How Pharmacists Can Play a Major Role in Tobacco Cessation Treatment
Quitting smoking is hard. We’re often reminded of the classic Mark Twain quote: “Giving up smoking is the easiest thing in the world. I know because I’ve done it thousands of times.” Smoking is addictive on an emotional and physical level that health care researchers are only beginning to fully understand, and even though fully 70 percent of adult smokers in the United States want to give up smoking, many tobacco cessation techniques fail them again and again.
Many pharmacists encounter patients who want to quit smoking. Rajeev, the 45-year-old accountant who has three “successful” six-month no-smoking stints under his belt, but always returns to the habit. Nora, the 24-year-old computer technician who started smoking socially in college and now smokes more than a pack a day, who can’t quit despite all her friends pleading with her. David, the 68-year-old retiree with emphysema who understands on a rational level what his several packs-a-day habit is doing to his body, but can’t seem to quit no matter what evidence he’s presented with.1
It’s proven that the key to quitting smoking is combining therapy with tobacco cessation treatments, including highly successful off-label regimens like clonidine or tricyclic antidepressants. Combination therapy treats the emotional and mental addiction to nicotine alongside the physical addiction through nicotine replacement therapy and other tobacco cessation therapies. For patients like Rajeev, Nora and David, working with a pharmacist, a therapist and their primary care physician could be the key to breaking the habit once and for all.2
Personalizing Tobacco Cessation Increases Success
There is no one-size-fits-all treatment for quitting smoking. People are all different, and their bodies and minds respond differently to different treatments. For pharmacists helping with tobacco cessation, working with patients to find the right combination of physical and cognitive assistance is crucial.
For a compounding pharmacist, personalizing patient care is what we do every day. Applying it to tobacco cessation can help guide patients to successfully quit smoking. It can be a similar idea to treating alcohol dependency, which has also benefited from research into compounded, custom-tailored medication solutions like baclofen.
The major pharmacological route to tobacco cessation is through nicotine replacement therapy (NRT), but not all patients will respond to NRT, and pharmacists should be aware of highly effective off-label therapies such as clonidine, doxepin, imipramine and nortriptyline (tricyclic antidepressants)
The long-term quit rates for treatments like clonidine are much higher than those for traditional nicotine-based therapy. The original non-nicotine prescription medication, the 2-noradrenergic agonist clonidine was originally used to treat hypertension, and effectively treats opiate, alcohol and nicotine withdrawal. Clonidine is most effective in transdermal delivery systems and when used in combination with behavioral therapy.3
When researchers realized that almost 60 percent of smokers had a history of clinical depression, pharmacists began pioneering the use of tricyclic antidepressants as part of tobacco cessation programs. Antidepressants like nortriptyline have proven effective in helping smokers quit for longer periods of time without showing symptoms of depression, essentially providing cessation therapy while also treating one of the primary symptoms of embarking on a cessation program in the first place.4
If pharmacists do choose to move forward with nicotine-based treatments, finding the right delivery system for each patient is crucial. This can include transdermal systems like nicotine patches, or other delivery systems like gum, lozenges, nasal sprays or inhalers. Lozenges and gums have similar pharmacokinetics, but lozenges have been found to be the more effective delivery method, increasing nicotine delivery by as much as 25 percent over nicotine gum, due to its dissolving properties.5
Here, too, combination therapy is the most effective. Pharmacists should encourage patients to use both long-acting treatments like a transdermal nicotine delivery system (typically a patch), in combination with a short-acting nicotine formulation like a gum to combat immediate cravings. This is similar to an asthma treatment routine with a longer-acting preventative drug paired with a short-term rescue inhaler, and similarly covers both eventualities to increase success.
Pharmacists should also be aware that while the advent of e-cigarettes could represent an additional tobacco cessation option for their patients, e-cigarettes have not been established as safe or effective for that purpose. Pharmacists should certainly be supportive of patients’ efforts to quit smoking, but avoid recommending or promoting e-cigarettes as first-line treatments for tobacco cessation. Instead, encourage patients to speak with their physicians about the use of e-cigarettes, as well as highly tailored nicotine replacement therapy as a possible treatment route.6
Growing Role for Pharmacists in Lifestyle and Wellness
Pharmacists have been involved in tobacco cessation for many decades now. Smoking and tobacco use has long been the foremost cause of preventable deaths in the United States and pharmacists have been involved in helping with treatments since the early 1980s. Despite as much as 52 percent of current smokers making an attempt to quit smoking in the past year, half of long-term smokers still die earlier than they would if they did not smoke.
The more pharmacists continue to be viewed as integral members of interdisciplinary health teams, the more they will be called upon to take an active role in public health issues like smoking. Pharmacists have a unique relationship with patients due to their frequency of contact and window into a patient’s overall health based on the complete picture of their medications. As with the integral role pharmacists play in fighting rising levels of opioid addiction, pharmacists can impact tobacco cessation.
The U.S. Public Health Service’s suggested model for tobacco use intervention is called the “5 A’s”:
- Ask patients about smoking habits
- Advise smokers to make a permanent lifestyle change through tobacco cessation
- Assess patients’ readiness to make that change
- Assist them to form a plan to quit smoking
- Arrange for follow-up consultations
Because pharmacists often see patients relatively frequently if they are already on medication, a pharmacist can easily begin the intervention process simply by asking patients about their smoking habits. Pharmacists should be educated on how to effectively implement the “5 A’s” into their patient interactions when possible. A truncated version called “Ask-Advise-Refer”—where pharmacists ask their patients about smoking habits, advise them to make the change and then refer them to resources like quitlines or a physician—can be easy to implement in the short-term as well.7
Pharmacists can also assist with quitting smoking through treating side effects such as stress and irritability that might sap a patient’s will to continue tobacco cessation treatments. To successfully climb the mountain and quit smoking, patients need to be at their fighting best in all possible ways, and reducing damaging side effects through compounded medication is one way pharmacists can give their patients a boost.8
Quitting smoking can be a beneficial lifestyle change for a casual smoker or a life-saving behavior change for a heavy smoker at risk for chronic diseases. Either way, it’s common for patients to need the help of health care professionals to surmount all the obstacles. Pharmacists are a critical advocate for patients trying to quit smoking. They are able to not only assist with nicotine replacement therapy that can double their patients’ chances of successfully quitting in combination with therapy, they can also help treat side effects from nicotine withdrawal.
Pharmacists who may already be seeing patients who seek help quitting smoking, or who wish to extend their services to include tobacco cessation programs, should reach out to a trusted supplier to ask about APIs like clonidine and compounding kits that can help create formulations to help their clients live fuller, smoking-free lives.
Pharmaceutica North America is a premier provider of high-quality bulk active pharmaceutical ingredients, unit-dose APIs and custom compounding kits. Contact us to learn more about how our products can help you provide the best possible patient care.
- “Smoking & Tobacco Use,” May 21, 2015, http://www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/; “Giving up smoking is the easiest thing in the world, I know because I have done it thousands of times,” January 2012, http://www.usmedicine.com/editor-in-chief/giving-up-smoking-is-the-easiest-thing-in-the-world-i-know-because-i-have-done-it-thousands-of-times/ ↩
- “FDA 101: Smoking Cessation Products,” Aug. 30, 2015, http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm198176.htm ↩
- “Non-Nicotine Pharmacotherapy May Prove Useful in Smoking Cessation,” 2001, http://www.medscape.com/viewarticle/406473_3; “Clonidine for smoking cessation,” March 2004, http://www.ncbi.nlm.nih.gov/pubmed/15266422 ↩
- “Antidepressants for Smoking Cessation,” Jan. 8, 2003, http://personales.unican.es/ayestaf/esh/Antidepressants%20for%20smoking%20cessation.htm ↩
- “Smoking Cessation,” Aug. 10, 2011, http://www.pharmacytimes.com/publications/issue/2011/august2011/smoking-cessation ↩
- “Promoting smoking cessation in pharmacy practice: Tips for busy pharmacists,” June 1, 2015, https://www.pharmacist.com/promoting-smoking-cessation-pharmacy-practice-tips-busy-pharmacists ↩
- “The Role of Academic Pharmacy in Tobacco Cessation and Control,” June 12, 2013, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3687126/ ↩
- “Smoking cessation and the pharmacist-patient relationship,” Aug. 10, 2014, http://drugtopics.modernmedicine.com/drug-topics/content/tags/cigarettes/smoking-cessation-and-pharmacist-patient-relationship?page=full ↩