Smoking Cessation
Aina Abell
In January, the Surgeon General released the first report on smoking cessation in 30 years. The report updates the latest findings on smoking cessation in the United States and highlights the important role pharmacists play in cessation efforts.
“One of the most striking aspects of the report, compared to prior reports, is the extent of emphasis on pharmacists,” said Karen Hudmon, BSPharm, DrPH, professor of pharmacy practice at Purdue University College of Pharmacy in West Lafayette, IN. “It’s been slow progress, but our profession has made major strides over the past 2 decades to advance our role in tobacco cessation.”
Progress and challenges
About 34 million American adults currently smoke cigarettes, and 16 million are living with a smoking-related disease. But according to the report, cigarette smoking among adults is at 14%—an all-time low. Nearly 70% of adults who smoke say they want to quit, and more than 50% try each year. Three out of five adults who have ever smoked cigarettes have successfully quit.
Despite this progress, smoking remains the leading cause of preventable disease, disability, and death in the country. It also poses significant financial and economic burden on individuals and society, contributing to more than $170 billion of health care spending annually.
The report found that fewer than 1 in 10 adults successfully quit smoking every year. This, in part, may be due to ineffective methods—less than one-third of individuals attempting to quit use behavioral counseling or FDA-approved cessation medications.
“There are two parts to smoking; thus there are two parts to quitting,” said Hudmon. “There’s the behavioral aspect, the habits and routines associated with smoking, which we address with programs that help retrain the way a smoker thinks. Then, there’s the addiction to nicotine, which we treat with medications.”
Both interventions, especially when combined, significantly increase patients’ likelihood of quitting successfully. But many often try to quit without assistance. Even when patients do use medications such as nicotine replacement therapy, some find limited success.
Insufficient self-treatment is partly to blame, said Robin Corelli, PharmD, professor of clinical pharmacy at the University of California San Francisco School of Pharmacy. “Medicines like the nicotine gum and lozenge should be dosed every 1 to 2 hours while awake during the initial 4 to 6 weeks of treatment. Time and time again, people compromise their treatment by underdosing or discontinuing medications too soon.”
Patients may also not know all of their options. While cessation advice from providers has increased over the years, the report notes that more than 40% of adult smokers still don’t receive advice to quit from a health professional.
A ‘call to action’ for pharmacists
This is where pharmacists can step in, said Corelli, whose research and practice focus on community pharmacists’ role in disease prevention and treatment, including tobacco cessation. “It’s a call to action for us that we’re cited in the report multiple times as a viable provider and an important resource to tackle this significant public health problem,” she said.
For Corelli, this means building interventions into the pharmacy workflow. Pharmacists and pharmacy technicians—whom she dubbed “the secret sauce,” as they are often the patient’s first contact—should always ask patients if they smoke, especially if they take medications that interact with tobacco. “Once you ask, the logical extension is to advise them to quit and assess their readiness to quit,” she said.
The key is to come from a space of caring, said Corelli. “You’re not shaming someone. You recognize it’s that person’s choice, and if and when they’re ready to quit, hopefully they will perceive you as a resource.”
Pharmacists should recommend medications when appropriate, said Hudmon, “including nonprescription products (the nicotine patch, lozenge, and gum) and prescription products (varenicline, bupropion SR, and the nicotine inhaler and nasal spray).”
The report notes that authorizing pharmacists to prescribe cessation therapies, and allowing them to bill for interventions, could help boost success. In Colorado, Idaho, Indiana, and New Mexico, pharmacists can now prescribe all cessation medications, with efforts underway in other states.
Pharmacists can also provide behavior counseling resources and refer patients to the tobacco quitline (1-800-QUIT-NOW), said Hudmon. They should continually support and follow up with patients to help prevent relapses.
Other major conclusions
The report also highlights the need for actions at the population and health-system levels. These include mass media campaigns, comprehensive smoke-free policies and statewide tobacco control programs, raising cigarette prices, and requiring pictorial health warnings.
Comprehensive insurance coverage for cessation treatments can also boost patient access and success rates, while being cost-effective. Disparities influenced by socioeconomic status, age, race/ethnicity, sexual orientation, gender identity, and more also need to be addressed.
The report emphasizes that there is currently insufficient evidence that e-cigarette use increases smoking cessation, and the products may pose serious health risks. Clinicians should steer interventions toward treatments backed by solid evidence.