Barriers to smoking interventions in community healthcare settings: a scoping review

Smoking is one of the major causes of preventable death and is considered the greatest threat to global public health. While the prevalence of smoking has decreased, population growth has led to an increase in the absolute number of smokers. There are many proven smoking cessation interventions available to support smokers in their quit attempts. Most people who smoke, however, underutilize the treatments available to them. This scoping review aimed to identify the current barriers experienced by all stakeholders (smokers, service providers and policymakers) to existing evidence-based smoking cessation interventions in community healthcare settings. Five electronic databases (CINAHL, Ovid MEDLINE, PsycINFO, Scopus and Web of Science) were searched for relevant literature. A total of 40 eligible articles from different countries published between 2015 and 2022 were included in the review and content analysis carried out to identify the key barriers to smoking cessation interventions. Seven key themes were found to be common to all stakeholders: (i) literacy, (ii) competing demands and priorities, (iii) time, (iv) access to product, (v) access to service, (vi) workforce and (vii) motivation/readiness. These themes were mapped to the Capability, Opportunity, Motivation-Behaviour (COM-B) model. This study presents the effect the barriers within these themes have on current smoking cessation services and highlights priorities for future interventions.

Community pharmacists' counseling regarding nicotine replacement therapy: A secret shopper study

BACKGROUND

Nicotine replacement therapy (NRT) is a safe and effective non-prescription tobacco cessation treatment. While most community-based pharmacists periodically provide patient education regarding NRT, there is a gap in real-world evidence assessing the counseling provided.

OBJECTIVES

To assess community pharmacist counseling regarding NRT in a real-world setting.

METHODS

A cross-sectional secret shopper audit was conducted to collect data regarding NRT counseling from 120 community pharmacist encounters. Seventeen trained college of pharmacy students presented to community pharmacies using a standardized script asking about 1 of 3 common NRT products (patch, gum, and lozenge). Pharmacies were randomly selected from a list of all community pharmacies open to the public in Bexar County, Texas. A standardized assessment form was used to document product availability, counseling length, whether or not the 7 counseling points and 6 assessment questions that could help guide the pharmacist's counseling regarding NRT products were provided without prompting, and potential inaccuracy of any recommendations and counseling points. Descriptive statistics were calculated, and analysis of variance and Fisher's exact test were used to test for variation across site type and time of day.

RESULTS

NRT was available for purchase without speaking to pharmacy staff in 99 of 120 (83%) pharmacies. The mean length of counseling was 136 (standard deviation = 91) seconds. The most common points discussed were recommended strength (72%), tapering schedule (58%), and assessment of the daily number of cigarettes smoked (56%). Forty-one (34%) pharmacists provided one or more potentially inaccurate counseling points, the most common being inaccurate tapering schedule (provided during 31 (26%) encounters). Only 15% of pharmacists referred auditors for additional help or recommended a follow-up.

CONCLUSION

NRT was commonly accessible in community pharmacies outside of the pharmacy area. Opportunities for pharmacists to provide more complete and accurate information to better assist patients with safe and effective smoking cessation were identified.

Bridging the Gap in Tobacco Cessation Services: Utilizing Community Pharmacists to Facilitate Transitions of Care in the USA

Interprofessional strategies for promoting tobacco cessation lead to enhanced quit rates among patients; however, current approaches might not effectively support patients with their quit attempts after they are discharged from the hospital. This paper explores opportunities for interprofessional collaboration between health system-based providers and community pharmacists, as one proposed approach to bridging tobacco cessation services during transitions of care. Suggested strategies include (1) increasing other healthcare professionals' awareness of legislative advances that permit pharmacists to prescribe cessation medications in some states, and (2) encouraging bi-directional communication between health system-based and community-based providers, especially via integrated electronic health records. Community pharmacists can offer a convenient solution to obtain the post-discharge medication and counseling support that patients need to increase their chances of quitting for good. Additional steps are discussed to improve broadscale capacity of this service being provided in community pharmacies.

Factors influencing implementation of personalized prevention plans among annual wellness visit patients using the theory of planned behavior: A quantitative study

BACKGROUND

The Affordable Care Act provides Medicare Part B beneficiaries access to cost-free Annual Wellness Visits (AWVs). Patients receive health behavior recommendations from a Personalized Prevention Plan (PPP) during AWV encounters.

AIMS

To identify factors clinical pharmacists can use to influence adoption of PPPs in primary care practices.

METHOD

Utilizing a cross-sectional design, 77 Medicare patients (mean age 74.05 ± 8.04 years) presenting for subsequent AWV completed a theory of planned behavior (TPB) based questionnaire at two primary care practices.

RESULTS

66.2% reported they were in the process of implementing PPPs and 51.9% reported implementing recommendations in the previous 12 months. TPB constructs accounted for 35.8% (p < .001) of the variation in intention, with subjective norm (SN) (β = 0.359, p = 0.004) as the strongest determinant, followed by attitude (β = 0.195, p = 0.093), and perceived behavioral control (PBC) (β = 0.103, p = 0.384). Intention accounted for 27.1% of the variance for implementing PPPs and was not a significant determinant (β = 0.047, p = 0.917). Addition of past behavior with TPB constructs significantly improved the predictability of the TPB model, accounted for 55% of the variation in intention (p < .001), and demonstrated a significant positive influence (β = 0.636, p < 0.001) on future PPP implementations.

DISCUSSION

This study demonstrates utility of the TPB in predicting implementation of PPPs.

CONCLUSIONS

Clinical pharmacists positioned as providers of AWVs can strengthen intention to adopt PPPs by integrating referents into AWV processes, and evaluating past behavior trends to improve future PPP implementation.

Evaluation of an intensive education program on the treatment of tobacco-use disorder for pharmacists: a study protocol for a randomized controlled trial

BACKGROUND

Tobacco use is presently responsible for the death of over seven million people across the world. In Qatar, it is one of the main causes of premature deaths and preventable diseases. To reduce tobacco use, Qatar has ratified the World Health Organization (WHO)'s Framework Convention on Tobacco Control (FCTC) and has implemented many tobacco-control initiatives. In spite of these measures, tobacco use is still considered a public health threat in Qatar. Pharmacists practicing in retail/community pharmacy settings are often the first port of call for individuals requiring general health advice. Evidence has proven that they have a pivotal role in health promotion and disease prevention including tobacco cessation. However, pharmacists in Qatar are not actively involved in tobacco control and many have not received any education or training about smoking cessation counseling in the past. In an effort to build the capacity of pharmacists towards tobacco control in Qatar, the aim of the proposed study is to design, implement, and evaluate an intensive education program on tobacco dependence treatment for pharmacists in Qatar.

METHODS/DESIGN

The study will be a prospective randomized controlled trial comparing an intensive tobacco-related education program versus non-tobacco-related training on pharmacists' tobacco-use-related knowledge, attitudes, self-efficacy, and skills. Community pharmacists practicing in Qatar will be eligible for participation in the study. A random sample of pharmacists will be selected for participation. Consenting participants will be randomly allocated to intervention or control groups. Participants in the intervention group will receive an intensive education program delivered by a multi-disciplinary group of educators, researchers, and clinicians with expertise in tobacco cessation. A short didactic session on a non-tobacco-related topic will be delivered to pharmacists in the control group. The study has two primary outcomes: post-intervention tobacco-related knowledge and post-intervention skills for tobacco cessation assessed using a multiple-choice-based evaluation instrument and an Objective Structured Clinical Examination (OSCE), respectively. The secondary study outcomes are post-intervention attitudes towards tobacco cessation and self-efficacy in tobacco-cessation interventions assessed using a survey instrument. An additional secondary study outcome is the post-intervention performance difference in relation to tobacco-cessation skills in the practice setting assessed using the simulated client approach.

DISCUSSION

If demonstrated to be effective, this education program will be considered as a model that Qatar and the Middle East region can apply to overcome the burden of tobacco-use disorder.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03518476 . Registered on 8 May 2018. Version 1/22 June 2018.

Smoking cessation at the pharmacy: feasibility and benefits based on a French observational study with six-month follow-up

Background

In comparison to other European countries, the number of smokers remains high in France. Approximately five million smokers wish to quit within the year and need support that is local, easily accessible, and efficient. As public health actors, pharmacists could provide this service. The Sevrage Tabagique à l’Officine: Smoking Cessation Program at the Pharmacy (STOP) study was carried out to explore the feasibility of a smoking cessation program provided at pharmacies.

Materials and methods

Pharmacists participating in the study were trained to provide a smoking cessation program to smokers recruited at the pharmacy, which included five pharmaceutical interviews in six months, along with counseling and support, in addition to nicotine replacement therapy. This observational, longitudinal, prospective study assessed the feasibility of the program by measuring the percentage of participants remaining at the six-month visit, the proportion of invited pharmacies that actually participated in the program, and the benefits to the participants.

Results

Ninety pharmacies were invited to participate, 79 (88%) pharmacies entered the study, and 49 (54%) included study participants and treated 227 subjects with a mean age of 45.4 years. At six months, 23.3% of participants attended their follow-up visit, among which 75% had been abstinent since their last visit and more than half for 90 days. From the second follow-up visit, their Short Form 12 physical and mental health composite scores were improved in comparison with baseline. Participants and pharmacists all reported being highly satisfied with the program; however, the attrition rate was substantial, possibly due to some study limitations.

Conclusion

The provision of support for smoking cessation by pharmacies is feasible despite some barriers such as lack of awareness and difficulty to change habits for the smokers or lack of time and training for the pharmacists. The conditions necessary for this program to be implemented on a large scale include training of pharmacists, access to a private space in the pharmacy, remuneration for the pharmaceutical interviews, collaboration with other health care professionals, and an effective communications program regarding the service, both inside and outside of pharmacies. The relatively low number of participants at the end of the study could be improved by increasing awareness of the program, involving health authorities, and enlarging the number of pharmacies engaged in the program.

Pharmacist prescriptive authority for smoking cessation medications in the United States

OBJECTIVES

To characterize the status of state laws regarding the expansion of pharmacists' prescriptive authority for smoking cessation medications and to summarize frequently asked questions and answers that arose during the associated legislative debates.

DATA SOURCES

Legislative language was reviewed and summarized for all states with expanded authority, and literature supporting the pharmacist's capacity for an expanded role in smoking cessation is described.

SUMMARY

The core elements of autonomous tobacco cessation prescribing models for pharmacists vary across states. Of 7 states that currently have fully or partially delineated protocols, 4 states (Colorado, Idaho, Indiana, New Mexico) include all medications approved by the U.S. Food and Drug Administration for smoking cessation, and 3 (Arizona, California, Maine) include nicotine replacement therapy products only. The state protocol in Oregon is under development. Most states specify minimum cessation education requirements and define specific elements (e.g., patient screening, cessation intervention components, and documentation requirements) for the autonomous prescribing models.

CONCLUSION

Through expanded authority and national efforts to advance the tobacco cessation knowledge and skills of pharmacy students and licensed pharmacists, the profession's role in tobacco cessation has evolved substantially in recent years. Eight states have created, or are in the process of creating, pathways for autonomous pharmacist prescriptive authority. States aiming to advance tobacco control strategies to help patients quit smoking might consider approaches like those undertaken in 8 states.

Provision of Lifestyle Counseling and the Prescribing of Pharmacotherapy for Hyperlipidemia Among US Ambulatory Patients: A National Assessment of Office-Based Physician Visits

BACKGROUND

An estimated 27.8% of the United States (US) population aged ≥20 years has hyperlipidemia, defined as total serum cholesterol of ≥240 mg/dL. A previous study of US physician office visits for hyperlipidemia in 2005 found both suboptimal compliance and racial/ethnic disparities in screening and treatment.

OBJECTIVE

The aim was to estimate current rates of laboratory testing, lifestyle education, and pharmacotherapy for hyperlipidemia.

METHODS

Data were derived from the US National Ambulatory Medical Care Survey (NAMCS), a nationally representative study of office-based physician visits, for 2013-2014. Patients aged ≥20 years with a primary or secondary diagnosis of hyperlipidemia were sampled. Study outcomes included receipt or ordering of total cholesterol testing, diet/nutrition counseling, exercise counseling, and pharmacotherapy prescription including statins, ezetimibe, omega-3 fatty acids, niacin, or combination therapies.

RESULTS

Compared with previously reported results for 2005, rates of pharmacotherapy have remained static (52.2 vs. 54.6% for 2005 and 2013-2014, respectively), while rates of lifestyle education have markedly declined for diet/nutrition (from 39.7 to 22.4%) and exercise (from 32.1 to 16.0%). Lifestyle education did not vary appreciably by race/ethnicity in 2013-2014. However, rates of lipid testing were much higher for whites (41.6%) than for blacks (29.9%) or Hispanics (34.2%). Tobacco education was ordered/provided in only 4.0% of office visits.

CONCLUSION

Compliance with guidelines for the screening and treatment of hyperlipidemia remains suboptimal, and rates of lifestyle education have declined since 2005. There exists an urgent need for enhanced levels of provider intervention to reduce the morbidity and mortality associated with hyperlipidemia.

Influenza vaccination for patients with chronic obstructive pulmonary disease: Implications for pharmacists

BACKGROUND

Influenza virus is responsible for substantial morbidity and mortality. Specific populations are at higher risk for exacerbations from influenza virus, such as patients with chronic obstructive pulmonary disease (COPD). Influenza vaccination coverage among COPD patients is low. Pharmacists can improve influenza vaccination among COPD patients by recognizing factors that influence vaccination and addressing these factors.

OBJECTIVES

To (1) determine the recent influenza vaccination coverage among patients with COPD, (2) identify factors that were associated with immunization, and (3) interpret the results based upon Andersen's healthcare utilization model.

METHODS

The 2012 Behavioral Risk Factor Surveillance System (BRFSS) was accessed for the study. Among respondents age ≥ 25 years with COPD, presence of influenza vaccination was captured along with demographic, provider, insurance, and clinical variables. Weighted multiple logistic regression was used to identify significant factors associated with receiving influenza vaccination. The findings were interpreted according to predisposing, enabling, and need factors relevant to Anderson's model.

RESULTS

Influenza vaccination rate was 53% among COPD patients. Older age was a significant predisposing factor that increased vaccination (adjusted odds ratio [AOR] = 2.4; 95% CI:2.02-2.88). Predisposing factors that decreased vaccination were being Black or Hispanic (AOR = 0.72, 95% CI:0.59-0.86, and AOR = 0.78, 95% CI:0.61-0.98 respectively), and being a non smoker (former and never smokers had higher vaccination rates [AOR = 1.53, 95% CI = 1.3-1.72, and AOR = 1.36, 95% CI = 1.19-1.55 respectively]). Significant enabling factors included having health insurance (AOR = 1.68, 95% CI = 1.37-2.06), a primary physician (AOR = 1.63, 95% CI = 1.30-2.02), and the ability to see a physician regardless of cost (AOR = 1.33, 95% CI = 1.17-1.52). Significant need factors included the presence of comorbidities such as asthma (AOR = 1.18, 95% CI = 1.1-1.3), or diabetes (AOR = 1.36, 95% CI = 1.20-1.53), activity limitation (AOR = 1.16, 95% CI = 1.04-1.29), and having the last medical checkup within less than one year (AOR = 1.49, 95% CI = 1.31-1.70).

CONCLUSION

Influenza vaccination coverage among COPD patients is far below the Healthy People 2020 national goal. Several predisposing, enabling, and need factors influenced vaccination rate among COPD patients. Pharmacists can improve vaccination rate among COPD patients by recognizing these influencing factors and by acting as advocates, counselors, and administrators of influenza vaccine. Ultimately, with the collaborative efforts of other healthcare providers and public health initiatives, pharmacists can help achieve Healthy People 2020 objectives related to influenza vaccination.