Tobacco Dependence Treatment: Pharmacist’s Role

Special Article - Tobacco and Smoking Cessation

J Fam Med. 2018; 5(1): 1135.

Tobacco Dependence Treatment: Pharmacist's Role

Gogineni HP1*, Huang B2, Lin J2, Yang F2, Gogineni RV3 and Lutfy K4

¹Assistant Professor, College of Pharmacy, Western University of Health Sciences, USA

²Doctor or Pharmacy Candidate 2018, Western University of Health Sciences, USA

³3BS in Neurology and Physiology Candidate 2018, University of San Diego, USA

4Professor, College of Pharmacy, Western University of Health Sciences, USA

*Corresponding author: Hyma P. Gogineni, Assistant Professor, College of Pharmacy, Western University of Health Sciences, USA

Received: December 22, 2017; Accepted: January 31, 2018; Published: February 07, 2018


Smoking prevalence and tobacco-related mortality have steadily declined in the recent decades. However, the use of e-cig and other nicotine-containing products used for smoking cessation and other reasons is on the rise. Chronic use of tobacco products leads to serious health issues, yet a limited number of pharmacotherapies are available to treat smoking related disorders. These pharmacotherapies in some cases are not effective or cause similar side effects as nicotine. Recently, with the inception of SB 493, pharmacists are authorized to be actively involved in smoking cessation. For example, California's legislature granted pharmacists authority to furnish FDA-approved nicotine replacement therapies through SB 493. Thus, pharmacists must complete a training course approved by the board of pharmacy, as well as annual continuing education on tobacco cessation to be able to make the appropriate decision which product to choose for their patients. In this review, we attempted to review the available pharmacotherapies for smoking cessation and discuss the role that pharmacists play to help patients benefit from these products.

Keywords: Tobacco dependence; Smoking cessation; Treatment; Pharmacist role; SB 493

Scope of the Tobacco Dependence

Since its inception in 1964 the Surgeon General's report, Smoking and Health, is viewed as transformative report that widely used to initiate concerted efforts to reduce tobacco use in the United States [1]. Overall smoking rates, exposure to secondhand smoke (SHS), and tobacco-related mortality has been declined based on research and implementation of evidence-based measures. For example, smoking rates have declined from 42% in 1965 to 15.1% in 2015 [2]. Tobacco control efforts dating from 1964 are credited with preventing an estimated 8 million premature deaths by 2012 [3]. An analysis published in The New England Journal of Medicine in August 2016 found that the adult smoking rate in the U.S. fell more than twice since 2009, and the analysis made it clear that this progress is no accident: “The recent accelerated decrease in cigarette smoking has not occurred in a vacuum. The striking declines since 2009 are most likely due to the implementation of an array of tobacco-control interventions at the federal, state, non-profit, and private-sector levels [4].”

Although smoking prevalence has declined over time, more than 36 million adults still smoke, and there are large disparities in smoking rates, with higher rates among people who live below the poverty level; those with less education; American Indians/Alaska Natives; residents of the Midwest; lesbians, gays and bisexual people; people with mental illness; and adults who are uninsured or on Medicaid [3]. Smoking leads to disability, premature death and damages nearly every organ of the body, yet more than 16 million Americans still live with a smoking-related disease [2]. United States spends about $170 billion per year on medical care to treat smoking-related illnesses in adults and more than $156 billion in lost productivity due to premature death and second hand exposure [3,5]. Tobacco industry spent more than $9 billion per year (nearly $25 million every day) for product advertising and promotion, outspending tobacco prevention funding nationwide by 18.5 to 1 [6]. To counteract the influence of tobacco industry, the Healthy People 2020 set its objective of reducing adult cigarette smoking prevalence to 12.0%. from 20.6% [7]. In March 2012, the Centers for Disease Control and Prevention (CDC) launched the national tobacco education campaign –Tips from former smokers® (Tips®), in 2014, the Tips campaign motivated 1.83 million Americans to try to quit smoking cigarettes and 104,000 smokers quit smoking for good [8].

In 2015, an estimated 68% of adult smokers want to stop smoking, 55.4% made a past-quit-attempt, 7.4% recently quit smoking, 57.2% had been advised by a health professional to quit, and 31.2% used cessation counseling and/or medication when trying to quit [9]. Many smokers want to quit; pharmacists can play a pivotal role in fighting tobacco use as they interface between patients and other health providers. Pharmacists are well situated in a community practice where patients do not require an appointment or insurance to see them, as it opens the door for communication and intervention for underserved populations, where higher disparities and incidence of tobacco-related illnesses [2,10,11]. When initiating a conversation about quitting tobacco use, pharmacists can utilize the Tips® campaign as a conversation starter, as this program offers resources for both pharmacists and patients [10].

In the state of California, SB 493 legislation has expanded the role of pharmacists and designed pharmacists as “healthcare providers”, whichallowed pharmacists to furnish prescription nicotine replacement products and devices for smoking cessation without a prescription. California Board of Pharmacy allowed this regulation to be effective as of January 25, 2016, for pharmacists to furnish nicotine replacement therapy (NRT) to assist patients in smoking cessation. To provide these services pharmacists must complete two hours of approved continuing education and ongoing biennial training and follow procedures set forth by California Board of Pharmacy for pharmacists furnishing nicotine replacement products [12,13] (Appendix 1). Majority of pharmacy practitioners are interested in providing assistance for patients to quit smoking, the most commonly cited barriers to provide counseling include time constraints and lack of knowledge and skills to provide these services [14,15]. There are various training programs and Web-based educational resources available for pharmacy students and pharmacists to enhance their knowledge in tobacco dependence treatment. This article provides a simple overview of tobacco use disorder, screening patients for tobacco dependence, nicotine addiction, counseling, pharmacotherapies, monitoring nicotine withdrawal symptoms, relapse prevention, special populations, role of electronic cigarettes and future directions.

Tobacco Use Disorder

The Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5) replaced the terms nicotine abuse and dependence with an overarching category called “tobacco use disorder” (Table 1) to avoid confusion between dependence and addiction [16]. Pharmacists can assess tobacco use disorder byeither using the CAGE questionnaire for smoking (modified from the familiar CAGE questionnaire for alcohol), or the Fagerstrom test and the calculation of pack year history whichever fits their style of practice. The CAGE questionnaire is a simple, accurate tool that has been utilized for many years to screen patients for addictive disorders such as alcohol, opioid, etc. The CAGE questions have been revised to apply to smoking behavior (Table 2) and can be included in a pharmacist interview [17]. Patients who quit smoking and relapse within two to three weeks usually do so to relieve withdrawal symptoms secondary to physical dependence on nicotine. The Fagerstrom Test for Nicotine dependence is a standard instrument (Table 3) for assessing the intensity of the physical addiction. The Fagerstrom score ranges from 1-10 points and the higher the scoring system the higher the dependence on nicotine [18]. The calculation of pack year history assigns a numerical value to lifetime tobacco exposure, this is calculated based on this formula: number of cigarettes per day times number of years smoked divided by 20 equals pack years. For example, a patient smoked 40 cigarettes per day for 40 years, then 40 cigarettes x 40 years/20 = 80 pack years. The time to first cigarette and total cigarettes per day are the two strongest predictors of nicotine addiction, most smokers addicted to nicotine and research suggests that nicotine may be as addictive as heroin, cocaine, or alcohol [2,19,20].