What works for whom in pharmacist-led smoking cessation support: realist review

Summary of findings and comparison with previous findings

This qualitative review, which links to the findings of a parallel quantitative review for the Cochrane EPOC group, included a wide range of study designs written up in 66 papers. It summarises and extends a substantial existing literature of systematic reviews (based on dozens of primary studies) on community pharmacy-based smoking cessation services. Most empirical studies on pharmacist involvement in smoking cessation were small trials undertaken by pharmacists; they focused on the impact of training on the confidence and capability of pharmacists and their staff (improved); pharmacists’ attitudes to their extended role (mixed); pharmacists’ perceived barriers to delivering smoking cessation (multiple, including insufficient training, insufficient time or space, insufficient interest from patients, inadequate remuneration and more pressing priorities), and pharmacists’ views on what would help them deliver such a service (multiple, including training, professional body support, more time and space, and additional staff roles). There was very limited empirical evidence on organisational and system influences on this extended role.

Our findings substantiate some key recommendations of previous systematic reviews: that pharmacists and their staff, when properly trained and supported, are capable of delivering the non-dispensing elements of a smoking cessation service as well as providing nicotine replacement products [4, 15–18, 20, 74, 75, 76]; that training improves their confidence and performance in this area [74, 75]; that there may be role ambiguity and/or issues of professional identity when pharmacists are invited to take on non-dispensing roles [13]; that primary studies have, to date, produced a very limited evidence base on the real-world implementation of smoking cessation services (for example, the active components of interventions have been poorly described and rarely theorised) [4, 13, 17, 20, 74]; that pharmacies may be run according to different business models but the evidence base on how these different models support non-dispensing pharmacy services is limited [4, 76]; and that there are policy implications of a major change in the professional jurisdiction of pharmacists [4, 17].

Our review adds to the existing literature by going beyond the search for ‘active components’ of a generic smoking cessation intervention and offering a more nuanced and theoretically informed analysis in a provisional realist analysis. Key findings from our realist analysis are that, firstly, for the community pharmacy to become the site of smoking cessation support, the pharmacist needs to view themselves as a public health professional rather than (merely) a dispenser of medicines – something that is far more likely to happen if undergraduate training, professional bodies and national policy depicts them in this way and endorses the role positively. Secondly, that training (oriented to increasing knowledge, communication, belief in one’s ability to deliver the intervention and belief in the efficacy of the intervention) is more likely to be effective at both undergraduate and postgraduate level if courses are affordable and accessible and if a broad curriculum is provided that goes beyond ‘tasks and facts’. Thirdly, that pharmacists are more likely to be motivated (from a professional, business and personal perspective) to deliver smoking cessation services if other pharmacists locally and nationally are also doing so; if the work is received positively at appraisal and performance review; if structural and logistical issues (time, space, priorities) are addressed; and if the work is adequately remunerated and avoids excessive claims paperwork. Finally, the shift to include smoking cessation services – as with other aspects of the non-dispensing role of the pharmacist – must have the confidence of other health professionals (especially general practitioners) and the trust of the wider public; this is more likely to happen if clear, consistent and positive messages are provided from the wider community of local health providers, doctors’ professional bodies and the media.

Early qualitative work by our own group on the STOP study confirms a number of barriers identified in this realist review, including, for example, pharmacy workers’ reluctance to risk threatening the relationship with ‘customers’; difficulties experienced by (often junior) pharmacy staff identifying who is a smoker at the pharmacy counter; the crucial importance of support from top and middle managers; and low public awareness of, and confidence in, the community pharmacy as a place to access smoking cessation support [82]. Our findings also confirm that a strong sense of professional ethics and a ‘public health’ orientation are associated with keenness to provide smoking cessation services; and that in multi-ethnic areas, pharmacy assistants (who may deliver the smoking cessation intervention) are more likely than pharmacists to reflect the diverse ethnic backgrounds of customers [82].