Pharmacy staff can play an important part in helping smokers to quit, by taking them through a stepwise process:

Cycle of change
The diagram should depict a continuous cycle with the following headings

a.Thinking about changes
b. Preparing to change
c. Making changes
d. Relapse
e. Maintaining changes

a. Thinking about changing
Before deciding what advice to give a customer, it is important to identify where in the ‘cycle of change’ they are. To do this, you should find out about their smoking habit, including smoking history, beliefs about the habit (such as health effects), and their reasons for considering smoking cessation. You can then offer advice tailored to their needs. For example, a smoker should be reminded of the damage the cigarettes are causing to their health and the various options available to them such as the many replacement therapy products available and the support from the local NHS stop smoking clinic.  Use patient information leaflets to emphasis the main points about smoking.

b. Preparing to change
Once a customer has made the decision to quit, they may want help and guidance to do it successfully. To do this they will need an action plan, and you can assist them in drawing one up. These are some of the measures they may want to adopt:
• Pick a specific day to stop
• Find a local NHS Stop Smoking clinic for support
• Get rid of all smoking accessories - including lighters and ashtrays
• Plan how to manage social situations where smoking would be the usual behaviour (e.g. the pub)
• Tell all family and friends and ask for their support
• Plan to buy something special with the money saved from quitting.

c. Maintaining change
If customers choose to use nicotine replacement therapy (NRT) to help them stop smoking, it is a good idea to encourage them to return to the pharmacy on a regular basis, so they can be offered support and to make sure the NRT is being used appropriately.
It is also important to continue offering this support, even if the quitter’s attempt is unsuccessful. Most quitters will make several attempts at quitting, but it can be helpful to discuss where things went wrong before a future quitting attempt.

PRIME theory
The cycle of change assumes that once the smoker has decided to stop smoking they have a true commitment to do so, and doesn’t take into account the part that human motivation plays in smoking.

The PRIME theory takes a different approach to helping support someone who wants to stop smoking, where motivation is key. It is based on the idea that stopping smoking is a ‘chaotic’ process involving a change in ‘identity’ for the customer (e.g. changing from being a smoker to a non smoker), while they also have to deal with different influences such as their own impulses and desires.

According to PRIME theory, people’s motivational systems involve elements organised in five levels: Plans, Responses, Impulses (urges and restraint), Motives (wants/needs) and Evaluations (beliefs about what is good or bad).

With this in mind, behavioural support of a customer wishing to stop smoking should aim to strengthen motivation to not smoke at the same time as decreasing motivation to have a cigarette. So, for example, you can help increase a customer’s motivation to stop smoking by:
o Reminding them of the benefits of cessation
o Strengthening the ‘non-smoker’ identity
o Attempting to encourage habits of thought, feeling and action that make smoking unattractive.
And you can help reduce their motivation to smoke by:
o Giving advice on ways to avoid smoking cues
o Telling the customer about and training them in mental and physical actions that can distract them from the urge to smoke
o Reshaping the way that they think about cigarettes and themselves as 'smokers'.
As time passes, the impulses, wants and needs to smoke will usually decrease as your customer gets used to not smoking and their identity as a ‘non-smoker’ strengthens.(xi)

<PRACTICE POINT>

Think about how you would deal with an initial request for the following customers to quit smoking:
1. The reluctant smoker who is only giving up smoking because his family says so!
2. A heavy smoker attempting to give up smoking for the first time
3. A smoker who has tried unsuccessfully several times to stop smoking.
Discuss your answers with your colleagues.