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Cough is one of the most common reasons for a pharmacy consultation. Most acute coughs are self-limiting, caused by upper respiratory tract infections that resolve within three weeks without treatment. Yet OTC cough medicines remain among the top-selling pharmacy categories, with NHS England estimating that the public spends over £400 million annually on cold and cough remedies.
The challenge for pharmacists is navigating a product category where patient expectation often exceeds the evidence base — while identifying the minority of coughs that warrant medical investigation.
Types of cough and what they suggest
| Cough type | Character | Common causes | Duration |
|---|---|---|---|
| Acute dry | Non-productive, irritating | Viral URTI, post-nasal drip | 1–3 weeks |
| Acute chesty | Productive, mucus-producing | Viral/bacterial chest infection | 1–3 weeks |
| Post-infectious | Dry or mildly productive | Airway inflammation after infection | 3–8 weeks |
| Chronic | Any character, >8 weeks | Asthma, GORD, ACE inhibitors, smoking | Ongoing |
OTC cough medicines: what the evidence shows
Cough suppressants (antitussives)
Cough suppressants aim to reduce the cough reflex. The main OTC options are:
- Dextromethorphan (e.g. Robitussin Dry Cough, Benylin Dry Cough): the most widely used OTC antitussive. Evidence of modest efficacy in adults — a Cochrane review found limited evidence that dextromethorphan is more effective than placebo for acute cough, though individual trials show small benefits
- Pholcodine: a mild opioid antitussive. Following an MHRA safety review in 2023 linking pholcodine to increased risk of anaphylaxis during subsequent general anaesthesia with neuromuscular blocking agents, pholcodine-containing medicines were withdrawn from the UK market in March 2023. Pharmacists should be aware that some patients may still have old stock at home
Expectorants
- Guaifenesin (e.g. Robitussin Chesty Cough, Covonia): intended to thin mucus and make productive coughs more effective. Evidence is limited — a Cochrane review found insufficient evidence to recommend guaifenesin for acute cough. However, it remains widely available and has a good safety profile
Demulcents and honey
- Simple linctus (citric acid monohydrate in a sugar syrup): a demulcent that soothes irritated throat tissues. No pharmacological cough-suppressing action, but the soothing effect may provide symptomatic relief
- Honey: NICE recommends honey as a first-line self-care treatment for acute cough in adults and children over 1 year. A 2021 BMJ Evidence-Based Medicine review found honey may be superior to usual care for improving cough symptoms. Not suitable for children under 12 months due to botulism risk
Age restrictions: critical pharmacy knowledge
Cough medicines have strict age restrictions in the UK:
| Age group | What can be supplied |
|---|---|
| Under 6 years | No OTC cough medicines. Simple measures only: honey (if over 1 year), warm drinks, nasal saline drops |
| 6–11 years | Simple linctus and glycerol-based preparations only. No codeine, dextromethorphan or pholcodine |
| 12+ years | Full range of OTC cough medicines (except pholcodine, now withdrawn) |
| Adults | Full range, with caution for interactions (e.g. dextromethorphan + SSRIs → serotonin syndrome risk) |
These restrictions followed the 2009 MHRA review that found the risks of OTC cough medicines outweighed benefits in young children.
Practical pharmacy advice
The most effective pharmacy consultation for cough is often not about choosing a product but about:
- Reassurance: most coughs resolve in 2–3 weeks. Antibiotics are rarely indicated for acute cough
- Honey and warm drinks: evidence supports this as first-line, especially for children 1–12 years
- Addressing the underlying cause: post-nasal drip responds to antihistamines or nasal decongestants; GORD-related cough responds to antacids or PPIs
- Steam inhalation: no strong evidence, but patients find it soothing. Advise caution with children due to scald risk
- Smoking cessation: for smokers with chronic cough, signpost to pharmacy stop smoking services
When to refer
Pharmacists should recommend a GP appointment for:
- Cough lasting more than 3 weeks (NICE threshold for chest X-ray consideration)
- Haemoptysis (coughing up blood) — urgent 2-week-wait referral pathway
- Associated weight loss, night sweats or persistent fever
- Cough in a patient taking ACE inhibitors (may need medication review)
- Recurrent cough with wheeze (possible undiagnosed asthma)
- Cough in a child with breathing difficulty, fever >5 days or feeding problems
Community pharmacies offer the most accessible healthcare advice for cough in England, with over 13,147 registered branches providing walk-in consultations. For patients seeking their nearest pharmacy, PharmSee's pharmacy finder provides location data for every registered branch.
Sources
- NICE, Cough (acute): antimicrobial prescribing (NG120, 2019)
- Cochrane Review, Over-the-counter medicines for acute cough in children and adults (2014)
- BMJ Evidence-Based Medicine, Honey for acute cough in children and adults (2021)
- MHRA, Pholcodine: product recall and withdrawal (2023)
- PharmSee pharmacy register data, April 2026