BACKGROUND

Tobacco is the single greatest cause of disease and premature death in America today and is responsible for 435,000 deaths annually.  About 20% of adults are smokers.² According to the Centers for Disease Control, lung cancer is the leading cause of cancer death and the second most common form of cancer among men and women. In 2011, 14% of all cancer diagnoses and 27% of all cancer deaths were due to lung cancer. Although cigarette smoking is the primary cause of lung cancer, other types of tobacco such as cigars and pipes as well as second hand smoke can be causes.³

The financial impact of smoking on society is staggering, approaching $96 billion dollars in medical expenses annually and $97 billion dollars in lost productivity.   More than 70% of current smokers have expressed the desire to quit smoking.²

Pharmacists are well positioned to play a vital role in smoking cessation and education. Pharmacists’ expertise and knowledge along with the number of pharmacies available and their convenient hours of operation allow pharmacists to make a difference in public health.

PHARMACIST ROLE AND BENEFITS 

Since smoking is a chronic condition, it may require multiple interventions and attempts to quit Pharmacist interact with patients each day, and therefore have a prime opportunity to impact the lives of smokers. 

• It is recommended that pharmacists ask patients at each visit if they smoke, and if yes, are they interested in quitting.
• Because time is sometimes limited in a pharmacy, this conversation should be brief, no more than 10 minutes.⁴

To ensure understanding of tobacco dependence and organize the treatment plan, the 5A’s of treating tobacco dependence were developed. The 5 A’s are:

• Ask the patient to describe their current smoking status. This includes current and past tobacco use and attempts for quitting.
• Advise all patients to quit using tobacco by providing clear information about tobacco use and how it impacts their life, including the patient themselves and their family.
• Assess the patient’s willingness to quit.
• Assist the patient in determining what is the appropriate treatment or action plan for them to quit.
• Arrange follow-up by asking about smoking cessation or smoking cessation progress at every visit.

Pharmacists’ time can be a limiting factor with the 5A’s interview approach.  If time does not allow, at minimum the pharmacist should “Ask” about tobacco use, “Advise” the patient to quit and refer them to resources.^4,6

Pharmacists can assist patients who wish to quit smoking with an action plan.  This includes setting a quit date, and helping patients select the most appropriate prescription or nonprescription treatment and to ensure correct use. Resources and additional information and tools can be provided and follow up with the pharmacist can occur each time the patient comes to the pharmacy.  It has been shown that counseling and medication are both effective for treating tobacco dependence, and using them together is more effective than using either one alone.²

The Centers for Disease Control provide multiple tools and resources for both pharmacists and patients regarding smoking cessation.

One tool that can be helpful for pharmacists is the Tobacco Intervention Pocket Guide. 

A resource that may prove helpful for patients is the Reasons to Quit Smoking handout created by the CDC.

More smoking cessation information for the pharmacist and patient, is available on the CDC page “Pharmacists: Help Your Patients Quit Smoking.”

SPECIFIC INFORMATION AND TREATMENT

Once a patient has made the decision to quit smoking, the pharmacist plays an essential role in determining what treatment options are optimal.  Both pharmacological and non-pharmacological treatment options are available.

Non-pharmacological treatments for smoking cessation include cognitive behavioral therapy, hypnotherapy, acupuncture, healthcare provider interventions, telephone counseling, and exercise programs. Many times, these treatments are used in conjunction with pharmacological treatment.  Pharmacists actively involved in smoking cessation may become familiar with providers of these services in their areas.⁵

There are quite a few options for pharmacological treatments that are both prescription and over the counter. 

• The most commonly prescribed smoking cessation treatments are Nicotine Replacement Therapy (NRTs). NRTs are available as a nicotine gum, patch, lozenge, nasal spray, and inhaler.⁶
• Pharmacists can advise patients on the selection of the correct product based upon the patient’s lifestyle and smoking habits, such as number of cigarettes per day and what triggers their smoking.
• During counseling, the pharmacist discusses proper use, side effects (most commonly skin reactions, vivid dreams, nausea) and the fact that treatment may take approximately 12 weeks to complete.⁶
• Pharmacological treatments that require a prescription include varenicline, bupropion, and nicotine inhalers and nasal sprays.
• Pharmacists consider past medical history and any contraindications to the drug.
• In addition, the patient should be counseled on proper use, including side effects such as weight fluctuations, hypertension and nose and throat irritation from sprays or inhalers.
• Some smoking cessation regimes require patients taking a nicotine replacement therapy or a combination of a nicotine replacement therapy and a non-nicotine containing product such as bupropion. Patients should understand that the therapy may take approximately 12 weeks to complete.⁶

E-cigarettes are an electronic device that produces a nicotine containing vapor that the patient inhales.  The FDA just recently finalized a rule regulating E-cigarettes.⁸ There have been multiple studies to determine the efficacy of E-cigarettes in smoking cessation therapy.  However due to small study size and conflicting results, more study is needed. ^8,9 For more information regarding E-cigarettes, visit the FDA website.

For more information regarding smoking cessation products:

FDA 101: Smoking Cessation Products. 

Nicotine Replacement Therapy Medications for Smoking Cessation

REGULATORY GUIDELINES   

Many states allow pharmacists to expand their scope of practice through collaborative practice agreements (CPA). State laws vary in the specific requirements for a collaborative practice agreement, including the agreements around smoking cessation.  Several states require pharmacists to complete additional education or practice requirements before they can enter a collaborative practice agreement.  Pharmacists need to understand their states laws and requirements and how they relate to smoking cessation.¹⁰

Four states have authorized pharmacists to prescribe smoking cessation products via statewide protocols issued by state boards or agencies. California, New Mexico and Oregon expressly authorize pharmacists to provide therapies specific to smoking cessation. Idaho’s Regulatory Code, while not specific to tobacco, allows pharmacists to perform drug management therapy or provide patient services and new protocols are being developed.More states are trying to enact these rules such s Arizona, and Minnesota.¹⁰

Additional Resources

Centers for Disease Control

 FDA