Independents, Community Pharmacies Can Get Involved in Tobacco Cessation Programs

In the second part of an interview with Pharmacy Times, Elisa K. Tong, MD, MA, discussed research on pharmacies’ roles in tobacco cessation programs. Tong emphasized that having the authority to prescribe nicotine replacement therapies does not mean that pharmacists are getting involved in these programs, so ongoing research is investigating how to create sustainable models with greater pharmacist involvement.

Q: What sorts of pharmacy-led nicotine replacement therapy (NRT) programs have you seen, and how can these programs be implemented and integrated into a pharmacy?

Elisa K. Tong, MD, MA: So, this is what our research study is trying to do. Just because you have the authority to do it doesn't mean that your pharmacy is doing it, so what we're working with are the independent pharmacies. I had to learn this, so there's maybe your work, but community pharmacies—and my dad was a pharmacist, he was a chain pharmacist in the 50’s, back when Thrifty existed before Rite Aid bought it. So, there's independent pharmacies, that sort of mom-and-pop shops, and I didn't realize until Robin introduced me to CPESN, and they were very much interested in this project and getting their members on board. And we train them, and then the study that we did shows that they were trained up, and then it became, how are we going to sustain this if we're not able to bill for it? And, you know, some of it is learning how to work with the health plans, but we were finding the health plans didn't have clear policy and procedures for this. One did, because their senior pharmacy director really advocated for this when the law came out, but others did not have that kind of champion. So, I think that's where our current study is now with that policy research center that I mentioned, where we're trying to show, how do you do policy implementation? And what are those barriers to getting pharmacists paid? And how do we make this a sustainable model, especially if you're an independent? And so we're finding new strategies and learning how to develop sort of a business model.

Q: What role do technicians play in these programs and services?

Tong: So, I think in that qualitative study, that was something that really came out for us. We know the pharmacist is super busy and can't do everything all at once and the technicians are the ones who are frontline and with the customer or clients coming in. And so, we found that the technicians play a really important role and wanted to be that frontline, so that was important to have that kind of partnership also. And that's one of the findings we found. And then now what we're exploring is how can the technician get paid for that service, too? So that's another thing that one of the health plans—Partnership HealthPlan, which I think is actually a nationwide health plan—they cover a lot of our rural northern counties. And they were very interested also to see there's a new state Medicaid benefit that we have for community health workers, which is available, I think, in 7 other states. And so, it's like, well, if they can play this health education role, how do we integrate that? So that's something we're exploring now in this new phase after we finished that study.

Q: Why could pharmacies be such crucial partners in tobacco cessation efforts?

Tong: Well, as a physician, I know that I heavily rely on my pharmacy team, whether I'm in the hospital or clinic, to help me navigate. Whether it's insurance coverage, or navigate dosage or alternative medication, our pharmacists are experts. And in this new age of all these new different tobacco industry products, it's important more than ever—how do we help our patients with titrating the nicotine cessation medications? And hopefully at some point our pharmacist will be able to have some furnishing authority over the 2 pills, too, because nobody quite knows. You know, all the dosing stuff is based on cigarettes, so when you have a patient come in and say, “Hey, I'm using this device with this many milligrams of nicotine,” it's sort of like with opiates, you kind of have to titrate to affect. Or hypertension, you know, it's like that. Not the first pill, but you’ve got to actually now do combinations, you have to do this. So, even though I am in a role of educating our health providers on the medications, our pharmacists are such an important part of that team that help us navigate all of that. And we're learning there's more formal structures now to do that, whether it's MTM, or, you know, we have some collaborative practice agreements. Even where I practice now with opiates, we need to do the sort of multi-team approach to deliver more effective care. So, to me, it's a no brainer. It's just how do we establish this and demonstrate that it makes sense for the pharmacists also, because they're asked to do so much. It's always competing priorities. But anyways, they're always thanking me for partnering, but I'm like, thank you for partnering because primary care and hospital care, it's so complex. We need more community support for sure.

Q: Is there anything you’d like to add?

Tong: You know, the way we tried to get this whole study started in the first place was trying to integrate medications with our tobacco quit line, because every state has a free quit line. And some states fund or offer nicotine patches more than others, but those are usually grant funded sources and take away from other, you know, maybe public health efforts. So, this is something that is a systems issue that we need to try to figure out how to have this implemented. And anyways, I'm just really glad to partner on this because I think this is a very innovative model that we haven't fully utilized, whereas we've thought about it for other chemicals, other addictions, opiates or whatnot. But nicotine addiction, we need to think of it not just as a behavior, but these products are so addictive now, and even the nicotine salts, you know, like the little Juul pod, you know, it was like 1 pack of cigarettes worth and maybe even more. So, we need to rethink not just 1 patch, it might be a lot of combination medication, too. So, we need to rely on our pharmacists to help guide us on this.