2. Introduction and Methodology
2.1 This report summarises the findings of a research project to explore users' views of smoking cessation services provided by community pharmacies. The project was commissioned by the Primary Care Division of the Primary and Community Care Directorate supported by Health Analytical Services. The research comprised telephone depth interviews with people who had accessed the smoking cessation service at a community pharmacy in Scotland.
2.2 Despite a continuing decline in smoking rates in Scotland (from 30.7% of adults in 1999 1 to 24.3% in 2009 2 ), levels of smoking remain high and this continues to have a significant influence on the health of the population. Indeed, smoking remains one of the principal preventable causes of illness and premature death in Scotland. It is estimated to be responsible for around 13,000 deaths annually, equating to nearly 25% of all deaths (with the figure rising to as much as 34% in some deprived areas) 3 . The economic consequences are also substantial: the direct cost of treating smoking related disease is estimated at £271m per annum (rising to approximately £1.1bn if indirect costs are taken into account) 4 .
2.3 Reducing smoking and tobacco-related harm is thus recognised as one of the main drivers to improving public health in Scotland and successive governments have committed to working towards a smoke-free Scotland.
2.4 It is widely accepted that an effective tobacco policy requires a broad-based package of actions including policies relating to the promotion, sale and price of tobacco products; control of smoking in public places; measures to educate and promote healthy lifestyles; and support mechanisms to help smokers to quit 5 . In line with this, recent policy in Scotland has adopted a multi-strand approach aimed at discouraging young people from starting to smoke (by raising the age for buying tobacco to 18 and legislating to restrict display of tobacco products), while also encouraging existing smokers to quit (by banning smoking in public places, as well as providing funding to Health Boards to develop smoking cessation services, and investing in the Smokeline telephone advice service).
2.5 Furthermore, several smoking-related targets are included in the National Indicators, against which the Scottish Government monitors performance. 6 Initially set in 2005 7 , the key indicator - to reduce the percentage of adults smoking to 22% by 2010 - was confirmed in the 2008 Smoking Prevention Action Plan. 8 More recently, since its introduction in 2008, the Public Health Service ( PHS) element of the Community Pharmacy Contract has encouraged the pro-active involvement of community pharmacy staff in supporting self-care public health, offering interventions to promote healthy lifestyles and establishing a health promoting environment across the network of community pharmacies.
2.6 The PHS comprises a number of services, including the provision of a 12 week smoking cessation programme in which people can visit their local pharmacist to discuss cessation strategies, be provided with personalised advice and support in their quit attempt, and be prescribed nicotine replacement therapy ( NRT). The approach is designed to increase choice and improve access to NHS stop smoking services, improve the affordability of NRT, and cut down the workload of GPs. The specification for the provision of the service ( NHS Circular PCA(P)(2008)17 Annex C) outlines the procedures for administering the service.
2.7 Smoking cessation and support services, such as those provided under the Community Pharmacy Contract, aim to play a pivotal role in supporting the national quit effort. By aiming to provide relevant, accessible, flexible, and free advice about stopping smoking, Scotland's 1,222 9 community pharmacies are increasingly used to provide a front-line source of assistance to help smokers quit. Indeed, the annual release of statistics from national smoking cessation monitoring 10 in Scotland, covering the 2009 calendar year, shows:
- there were 69,882 quit attempts made with the help of NHS smoking cessation services in Scotland during the 2009 calendar year (an increase of 35% on 2008 figures)
- pharmacy services accounted for 56% of quit attempts made using NHS smoking cessation in Scotland in 2009 (and over 70% of quit attempts made in some NHS boards).
2.8 It was against this background that the Scottish Government commissioned Ipsos MORI to evaluate users' views on smoking cessation services provided by pharmacists as part of the PHS element of the Community Pharmacy Contract.
Aims and objectives of the research
2.9 The overall aim of the research was to understand the experience and perceptions of users of the pharmacy-based smoking cessation services, in order to provide evidence for a review of PHS patient services being undertaken by the Scottish Government. This research on the views of service users was commissioned to compliment in-house research undertaken by Scottish Government on the uptake and outcomes, and stakeholder views, of the PHS service. A separate report, summarising the findings of both research exercises, will be published by the Scottish Government.
2.10 More specifically, the research explored service users' views on:
- the accessibility of the service
- levels of satisfaction with service
- the effectiveness of the service
- potential improvements to the service.
- 2.11 The research comprised a series of qualitative depth interviews with people who had used the service in October 2010. This timeframe was chosen because it allowed the research to include users who had reached different stages of the service, including the initial meeting and subsequent four- and twelve-week milestones, as well as those who had dropped out of the service before these milestones. The interviews were conducted in early 2011, which was recent enough to allow participants to have sufficient recall of their experiences. The sample was designed to obtain a range of views and experiences and was not intended to be representative of pharmacies and/or service users. Participants were recruited using a three-stage sampling process, which involved:
- selecting a range of community pharmacies from across Scotland
- inviting people who had used these pharmacies to take part in the research
- selecting a sample of potential participants for interviews.
2.12 The first stage involved selecting community pharmacies from across Scotland who had provided the PHS smoking cessation services in 2010. A sampling matrix was created to ensure a range of types of pharmacies were included in the sample, based on:
- the volume of claims (based on the number of smoking cessation claims submitted in July 2010 11 . Pharmacies submitting 0-5 claims were excluded because they were deemed likely to be too small to allow recruitment of sufficient numbers of users)
- the deprivation level of the area in which they are based (5 levels: 20% most deprived through 20% least deprived)
- the urban/rural category of the area in which they are based (3 levels: urban, semi-rural and rural)
- whether it was an independent pharmacy or part of a larger chain of pharmacies (independent = 4 or fewer pharmacies; multiple = 5 or more pharmacies)
- health board area.
2.13 The deprivation and urban/rural classifications were in line with those used by the Information Services Division of NHS National Services Scotland based on each pharmacy's postcode. The sampling matrix set out the criteria for selecting pharmacies to be included in the study and ensured a spread across the sample (of each of the five factors set out in paragraph 1.12).
2.14 A sample of 32 community pharmacies was drawn to match criteria in the sampling matrix. Pharmacies from 11 of the 14 Health Board areas in Scotland were selected - Orkney, Shetland and the Western Isles Health Boards were not included because they did not have any pharmacies with more than five claims in July 2010.
2.15 Selected pharmacies were sent an invitation to participate. This included a letter from Ipsos MORI, and a letter from Community Pharmacy Scotland. The letters included instructions on what would be required of pharmacies to help facilitate the research, and offered the opportunity to opt out. Five pharmacies opted out. These pharmacies were replaced by other pharmacies that matched the relevant sampling matrix criteria.
Inviting service users to participate
2.16 The second stage of sampling involved asking pharmacies to send an invitation pack to everyone who accessed the service in October 2010. Invitation packs were provided by Ipsos MORI. These contained a letter from Ipsos MORI explaining the purpose of the research and what would be involved, and a short questionnaire for service users to complete and return if they wished to participate ( Appendix 1). In addition to contact details, the questionnaire collected data on gender, age, number of cigarettes smoked, number of previous quit attempts, when they began using the pharmacy service, how they rated the service overall, the forms of NRT they used, the key appointments they attended and whether they had stopped smoking or not. Female service users were also asked whether they had been pregnant at the time they accessed the service. Questionnaires were returned directly to Ipsos MORI. An incentive of £20 was offered to potential participants to thank them for their time and encourage participation from the broadest range of service users.
2.17 In total, 757 invitations were issued and 80 questionnaires were returned from which 24 were selected for interview. Participants were selected to ensure a spread of service users based on the key aspects outlined in paragraph 1.16 above. Details of the sample profile are provided below.
2.18 All interviews were conducted by telephone using topic guides designed by the research team and agreed by the Scottish Government ( Appendix 2). Interviews were conducted between 14 th February and 4 th April 2011. Interviews lasted between 20 and 30 minutes and were conducted by members of the research team. With the permission of participants, interviews were recorded and transcribed for analysis.
2.19 Table 1, below, provides details of the sample profile.
Table 1: Sample profile
|Criteria||Number of participants|
|Volume of claims from pharmacy||Small||10|
|Deprivation (pharmacy)||1 - 20% most deprived areas||8|
|5 - 20% least deprived areas ||3|
|Number of milestone appointments 12||First only||9|
|First and second||2|
|All three ||9 13|
|Number of previous quit attempts||None||3|
Limitations of the research
2.20 The research was designed to explore the perceptions and views of service users. It was not designed to measure the effectiveness of the service in terms of smoking cessation outcomes. Comments on the service reflect only the views and experiences of those who have accessed the service; people who have never heard of the service, or who have heard of it but have chosen not to use it, are not represented. We therefore cannot comment on levels of awareness of the service or the effectiveness of advertising and promotion. We also do not know why it does not appeal to some people or what the other barriers to access are. The research team tried to maximise the chances of encouraging those who were less satisfied or who dropped out of the programme to opt in to the research (by making clear in the letter that the research was interested in everyone regardless of whether or not they had completed the 12 weeks and by offering an incentive). However, there is a possibility that those less happy were less likely to take part, which would mean we have less information about negative experiences and ways in which the service can fail.
Structure of the report
2.21 The first section of the report examines the accessibility of the service before subsequent sections move on to explore users' satisfaction with the service and its effectiveness. The final section of the report presents conclusions and recommendations for further development of the service.