Tobacco Interventions Delivered by Pharmacists

Abstract and Introduction

Abstract

Background: As one of the most accessible health care professionals, pharmacists are in an ideal position to provide tobacco-cessation and prevention services. Although there is growing interest in expanding the pharmacist's role in tobacco treatment, few published studies have assessed the efficacy or effectiveness of tobacco-cessation services delivered by pharmacists in the United States.
Objective: To summarize and critique studies that examined pharmacist-delivered tobacco-cessation services.
Methods: Articles written in English that appeared in peer-reviewed journals were identified from a systematic review of literature published from 1980­2006. Publications were selected for review if the interventions were delivered by pharmacists, if the intervention included United States Food and Drug Administration­approved drugs (if drug therapy was used), and if smoking-cessation rates could be calculated.
Results: Fifteen studies met inclusion criteria. Fourteen of the studies targeted smoking, and one targeted spit (chewing) tobacco. Five studies were controlled, and 10 were uncontrolled. One of the controlled studies (chewing tobacco) and eight of the uncontrolled studies were conducted in the United States. Findings of the uncontrolled U.S. studies suggest that pharmacists can deliver smoking-cessation services. Three of the controlled studies found statistically significant differences between the pharmacist-based intervention and the control group, and the trend in the other two studies was toward the effectiveness of the pharmacist-delivered intervention. Only six of the 15 studies reviewed used biochemical measures to verify self-reported cessation.
Conclusion: The uncontrolled and controlled studies reviewed demonstrate that pharmacists can deliver tobacco-cessation interventions, and the evidence strongly suggests that they are effective in helping smokers to quit. Future studies conducted in the United States that are well controlled and include biochemical verification of smoking status are needed to provide definitive confirmation that pharmacist-delivered interventions are effective for smoking cessation. With the availability and expanded training of pharmacists, this is an opportune time for testing and disseminating evidence-based research evaluating the effectiveness of pharmacist-delivered tobacco-cessation services.

Introduction

Tobacco use produces substantial health-related economic costs to society and is the single most common cause of preventable death and disease in the United States. Although in the United States more than 47 million adults smoke, an estimated 70% want to quit. Cigarette smoking results in more than $100 billion in direct and indirect costs annually. Even minimal (< 3 min) tobacco interventions delivered by clinicians increase the proportion of smokers who quit from 7.9% to 10.2% (odds ratio 1.3, 95% confidence interval 1.1­1.6). Such small changes applied over a large population have a large public health impact and are the basis for the U.S. Clinical Practice Guideline recommendation that all clinicians (e.g., physicians, nurses, dentists, pharmacists) should provide every tobacco user with at least minimal tobacco intervention.

Pharmacists are in an ideal position to provide tobacco-cessation services on-site, in the pharmacy, where tobacco-cessation drugs are obtained. Tobacco companies have commonly used point-of-purchase strategies, such as instant price reductions, to promote existing and new products. Public health interventions have also begun to adopt strategies of delivering interventions at the point of purchase, and these have been effective in promoting healthy behaviors, such as increasing physical activity and healthier eating.

Further, pharmacists are the most accessible health professionals in the U.S. health care system. More than 200,000 pharmacists are employed in various practice environments across the United States, and the number of pharmacists is expected to grow to 250,000 by 2020. Pharmacists are particularly accessible health care providers in rural areas where the number of pharmacists/100,000-population was 71.2 in 2000 and is expected to increase to 76.7 in 2020.

Pharmacists are receiving training in tobacco-cessation approaches and are interested in providing tobacco-cessation services. Using a train-the-trainer model, pharmacist educators are disseminating curricula to pharmacy schools to enhance tobacco-cessation training of pharmacy students. This approach has led to increasing pharmacists' interest and confidence in providing tobacco services. In a recent survey, 71% of pharmacists thought that tobacco-cessation counseling is an important activity, and 45% were interested in providing such counseling.

Automation technology and certification of technicians are freeing pharmacists from traditional dispensing responsibilities. Updated pharmacy practice laws that allow collaborative practice agreements with physicians are empowering pharmacists to initiate and modify drug therapy for patients. Pharmacists in a wide variety of settings have begun to provide direct patient care, including smoking cessation. For example, in the Delaware project more than 100 pharmacists were trained and provided counseling to 4000 patients. Participating pharmacists received reimbursement for smoking-cessation counseling, which consisted of an initial session and two follow-up sessions. Further, with an approved protocol, pharmacists in New Mexico can prescribe bupropion and nicotine replacement therapy (NRT). In addition, pending final legislature approval, Medicaid will pay pharmacists in New Mexico for their services.

Although there is growing interest in expanding the pharmacist's role in treating tobacco use, we were able to locate only two published reviews of studies testing pharmacist-delivered interventions. One systematic review conducted by the Cochrane Collaboration was limited to studies of smoked tobacco that used randomized designs with control groups. The other review included only a 10-year period, was limited to studies conducted in community pharmacies, and did not identify all of the published reports testing pharmacist-delivered tobacco interventions. We reviewed a broader range of studies and provide readers with a summary of each study.