Revealing the complexity of quitting smoking: a qualitative grounded theory study of the natural history of quitting in Australian ex-smokers

Objective

To explore the quitting histories of Australian ex-smokers in order to develop an understanding of the varied contribution of smoking cessation assistance (either pharmacotherapy or professionally mediated behavioural support) to the process of quitting.

Design

Qualitative grounded theory study; in-depth interviews.

Participants

37 Australian adult ex-smokers (24–68 years; 15 men, 22 women) who quit in the past 6–24 months.

Results

Although participants’ individual quitting histories and their overall experiences of quitting were unique, when the 37 quitting histories were compared it was clear two experiences were common to almost all participants: almost no one quit at their first quit attempt and almost everyone started out quitting unassisted. Furthermore, distinct patterns existed in the timing and use of assistance, in particular the age at which assistance was first used, how some participants were resolutely uninterested in assistance, and how assistance might have contributed to the process of successful quitting even if not used on the final quit attempt. Importantly, three patterns in use of assistance were identified: (1) only ever tried to quit unassisted (n=13); (2) started unassisted, tried assistance but reverted back to unassisted (n=13); (3) started unassisted, tried assistance and quit with assistance (n=11). For most participants, insight into what quitting would require was only gained through prior quitting experiences with and without assistance. For a number of participants, interest in assistance was at its lowest when the participant was most ready to quit.

Conclusion

Quitting should be viewed as a process drawing on elements of assisted and unassisted quitting rather than a stand-alone event that can be labelled as strictly assisted or unassisted.

Nicotine Metabolite Ratio (NMR) Prospectively Predicts Smoking Relapse: Longitudinal Findings From ITC Surveys in Five Countries

INTRODUCTION

The ratio of trans 3'-hydroxycotinine (3HC) to cotinine (nicotine metabolite ratio [NMR]) is a biomarker of the rate of nicotine metabolism, with higher NMR indicating faster metabolism. Higher NMR has been found to be associated with higher daily cigarette consumption and less success stopping smoking in cessation trials. This study examines differences in NMR among population-based samples of smokers in the five countries and explores the relationship between NMR and smoking abstinence.

METHODS

Participants (N = 874) provided saliva samples during International Tobacco Control (ITC) surveys in the United States, United Kingdom, Mauritius, Mexico, and Thailand conducted in 2010/2011 with follow-up surveys in 2012/2013. When all samples were received, they were sent to a common laboratory for analysis using liquid chromatography and tandem mass spectroscopy.

RESULTS

There was significant variation in NMR across countries (F = 15.49, p < .001). Those who reported smoking at follow-up had a mean NMR of 0.32, compared to a mean NMR of 0.42 in participants who reported that they had stopped (F = 8.93; p = .003). Higher mean NMR values were also associated with longer quit duration (p = .007). There was no substantial difference in NMR between current smokers who made a failed quit attempt and those who made no attempt-both had significantly lower NMR compared to those who quit and remained abstinent. Smokers with a higher NMR were more likely to report that they stopped smoking compared to those with a lower NMR (odds ratio = 2.67; 95% confidence interval: 1.25 to 5.68).

CONCLUSIONS

These results suggest faster nicotine metabolizers may be less likely to relapse following a quit attempt. This finding differs from results of clinical trials testing stop smoking medications, where slower metabolizers have been found to be more likely to maintain abstinence from smoking.

IMPLICATIONS

Results of this study suggest faster nicotine metabolizers may be less likely to relapse following a quit attempt. This finding differs from results of clinical trials testing stop smoking medications, where slower metabolizers have been found to be more likely to maintain abstinence from smoking.

Provision of smoking cessation services in Australian community pharmacies: a simulated patient study

BACKGROUND

With the rising interest in expanding pharmacists' role in smoking cessation, it is pertinent that community pharmacists be equipped with up-to-date knowledge and competence to provide optimal therapeutic services that meet the demands of various presenting subsets of smokers.

OBJECTIVE

To investigate and evaluate responses to requests of quitting smoking from 'high risk' smokers seeking assistance and treatment within the pharmacy venue.

SETTING

Community pharmacies located within Sydney greater metropolitan area, New South Wales, Australia.

METHOD

A simulated patient methodology was utilised. Two scenarios were developed and enacted by two trained simulated patients in 100 randomly selected pharmacies. Scenario 1 involved a 28-year-old pregnant female who presents with a request for help in quitting smoking. Scenario 2 involved a 22-year-old female requesting a quit smoking product for her 55-year-old father who has cardiovascular problems. A standardised scoring key was designed to assess the performance of pharmacists during each encounter.

MAIN OUTCOME MEASURE

The primary outcome measure was the supply/non-supply of nicotine replacement products and the corresponding provision of counselling and advice to facilitate smoking cessation.

RESULTS

A product(s) was supplied in 42 % of the 100 encounters, while a product was adequately suggested pending doctor's referral in 45 %. In 13 % of the cases, a product was not supplied based on inappropriate notions of nicotine replacement therapy not being safe in the presented scenario. Pharmacists performed better in dispensing scores (counselling about product use) as compared to pre-dispensing scores (eliciting patient history). ANOVA followed by regression analysis indicated that the estimated age and gender of the pharmacist/staff were significant predictors affecting total scores.

CONCLUSION

Whilst pharmacists' counselling about smoking cessation aids seems satisfactory, further education is required to improve practice standards in terms of matching a patient's history and smoking status to an appropriate product.

A workshop on smoking cessation for pharmacy students

OBJECTIVE

To develop, implement, and evaluate a targeted educational intervention focusing on smoking cessation with final-year undergraduate pharmacy students.

DESIGN

A smoking-cessation educational workshop entitled Smoking Cessation in Pharmacy (SCIP) was designed on the principles of adult learning and implemented with a full cohort of final-year undergraduate pharmacy students at the University of Sydney. A previously validated questionnaire testing the knowledge and attitudes of respondents was administered both before and after implementation of the designed workshop to evaluate changes resulting from the intervention. Informal feedback was obtained from students.

ASSESSMENT

Pre-course mean total knowledge and attitude scores calculated were 65.8±9.1 and 86.4±12.1, respectively. The post-course mean total knowledge score was 74.9±8.1, and the attitude score was 88.8±9.1 Improvement in knowledge and attitudes was significant (p<0.05).

CONCLUSION

Educational interventions for pharmacy students designed with careful attention to pedagogic principles can improve knowledge about evidence-based smoking-cessation strategies and enhance positive attitudes to pharmacist roles in smoking cessation.

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

Background

With the emerging role of pharmacists in implementing smoking cessation services and the recent evidence about smoking cessation pharmacotherapies, a needs analysis to assess baseline knowledge about current smoking cessation practice is needed; hence, training and development in this area can target possible ‘gaps’.

Objective

This study aimed at exploring pharmacy students’ knowledge about and attitudes toward smoking cessation, as compared to practicing community pharmacists and smoking cessation educators. The overall objective was to uncover underlying ‘gaps’ in pharmacy-based smoking cessation practice, particularly clinical gaps.

Setting

Final-year pharmacy students at the University of Sydney, practicing community pharmacists and smoking cessation educators in Australia.

Method

As no previous standard pharmacist-focused smoking cessation knowledge questionnaires exist, a review of the literature informed the development of such a questionnaire. The questionnaire was administered to a cohort of fourth-year pharmacy students at the University of Sydney, practicing pharmacists and smoking cessation educators. Data analysis was performed using Predictive Analytics SoftWare (PASW® Statistics 18). Mean total scores, independent t-tests, analysis of variances and exploratory factor analysis were performed.

Main outcome measure

To determine areas of major clinical deficits about current evidence related to smoking cessation interventions at the pharmacy level.

Results

Responses from 250 students, 51 pharmacists and 20 educators were obtained. Smoking educators scored significantly higher than pharmacists and students (P < .05), while score differences in the latter two groups were not statistically significant (P > .05). All groups scored high on ‘general’ knowledge questions as compared to specialised pharmacologic and pharmacotherapeutic questions. All respondents demonstrated positive attitudes toward the implications of smoking cessation. Factor analysis of the 24-item knowledge section extracted 12 items loading on 5 factors accounting for 53% of the total variance.

Conclusions

The results provide a valid indication of ‘gaps’ in the practice of up-to-date smoking cessation services 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. These gaps should be addressed, and the results should inform the design, implementation and evaluation of a pharmacy-based educational training program targeting current clinical issues in smoking cessation.