge if not tolerated a 24 hour NiQuitin patch is used and should be removed before going to bed Breastfeeding Breastfeeding should not longer be a contraindication to use NRT The risks towards the mother and the baby of continuing to smoke and exposure to secondhand smoke far outweigh the potential adverse effects of a comparatively small amount of nicotine in breast milk from NRT If unable to quit without NRT professional judgement should be used to decide if NRT is recommended or prescribed however it is recommended that the risks and benefits of using NRT are discussed In addition it is recommended that all women who are breastfeeding are referred to the Smokefree Pregnancy Service to be seen by a Smokefree Pregnancy Service Advisor This is to ensure that a risk benefit analysis has been completed and understood by the mother which is retained in the mother s medical records Intermittent forms of NR
34. s after the quit date This triggers the third payment of 20 Patients who do not attend the arranged appointment should be contacted to reschedule If no response after three attempts of contact then record as lost to follow up in the smoking cessation support tool within PCR and submit it electronically Details of patients who are lost to follow up should be relayed to the Pharmacy Office 0141 201 4945 If at the appointment the patient reports having more than five cigarettes since the 4 week follow up they are deemed a smoker Any further cessation support to the patient should be defined as a new quit attempt Under these circumstances a new quit attempt can be started at any point thereafter based on the professional judgement of the pharmacist Beyond Week 12 Where a patient requires advice beyond the 12 week period then they should be advised that they can also seek support from local specialist smoking cessation services and the national telephone support line Smokeline on 0800 848 484 The service is open every day from 8am 10pm and is supported by a website which offers interactive web chat with trained support staff http www canstopsmoking com 1 A CPUS form including the client s CHI number must be completed each week for each client 2 If a GP10 is received for NRT please advise either the GP that in NHS GG amp C NRT should be prescribed solely on a CPUS or telephone the office 201 4945 August 2014 7
35. s of NRT and varenicline e To involve both the pharmacist and the counter assistants in the support e To collect appropriate data e Which product is recommended The GGC Formulary product of choice is currently NiQuitin Clear a 24 hour patch available in three strengths Other products from the NiQuitin range can be prescribed as second line products in Glasgow and Clyde See page 16 for further guidance on NRT products NICE guidance does not differentiate between the efficacy of 16 hour and 24 hour patches www nice org uk pdf niceNRT 39GUIDANCE pdf e If a patient has tried and failed to quit using NRT as per GGC criteria varenicline can be considered as an alternative product Service Support e The Smokefree Service is supported by the Public Health Pharmacy Facilitator Network amp outside agencies who will undertake to visit mail each of the participating pharmacies to address any problems or difficulties and ensure supplies of appropriate materials e A window sticker is provided showing that the pharmacy is accredited to take part in the service together with posters leaflets amp a Carbon Monoxide monitor e The pharmacist orders NRT from their wholesaler in the usual way SMOKEFREE TRAINING FOR PHARMACISTS amp ASSISTANTS Smoking cessation training is compulsory for every staff member involved in the service A minimum of one pharmacist must attend the NHS GG amp C Pharmacy Smokefree Services training programme
36. s visit e Return appointment Quit Date when the patient attends the return appointment Determine the patient s initial smoking status using a Carbon Monoxide CO monitor Discuss pages from the relevant sections of the How to Stop Smoking and Stay Stopped booklet to ensure the patient wants to stop smoking Advise the patient s GP that their patient will be starting a stop smoking attempt using varenicline Confirm the quit date for within the next few days Complete a CPUS form for the titration pack Patients CHI number must be on the form for payment August 2014 10 Record any additional patient data in PCR Record the results of the CO reading in PCR and also on the patient s CO Monitoring Card Electronically submit the MDS data detailing the quit date from PCR immediately after the appointment This will trigger the first payment 30 Explain to the patient the use of the recording of their data on the national database i e that by signing the CPUS form they are consenting for data sharing with relevant NHS personnel and that they may be contacted for follow up at a later date Invite the patient to attend the pharmacy to receive ongoing support and further supplies of NRT for up to a 12 week time period Explain to the patient that if they do not attend any arranged appointments they will be contacted to reschedule e Subsequent weeks prior to 4 week post quit date follow up appointment
37. sented Group support closed oO groups Select type of therapy and record number of weeks used so far if patient has already started record number of weeks otherwise 0 IMPORTANT NOTE These fields must be updated before each of the subsequent submissions Total number of weeks of known product use a r ee August 2014 26 Start Quit Attempt and Confirm Quit Date Before recording the quit attempt information any missing data will be highlighted Use the Edit initial data capture or Edit patient links to update Please correct the following validation errors before attempting to proceed Date of initial appointment is a required field Intervention s is a required field Post code is a required field At least one line of address information is required to proceed w At least one telephone number is required to proceed Orne quit date is not editable and drives the dates for the 4 week and 12 week submissions It is recommended that at the point of initial appointment a provisional date is discussed but only recorded at the point of the first return appointment 0 should therefore click the Cancel Button when the Confirm Quit date and record contact screen is displayed after entering the initial data When the client returns on the agreed date around 7 days after initial visit use the link in the Next Action section to record the quit date and first contact R
38. stine alford nhs net Renfrewshire Paisley amp Renfrew Dorothy Gillespie Pregnancy Smokefree Services Smokeline Freephone Number 0800 84 84 84 August 2014 dorothygillespie nhs net 20 Inverclyde 0141 201 2335 Opening Hours 8am 10pm HEALTH IMPROVEMENT TELEPHONE NUMBER ADDRESS PRACTITIONER North West Glasgow Mima Muir 0141 232 2110 Northwest Sector Health Improvement Team Sharifa McKechnie No secure answering machine Glasgow CHP Modular Building Velicia Dovaston Dick Gartnavel Royal Building 1055 Great Western Road Glasgow G12 0XH North amp South Sheila MacFadyen 01698 366981 Netherton House Wishaw General Hospital 94 104 Lanarkshire Netherton St Wishaw ML2 0DZ Farm Road Hamilton ML3 9LA North East Glasgow Admin Team 0141 201 9832 secure Eastbank Training amp Conference Centre answering machine Patricia Thomson 0141 201 9804 07795612754 22 Academy Street Gerry Crawley 0141 201 9811 07766085631 Glasgow G32 9AA Ceri Cadogan 0141 201 9816 07824476696 South Glasgow Bernadette Campbell 0800 028 5208 Pollok Health Centre Lorna McGhie Secure Answering Machine 21 Cowglen Road Wendy Thompson Glasgow East Dunbartonshire Cathy Williamson 0141 355 2327 Kirkintilloch Health amp Care Centre 10 Saramango Street Kirkintilloch G66 3BF West Dunbartonsire Maureen Devine 01389 776990 West Dunbartonshire Council Offices Jane Do
39. t access to NRT In addition these pharmacists amp staff can offer support amp advice to patients prescribed varenicline It is however anticipated that annually at least 85 of smokers motivated to stop will do so through the Pharmacy Smokefree Service Health Efficiency Access and Treatment HEAT Targets The HEAT targets are a core set of Ministerial objectives targets and measures for the NHS A HEAT target has been set in relation to smoking cessation The 2014 15 target is for NHS Scotland to deliver at least 12 000 successful quits at 12 weeks post quit ending March 2015 From these quits 40 must be from the most deprived datazones 60 in island Health Boards As Health Boards are accountable for delivery of the targets set a huge amount of importance is focused on Pharmacy Smokefree Services Further information on HEAT targets can be found at www scotland gov uk August 2014 2 Aim of the Smokefree Pharmacy Service To develop a network of accredited community pharmacies throughout NHS Greater Glasgow and Clyde offering an easily accessible cost effective smoking cessation service by means of support supply and dispensing of NRT Varenicline can also be supplied in accordance with a Patient Group Directive PGD Professional Objectives e To provide structured evidence based support to patients supplied NRT or varenicline on a weekly basis for a maximum of 12 weeks e To promote compliance and maximise effectivenes
40. tend the pre arranged appointment If patient does not consent they are ineligible to join the Service Record contact details for the patient including telephone numbers Check if the patient is motivated to stop smoking Ascertain if group sessions are preferable if so refer Discuss the advantages and disadvantages of stopping smoking Provide information on the NRT options in line with GGC Formulary guidance for the patient to consider and issue Discuss the Want to Stop Smoking leaflet Record the patient s details and motivation to quit in the smoking cessation support tool within PCR Discuss setting a formal quit date around 7 days after initial visit if the patient is deemed ready to quit Do not set the quit date in the smoking cessation support tool at this stage Arrange an appointment for the patient to return for NRT and further support as near as possible to the quit date Provide the How to Stop and Stay Stopped booklet and encourage the patient to complete the relevant sections Show these to the patient Offer the patient the Smokefree Services diary If accepted help them complete the mission statement and show them how to use the diary Introduce the patient to the member of staff who will help support them through their journey and record their name on the support card DO NOT routinely provide NRT at this visit e Return appointment Quit Date when the patient attends the return appointment Determine
41. the patient s initial smoking status using a Carbon Monoxide CO monitor Discuss pages from the relevant sections of the How to Stop Smoking and Stay Stopped booklet to ensure the patient wants to stop smoking August 2014 4 Identify the NRT product s most suitable in line with GGC Formulary and Service guidance Patients who have tried and failed before and are smoking on average 20 cigarettes or more per day are eligible for dual NRT for the first four weeks Enhanced patients for 12 weeks Ensure that the patient has been fully assessed for the use of NRT in relation to medical conditions medicines and pregnancy breastfeeding Confirm the quit date for within the next few days Complete a CPUS form for each supply of NRT made Ensure that the patient s CHI number is recorded on the form for payment Record any additional patient data in PCR Record the results of the CO reading in PCR and also on the patient s CO Monitoring Card Electronically submit the MDS data detailing the quit date from PCR immediately after the appointment This will trigger the first payment 30 Explain to the patient the use of the recording of their data on the national database i e that by signing the CPUS form they are consenting for data sharing with relevant NHS personnel and that they may be contacted for follow up at a later date Invite the patient to attend the pharmacy to receive ongoing support and further supplies of
42. to become an accredited pharmacy in terms of the Service Assistants can also offer this service by attending the training day We particularly encourage highlighting the training opportunities to regular locum pharmacists The training programme incorporates the NES Smoking Cessation distance learning pack SERVICE OVERVIEW This specialised service is based on the brief intervention model Research has shown that the more support offered to clients the better By spending 10 minutes with clients and helping them through their quit attempt their chances of success increase by more than 230 compared with no intervention It is therefore vital that a minimum of 10 minutes is spent with clients at each visit Clients can either be approached directly sign posted by a healthcare professional Or opportunistically asked about their smoking habits or the pharmacist assistant August 2014 3 can wait until approached by the customer The option of joining a Smokfree Community Group as an alternative to the pharmacy service should be discussed with the client If a client wishes to join a local smoking cessation group provide the client with the phone number to register a Client J ourney through the Pharmacy Service with NRT e Pre quit attempt when the patient is initially identified Assess the patient s current smoking status and previous quit attempts Obtain consent to follow up the patient This includes times when the patient fails to at
43. which is an indirect non evasive measure of the percentage of blood carboxyhaemoglobin Y COHb The CO readings demonstrate the levels of poisonous inhaled CO while the COHb reading shows the percentage of vital oxygen that has been replaced in the bloodstream Please consult the user manual for more detailed information on the CO monitor General infection control processes General infection control processes must be adhered to when using the CO monitor Please refer to and follow the CO monitor protocol for use as outlined below A new single use disposable mouthpiece should be used for each breath test taken August 2014 14 Bedfont piCO Smokerlyzer CO Monitor Protocol for Use In order to minimise the chance of infection when using CO monitors we would recommend the following procedure 1 6 Wash hands with hot water and soap before starting session or if no hot water and soap available use non alcohol hand gel Attach D piece Attach new cardboard tube Use a new cardboard tube for each client After each test ask the patient to remove the cardboard tube and place in a leak proof bag for disposal Remove D piece to allow air to circulate through sensor 7 Once CO validation is completed then wash hands with hot water and soap or if no hot water and soap available use non alcohol hand gel Please remember to wipe down the machine with a non alcohol wipe after each use and to replace the D piece every month Y
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