Pharmacists have a strong but complex role in helping patients kick the habit, writes Jarrod McMaugh
Smoking tobacco in any form is probably the most important preventable cause of serious disease and death in Australia. While changes in society’s perception of smoking, laws regarding marketing, and treatment options have all had a huge impact on the decline of smoking prevalence, smoking still contributes to roughly 20% of all instances of cancer and contributes to 11% of all causes of death in Australia.
While nicotine is the primary addictive substance found in tobacco, cigarettes and other tobacco products contain many other ingredients that make the addictive properties of nicotine far more potent. Addressing addiction to tobacco products is therefore not as simple as using nicotine replacement therapies.
Quitting tobacco products is also complicated by the way tobacco is used in Australia. While cigarette smoking rates have dropped steadily to 15-16% in the last 80 years (see table 1), tobacco use amongst “heavy” smokers is still significant.
People who smoke marijuana often mix with tobacco; with 300,000 people using marijuana at least daily in Australia, this is still a significant number of people who are exposed to tobacco that may not report usage of tobacco products.
Table 1: Percentage of current smokers in Australia, 1945–1976 (%)
2016 figures: 18% of males, 14% of females.
National strategies to reduce smoking
Taxation and national health campaigns have contributed to the reduction in smoking in Australia, as have advertising restrictions, limits on smoking portrayal in the media, and education sessions in schools aimed to prevent children from becoming smokers.
The introduction of plain labelling of tobacco products, and to a lesser degree the requirement for graphic health risk messages on these products have had the greatest impact on smoking rates in recent years.
It can be argued that while governments have significant revenue from tobacco products, this will prevent the outright banning of these products. Despite this, governments have clearly made huge inroads with reducing the impact of smoking in Australia.
The Victorian Government recently introduced laws preventing smoking within four metres of people eating food in outdoor dining areas unless a barrier 2.1 meters high exists. As with all new rules, loopholes were found to circumvent the intent of the law.
Quitting smoking and the role of pharmacists
When thinking of smoking cessation, most people think of patches and lozenges that contain nicotine. There is often an expectation from smokers who have never tried to quit that these will be very effective. For those people who have attempted to quit, they may see these products as being next to useless.
The problem with these perceptions is that the nicotine available from NRT will never provide the same plasma levels of nicotine that smoking will.
The way in which people smoke affects plasma levels rapidly, with spikes in nicotine that lead to the enjoyment of smoking. NRT struggles to replicate this; explaining that NRT is an adjunct to willpower and actively avoiding smoking is important to the success of an individual’s quit attempt.
If a person is not ready to quit, then NRT will not work for them.
Stages of quitting
The stages of quitting are well understood by pharmacists. It is important to remember that this is a cyclical spectrum that a smoker never departs from – while someone may quit smoking successfully for many years, there will always be a cognitive association with the pleasurable memories associated with smoking, and relapse can occur years after a successful quit attempt.
Pharmacists have a role to play in identifying when a patient is in the contemplation phase or preparation phase, and encourage their progress through to the action phase. This can be as simple as talking about smoking when a patient presents a prescription that smells like smoke; when a person is seen to be browsing the NRT section of the pharmacy; or when a patient has an acute illness such as a cold.
Raising the subject in a non-judgemental manner can go a long way to building the relationship needed to support an individual through their next quit attempt.
Motivational counselling is a method of maintaining a person’s intent to quit, and can be seen as helping people stay in the action or maintenance phase when their motivation is waning. It should never be underestimated just how difficult quitting can be, especially considering the language used around this process (even the term “quitting” has negative connotations in every other use of the word).
Pharmacists have access to training in motivational counselling, either through quit-smoking specific training, or through other providers. This can be a very useful topic for pharmacist to upskill in, as it will assist in other areas such as medication adherence, weight loss, and chronic health considerations – basically in any situation where the best course of action for health isn’t necessarily the course of action that people want to take!
Undertaking a quit smoking training course that focuses on motivational counselling techniques provides the pharmacist with the opportunity to join the Australian Association of Smoking Cessation Professionals – a professional body that provides support and resources to health professionals working in smoking cessation.
Nicotine replacement: Nicotine replacement is available in various forms (patches, lozenges, films, sublingual sprays, etc). As discussed already, each of these provides a modest amount of nicotine in a manner that does not replicate smoking; but may assist in controlling cravings.
Patches provide a steady state of nicotine – this can be useful in conjunction with other quit smoking options, and may be supplemented with ad-hoc doses of NRT if the individual finds cravings are particularly difficult in specific situations.
Other forms of NRT provide sharp spikes in nicotine levels that can simulate the spike in nicotine a smoker receives from smoking – again, this will not provide the same level of nicotine as smoking, and is therefore not able to work alone without the will and motivation to quit.
Prescribed medications: Varenicline and Bupropion are both effective options to assist with smoking cessation. Individuals who are ready to quit should discuss these options with their pharmacist and seek referral if these will improve their quitting success.
Some individuals may be put off by the idea of using prescribed medications, despite the evidence and benefits of utilising these methods. Addressing misconceptions and supporting the decision to quit should be the priority in this situation, rather than trying to convince someone to use a method that they are not ready to consider.
e-cigarettes: There is an extraordinary amount of controversy surrounding e-cigarettes as a smoking cessation aid in Australia. Currently, it is not legal to purchase nicotine for use in vaporisers; a person can import for personal use if they have a prescription, and it is possible to have these items compounded if the person has a prescription.
In the UK, e-cigarettes are endorsed for use by the NICE guidelines. The New Zealand Ministry of Health currently encourages people to quit using e-cigarettes. In Australia, the TGA recently rejected proposals to list e-cigarettes as a product approved for human use as a smoking cessation agent.
Controversy exists for many reasons. Much of the discussion is about whether a person should have the autonomy to choose to use e-cigarettes for recreational use or as a smoking cessation option without medical intervention.
This would seem to be a valid point of view. Even if we do not have enough evidence (this is debatable) to list these products for medically instigated smoking cessation, it could be argued that since these products are less harmful than smoking, they should be available for self-selection by an individual who wishes to access them.
Another consideration is the worry that we don’t yet know if this form of nicotine consumption could have adverse health outcomes. While it may take years of use for some health consequences to manifest, we should not lose sight of the fact that smoking has well documented health concerns, and any seemingly safe method of quitting smoking should be considered a valid option until such time that harms from such a quitting method manifest.
These devices have been used for a long-enough period of time that the balance of safety compared to smoking is well on the side of e-cigarettes.
A third point of controversy is whether these products are providing the tobacco industry with a last grasp on smokers – do they keep tobacco companies in business? Are they providing a pathway to smoking for those people who would not otherwise become smokers?
Evidence for either of these is poor, although as the market matures, it should be expected that tobacco companies will invest heavily in this area. Evidence is lacking around the potential for people to become smokers via e-cigarettes when they had not smoked prior to this. While this may occur in small numbers, the overall balance of health benefit to the community is probably on the side of significantly fewer smokers, not more.
For now, until the TGA alters their position on the evidence for smoking cessation potential of e-cigarettes, the use of these items as a health intervention is limited.
Jarrod McMaugh is a community pharmacy practitioner with Capital Chemist in the northern suburbs of Melbourne. He has extensive experience in developing and delivering professional services in the community pharmacy setting.