Clinical pharmacist's role in implementing a smoking cessation intervention in a Swiss regional hospital: an exploratory study

Hospitalised Smokers' and Staff Perspectives of Inpatient Smoking Cessation Interventions and Impact on Smokers' Quality of Life: An Integrative Review of the Qualitative Literature

Aim

To identify, integrate, and appraise the evidence on hospitalised smokers' and staff perspectives of inpatient smoking cessation interventions and the impact on smokers' quality of life.

Design

The integrative review method was used to present hospitalised smokers' and staff perspectives of inpatient smoking cessation interventions. Search Method. This integrative review consisted of a comprehensive search on smoking cessation interventions that take place during an inpatient admission to hospital for adults (> age 18 years) of the following online databases: Ovid Medline, Joanna Briggs Institute, APA PsycInfo, CINAHL, Cochrane, Google Scholar, PEDro, and Scopus. The search strategy was inclusive of peer-reviewed studies limited to the English language or translated to English. A search of grey literature and manual searching of reference lists was also conducted to identify further studies not identified in the online database search. All studies that produced any qualitative data (i.e., qualitative, mixed methods, and surveys) on inpatient-initiated smoking cessation programs were included. Outcomes of interest are included but were not limited to education, counselling, and the use of pharmacotherapy. Studies undertaken in the psychiatric, adolescent, and paediatric settings were excluded.

Results

The key findings from this integrative review included positive evaluations from both patients and staff involved in inpatient smoking cessation interventions, reporting that hospitalisation was an appropriate opportunity to address smoking cessation. A number of facilitators and barriers to inpatient smoking cessation interventions included creating a supportive patient-centred environment and consideration of the cost of nicotine replacement therapy and time to deliver inpatient smoking cessation interventions. Recommendations/preferences for future inpatient smoking cessation interventions included the use of a program champion and ongoing education to demonstrate the effectiveness of the intervention, and despite the cost of nicotine replacement therapy being identified as a potential barrier, it was identified as a preference for most patients. Although quality of life was only evaluated in two studies, statistically significant improvements were identified in both.

Conclusion

This qualitative integrative review provides further insight into both clinician and patient participants' perspectives on inpatient smoking cessation interventions. Overall, they are seen to produce positive benefits, and staff training appears to be an effective means for service delivery. However, insufficient time and lack of resources or expertise appear to be consistent barriers to the delivery of these services, so they should be considered when planning the implementation of an inpatient smoking cessation intervention.

Abstinence Rate, Adverse Events and Withdrawal Symptoms after Varenicline Use and Predicting Factors of Smoking Abstinence: A Multicentre Single-State Study in Malaysia

(1) Background: Varenicline is a widely prescribed agent in smoking cessation. However, the abstinence rate, the incidence of adverse events and withdrawal symptoms, have not been widely studied locally. This study aimed to determine the prevalence of smoking abstinence, adverse events and withdrawal symptoms associated with varenicline use, as well as possible factors contributing to successful smoking abstinence. (2) Methods: This was a retrospective, cohort study conducted in twenty-two government-operated smoking cessation clinics across the state of Perak, Malaysia. The medical records of adult smokers (age ≥ 18 years old) who were prescribed with varenicline between January 2017 and June 2018 were traced. The medical records of smokers who used pharmacotherapy other than varenicline, those who received less than four weeks of varenicline treatment, and with missing data were excluded. (3) Results: Sixty-eight out of 114 subjects (59.6%) successfully achieved smoking abstinence. Probable varenicline-induced chest pain was documented in three subjects. Altered behaviour (n = 2) and auditory hallucinations (n = 1) were also reported. Varenicline treatment duration is a significant predictive factor for successful smoking abstinence (odds ratio (OR) = 2.45; 95% confidence interval (CI) 1.74−3.45; p < 0.001), followed by age (OR = 1.25; 95% CI 1.005−1.564; p = 0.045), the presence of adverse events (OR = 0.096; 95% CI 0.014−0.644; p = 0.016) and withdrawal symptoms (OR = 0.032; 95% CI 0.016−0.835; p = 0.032). (4) Conclusion: Almost two-thirds of the subjects achieved smoking abstinence with varenicline. The duration of the treatment, as well as the patients’ ages had a significant influence on successful smoking abstinence. Rare cases of cardiovascular and neuropsychiatric-related adverse events were reported, warranting continuous surveillance and adverse drug reaction reporting.

Development of a Pharmacist-Led Opt-Out Cessation Treatment Protocol for Combustible Tobacco Smoking Within Inpatient Settings

Background: Although people who smoke cigarettes are overrepresented among hospital inpatients, few are connected with smoking cessation treatment during their hospitalization. Training, accountability for medication use, and monitoring of all patients position pharmacists well to deliver cessation interventions to all hospitalized patients who smoke. Methods: A large Midwestern University hospital implemented a pharmacist-led smoking cessation intervention. A delegation protocol for hospital pharmacy inpatients who smoked cigarettes gave hospital pharmacists the authority to order nicotine replacement therapy (NRT) during hospitalization and upon discharge, and for referral to the Wisconsin Tobacco Quit Line (WTQL) at discharge. Eligible patients received the smoking cessation intervention unless they actively refused (ie, "opt-out"). The program was pilot tested in phases, with pharmacist feedback between phases, and then implemented hospital-wide. Interviews, surveys, and informal mechanisms identified ways to improve implementation and workflows. Results: Feedback from pharmacists led to changes that improved workflow, training and patient education materials, and enhanced adoption and reach. Refining implementation strategies across pilot phases increased the percentage of eligible smokers offered pharmacist-delivered cessation support from 37% to 76%, prescribed NRT from 2% to 44%, and referred to the WTQL from 3% to 32%. Conclusion: Hospitalizations provide an ideal opportunity for patients to make a tobacco quit attempt, and pharmacists can capitalize on this opportunity by integrating smoking cessation treatment into existing inpatient medication reconciliation workflows. Pharmacist-led implementation strategies developed in this study may be applicable in other inpatient settings.

Models for pharmacist-delivered tobacco cessation services: a systematic review

OBJECTIVES

To summarize delivery models of pharmacist-led tobacco cessation services.

DATA SOURCES

Studies published from July 1, 2003, to April 1, 2019, describing pharmacist-led tobacco cessation services in the United States were identified via PubMed/MEDLINE and EBSCO searches.

STUDY SELECTION

Studies were considered for inclusion if they met the following criteria: population, patients 18 years of age and older using tobacco products; intervention, pharmacist-led tobacco cessation services; comparator, not required; and outcome, tobacco cessation. We used a web-based tool, Rayyan QCRI, to assist with study selection.

DATA EXTRACTION

We used a data extraction tool to collect article reference, study design, primary and secondary objectives, brief description of intervention, pharmacologic interventions, service model, business model, method to measure tobacco cessation, tobacco cessation rates, and other comments.

RESULTS

A total of 16 articles were incorporated into this review. Most studies included were observational (87.5%). The pharmacy settings included ambulatory care (68.8%), community (25%), and managed care (6.3%). Service models described most frequently followed an appointment-based, individual, face-to-face session between the patient and pharmacist. Business models included grant funding (12.5%), fee-for-service (6.3%), value-based (6.3%), and free services (6.3%), but most studies (56.3%) did not address reimbursement. Cessation rates ranged from 3.98% to 77.14% and were predominantly measured through self-report (62.5%). The timing of follow-up varied from 1 to 6 months after program completion, but in some articles was not reported (37.5%).

CONCLUSION

Pharmacists currently manage tobacco cessation services via an assortment of methods and can successfully assist patients in achieving abstinence. Gaps in the literature necessitate further guidance on consistent outcomes reporting, impact of service model on tobacco cessation, and economic data of business models. The profession will benefit from such information to further expand the pharmacists' role within tobacco cessation services.

Smoking cessation and the general practice pharmacist

Introduction

Roles for pharmacists in general practice are developing in Australia. It is known that pharmacists can provide effective smoking cessation services in other settings but evidence in general practice is lacking.

Aim

To determine whether a pharmacist can provide effective smoking cessation services within general practice.

Method

Data from smoking cessation consultations were obtained for 66 consecutive patients seen by one practice pharmacist. The pharmacist tailored interventions to the individual. Medication was offered in collaboration with community pharmacists and general practitioners. Quit coaching, based on motivational interviewing, was conducted. Smoking status was ascertained at least 6 months after the intended quit date and verified by a carbon monoxide breath test where possible.

Results

The patients’ median age was 43 years (range 19–74 years); 42 were females (64%). At baseline, the median (i) number of pack years smoked was 20 (range: 1–75); (ii) Fagerstrom Test of dependence score was 6 (1–10); and (iii) number of previous quit attempts was 3 (0–10). Follow-up after at least 6 months determined a self-reported point prevalence abstinence rate of 30% (20/66). Of all patients who reported to be abstinent, 65% (13/20) were tested for carbon monoxide breath levels and were all below 7 ppm. The biochemically verified smoking abstinence rate was therefore 20% overall (13/66). Successful quit attempts were associated with varenicline recommendation (69% v 25%), increased median number of practice pharmacist consultations (4 v 2 per patient) and mental health diagnosis (85% v 51%).

Conclusion

Our observed abstinence rate was comparable or better than those obtained by practice nurses, community pharmacists and outpatient pharmacists, indicating the general practice pharmacist provided an effective smoking cessation intervention. A larger randomised trial is warranted.

Implementation of a Pharmacist-Led Inpatient Tobacco Cessation Intervention in a Rehabilitation Hospital: A Before-and-After Pilot Study

BACKGROUND

Inpatient rehabilitation presents a unique opportunity for smoking interventions, given the typical lengths of stay, the relevance of smoking to the admission diagnosis of many patients, and the occurrence of nicotine withdrawal during the hospital stay.

OBJECTIVE

To evaluate the feasibility of implementing a pharmacist-led version of the Ottawa Model for Smoking Cessation (OMSC) program at a rehabilitation hospital, using the indicators of reach, effectiveness, adoption, and implementation.

METHODS

A before-and-after pilot study was conducted. Smoking cessation data were collected from 2 cohorts of eligible smokers identified during 4-month periods before (control) and after (intervention) implementation of the OMSC program. Control participants received usual care (i.e., no cessation intervention). Intervention participants received initial in-hospital smoking cessation support (counselling and nicotine replacement therapy), inpatient follow-up during the hospital stay, and 3 months of postdischarge follow-up calls, with all aspects led by hospital pharmacists.

RESULTS

Among all patients admitted to participating inpatient rehabilitation units during the 2 study periods, smoking prevalence was 7.8% (127/1626). After exclusions, deaths, and withdrawals, 111 patients were retained for analysis: 55 in the control group and 56 in the intervention group. The overall mean age of participants was 64.9 (standard deviation [SD] 14.3) years, with a mean smoking history of 35.0 (SD 24.8) pack-years. There were no significant differences between groups in terms of baseline characteristics. Self-reported abstinence rates (determined 3 months after discharge) were higher after compared with before implementation of the OMSC program: for continuous abstinence, 16/56 (28.6%) versus 9/55 (16.4%), χ² = 4.462, p = 0.035; for 7-day point prevalence abstinence, 21/56 (37.5%) versus 10/55 (18.2%), χ² = 6.807, p = 0.009.

CONCLUSIONS

Implementation of the OMSC program at a large rehabilitation hospital was feasible and led to an increase in 3-month smoking abstinence. This study provides preliminary evidence to support inclusion of smoking interventions as part of inpatient rehabilitation care.

Motivational Interviewing to Increase Postdischarge Antibiotic Adherence in Older Adults with Pneumonia

OBJECTIVE

To evaluate the impact of a pharmacist-led, motivational interviewing on antibiotic adherence following discharge in older adults with pneumonia.

SETTING

Inpatient medical wards in a large tertiary academic medical center.

PRACTICE DESCRIPTION

Older adults diagnosed with pneumonia were enrolled from December 1, 2013, to August 1, 2014, at Yale-New Haven Hospital.

PRACTICE INNOVATION

Motivational interviewing-a patient-centered method of communication-has gained recognition as a tool that can aid pharmacists in addressing negative health behaviors (e.g., medication adherence, health screenings, substance abuse during counseling sessions). However, the potential role of motivational interviewing in older adults to improve medication adherence during transitions of care is not clear. In this study, in addition to standard discharge care, older adults hospitalized with pneumonia who were randomized to the intervention group received enhanced care: pharmacist-led motivational interviewing.

MAIN OUTCOME MEASUREMENTS

Evaluation of adherence to prescribed antibiotic regimens and patient satisfaction with the motivational interviewing, enhanced-care session.

RESULTS

Ultimately, 87% of patients in the intervention group (n = 16) compared with 64% of patients in the control group (n = 14) were adherent to their antibiotic regimens. Patient satisfaction with the motivational interviewing intervention was high.

CONCLUSION

Pharmacist-led motivational interviewing sessions have the potential to positively influence antibiotic adherence rates and patient satisfaction.

Utilisation of Nicotine Replacement Therapy within a Hospital Pharmacist Initiated Smoking-Cessation Intervention – A Pragmatic Randomised Controlled Trial

Introduction:Hospital pharmacists currently play a limited role in the management of nicotine withdrawal and smoking-cessation. They have multiple tasks and limited time; a strong evidence base is required to determine importance of including smoking-cessation interventions into their routine practice.

Aims:The aims of this study were to evaluate the effectiveness of a hospital pharmacist initiated smoking-cessation intervention (SCI) in increasing the utilisation of Nicotine Replacement Therapy (NRT) in hospitalised smokers, and in increasing quit rates post-discharge.

Methods:This study was conducted in a tertiary referral hospital using a pragmatic randomised control design. After screening, 100 inpatient smokers were enrolled and randomised by the research pharmacist (RP) to either the intervention or usual care arm (n= 50 for both arms). Smoking-cessation advice was available to all smokers during their hospital stay under the smoking management policy, which represented usual care. However, this approach is often unstructured and provided on an ad-hoc basis. Those in the intervention arm received brief SCI from the RP, who also facilitated NRT prescribing if required. Prescribing rates of NRT in the hospital and on discharge in both the groups were compared. Participants were contacted by phone three-months after enrolment to assess their seven-day point prevalence of abstinence (PPA) from smoking and use of NRT post-discharge.

Results:A significantly higher proportion of participants in the intervention arm used NRT in the hospital (82% vs. 24%,Χ2= 33.8,p< 0.001) and at discharge (68% vs. 12%,Χ2= 32.7,p< 0.0001) and significantly more participants who received SCI from the RP continued to use NRT after discharge (OR 3.1, CI 1.2 to 8.2). A similar number of participants in both the groups claimed seven-day PPA after three-months (18% usual-care vs. 15% intervention-arm, OR 0.8, CI 0.24 to 2.67).

Conclusions:Hospital pharmacist led brief SCI can enhance the utilisation of NRT in hospital and after discharge; there was no clear effect on cessation rates at three months. There is a need to explore feasible options for a coordinated, multidisciplinary approach to smoking-cessation in hospital and across the continuum, which may have a greater impact on long term smoking-cessation rates.

Tobacco related knowledge and support for smoke-free policies among community pharmacists in Lagos state, Nigeria

Background:

There are no safe levels of exposure to second hand smoke and smoke-free policies are effective in reducing the burden of tobacco-related diseases and death. Pharmacists, as a unique group of health professionals, might be able to play a role in the promotion of smoke-free policies.

Objective:

To determine the tobacco-related knowledge of community pharmacists and assess their support for smoke-free policies in Lagos state, Nigeria.

Methods:

A cross-sectional descriptive study design using both quantitative and qualitative methods was employed. Two hundred and twelve randomly selected community pharmacists were surveyed using a pre-tested self-administered questionnaire. In addition, one focus group discussion was conducted with ten members of the Lagos state branch of the Association of Community Pharmacists of Nigeria.

Results:

The quantitative survey revealed that the majority (72.1%) of the respondents were aged between 20 and 40 years, predominantly male (60.8%), Yoruba (50.2%) or Igbo (40.3%) ethnicity and had been practicing pharmacy for ten years or less (72.2%). A majority (90.1%) of respondents were aware that tobacco is harmful to health. Slightly less (75.8%) were aware that second hand smoke is harmful to health. Among the listed diseases, pharmacists responded that lung (84.4%) and esophageal (68.9%) cancers were the most common diseases associated with tobacco use. Less than half of those surveyed associated tobacco use with heart disease (46.9%), chronic obstructive pulmonary disease (27.8%), bladder cancer (47.2%), peripheral vascular disease (35.8%) and sudden death (31.1%). Only 51.9% had heard of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC). A little over half of the respondents (53.8%) were aware of any law in Nigeria controlling tobacco use. The majority of respondents supported a ban on smoking in homes (83.5%), in public places (79.2%), and in restaurants, nightclubs and bars (73.6%). For every additional client attended to daily, knowledge scores increased by 0.022 points. Current smokers were 1.3 times less likely to support smoke-free policies compared with non-smokers. The findings emanating from the focus group discussion reinforced the fact that the pharmacists were in support of smoke-free policies particularly in homes and public places. It also demonstrated that most of them were aware of the health risks associated with tobacco use and second hand smoke however some misconceptions seemed to exist.

Conclusion:

The pharmacists surveyed expressed support of smoke-free policies and most of them were aware of the health risks associated with tobacco use. However, awareness of WHO FCTC and country-level tobacco legislation was low. Current smokers were less likely to support smoke-free policies. Community pharmacists should therefore be considered worth engaging for the promotion of smoke-free policies. Efforts should also be made to educate pharmacists about country level smoke-free laws.