Pharmacy has a vital role to play in the education and support of patients seeking to quit smoking, writes Isaac Bober
Tobacco use is considered to be one of the most significant contributors to both death and premature death in developed and developing countries. Here in Australia, according to Australian Bureau of Statistics figures, every single year, smoking kills around 19,000 people and costs the economy, in social, healthcare and economic expenditure a staggering $31.2 billion.
Globally, the annual economic costs of tobacco (healthcare costs plus costs to the economy) exceed $600 billion.
And this cost to the economy, locally, is out of all proportion to the amount Australians spend on cigarettes which has been falling since 1959 when a whopping $5.135 billion was spent on cigarettes. This fell to $3.405 billion in 2014, which based on the most recent figures, is the lowest ever recorded expenditure on cigarettes in this country.
While we’re on this strain of number crunching, let’s look beyond Australia and take a world view of the toll tobacco use has… On average, smokers die 13 to 14 years earlier than non-smokers, and it’s estimated that one out of every 13 children born right now will die early due to smoking-related illnesses.
Globally, almost 6 million people die from tobacco use with around 600,000 people dying every year as a result of second-hand smoke exposure. Indeed, the total number of premature deaths in the 20th century, according to the World Health Organisation, stands at 100 million people.
These premature deaths are completely preventable.
Pharmacist intervention in smoking cessation
The International Pharmaceutical Federation (FIP) recently released a paper, Establishing tobacco-free communities which outlined the importance of community pharmacists and their provision of easily accessed healthcare and expertise.
It’s widely acknowledged that community pharmacists are in a perfect position to provide advice, education and assistance to those people who want to stop using tobacco.
Pharmacists are a reliable source of information and advice and, in their role as a health care professional, have a unique position in their community unlike that of any other health care professional. Pharmacists, says FIP, can act as the initiators of communication campaigns, educational programs and even in-pharmacy or local area lectures on the dangers of smoking and the pathways to quitting.
Beyond discussing tobacco use with the community, FIP recommends pharmacists open up a dialogue with their patients who they know are smokers.
“Pharmacists should be inquiring about tobacco use for every patient and provide counselling and intervention strategies. With simple questions (eg, Do you smoke?) a conversation on individual reasons for smoking and, more importantly, any wish to quit (eg. ‘Have you ever considered quitting?’; ‘Is now a good time to quit?’) can be started.”
As is well known and well supported through extensive research, there is a physical and psychological addiction to tobacco products and when it comes time to assist a patient, it’s important the pharmacist know what stage of addiction the patient is at. FIP recommends the Stages of Assesment model, which identifies five behavioural stages that a person with an addiction can cycle through over time. These are:
Situation: The patient has no considered quitting and may be defensive and unwilling when approached about smoking cessation.
Intervention: After first seeking permission to intervene, pharmacists should provide information about benefits of smoking cessation and offer assistance and a follow-up appointment.
Dialogue: “When, if ever, you are ready to discuss your smoking habits I would be happy to help.”
Situation: The patient has considered quitting but has not made a decision to take action.
Intervention: The pharmacist can help identify and decrease barriers to quitting as well as inquiring about motivators for quitting.
Dialogue: “What do you think may be preventing you from making the decision to quit smoking?”, “What are some reasons for you to quit smoking?”
Situation: The patient is willing and ready to try quitting and has made a commitment to action.
Intervention: Help the patient to set a quit date, assess degree of nicotine addiction, identify if nicotine replacement therapy is appropriate, and help the patient create a plan and strategy for quitting.
Dialogue: “Congratulations on making the decision to quit smoking”, “I can assist you in making a plan to help you be successful in your attempt.”
Situation: The patient is within six months of his/her quit date.
Intervention: Provide ongoing support and identify possible triggers for relapse and implement strategies to prevent relapses.
Dialogue: “What has been your biggest challenge since you quit smoking?”, “Have you been experiencing any adverse side effects of medicines or withdrawal symptoms?”
Situation: The patient has maintained smoke-free status for at least six months.
Intervention: Support and encourage progress while monitoring for improvement in health.
Dialogue: “What positive changes have you noticed since you quit smoking?”, ““What strategies have been useful for you to avoid smoking?”
Dr Mendelsohn recently told the AJP, “‘Healthcare professionals should discourage patients from simply buying nicotine replacement therapy off the shelf and trying it on their own.
“This strategy may be even less effective than unaided quitting. Not only is it ineffective, but it may also undermine future quit attempts by making smokers feel that pharmacotherapy will not work for them.”
He sad the average age of quitting is about 42 years. By this time many people are becoming concerned about the health effects of smoking. However, a study by cooper and Borland revealed that the average 40-year-old has tried to quit 10-20 times.
“Pharmacists can normalise this for people. Explain that it’s usual to have tried multiple times but this is the age that people tend to succeed. Encourage them not to give up based on past failures.
‘Pharmacists could personalise their advice by linking the adverse effects of smoking to the patient’s health problems,” Dr Mendelsohn said.
“Research has shown that those who stop smoking gain about 5 kg in the first 12 months after quitting while those that continued smoking gained 1.2kg, but what was interesting is in the group that gained the most weight, their cardiovascular risk dropped dramatically.
“Quitters reduced their 10yr risk of cardiovascular disease from 14.2% to 9.3%– even after putting weight on. There was no change in the risk of continuous smokers.
“So the bottom line and an important issue for patients to understand, is that stopping smoking might cause them to gain a little bit of weight but overall their risk of heart attack is going to be dramatically reduced.”