1
Florida Heart CPR*
Smoking Cessation Methods and Facilitation
2 hours
Objectives
On completion of this course, students will be able to:
1. Discuss diagnosis and monitoring for asthma and the long-term consequences of
poorly controlled asthma.
2. Describe devices that are specifically designed for monitoring and medication
delivery in children.
3. Describe the correct use and importance of the latest guidelines for smoking
cessation.
4. Describe the appropriate use of behavioral therapies and medications shown to
be effective for patients attempting to quit smoking.
5. Understand opportunities and strategies for developing smoking-cessation
programs or clinics.
6. Understand the mechanism of action of currently available options for
contraception.
7. Review education strategies and counseling tips for individuals seeking
emergency contraception.
Introduction
Tobacco is the number one cause of preventable death and disease in the United
States. Currently, approximately 24.7% of adults in the United States smoke.[1] Smokers
have an increased risk of cerebrovascular disease, chronic obstructive pulmonary
disease, and heart disease.[2] Cigarette smoking contributes to 30% of all cancer deaths
and to 87% of lung cancer deaths annually.[3] More than 400,000 Americans die each
year as a result of smoking-related illness, and this number continues to increase.[4] It
has been estimated that smokers of 1 to 2 packs of cigarettes a day lose anywhere from
4.4 to 6.8 years of life.[5] The estimated annual direct and indirect costs attributed to
smokers in the United States is $100 billion.[1]
The prevalence of adult smokers has remained consistent since the mid-1990s.[6] A
more disturbing trend is the prevalence of cigarette smoking among high school
students, which increased during the 1990s.[7] The National Youth Tobacco Survey
(NYTS) administered during the fall of 1999 indicated that 12.8% of middle school
students (grades 6-8) and 34.8% of high school students (grades 9-12) had used some
type of tobacco within 30 days of the survey.[8] This report also estimated that the
percentages of high school students who currently use bidis (5.0%) and kreteks (5.8%)
are nearly as high as those who use smokeless tobacco (6.6%). Bidis are small, handrolled, flavored cigarettes primarily made in India and Southeast Asian countries.[9]
Kreteks are produced predominantly in Indonesia and consist of two thirds tightly
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2
packed tobacco with one third shredded cloves.[10] These new tobacco products are of
particular concern because they are desirable to the young smoker. They also may
deliver more tar and nicotine due to the strain of tobacco used and the fact that these
products are unfiltered. The Massachusetts Tobacco Control Program conducted a pilot
study to determine the use of bidis in adolescents during March and April 1999. [9] This
report demonstrated that of the 642 youths surveyed (self-reported grades 7-12), 40%
had smoked bidis at least once and 16% were current smokers of bidis.
A healthcare professional can greatly influence a quit attempt by an adolescent smoker
through patient education and counseling.[11] Educating children about the dangers of
starting smoking cannot be emphasized strongly enough, as more than 80% of current
adult tobacco users started before the age of 18.[12] If current trends continue, as many
as 5 million children living today will die prematurely from the initiation of cigarette
smoking as adolescents.[13]
All healthcare professionals must be aware of these trends and promote smoking
cessation to decrease the health burden and economic impact ($50 billion in medical
expenditures and $50 billion in indirect costs annually) caused by smokers.[1] Despite
these facts, the response of both clinicians and the US healthcare system has been
lacking.[14] A recent evaluation of smoking cessation practices by pharmacists disclosed
that pharmacists do not routinely identify smokers, engage smokers in smoking
cessation-related activities, or document smoking cessation patient information and
outcomes.[15]
Due to the staggering morbidity, mortality, and economic impact of cigarette smoking in
the United States, it is believed that pharmacists could assume a leadership role in
smoking cessation and prevention. The pharmacist is in an ideal position to promote
smoking cessation because of the number of patients seen in pharmacy practice as well
as the availability of nonprescription nicotine replacement therapies (NRTs). A
pharmacist's role in a smoking cessation program at a managed health care
organization, as well as at a health maintenance organization, has been described in
the literature.[16,17] Favorable outcomes of a smoking cessation program offered to
community, managed care, and hospital pharmacists have also been reported. [18]
However, an intensive, patient-specific model of smoking cessation designed
exclusively for implementation in community pharmacy practice is not currently
available.
With a summary of the literature justifying the need for smoking cessation clinics to be
established, individuals from the Virginia Commonwealth University (VCU) School of
Pharmacy sought a partner in community pharmacy practice who had similar concerns
and vision for preventing tobacco-related illnesses. With the patient care and service
focus of Target Pharmacy, and the goal of the VCU School of Pharmacy to establish a
program to help people quit smoking, a collaboration was initiated. The goal was to
provide an ongoing smoking cessation program that would assist people who smoke to
quit and therefore, enhance the quality and length of their lives. Realizing that this would
be a long-term program, a mutually agreeable strategic plan was developed. This
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3
allowed the partners to discuss and include in their plans such topics as use of clinical
practice guidelines, integration of practice tools with everyday responsibilities, potential
use of educational resources, training of health professionals in smoking cessation,
appropriate opportunities for referral to a physician, and overlap of disease state
management programs with the screening and prevention efforts of the pharmacy staff.
New Smoking Cessation Guidelines
Pharmacotherapies have been recommended by the U.S. Department of Health and
Human Services' Public Health Service in its clinical practice guidelines for 2000,
"Treating Tobacco Use and Dependence."[14]
A comparison of the 2000 guidelines with the previous (1996) guidelines reveals the
progress made in tobacco research. Among the important differences between the
documents are the following:



There are now 7 efficacious smoking cessation medications, allowing the
clinician and patient many more treatment options than previously. Further
information is also available on the efficacy of combinations of NRTs and
pharmacotherapies that are obtained over the counter.
The updated guidelines point to additional efficacious counseling strategies.
These include telephone counseling as well as counseling that helps smokers
enlist support outside the treatment context.
The updated guidelines contain strong evidence that smoking cessation
treatments shown to be efficacious are cost-effective relative to other routinely
reimbursed medical interventions, such as treatment of hyperlipidemia and
mammography screening.
The updated guidelines contain the following statements that may give hope to the 7 out
of 10 smokers who try to quit each year:




Tobacco dependence is a chronic condition that often requires repeated
intervention. However, effective treatments exist that can produce long-term or
even permanent abstinence.
Patients willing to quit tobacco use should be provided with treatments identified
as effective in these guidelines; patients unwilling to try quitting should be
provided with a brief intervention designed to increase their motivation to quit.
Clinicians must actively assess and treat tobacco use. In addition, it is essential
that healthcare administrators, insurers, and purchasers adopt and support
policies and practices aimed at reducing tobacco-use prevalence.
The guidelines recommend that brief tobacco dependence treatment -- even a
few minutes spent by a provider talking to a patient -- is effective.
There is a strong dose response relationship between the intensity of tobaccodependence counseling and its effectiveness. Treatments involving person-to-person
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4
contact (via individual, group, or proactive telephone counseling) are called consistently
effective, and effectiveness increases with treatment intensity.
Three types of counseling and behavioral therapies were found to be especially
effective and should be used with all patients attempting tobacco cessation: provision of
practical counseling, provision of social support as part of treatment, and help in
securing social support outside of treatment.
Smoking Cessation Modalities
Behavioral Modifications
Lifestyle modification and behavioral modification are important. Patient education
should be given during the initial visit and revisited over the course of a year during
follow-up visits for each patient. Suggestions could include counter-conditioning such as
waiting an additional 5 minutes before lighting up, smoking a cigarette only halfway,
and/or reducing smoking by 1 cigarette per day every other day. Patients should be
encouraged to keep a "cigarette diary" from the time of the initial visit to the specified
quit date to track tapering of tobacco use. In reality, few patients taper tobacco use
(cigarette fading) significantly during this preparation phase, but the point of becoming
"mentally" ready is reinforced with this exercise. Instruction should also include
suggestions about stimulus control, such as removing visual cues and staying away
from situations that make them want to smoke. For example, patients may be
encouraged to remove ashtrays from the home and workplace and to avoid alcohol and
bars where smoking commonly occurs. Each patient's family, friends, and significant
others should be encouraged to provide support. It is believed that a support system
could assist the smoking cessation candidate through the preparation, action, and
maintenance phases.
The biggest concern that many patients have is weight gain. The average person gains
only 5-10 pounds when attempting to stop smoking. Patients may not gain any weight,
or they may gain significantly more than the average. Patients should be instructed to
not try to diet and stop smoking at the same time. Start with smoking cessation, and
after 3 months of being smoke-free, a diet can be discussed. Additional patient
information pertaining to healthy snacks and food choices should be made available for
interested patients.
Fagerstrom Test
When an attempt to stop smoking is initiated, withdrawal symptoms such as irritability,
drowsiness, anxiety, hunger, sleep disturbances, and difficulty concentrating reach
maximal intensity 1 to 2 days after cessation and gradually decrease in intensity over a
period of 2 weeks.[19,20] However, the desire to smoke may persist for a lifetime in the
patient who has successfully stopped smoking.
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5
The Fagerstrom Test for Nicotine Dependence (FTND) is a 6-item questionnaire
designed to assist the healthcare professional in determining the likelihood of nicotine
dependence.[21] A score of 6 or greater (maximum score of 10) on the FTND indicates a
high level of nicotine dependence (see Table 2). The FTND, along with a history of prior
attempts to quit, is a valuable tool for determining a course of action for smoking
cessation. Therapeutic interventions are based on the FTND, previous attempts to quit,
and patient preferences.
Smoking Cessation Therapies: Cold Turkey
The cold turkey method of smoking cessation is a feasible initial option, as well as the
least expensive option for the smoking cessation candidate. The best candidates for this
method are those who smoke fewer than 10 cigarettes (half a pack) per day, have a
relatively low level of nicotine dependence per the FTND (score lower than 6 out of the
possible 10 points), and individuals who don't feel they need the "extra help" an NRT or
bupropion could provide. Even those who smoke more than 10 cigarettes per day, or
who have a high score on the FTND, can try the cold turkey method. If that method is
unsuccessful in assisting the patient to long-term smoke-free status, then
pharmacologic therapy can be initiated.
Smoking Cessation Therapies: Nicotine Patch
The nicotine patch is first-line pharmacotherapy to be recommended in the smoking
cessation clinics due to long-term success rates, safety, ease of patient use, and cost
associated with this method.[14] Pharmacist information on the use of the nicotine patch
can be found in Table 3. The 24-hour patch is associated with an increase of adverse
events (eg, skin irritation, vivid dreams) but is definitely indicated in patients who get up
at night to smoke or those who smoke first thing in the morning (within 30 minutes of
awakening) due to the pharmacodynamics of this delivery system. [22] It is recommended
to limit duration of therapy with the patch to no longer than 6-8 weeks, because little
benefit of a longer duration has been reported in the literature.[23] Tapering of the patch
is also discouraged based on reports from the literature.[22,23] Recommendations
secondary to the wants and needs of each patient should be created.
Smoking Cessation Therapies: Nicotine Gum
Nicotine gum is also adequate first-line therapy, but it is recommended to patients only if
relapse occurred with the nicotine patch or bupropion or if patients did not want to use
the patch. The reasons for this are the extensive patient education that is required for
proper use of the nicotine gum and the higher cost of the gum than the nicotine patch.
Information about the use of nicotine gum is provided in Table 4. Nicotine gum should
be scheduled (eg, 1 piece every hour while awake) instead of used on an as-needed
basis. This is due to the pharmacodynamics of the nicotine gum, as it takes up to 30
minutes for the nicotine from the gum to reach the central nervous system via buccal
absorption.[24] Tapering of the nicotine gum is also strongly encouraged, as patients
may become addicted to this cessation modality. Incorrect use of the nicotine gum is
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Smoking Cessation Methods
6
evidenced by hiccups, dyspepsia, and rapid chewing motion by the patients. Rotation of
the buccal site where the nicotine gum is "parked" is done to minimize mouth sores
commonly associated with the use of this agent.
Smoking Cessation Therapies: Bupropion
Bupropion is first-line therapy for those who have failed other NRTs, in combination with
the nicotine patch, or in those who specifically request this modality to facilitate a quit
attempt. Information on the use of bupropion is provided in Table 5. Drug interactions
with bupropion are important to be aware of, and one should avoid this agent in patients
with a history of seizures. Patients could be started on bupropion 1-2 weeks prior to the
quit date, and total duration of therapy should last no longer than 12 weeks with no
tapering of the medication.[25] Commonly reported side effects are headache, insomnia,
and dry mouth.[25,26] Combination therapy with bupropion and the nicotine patch are
considered to be an option in patients based on prior quit attempts, number of cigarettes
per day (> 30 cigarettes per day), and Fagerstrom test (score of 6 or greater). Because
of the higher cost of bupropion, nicotine patches were often more attractive to
consumers as first-line therapy.
Smoking Cessation Therapies: Nasal Spray Inhaler and Nicotine Inhaler
The nicotine nasal spray is an alternative for patients who have failed to stop smoking
through nicotine patch or nicotine gum therapy, but bupropion is an equally effective
and more convenient method for this group. Because of its quick onset of action, the
nicotine nasal spray may benefit heavy smokers (those smoking 2 packs or more per
day) and patients with higher levels of nicotine addiction. Frequent dosing and patient
education is vital to success with the nicotine nasal spray. The method of delivery may
cause bothersome adverse effects, limiting the use of this product by many patients.
The Nicotrol Inhaler is a very expensive alternative that adds no added efficacy over the
other methods. Patients who rely on the hand-to-mouth ritual may derive the greatest
benefit from the nicotine inhaler. See Table 6 for information on the nicotine nasal spray
and nicotine inhalation system.
A Smoking Cessation Clinic in a Chain Community Pharmacy Practice
VCU School of Pharmacy has collaborated with Target Pharmacies in Virginia to
advance patient-care oriented clinical pharmacy services. Smoking cessation was
chosen as the first disease state to be implemented because of the nonprescription
availability of NRT products and the numerous inquiries the Target pharmacists were
receiving about them. Fifteen pharmacists at 7 Target Pharmacies in Virginia
participated in the smoking cessation demonstration project from April 1997 to
December 1999.
Training of the Target pharmacists was conducted using a smoking cessation training
manual developed by the VCU School of Pharmacy. Throughout the manual, the
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7
transtheoretical model for smoking cessation is applied to individuals who wish to quit
smoking.[18] Pharmacist training consisted of an explanation of the transtheoretical
model for smoking cessation, essential components required for documentation in the
patient chart, appropriate behavioral modification techniques for smoking cessation, and
categorization of smokers regarding their stage of change (precontemplation,
contemplation, preparation, action, and maintenance). Use of the FTND was
demonstrated as an important tool for selecting a treatment modality for smoking
cessation.[21] A workshop approach was used for education about both nonprescription
and prescription smoking cessation therapies, demonstration on the use of
nonprescription NRTs (nicotine patch and gum), patient counseling techniques for
smoking cessation therapies, and the method for developing an individual action plan to
assist the patient with smoking cessation. The Target pharmacists were also instructed
on physical assessment skills, such as blood pressure and pulse monitoring, to be used
in the smoking cessation clinic. The training sessions were conducted at both the
pharmacy and off-site locations based on scheduling and pharmacist convenience.
Following the training session, the Target pharmacists were prepared to incorporate the
smoking cessation program into the pharmacy sites. Patient recruitment involved a
pharmacist asking every pharmacy customer if they smoked, and if so, would they like
to quit. Patients were also referred to the pharmacy from local family practice physicians
and nurse practitioners. Marketing materials consisted of signs and displays in the
pharmacy and informational pamphlets describing the smoking cessation program. The
pamphlets were distributed to interested individuals and available in brochure holders
on the nonprescription shelves containing NRTs. The Target patient profile sheet was
also used for identifying new patients to the pharmacy who were smokers.
Interested patients met individually with a trained Target pharmacist during scheduled
clinic times at the semiprivate counseling area in the Target pharmacies. Patient
education about behavioral modification and smoking cessation pharmacotherapy was
discussed, and if appropriate, a quit date was established. A patient chart was
maintained at the site and updated after each visit. Each patient was followed for 1 year
from the determined quit date. Information collected about abstinence from smoking
was self-reported by each patient during follow-up. Pharmacist follow-up with patients
making a quit attempt was strongly emphasized. A random subset of 30 patients, 63%
of the total population, was asked to complete a questionnaire on the third visit to the
smoking cessation clinic (Table 7). This questionnaire was developed at the VCU
School of Pharmacy for the smoking cessation clinic, and was used to assess patient
satisfaction with both the pharmacist and the overall program. Patients were asked to
complete the questionnaire outside of the pharmacy and to mail it to VCU upon
completion. All survey responses were confidential, and patient anonymity was
maintained.
Upon completion of the training session, the role of the VCU faculty was to make
periodic visits to the sites to assist with the smoking cessation clinics and to observe the
pharmacists in the clinics. The observations were performed to maintain quality control
in the smoking clinics and provide feedback on individual pharmacist performance. The
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8
faculty also served as a readily accessible source of drug information for the Target
pharmacists. Fourth-year PharmD candidates from VCU who were completing clerkship
rotations were available during scheduled clinic times to assist the Target pharmacists,
maintain patient charting, and coordinate data collection via patient questionnaires.
These individuals also played an active role in recruiting new patients for the smoking
cessation clinic. The student participants received the same training as the pharmacists
prior to contributing at the sites. The Target pharmacists were responsible for
scheduling clinic times, meeting individually with patients in the smoking cessation
clinic, and maintaining patient charts. Additional information about this smoking
cessation program in the chain pharmacy setting has been previously described in the
literature.[27,28]
For the purposes of this project, relapse is defined as smoking on a daily basis after
abstaining from tobacco products for at least 24 hours, and refers to individuals who did
not achieve long-term cessation. Long-term cessation is defined as at least 12 months
(1 year) of abstinence from tobacco products. Descriptive statistics were used to
describe patient demographics and smoking cessation rates. Nominal data were
evaluated using chi-squared and Fisher's exact tests where appropriate, and continuous
data were evaluated using 2-tailed T-tests. The statistical analyses were conducted
using Microsoft Excel 1997 software (Microsoft, Redmond, Wash.) and SAS System for
Windows release 6.12 (SAS Institute, Cary, NC). Data were deemed significant at P </=
.05.
Smoking Cessation Clinic: Results
The results for the evaluation of a smoking cessation clinic in community pharmacy
practice are shown in Table 8. Forty-eight patients were followed for at least 1 year after
their determined quit date in the smoking cessation program. Of these, 12 patients
(25%) abstained from smoking cigarettes for 12 months or more beyond their
determined quit dates. These patients were considered to be abstinent for at least 1
year, achieving long-term cessation. Abstinence rates for 1, 3, and 6 months were
43.8% (21/48), 31.3% (15/48), and 25% (12/48), respectively. Thus, 6- and 12-month
cessation rates were unchanged at 25%. Women were nearly 5 times more successful
in attaining long-term abstinence than men (33.3% and 6.7%, respectively). Statistical
analysis of gender and abstinence from smoking was statistically significant (P = .047).
Adults ranging in age from 21 years to 70 years were included into the 1-year analysis.
The highest cessation rate of 33.3% was observed in patients 20-29 years of age and
those greater than 50 years of age. Participants aged 30-39 years and 40-49 years had
lower 1-year smoking cessation rates of 15.8% and 22.2%, respectively. However, no
statistically significant difference was observed for obtaining long-term cessation status
and a particular age cohort.
Pharmacists determined each patient's smoking history. Forty-four (91.7%) of the
patients smoked 30 cigarettes (1.5 packs) per day or less, with 47.9% of all patients
smoking 11-20 cigarettes, or a half to 1 pack per day. Long-term cessation rates were
similar for those who smoked 1-10 cigarettes, 11-20 cigarettes, and 21-30 cigarettes per
Florida Heart CPR*
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9
day (33.3%, 26.1%, and 22.2%, respectively; NS). A smoker's level of nicotine
dependence was categorized by the calculation of a Fagerstrom addiction scale
score.[21] A score of 6-10 indicated a high level of nicotine dependence, and a score
lower than 6 was associated with a lower level of dependence. A mean Fagerstrom
score of 5.1 was observed for all patients attempting to quit smoking. The 12 patients
abstaining for at least 1 year had a mean Fagerstrom score of 4.2. Statistical analysis
revealed that patients considered to be of high nicotine dependence (Fagerstrom scores
of 6-10) achieved long-term cessation status at a rate nearly equal to those with lower
nicotine dependence (23.81% and 26.92%, respectively). Most patients (87.5%) had
attempted to quit smoking at least 1 time before entering the program. Ten of the
smoke-free patients had a history of 1 previous quit attempt. Statistical analysis
revealed no significant difference in 1-year abstinence status rates between those
smokers with 1 previous quit attempt and those who had never attempted to quit.
Forty-five percent of patients with prior diagnoses of hypertension, coronary artery
disease, or dyslipidemia quit smoking for the duration of follow-up. Long-term cessation
was also achieved in patients with known psychiatric disorders, respiratory disease, and
thyroid disease (13.3%, 25.0%, and 66.6%, respectively). Only 1 diabetic patient was
followed for 12 months and did not ultimately quit smoking.
A comparison of smoking cessation methods is described in Figure 1. Twenty-five
patients attempted to quit smoking using transdermal nicotine replacement patch
therapy. Six of these patients achieved long-term cessation status. Other successful
therapies included "cold turkey," nicotine gum, and combination patch with bupropion
therapy. Four patients used bupropion and 1 patient used nicotine nasal spray to assist
with the quit attempt, but none of these patients refrained from smoking for the 1-year
follow-up period. Statistical analysis of those employing a pharmacologic agent vs those
who did not showed no statistically significant difference between the strategies and
long-term cessation. The mean time until relapse for all methods of smoking cessation
was 41.7 days. Patients quitting "cold turkey" relapsed at a mean of 23 days, while
those using nicotine replacement dosage forms and/or bupropion had a mean relapse
time of 46.6 days; however, this difference was not statistically significant.
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10
Figure 1.
Increased appetite and weight gain were the most frequently reported smoking
cessation withdrawal symptoms at a rate of 16.7% across the sample population.
Tobacco cravings and feelings of anxiety, nervousness, and jitteriness were reported by
12.5% of the patients. Anger, frustration, irritation, drowsiness, fatigue, and headache
were reported by less than 10% of the population during follow-up. None of the patients
reported a depressed mood upon smoking cessation.
Smoking cessation clinic patients reported few adverse drug reactions (ADRs). Mild skin
reactions from nicotine replacement patches were the most frequently reported ADR,
experienced by 20% of patch users. Users of these cessation methods reported nasal
irritation from nicotine nasal spray, insomnia and vivid dreams from bupropion and
nicotine replacement patch therapy, and jaw aches from nicotine gum.
Thirty patient questionnaires were distributed and 19 (63%) were completed and
returned. Patients were instructed to evaluate each of the 18 statements on a 0-10
scale, with a score of "10" indicating strong agreement. Analysis of the questionnaire
revealed that 82% (279/342) of the possible responses by the patients were "10" and
94% (320/342) were "8" or higher. Results of the patient questionnaires are detailed in
Table 7.
Smoking Cessation Clinic: Discussion
A Centers for Disease Control and Prevention (CDC) survey of 20,000 people in 1994
found that 2.5% to 7.5% of the smokers were able to maintain long-term abstinence
after a quit attempt.[29] It has been estimated that only 3% of patients abstain from
smoking for 6 months when they attempt to quit on their own, without the assistance of
a healthcare provider.[30] The community pharmacist-managed smoking cessation clinic
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11
model presented here resulted in 25% of clinic enrollees being able to maintain smoking
cessation for at least 1 year.
Factors such as gender, age, number of cigarettes smoked per day, level of nicotine
dependence, a history of previous quit attempts, and method of cessation were
examined for their association as predictors of achieving long-term smoking cessation.
The percentage of women who abstained from smoking for 1 year was much higher
than that of men enrolled in the clinic, and data analysis revealed these gender
differences to be statistically significant. The reason for this difference is unclear, but the
investigators and pharmacists felt that women seemed more enthusiastic about the
program and were more willing to follow-up.
Achievement of a successful outcome from the clinic was not influenced by a smoker's
age. Long-term cessation from smoking was achieved by patients of ages greater than
20 years, with no observable differences in 1-year abstinence rates among the 10-year
age cohorts examined.
All of the abstinent patients smoked 1.5 packs of cigarettes or less per day. Clinic
enrollees who smoked more than 1.5 packs per day were unsuccessful, but only
accounted for 8.3% of the follow-up population. According to the Fagerstrom addiction
scale, the clinic population was considered to possess a lesser nicotine dependence on
average (mean = 5.1). Also, those smokers who quit smoking for at least 1 year had an
even lower mean score of 4.2. However, the clinic was successful in achieving longterm cessation for both the higher and lower nicotine-dependent groups, as the
outcome differences were statistically insignificant. Clinic patients with a history devoid
of prior quit attempts achieved long-term cessation status similar to those with at least 1
previous quit attempt.
Notably, 3 of the 12 patients who achieved long-term cessation had a "slip" (relapsed to
smoking for a short period of time), and then went on to be smoke-free for at least 1
year from the date of the "slip." This may suggest that more quit attempts can lead to
long-term cessation, although this factor was not found to be statistically significant in
this project. The employment of a smoking cessation strategy that did not use an NRT
and/or bupropion was as successful in maintaining abstinence for 1 year as the use of a
pharmacologic agent. Although relapse occurred later for patients using drug therapy
than those trying a "cold-turkey" approach, the difference was not statistically
significant.
The statistically insignificant differences among many of the various predictors are
interesting. For example, the use of an NRT and/or bupropion has been shown to
prevent relapse and increase smoking cessation rates vs a quit attempt not using a
pharmacologic agent.[14] Though outcome differences between the factors examined
were observed, a larger sample size would be needed to provide enough statistical
power to reveal significant differences between the variables. It also should be noted
that duration of NRT therapy varied among participants in the program. For example,
patients applying nicotine patches used the therapy from 7 days to 12 weeks, and both
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12
16- and 24-hour patch regimens were used. These decisions were made following the
initial intervention based on patient medical history, prior quit attempts, Fagerstrom test
score, and patient preference. This emphasizes the importance of an individualized
smoking cessation plan vs a "one size fits all" program. After gathering information and
providing education, the pharmacists who participated in the project empowered each
patient to make an appropriate decision.
The clinic patients tolerated their quit attempt well and were generally satisfied with the
pharmacy service. Only 12.5% of the patients experienced tobacco cravings and
anxiety associated with nicotine withdrawal. Drug therapy also appeared to be well
tolerated, as the most common ADR was an expected mild skin reaction experienced by
20% of nicotine transdermal patch users. According to the patient questionnaire results,
the educational materials, counseling, and pharmacist service were very well received.
It is noteworthy that clinic enrollees who did not maintain their quit attempt for 1 year still
responded favorably to the pharmacy service.
Smoking Cessation Clinic: Conclusion
A community pharmacist-managed smoking cessation clinic can achieve long-term
smoking cessation rates that exceed those for patients who do not use a healthcare
provider during a quit attempt. The chain pharmacy model presented here can be
readily implemented into a community pharmacy after initial pharmacist training and at
minimal cost. The benefits that may be achieved are improved patient health outcomes
and increased patient satisfaction with pharmacist-managed clinical services.
Conclusion
Tobacco-dependence treatments are both clinically effective and cost-effective relative
to other medical and disease-prevention interventions. As such, insurers and
purchasers should ensure that all insurance plans include as a reimbursed benefit the
counseling, clinic fees, and pharmacotherapeutic treatments identified as effective in the
new guidelines. Clinicians should be reimbursed for providing tobacco-dependence
treatments just as they are reimbursed for treating other chronic conditions.
References
1. CDC. Tobacco use - United States, 1900-1999. MMWR Morb Mortal Wkly Rep.
1999;48:986-993.
2. American Cancer Society. Cancer Facts and Figures - 1996. Atlanta, Ga:
American Cancer Society.
3. Garnett WR. The vital role of the pharmacist in patient management for OTC
smoking cessation products. Pharm Times. 1996;1A-28A.
4. Wongwiwatthananukit S, Jack HM, Popovich NG. Smoking cessation: Part 1 - An
overview. J Am Pharm Assoc. 1998;38:58-70.
5. Rogot E. Smoking and the life expectancy among U.S. veterans. Am J Public
Health. 1978; 68:1023-1025.
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6. CDC. Cigarette smoking among adults - United States, 1997. MMWR Morb
Mortal Wkly Rep. 1999;48:993-996.
7. CDC. Tobacco use among high school students - United States, 1997. MMWR
Morb Mortal Wkly Rep. 1998;47:229-233.
8. CDC. Tobacco use among middle and high school students - United States,
1999. MMWR Morb Mortal Wkly Rep. 2000;49:49-53.
9. CDC. Bidi use among urban youth - Massachusetts, March-April 1999. MMWR
Morb Mortal Wkly Rep. 1999;48:796-799.
10. International Smoking Cessation Specialist Program Newsletter. University of
Pittsburgh School of Pharmacy. April 2000.
11. CDC. Trends in cigarette smoking among high school students - United States,
1991-1999. MMWR Morb Mortal Wkly Rep. 2000;49:755-758.
12. CDC. Preventing tobacco use among young people: report of the Surgeon
General. Atlanta, Georgia: US Department of Health and Human Services, Public
Health Service, CDC, National Center for Chronic Disease Prevention and Health
Promotion, Office on Smoking and Health, 1994.
13. CDC. Projected smoking-related deaths among youth - United States. MMWR
Morb Mortal Wkly Rep. 1996;45:971-974.
14. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence.
Clinical practice guideline. Rockville, Md: U.S. Department of Health and Human
Services. Public Health Service. June 2000. Available at:
http://www.surgeongeneral.gov/tobacco/
15. Williams DM, Newsom JF, Brock TP. An evaluation of smoking cessation-related
activities by pharmacists. J Am Pharm Assoc. 2000;40:366-370.
16. Gauen SE, Lee NL. Pharmacists' role in a smoking-cessation program at a
managed health care organization. Am J Health-Syst Pharm. 1995;52:294-296.
17. Baluch WM. Pharmacists' role in a smoking-cessation program at a health
maintenance organization. Am J Health-Syst Pharm. 1995;52:287-293.
18. Smith MD, McGhan WF, Lauger G. Pharmacist counseling and outcomes of
smoking cessation. Am Pharm. 1995;8:20-32.
Florida Heart CPR*
Smoking Cessation Methods
14
Florida Heart CPR*
Smoking Cessation Methods Assessment
1. ______ is the number one cause of preventable death and disease in the United
States.
a. Cardiovascular disease
b. Diabetes
c. Cancer
d. Tobacco
2. Smokers have an increased risk of
a. Cerebrovascular disease
b. Chronic obstructive pulmonary disease
c. Heart disease
d. All of the above
3. These new tobacco products are of particular concern because they are
desirable to the young smoker. They also may deliver more tar and nicotine due
to the strain of tobacco used and the fact that these products are unfiltered.
a. Bidis
b. Kreteks
c. Cigars
d. A and B
4. The prevalence of cigarette smoking among high school students
________during the 1990s.
a. Increased
b. Decreased
c. Remained stable
d. Was unprecedented
5. The nicotine patch is first-line pharmacotherapy to be recommended in the
smoking cessation clinics due to long-term success rates and _____.
a. Safety
b. Ease of patient use
c. Cost associated with this method
d. All of the above
6. Precontemplation, contemplation, preparation, action, and maintenance are the
five stages of the _________.
a. Fagerstrom model
b. Transtheoretical model
c. Transdermal model
d. None of the above
Florida Heart CPR*
Smoking Cessation Methods
15
7. Bupropion is first-line therapy
a. For those who have failed other NRTs
b. In combination with the nicotine patch
c. For those who specifically request this modality to facilitate a quit attempt.
d. All of the above
8. _________ is/are the most frequently reported smoking cessation withdrawal
symptom(s).
a. Weight gain
b. Weight loss
c. Increased appetite
d. A and C
9. A Centers for Disease Control and Prevention (CDC) survey of 20,000 people in
1994 found that _____ of the smokers were able to maintain long-term
abstinence after a quit attempt.
a. Less than 10%
b. Less than 15%
c. Less than 20%
d. Less than 25%
10. Tobacco-dependence treatments are ________ relative to other medical and
disease-prevention interventions.
a. Clinically effective
b. Cost effective
c. Both clinically and cost effective
d. None of the above
Florida Heart CPR*
Smoking Cessation Methods