Smoking Cessation: A Collaborative Model

Many methods of smoking cessationare available today. Theresults are still less than optimal,however, especially when eachmethod is used alone. This problem hascreated the need for innovative, collaborativemethods in the area of tobaccocessation.

Two pharmacists working in collaborationwith a registered respiratory therapisttook a special interest in filling thisvoid. This team developed a modeldesign that incorporated spirometry andnicotine replacement therapy (NRT). Therationale behind this model was thatequipping patients with objective healthinformation provided by spirometryresults, traditional NRT, and professionalcounseling could further improve smoking-cessation rates.

Using spirometry is a new technique insmoking cessation backed by theNational Lung Health Education Program(NLHEP). Lung age and airway limitation,as well as any signs of restrictive orobstructive lung disease, can be estimatedvia a spirometer, a device used tomeasure lung health. When these resultsare shared with patients, higher cessationrates among smokers have beenreported.¹

In the recent intervention, the teamcreated a program to implement the newmodel with 450 participants recruitedfrom large clinics in southern Indiana.These clinics were typically located athospitals or community pharmacies.Recruitment was completed using flyersand advertisements in local newspapers.All participants signed informed consentforms and were instructed on the possiblerisks and adverse effects of nicotinepatches and spirometry. Participantscould attend the smoking-cessation clinicif they were at least 18 years of ageand smokers. Participants were excludedif they had any health contraindicationsor allergies to any component of thenicotine patches.

Self-evaluations

Each participant was required to complete3 self-evaluations that are commonplacein smoking-cessation clinics.These self-evaluations were as follows:

• Stages of Change (which addressesreadiness to quit, precontemplation,contemplation, preparation, action,maintenance)
• Fagerstrom Test for Nicotine Dependence(which estimates nicotinedependence—low, medium, high)
• Center for Epidemiologic StudiesDepression Scale (which evaluatesdepressive feelings and behaviorsover the previous week—major,mild-to-moderate, or no indication ofdepression)

The participants'readiness to changewas reviewed to customize their therapyand consultation. The Fagerstrom testwas used to calculate the correctstrength of NRT to be used. Depressionwas assessed in the study to seewhether the use of bupropion hydrochloride,an antidepressant used in smokingcessation, should be considered. Eachperson's past medical history, medicationhistory, current packs per day (PPD)of cigarettes smoked, and average packyears (APY) also were documented.

Spirometry

A respiratory therapist performed andinterpreted spirometry tests and explainedthe results to the participants individuallyfor ~15 minutes. All spirometrywas based on the American Associationof Respiratory Care guidelines and theNLHEP. The following information wasrecorded for each participant:

• Forced expiratory volume in 1 second(FEV₁)
• Forced expiratory volume in 6 seconds(FEV₆)
• FEV₁/FEV₆ ratio
• An estimate of lung age
• The calculated percentage of thepredicted values

Detection of restriction and obstructionof airflow was designated by aFEV₁/FEV₆ ratio of <0.7.

Pharmacist Counseling

Next, the participants were engaged ina 15-minute pharmacist counseling sessionconcerning smoking cessation andthe use of nicotine patches. At this session,a pharmacist also reviewed thespirometry results and stressed the lungage that was determined. The patientscould objectively see their results andthe effects of smoking cessation by theuse of a graph comparing the FEV¹ of aperson who never smoked, a personwho stopped smoking before 50 years ofage, and a person who stopped smokingat 65 years of age. The pharmacist alsoassessed each patient's medication historyfor any drug or disease interactions.If deemed medically safe, participantswere given a free 1-week supply of nicotine(Nicotrol) patches.

The pharmacist counseled each patientextensively about nicotine replacement,using materials provided with theproduct's packaging, including properuse, dosage, and signs of toxicity.Participants who received patches weretold where to purchase more patcheswhen the sample patches ran out. Theywere contacted via telephone 6 monthspost intervention to determine theirsmoking status.

Results

During the first project, the researchersfound the average lung age of participantsto be >20 years older than their actualaverage age. Twenty percent of thoseenrolled had an FEV₁/FEV₆ of <0.7. Theaverage PPD was 1.23, and the APY wasalmost 30 years. Only 268 of the 450 participantsfrom the first venture werereached for follow-up. Upon follow-upafter 6 months, 55% (n = 147) of participantswere classified as "smokers," 23%(n = 62) as "cut back," and 22% (n = 59) as"ex-smokers." The majority of participantswere found to be highly nicotine-dependent,based on their Fagerstrom score.

In June 2004, a second arm of the projectbegan, utilizing a 2-week supply ofnicotine patches. Patches for an additionalweek were supplied in the hopes ofimproving compliance rates. For the secondprogram, 363 participants wererecruited from southern Indiana clinicsduring the period from July 2004 throughJuly 2005.

Of these 363 people, 44 participantsresponded to follow-up via telephone 6months after the intervention. Their averagelung age was >20 years older thanthe participants'actual average age.Almost 18% of the participants had anFEV₁/FEV₆ ratio of <0.7. The average PPDwas found to be 1.22, and the APY was~66 years. The majority of participantswere found to be highly nicotine-dependentper Fagerstrom scores. After the 6-month follow-up, 45.5% (n = 20) of theparticipants were classified as "smokers,"11.3% (n = 5) as "cut back," and43.2% (n = 19) as "ex-smokers."

When designing this method, theresearchers aimed for a more practicalapproach to helping patients. Meetingwith health care professionals on only 1occasion seems to be more feasible inlight of the hectic lifestyle many peoplehave today.

The success of this 1-stop clinicapproach has been an encouragingexperience. Smoking-cessation ratesusing health care professional counselingalone are ~12%, whereas successrates with NRT alone after 6 months haveranged from 3.0% to 9.2%.² In the firstarm of this program, 22% of people hadquit smoking after 6 months. The outcomerates were even higher in the secondproject, 43%, even with limited participationin follow-up.

Conclusion

Smoking contributes to many medicalconditions and disease states. Outcomesfrom this model show the effectivenessof spirometry results as a motivationaltechnique and further evidence of its useas an important tool in the diagnosis ofabnormal airway function. The NLHEPadvocates the use of spirometry, with thegoal being the prevention of lung diseaseand promotion of lung health.³

The objective spirometry data also aregood for smokers who have made multipleattempts to refrain from using tobacco.These patients learn valuable informationconcerning their lung functionthat can be used for motivation eachtime they try to quit smoking.

The results of these programs shedlight on the effectiveness of using a pharmacist,NRT, a respiratory therapist, andspirometry within a smoking-cessationmodel. Patients exposed to this modelnow have valuable knowledge about nicotinereplacement and have been presentedwith objective knowledge of their lungfunction, which may serve to improveawareness of the damage that can resultfrom chronic obstructive pulmonary diseaseor other airway limitations.

Mr. Gold is a pharmacist at St. Mary'sMedical Center in Evansville, Ind. Healso is an affiliate associate professorof clinical pharmacy at PurdueUniversity.

For a list of references, send astamped, self-addressed envelope to:References Department, Attn. A. Stahl,Pharmacy Times, 241 Forsgate Drive,Jamesburg, NJ 08831; or send an e-mailrequest to: astahl@ascendmedia.com.

The project was made possiblewith the support of the IndianaTobacco Prevention and CessationBoard, NDD EasyOneSpirometers, and Pfizer Inc.