Smoking cessation in community pharmacy practice–a clinical information needs analysis

The tobacco epidemic represents one of the biggest public health threats affecting billions of lives (Shafey et al., 2003). Smoking, as a result, remains to be a major cause of preventable mortality and morbidity in the developed world (Chandler and Rennard 2010).

With nicotine dependence being classified as a ‘disease’ in the World Health Organization International Classification of Diseases (ICD-10-CM Diagnosis Codes 2013), addressing individual patient needs and providing adequate treatment requires a thorough understanding of the pharmacology of addiction, specialised therapeutic knowledge and psychosocial intervention skills. Whilst many smokers are able to quit ‘cold turkey’, therapeutic services need to be tailored to meet the demands of recalcitrant smokers who cannot quit unassisted, those who have had previous unsuccessful quit attempts and highly dependent smokers with a greater prospect of relapse (Chapman and MacKenzie 2013). This necessitates that healthcare professionals be equipped with evidence-based knowledge to facilitate smoking cessation interventions.

Smoking cessation research is dynamic, and new revised guidelines suggest different approaches to those used conventionally (Zwar et al., 2012; National Institute for Health and Clinical Excellence 2008). Current emerging recommendations debunk previous myths regarding the use of smoking cessation aids. For instance, it is now clear that nicotine replacement therapy (NRT) can be used while still smoking, with a view to cutting down as a prelude to quitting (Wennike et al., 2003; Rennard et al., 2006). NRT can be used beyond the recommended duration of 8 to12 weeks for as long as needed to help patients quit (Medioni et al., 2005). In fact, NRT can be continued after smoking lapses to promote recovery of abstinence (Ferguson et al., 2012). It is also evident that higher doses of NRT are more effective than lower doses, particularly in highly dependent smokers (Stead et al., 2012). Furthermore, the combination of more than one form of NRT is significantly effective (Stead et al., 2012). Indeed, NRT exhibits a wide safety profile and can be administered during pregnancy after failure of non-pharmacological interventions, in patients with cardiovascular diseases and in smokers aged 12 years and over (Schroder et al., 2002; Coleman et al., 2011; Thomas 2012; Hanson et al., 2003); though many healthcare professionals would be, based on conventional wisdom, unclear or hesitant to initiate this. Hence again, it is crucial for healthcare practitioners to keep abreast in order to successfully assist smokers in quitting.

Pharmacists, among other primary healthcare professionals, can play a fundamental role in smoking cessation. They represent a highly accessible trained workforce with a wide range of therapeutic expertise. They characterise highly trusted practitioners with whom patients often consult about health and medication-related issues (Pharmacy Guild of Australia 2010). Moreover, in the last 2 decades, community pharmacies have broadened their scope of service to include, besides conventional medicine supply, a variety of specialised services, such as health screening and disease management (Schulz et al., 2001; Monte et al., 2009). Pharmacists are well-positioned to provide smoking cessation services within pharmacies, where smoking cessation products are stocked and retailed. They can approach a wide spectrum of patients in need of support, motivation and enhanced awareness about nicotine dependence and avenues of treatment (Li 2010). Additionally, systematic reviews, assessing the effectiveness of pharmacist-delivered smoking cessation interventions, indicated that trained community pharmacists, providing counselling and ongoing support, may have a positive effect on abstinence rates (Roughead et al., 2003; Sinclair et al., 2004; Dent et al., 2007). The counselling delivered by pharmacists ranged in nature from simple advice about the importance of smoking cessation, identifying barriers to quitting and providing motivation to more intensive behavioural approaches such as providing support based on the ‘stage-of-change model’ (Sinclair et al., 2004). Preliminary studies also suggest that pharmacy-based smoking cessation services are cost-effective (Sinclair et al. 1999; Bauld et al., 2011).

In Australia, in 2011–12, it was estimated that nearly 20.4% of the adult male and 16.3% of the adult female population were smokers (Australian Bureau of Statistics 2013). These rates are far lower than a quarter of a century ago, and quit attempts have doubled since then (Germain et al., 2012). In an attempt to provide disincentives to purchase tobacco products, new political and social protocols have recently been instituted countrywide. These included the implementation of the “plain” (no brand images/advertisement) packaging legislation and the raised taxes on cigarettes (Cancer Council Victoria 2012). In Australia, over-the-counter NRT and prescription-only varenicline are available. NRT patches (21 mg/24 hours and 15 mg/16 hours) and varenicline can be accessed through subsidised pricing via the Pharmaceutical Benefits Scheme, for a period of 12 weeks for the patches and up to 24 weeks for varenicline. Despite this infrastructure, little is known about the smoking cessation services provided in this sector. Published data suggest that sales of smoking cessation products have increased, but only a minority of smoking cessation product users report receiving any advice or support (Bittoun 2007; Paul et al., 2003). Some studies have shown that smokers consistently underutilise NRT, both in terms of the number of pieces administered per day and the duration of time that treatment is used (Ferguson et al., 2011). For instance, despite Australia’s active pharmacy practice researchers in the areas of asthma, diabetes and Home Medicines Review (Australian Government, Department of Health and Ageing 2009; 2011; The University of Sydney, Faculty of Pharmacy Faculty of Pharmacy 2005), comprehensive pharmacy-delivered smoking cessation programs have not been developed or evaluated yet. This situation may also stem from lack of positive attitudes toward pharmacist-delivered smoking cessation services and the lack of pharmacists’ skills and confidence in being able to provide these services in line with the current therapeutic guidelines. In a previous simulated patient study conducted in Sydney, authors concluded that evidence-based smoking cessation advice in pharmacies was fragile and may be compromised by commercial concerns (Chiang and Chapman 2006). Another unclear issue is whether smoking cessation is handled by pharmacy frontline staff or pharmacists. Anecdotally, it is known that often Australian pharmacy assistants may be in charge of the smoking cessation products area. To add, whilst tobacco education is common in pharmacy schools in the United States (Corelli et al., 2005), for instance, little is known about the depth and scope of tobacco cessation content in Australian pharmacy curricula. As a result, an identification of needs, preferences and current awareness levels is crucial, as for pharmacists to perform competent smoking cessation interventions throughout their daily practice, they need to attain and demonstrate knowledge, skills and confidence in this field.

Given that early sources of knowledge that contribute to one’s professional career are generally acquired at professional courses, i.e., while undertaking a degree, it was anticipated that mapping the knowledge and attitudes of final-year pharmacy students would be an important marker of the “level of awareness” of pharmacy professionals about smoking cessation. Pharmacy students during their final year serve as a pertinent target population because of their imminent entry into the profession, recency of knowledge acquisition, possible personal smoking status or contact with peers who smoke. It may also be hypothesised that experience with providing smoking cessation services and advice should enhance the skill base of professionals and that practicing professionals would have higher awareness and more positive attitudes toward their role in smoking cessation service provision.

A cross-sectional questionnaire method was utilised. Since there are no pre-existing standard tools in the literature that assess knowledge and attitudes regarding smoking and smoking cessation, the first step was to design the questionnaire.

Questionnaire development

The “Smoking Cessation In Pharmacy (SCIP)” questionnaire was constructed by the principal author based on a review of the literature (Centers for Disease Control and Prevention 2005). The questionnaire comprised 4 sections as highlighted in Figure 1. The face and content validity of the questionnaire were assessed by smoking cessation experts, experienced practicing pharmacists and academic pharmacists specialising in the field of smoking cessation and respiratory health.

A total of 250 students (89.9% response rate), 51 pharmacists (72.9% response rate) and 20 smoking cessation educators (22.2% response rate) completed the questionnaire. Overall, 90.3% of all the participants submitted completed questionnaires, particularly providing answers to all the questions in the knowledge and attitude sections.

Figures 2 and 3 illustrate total knowledge and attitude score variability with respect to participant demographics. Table 5 summarises the ANOVA results for the latter. It was interesting to note that the recipients of some form of training in smoking cessation had significantly higher knowledge and more positive attitudes as compared with those without this training.

Currently, there is no published literature assessing Australian community pharmacists’ awareness about and attitudes toward smoking-related health issues or smoking cessation (El Hajj et al., 2012; Saulle et al., 2013; Vanderhoek et al., 2013; Moxham et al., 2012); nor are there any valid instruments measuring these factors. Given the new clinical guidelines for the use of various pharmacotherapies (Wennike et al., 2003), it is imperative that smoking cessation-related knowledge be updated for practicing pharmacists. This study has identified clear ‘gaps’ in knowledge levels among Australian pharmacy professionals, particularly in clinical expertise areas involving assessment of nicotine dependence and indications, dosages, adverse effects, contraindications, drug interactions and combinations of available pharmacotherapies (Beard et al., 2012). Further, a smoking cessation questionnaire was developed and psychometrically evaluated with satisfactory results. This instrument can be used in other studies and as a basis for the evaluation of educational interventions that focus on smoking cessation.

It was expected that smoking cessation educators, who work with smokers on a daily basis, would achieve the highest knowledge and attitude scores, and the obtained results confirmed this assumption. Practicing community pharmacists, who also encounter patients who smoke or those requesting assistance with smoking cessation, were expected to exhibit more positive attitudes and superior knowledge levels as compared to pharmacy students. However, the results indicated no statistically significant difference between the 2 groups. It should be noted, though, that 51% of the pharmacists who completed the questionnaire were in the 20–29 age group. This indicates that nearly half of the respondents in group 2 were fresh pharmacy graduates with minimal practical experience. This may have contributed to the absence of statistical difference in total scores between pharmacists and pharmacy students. Results indicated that recipients of some form of training demonstrated better knowledge (Zhang et al., 2012). Non-smokers were also expected to score higher than smokers (Yang et al., 2010); nevertheless, results revealed that, although non-smokers exhibit more positive attitudes, both groups share similar levels of knowledge. Gender was an unexpected contributor to the variance in knowledge, with females exhibiting higher knowledge levels and more positive attitudes than males.

Besides having positive attitudes toward smoking cessation and the corresponding role of health professionals, interestingly, all 3 groups exhibited a certain base level of ‘general’ knowledge about smoking and smoking health-related issues. For instance, when asked whether nicotine is the most addictive substance in a cigarette or whether passive smoking is harmful to the health, a high proportion of participants in all groups responded correctly. This basic knowledge could be attributed to the fact that smoking has become a common public health issue and is a major focus of various public health campaigns and mass media messages. On the other hand, questions related to prevalence of smoking, pharmacology of nicotine dependence, methods of assessment of nicotine dependence and pharmacotherapy generated significantly lower scores. For items testing knowledge of specific pharmacotherapeutic issues including dosages, side effects, interactions and contraindications of smoking cessation aids, smoking cessation educators scored lower than pharmacists. For instance, when asked which smoking cessation therapy is contraindicated in patients with severe hepatic impairment, only 16% of smoking cessation educators answered correctly as compared with 27% of pharmacists and 23% of students. However, when asked about the therapy that could be associated with the development of suicidal ideations, only 6% of students, 13% of pharmacists and 20% of educators answered correctly. This could be explained by the fact that little is known about smoking cessation aids beyond what is provided on the pack by the manufacturers of NRT. Overall, the mean knowledge scores for the various smoking-related themes matched the total scores obtained by the 3 groups for both the general and clinical-based knowledge sections; thus, this trend indicates a reasonable extraction process and construct validity.

The fact that pharmacists’ level of awareness is not greater than that of students is a matter of concern. In a previous simulated patient study conducted in Australia, authors concluded that evidence-based smoking cessation advice in pharmacies was sub-optimal (Chiang and Chapman 2006).

Factor analysis was used to establish construct validity of the questionnaire. Although the reliability estimate was low as characterised by the obtained Cronbach’s alpha coefficient, this may be accounted for by the fact that smoking and smoking cessation are viewed as general social and public health topics, and therefore knowledge levels in such areas are expected to be diverse. Total scores for the SCIPV2 (12 retained T/F items of knowledge section), were significantly lower than the scores for the 24-item original version, thus confirming that the factor analysis exercise allowed the deletion of superfluous items, leaving a more streamlined version. Score patterns obtained by the respective groups (students = pharmacists < experts) were similar before and after factor analysis, i.e., on both versions of the SCIP, which indicates consistency.

A possible limitation of this study could be the small sample size of smoking cessation educators (n = 20) as compared with pharmacists (n = 51) and students (n = 250). Furthermore, the methods of sample recruitment used for groups 2 and 3 may have led to selection bias, as people with strong beliefs or substantial knowledge, or those interested in continuing education may be more willing to respond to the questionnaire than others.

Future directions should explore the development, implementation and evaluation of pharmacist-directed smoking cessation educational programs that focus mainly on ‘deficit’ areas. Such programs should, therefore, incorporate diverse topics, including pharmacokinetics of nicotine and pharmacology of dependence essential for dictating pharmacotherapy (Benowitz 2008), different methods for assessing dependence, such as carbon monoxide (CO) monitoring and utilising the Fagerström test, psychosocial behavioural interventions and a thorough exposure to various pharmacotherapeutic aspects in light of current clinical guidelines, as highlighted in Table 8. Tobacco cessation education should all also be introduced into the academic curricula of pharmacy and medical students.

Overall results of this study indicate the presence of major clinical deficits about current evidence related to smoking cessation interventions at the pharmacy level. This study not only developed and validated a questionnaire to measure and assess smoking cessation-related knowledge, but also provides guidance on key areas for future smoking cessation education/training for pharmacy professionals. Given the evidence for pharmacist-delivered smoking cessation interventions and consumer acceptance of the pharmacy as a venue for smoking cessation services (Patwardhan and Chewning 2010), the time is now pertinent to disseminate research on the effect of structured smoking cessation educational training programs on pharmacy students’ and pharmacists’ awareness and confidence in the practice of smoking cessation services.