Use of Bupropion SR in a Pharmacist-Managed Outpatient Smoking-Cessation Program

Community pharmacy personnel interventions for smoking cessation

BACKGROUND

Community pharmacists could provide effective smoking cessation treatment because they offer easy access to members of the community. They are well placed to provide both advice on the correct use of smoking cessation products and behavioural support to aid smoking cessation.

OBJECTIVES

To assess the effectiveness of interventions delivered by community pharmacy personnel to assist people to stop smoking, with or without concurrent use of pharmacotherapy.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, along with clinicaltrials.gov and the ICTRP, for smoking cessation studies conducted in a community pharmacy setting, using the search terms pharmacist* or pharmacy or pharmacies. Date of the most recent search: January 2019.

SELECTION CRITERIA

Randomised controlled trials of interventions delivered by community pharmacy personnel to promote smoking cessation amongst their clients who were smokers, compared with usual pharmacy support or any less intensive programme. The main outcome measure was smoking cessation rates at six months or more after the start of the intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane for study screening, data extraction and management. We conducted a meta-analysis using a Mantel-Haenszel random-effects model to generate risk ratios (RRs) and 95% confidence intervals (CIs).

MAIN RESULTS

We identified seven studies including 1774 participants. We judged three studies to be at high risk of bias and four to be at unclear risk. Each study provided face-to-face behavioural support delivered by pharmacy staff, and required pharmacy personnel training. Typically such programmes comprised support starting before quit day and continuing with weekly appointments for several weeks afterwards. Comparators were either minimal or less intensive behavioural support for smoking cessation, typically comprising a few minutes of one-off advice on how to quit. Participants in both intervention and control arms received equivalent smoking cessation pharmacotherapy in all but one study. All studies took place in high-income countries, and recruited participants visiting pharmacies. We pooled six studies of 1614 participants and detected a benefit of more intensive behavioural smoking cessation interventions delivered by community pharmacy personnel compared with less intensive cessation interventions at longest follow-up (RR 2.30, 95% CI 1.33 to 3.97; I² = 54%; low-certainty evidence).

AUTHORS' CONCLUSIONS

Community pharmacists can provide effective behavioural support to people trying to stop smoking. However, this conclusion is based on low-certainty evidence, limited by risk of bias and imprecision. Further research could change this conclusion.

Effectiveness of a pharmacist-delivered smoking cessation program in the State of Qatar: a randomized controlled trial

Background

Cigarette smoking is one of the major preventable causes of death and diseases in Qatar. The study objective was to test the effect of a structured smoking cessation program delivered by trained pharmacists on smoking cessation rates in Qatar.

Methods

A prospective randomized controlled trial was conducted in eight ambulatory pharmacies in Qatar. Eligible participants were smokers 18 years and older who smoked one or more cigarettes daily for 7 days, were motivated to quit, able to communicate in Arabic or English, and attend the program sessions. Intervention group participants met with the pharmacists four times at 2 to 4 week intervals. Participants in the control group received unstructured brief smoking cessation counseling. The primary study outcome was self-reported continuous abstinence at 12 months. Analysis was made utilizing data from only those who responded and also using intent-to-treat principle. A multinomial logistic regression model was fitted to assess the predictors of smoking at 12 months. Analysis was conducted using IBM-SPSS® version 23 and STATA® version 12.

Results

A total of 314 smokers were randomized into two groups: intervention (n = 167) and control (n = 147). Smoking cessation rates were higher in the intervention group at 12 months; however this difference was not statistically significant (23.9% vs. 16.9% p = 0.257). Similar results were observed but with smaller differences in the intent to treat analysis (12.6% vs. 9.5%, p = 0.391). Nevertheless, the daily number of cigarettes smoked for those who relapsed was significantly lower (by 4.7 and 5.6 cigarettes at 3 and 6 months respectively) in the intervention group as compared to the control group (p = 0.041 and p = 0.018 respectively). At 12 months, the difference was 3.2 cigarettes in favor of the intervention group but was not statistically significant (p = 0.246). Years of smoking and daily number of cigarettes were the only predictors of smoking as opposed to quitting at 12 months (p = 0.005; p = 0.027 respectively).

Conclusions

There was no statistically significant difference in the smoking cessation rate at 12 months between the groups. However, the smoking cessation program led to higher (albeit non-significant) smoking cessation rates compared with usual care. More research should be conducted to identify factors that might improve abstinence.

Trial registration

Clinical Trials NCT02123329. Registration date 20 April 2014

Treatment Outcome Assessment of the Pharmacist-Managed Quit Smoking Clinic in Malaysia

Introduction: Evaluating a new health service is different from evaluating a new drug, as the former depends on the local delivery structure and culture. No data are available on the effectiveness of the existing pharmacist-managed quit smoking clinic (PM-QSC) in Malaysia. We evaluated the effectiveness in terms of the quit and default rate, the cost per quitter, cost per patient and the number of days of the patient remained in the managed care of the pharmacist.

Methods: The patients’ medical records at the PM-QSC in a tertiary hospital in Melaka, Malaysia, were examined retrospectively from January 2009 to December 2010. Patients were grouped into current smokers, attempted to quit and quitters. Costs were calculated per patient visit on the basis of resource used (smoking cessation agents (SCAs)) and the personnel involved (time spent by the pharmacist). This study was reviewed and approved by the Malaysia Research Ethics Committee (MREC).

Results: The quit rate between January 2009 and December 2010 was 5.8%, and the default rate was 71.8%. The average quit period for all smokers enrolled was 298 days. From the health provider perspective, the average costs per quitter, per patient and per quit attempt were MYR 953.28 (USD 308), MYR 55.71 (USD 18) and MYR 34.74 (USD 11), respectively.

Conclusion: The pharmacist delivery of cessation services at a public-funded QSC was associated with a high default rate. The pharmacist could not be dismissed entirely as an ineffective health care professional (HCP) for the provision of the cessation service based solely on this preliminary data, but these findings stress the need to address the high default rate prior to the expansion of the service.

A method for educating patients and documenting smoking status in an electronic medical record

BACKGROUND

Published evidence demonstrates benefit from pharmacist smoking cessation interventions; however, there is limited research evaluating the impact of a template within an electronic medical record used at pharmacy disease state management visits.

OBJECTIVE

To determine the rates of smoking cessation and movement along the transtheoretical model of change after implementation of a template into existing pharmacy-related progress notes within the electronic medical record.

METHODS

Patients who were routinely followed by clinical pharmacists for anticoagulation and diabetes mellitus education at 3 clinics at the Medical University of South Carolina were included. At each visit, the pharmacist would document patient smoking information in a newly designed template within the existing progress note. In addition, pharmacists would educate patients on the benefits of smoking cessation and pharmacologic options that may be available to them. Data were collected between April 2007 and March 2008. Baseline demographic data and smoking cessation rates and products were compared using descriptive statistics. The McNemar chi(2) test was used to compare the groups of patients achieving smoking cessation pre- and postintervention.

RESULTS

Of the 90 current smokers, 38 (42%) achieved smoking cessation postintervention. Movement along the transtheoretical model of change was also seen, with 52 (58%) patients progressing to at least the next stage. Thirty-four patients in the contemplation/preparation stage and 4 patients in the precontemplation stage moved to the action or maintenance stage by the end of the study period (p = 0.03). A variety of pharmacologic therapies were used in individuals who stopped smoking, although varenicline was most common. Thirty-nine percent of the patients used no medications to achieve cessation.

CONCLUSIONS

Incorporating a smoking cessation template into existing progress notes and providing education during existing pharmacy referral visits is a simple and effective method to assist patients in achieving smoking cessation.

Randomized trial assessing the effectiveness of a pharmacist-delivered program for smoking cessation

BACKGROUND

As trained and accessible healthcare professionals, pharmacists are in an ideal position to provide tobacco cessation interventions. Of the 15 studies identified in the literature assessing the effectiveness of tobacco cessation interventions delivered by pharmacists, this is the first randomized controlled trial conducted in the US of a pharmacist-delivered program for smoking cessation using biochemical confirmation.

OBJECTIVE

To assess the effectiveness on smoking cessation of a face-to-face group program conducted by the pharmacist team compared with a brief standard care session delivered by a pharmacist over the telephone.

METHODS

An open-label, prospective, randomized, controlled trial was conducted at a Veterans Health Administration, community-based outpatient clinic in the Rocky Mountain region. Participants were randomly assigned to receive a 3-session face-to-face group program conducted by the pharmacist team or one 5- to 10-minute standard care session delivered by the pharmacist team over the telephone. Participants in both groups were offered either immediate-release bupropion or nicotine patch at no cost. The primary outcome of self-reported abstinence was biochemically confirmed by urinary cotinine at 6 months after the quit date.

RESULTS

One hundred one smokers were randomized from October 3, 2005, to March 30, 2007, with the last 6-month follow-up survey completed on November 6, 2007. Analysis of data was completed in December 2007. Using intent-to-treat procedures, confirmed abstinence rates at the end of 6 months were 28% in the pharmacist-delivered face-to-face treatment group and 11.8% in the standard care telephone session control group (p < 0.041).

CONCLUSIONS

This study demonstrates that pharmacists are effective providers of tobacco cessation interventions. Greater utilization of pharmacists in tobacco cessation efforts could have a significant impact on smoking rates, prevention of tobacco-related diseases, and overall improvement in public health across the US.

Smoking cessation treatment in a real-life setting: the Greek experience

OBJECTIVES

The aim of this study was to estimate the clinical efficacy of counseling combined with currently used pharmacotherapy for smoking cessation (bupropion SR and nicotine replacement therapy, NRT) in actual clinical practice, and to identify predictors of successful abstinence at the end of therapy, as well as predictors of sustained abstinence in one year.

METHODS

895 smokers, self-motivated to quit, received bupropion SR for 7 or 19 weeks and/or nicotine replacement therapy (NRT) (nicotine patch) for 9 weeks in combination with individual behavioural therapy. An intensive program including repetitive visits and telephone contacts during treatment and one year's follow-up period was available for supporting and motivating smokers to prevent relapse.

RESULTS

Post-treatment abstinence rates were 71.6% and 53.2% in bupropion SR groups for 7 and 19 weeks of treatment, respectively, (p < 0.001), 63.4% in bupropion SR plus nicotine patch group and 45% (p < 0.001) in nicotine patch group. One year's follow-up abstinence rates were 43.1%, 29.6%, 30.4% and 18.4% (p < 0.05), respectively. Predictors of successful abstinence at the end of therapy included (a) bupropion SR, (b) lower DSM IV symptom score, and (c) lower nicotine addiction, while predictors for sustained abstinence in one year included: (a) bupropion SR, (b) lower nicotine addiction, and (c) smoker's motivation.

CONCLUSIONS

Smoking cessation interventions implementing intensive multi-component programs and constant smokers' motivation in health care settings of actual practice seem promising for increasing short and long-term abstinence rates.

Implementation of inpatient and outpatient tobacco-cessation programs

PURPOSE

Two programs in which pharmacists have an active role in the provision of tobacco-cessation education are described.

SUMMARY

An algorithm for tobacco- cessation education was created for use in an inpatient tobacco-cessation program. Patient education handouts were created, and the content of each handout varied by the patient's level of readiness to make a quit attempt. Doctor of pharmacy students who were assigned to the general internal medicine clerkship rotation at the hospital provided tobacco-cessation education to patients. During monthly rotations, these students assess the smoking status of each patient, gauge the patient's readiness to quit, and provide brief tobacco-cessation education to those who smoke. Patients who are willing to quit smoking are asked if they can be contacted by a representative of the health system's tobacco-cessation program. This program includes a series of three group classes focusing on behavior modification and pharmacotherapy provided at a discounted price. An outpatient tobacco-cessation clinic was initiated to provide all patients of the network an opportunity to participate and have access to tobacco-cessation services. The clinic consists of group and individual classes using the principles and interventions highlighted in national clinical practice guidelines. All referred patients must attend an initial one-on-one visit with the clinical pharmacist before enrollment into the group class. During this visit, general medical information is collected, and the patient's stage of change and willingness to set a quit date are determined. A medication review for drug-smoking interactions is conducted, individual goals are discussed, and a care plan is created.

CONCLUSION

Tobacco-cessation services were implemented by pharmacists working in inpatient and outpatient settings.

Tobacco interventions delivered by pharmacists: a summary and systematic review

BACKGROUND

As one of the most accessible health care professionals, pharmacists are in an ideal position to provide tobacco-cessation and prevention services. Although there is growing interest in expanding the pharmacist's role in tobacco treatment, few published studies have assessed the efficacy or effectiveness of tobacco-cessation services delivered by pharmacists in the United States.

OBJECTIVE

To summarize and critique studies that examined pharmacist-delivered tobacco-cessation services.

METHODS

Articles written in English that appeared in peer-reviewed journals were identified from a systematic review of literature published from 1980-2006. Publications were selected for review if the interventions were delivered by pharmacists, if the intervention included United States Food and Drug Administration-approved drugs (if drug therapy was used), and if smoking-cessation rates could be calculated.

RESULTS

Fifteen studies met inclusion criteria. Fourteen of the studies targeted smoking, and one targeted spit (chewing) tobacco. Five studies were controlled, and 10 were uncontrolled. One of the controlled studies (chewing tobacco) and eight of the uncontrolled studies were conducted in the United States. Findings of the uncontrolled U.S. studies suggest that pharmacists can deliver smoking-cessation services. Three of the controlled studies found statistically significant differences between the pharmacist-based intervention and the control group, and the trend in the other two studies was toward the effectiveness of the pharmacist-delivered intervention. Only six of the 15 studies reviewed used biochemical measures to verify self-reported cessation.

CONCLUSION

The uncontrolled and controlled studies reviewed demonstrate that pharmacists can deliver tobacco-cessation interventions, and the evidence strongly suggests that they are effective in helping smokers to quit. Future studies conducted in the United States that are well controlled and include biochemical verification of smoking status are needed to provide definitive confirmation that pharmacist-delivered interventions are effective for smoking cessation. With the availability and expanded training of pharmacists, this is an opportune time for testing and disseminating evidence-based research evaluating the effectiveness of pharmacist-delivered tobacco-cessation services.

Outcomes of bupropion therapy for smoking cessation during routine clinical use

BACKGROUND

Knowledge pertaining to the effectiveness of smoking cessation treatments and patient characteristics that may affect success may enable smokers and clinicians to select individualized treatment for each patient and ultimately increase the success rate of smoking cessation in general.

OBJECTIVE

To evaluate the effectiveness of bupropion as a smoking cessation agent when used in routine clinical practice.

METHODS

This was a prospective, observational study with a one year follow-up period. Adult smokers presenting to community pharmacies in British Columbia, Canada, with an index prescription for bupropion for smoking cessation (N = 205) were eligible. The primary outcome was the biochemically validated 12 month point abstinence (PA) rate from smoking. Secondary outcomes included the frequency of adverse events, patterns of bupropion use in routine clinical practice, and possible predictors of bupropion effectiveness.

RESULTS

The validated 12 month PA rate was 21.0%. Of subjects who reported taking at least one dose of bupropion, 70.4% (126/179) experienced at least one adverse event and 29.6% (53/179) reported stopping the drug due to adverse effects. Greater length of time on bupropion (OR 0.98) and a lower cigarette pack-year history (OR 1.05) were associated with an increase in the odds of smoking cessation.

CONCLUSIONS

Subjects receiving bupropion in a real-life setting exhibited a similar abstinence rate at 12 months as has been observed in the active drug groups of placebo-controlled clinical trials. However, the patterns of use and discontinuation rate due to adverse events differed substantially from those observed in early efficacy studies.

Adverse effects of pharmacological therapy for nicotine addiction in smokers following a smoking cessation program

This multicenter, community-based, prospective, longitudinal study evaluated the safety of nicotine replacement therapy (NRT), bupropion, and combined therapy of NRT and bupropion for smokers seeking to quit, when these therapies were used under real-world conditions following a smoking cessation program. Participants were smokers aged 18 years or older who attended five smoking cessation clinics. Evaluations were made at 15, 30, 60, and 90 days. We investigated the possible existence of adverse effects as well as the severity of each adverse effect and its influence on the treatment course. The study included 904 smokers: 370 received NRT, 413 received bupropion, and 121 received combined therapy. At 15, 30, 60, and 90 days, adverse effects were reported by 43.8%, 33.1%, 22.3%, and 5.7% of subjects, respectively. Adverse effects were significantly more frequent in subjects receiving combined therapy or bupropion alone than in NRT-treated subjects at the 15-, 30-, and 60-day follow-ups. A total of 83 smokers (9.3%) withdrew from treatment and 116 (12.8%) stopped temporarily because of adverse effects. No differences were found in the percentages of discontinuation among the different treatment options. Adverse effects rarely were severe (n=10). Nevertheless, 41 subjects (4.5%) discontinued drug therapy indefinitely and 55 (6.1%) discontinued it temporarily because of mild adverse effects. Pharmacological therapies for smoking cessation are safe as long as they are appropriately prescribed and supervised by clinicians according to clinical practice guidelines. Adverse effects are primarily mild. Nonetheless, mild adverse effects may be perceived by patients as a serious enough problem to cause them to discontinue treatment.

Pharmacist-managed tobacco cessation program in Veterans Health Administration community-based outpatient clinic

OBJECTIVE

To describe an ongoing pharmacist-managed tobacco cessation clinic and assess the long-term effectiveness of the program.

SETTING

Veterans Health Administration (VHA) community-based outpatient clinic in Missoula, Montana.

PARTICIPANTS

Pharmacy professor/clinical pharmacy specialist, advanced pharmacy practice experience students, and tobacco cessation participants.

PRACTICE DESCRIPTION

Ongoing, pharmacist-managed tobacco cessation program offered to veterans.

PRACTICE INNOVATION

With use of the "Vets without Cigarettes" program developed by the Montana VHA and the most current strategies reported in the literature, the clinical pharmacy specialist and pharmacy students provide tobacco cessation services for Missoula Veterans Affairs Primary Care Center veterans. Activities include a three-session program using the Transtheoretical Model of Change, tobacco cessation pharmacotherapy, behavioral strategies, cognitive techniques, documentation, and follow-up survey.

MAIN OUTCOME MEASURE

Percentage of veterans contacted reporting tobacco abstinence.

RESULTS

Follow-up survey results were obtained for 130 (87.8%) of 148 veterans attending one or more sessions of the tobacco cessation class between November 1999 and December 2003. Of the 130 veterans contacted, 54 (41.5%) continued to be tobacco free.

CONCLUSION

This program demonstrates that pharmacists are effective providers of tobacco cessation services. Furthermore, a comprehensive tobacco cessation program is provided that can serve as a model to guide pharmacists in assisting more patients to become tobacco free and live healthier lifestyles.

Outcomes from an Outpatient Smoking-Cessation Clinic

STUDY OBJECTIVES

To determine the success of an outpatient smoking-cessation clinic by assessing smoking abstinence rates and factors associated with lower abstinence rates. We also sought to determine whether smoking abstinence rates differed among various smoking-cessation products.

METHODS

Patients were referred by primary care providers to a pharmacist-managed smoking-cessation clinic. Patients received tailored behavioral counseling, educational materials, and drug therapy consisting of sustained-release (SR) bupropion; nicotine patch, inhaler, or nasal spray; or combination therapy. Patients were monitored by phone or clinic visit for 6 months, if possible. Outcomes assessed were abstinence (both point prevalence and continuous abstinence) and adverse effects. Patients lost to follow-up were assumed to be smoking.

RESULTS

Over 2 years, 198 patients were enrolled in the program. At the initial visit, 35.4% received the patch, 32.8% bupropion SR, 18.2% a combination of patch plus inhaler, 9.6% inhaler alone, and fewer than 5% other therapies. At 6 weeks, a statistically significant difference was observed in continuous abstinence rates between the nicotine patch versus bupropion SR groups (22.9% vs 7.7%, p=0.02) and between the combination patch-inhaler versus bupropion SR groups (25% vs 7.7%, p=0.02). However, this difference was not significant beyond the 6-week visit. A trend toward higher abstinence rates was noted at 6 weeks in the nicotine patch-inhaler versus the other treatment groups, possibly suggesting the need for more intense treatment regimens with combination therapy. Point prevalence abstinence rates after 12 weeks were 18.6%, 15.4%, 22.2% and 21.1% respectively, for the patch, bupropion SR, patchinhaler, and inhaler alone treatment groups. The corresponding continuous abstinence rates were 10.0%, 3.1%, 11.1%, and 10.5%.

CONCLUSION

Although statistically significant differences between products were noted at 6 weeks, no sustained difference in smoking abstinence rates was observed between products. At 6 months, point prevalence and continuous abstinence rates were small, but the decline in success noted over time and the limited overall success rates are consistent with rates for the United States. Our findings suggest that when smokers are assisted in quitting, initial contact as well as follow-up evaluation and monitoring must be intense and sustained to increase the likelihood of successful abstinence. Tobacco dependence is clearly a chronic condition warranting repeated treatment and monitoring until continuous abstinence is achieved.

Training Future Pharmacists at a Minority Educational Institution: Evaluation of the Rx for Change Tobacco Cessation Training Program

Objective: To estimate the impact of Rx for Change, an 8-h tobacco cessation training program on pharmacy students' perceived counseling skills, confidence for counseling, and future counseling of patients for tobacco cessation. Methods: Unlinked, pre- and post-training surveys were administered to 142 pharmacy students enrolled at Texas Southern University, a primarily minority and historically black educational institution. Results: Post-training counseling abilities were significantly improved over pretraining values for each of the five key components of tobacco cessation counseling (Ask, Advise, Assess, Assist, and Arrange), overall counseling abilities, and confidence for counseling (P &lt; 0.001). Racial/ethnic differences in self-reported overall counseling was observed (P = 0.01). Ninety-one percent of participants believed that the training would increase the number of patients whom they counsel for cessation, and 95% believed that it would improve the quality of counseling that they provide. At least 95% of participants believed that the pharmacy profession should be more active in preventing patients from starting smoking and helping patients to stop smoking. Conclusion: The Rx for Change program had a positive impact on perceived abilities and confidence for providing tobacco cessation counseling to patients. While it is important that all current and future health care providers receive specialized tobacco cessation training, it is particularly important for clinicians of racial/ethnic minority backgrounds, who are more likely to practice in geographic areas with a high density of population subgroups at an elevated risk for tobacco-related mortality. In particular, pharmacists, who are uniquely positioned within the community to provide care to all patients, including the medically underserved, must be equipped with the necessary skills to assist patients with quitting.

Bupropion as an aid to smoking cessation: a review of real-life effectiveness

Clinical trials rigorously demonstrate the efficacy of new products and justify their marketing. However, it is only after use in real-life settings that the clinical value (effectiveness) of a new treatment is fully known. The purpose of this review was to summarise the effectiveness data for bupropion SR as an aid to smoking cessation. Available reports of effectiveness data for bupropion SR were obtained from the literature, presentations at smoking cessation meetings and from the manufacturer. Twelve sources of effectiveness data were found and included clinical practice trials, observational studies/surveys, motivational support programme results and employer-based cessation programme results. The 6-month point prevalence smoking cessation rates ranged from 25 to 49%. There is a growing body of evidence supporting the effectiveness of bupropion SR as an aid to smoking cessation. Real-life quit rates for bupropion SR are similar to those seen in the original clinical trial programme.

The pharmacist's role in smoking cessation counseling: perceptions of users of nonprescription nicotine replacement therapy

OBJECTIVES

To characterize nonprescription nicotine replacement therapy (NRT) users with respect to sociodemographic characteristics, tobacco use history, and support for tobacco cessation received from health care professionals; assess the methods used for quitting (past and present) by NRT users; assess NRT users' perceptions of the need for and usefulness of pharmacist-facilitated cessation interventions; and determine the types of pharmacy-based interventions that would be most helpful before and during quit attempts.

DESIGN

One-time attitudinal assessment.

SETTING

Primarily Northern California.

PARTICIPANTS

One hundred three individuals who had recently purchased nonprescription NRT products for use during their current or upcoming quit attempt.

INTERVENTION

In-depth telephone interviews.

MAIN OUTCOME MEASURE

Perceptions of pharmacy-based tobacco cessation counseling services.

RESULTS

The concept of pharmacist-facilitated assistance was appealing to many NRT users. Sixty-three percent of participants believed that receiving advice or assistance from a pharmacist would either probably (46%) or definitely (17%) increase a smoker's likelihood of being able to quit. Twenty-one percent were unsure, and 16% thought pharmacist assistance would not increase the chance of success. Forty-six percent reported that they would be either very or extremely likely to meet with a pharmacist for one-on-one counseling if a nominal ($10) co-payment were required; this percentage increased to 68% if the service were provided free of charge. The preferred structure for counseling interventions varied widely among participants, suggesting that individually tailored counseling programs are necessary.

CONCLUSION

A substantial proportion of nonprescription NRT users view pharmacist-assisted cessation as an appealing approach to smoking cessation.

Community pharmacy personnel interventions for smoking cessation

BACKGROUND

Smoking cessation is a potentially appropriate role for community pharmacists because they are encouraged to advise on the correct use of nicotine replacement therapy (NRT) products and to provide behavioural support to aid smoking cessation.

OBJECTIVES

This review assessed the effectiveness of interventions by community pharmacy personnel to assist clients to stop smoking.

SEARCH STRATEGY

A search was made of the Cochrane Tobacco Addiction Group database for smoking cessation studies conducted in the community pharmacy setting, using the search terms pharmacist* or pharmacy or pharmacies. Date of the most recent search: March 2003.

SELECTION CRITERIA

Randomized trials which compared interventions by community pharmacy personnel to promote smoking cessation amongst their clients who were smokers compared to usual pharmacy support or any less intensive programme. The main outcome measure was smoking cessation rates at six months or more after the start of the intervention.

DATA COLLECTION AND ANALYSIS

Data were extracted by one author and checked by the second, noting: the country of the trial, details of participant community pharmacies, method of subject recruitment, smoking behaviour and characteristics of participants on recruitment, method of randomization, description of the intervention and of any pharmacy personnel training, and the outcome measures. Methodological quality was assessed according to the extent to which the allocation to intervention or control was concealed. Because of the potentially important cluster effects, we also rated trials according to whether they checked for or adjusted for these but, in the absence of consensus on how to pool cluster level data, we adopted a narrative approach to synthesizing the data, rather than a formal meta-analysis.

MAIN RESULTS

We identified two trials which met our selection criteria. They included a total of 976 smokers. Both trials were set in the UK and involved a training intervention which included the Stages of Change Model; they then compared a support programme involving counselling and record keeping against a control receiving usual pharmacy support. In both studies a high proportion of intervention and control participants began using NRT. Both studies reported smoking cessation outcomes at three time points. However, the follow-up points were not identical (three, six and 12 months in one, and one, four and nine months in the other), and the trend in abstinence over time was not linear in either study, so the data could not be combined. One study showed a significant difference in self-reported cessation rates at 12 months: 14.3% versus 2.7% (p < 0.001); the other study showed a positive trend at each follow-up with 12.0% versus 7.4% (p = 0.09) at nine months.

REVIEWER'S CONCLUSIONS

The limited number of studies to date suggests that trained community pharmacists, providing a counselling and record keeping support programme for their customers, may have a positive effect on smoking cessation rates. The strength of evidence is limited because only one of the trials showed a statistically significant effect.

Drug effects on salivary glands: dry mouth

OBJECTIVE

To identify drugs associated with the complaint of dry mouth.

MATERIALS AND METHODS

MEDLINE was searched for papers 1980-2002 using keywords, oral, mouth, salivary, drugs, dry mouth and xerostomia, and relevant secondary references were hand-searched.

RESULTS

Evidence was forthcoming for a number of xerogenic drugs, especially antimuscarinic agents, some sympathomimetic agents, and agents affecting serotonin and noradrenaline uptake, as well as a miscellany of other drugs such as appetite suppressants, protease inhibitors and cytokines.

CONCLUSION

Dry mouth has a variety of possible causes but drugs--especially those with anticholinergic activity against the M3 muscarinic receptor--are the most common cause of reduced salivation.

Review of bupropion for smoking cessation

The advent of bupropion hydrochloride sustained release (Zyban) has heralded a major change in the options available for smoking cessation pharmacotherapy. Bupropion is a selective re-uptake inhibitor of dopamine and noradrenalin which prevents or reduces cravings and other features of nicotine withdrawal. Bupropion is a useful oral and non-nicotine form of pharmacotherapy for smoking cessation. For this review a total of 221 papers were reviewed plus poster presentations. This review examines in detail original clinical trials on efficacy, categorised according to whether they were acute treatment trials in healthy smokers; studies in specific populations such as people with depression, chronic obstructive pulmonary disease (COPD) or cardiovascular disease; or relapse prevention studies. Overall, these studies in varying populations comprising over four thousand subjects, showed bupropion consistently produces a positive effect on smoking cessation outcomes. The evidence highlights the major public health role that bupropion has in smoking cessation. The methodological issues of published clinical trials reporting one year outcomes were examined in detail including: completeness of follow-up; loss to follow-up; intention to treat analysis; blindness of assessment; and validation of smoking status. The review discusses contraindications, adverse effects, dose and overdose, addictive potential, and the role of bupropion in reducing cessation-related weight gain. Bupropion combined with or compared to other pharmacotherapies (nicotine patch; nortriptyline) is considered. Impressive evidence exists for the use of bupropion in smoking cessation among difficult patients who are hard-core smokers such as those with cardiovascular disease, chronic obstructive pulmonary disease (COPD) and depression. Bupropion reduces withdrawal symptoms as well as weight gain and is effective for smoking cessation for people with and without a history of depression or alcoholism. Serious side effects of bupropion use are rare. The major safety issue with bupropion is risk of seizures (estimated at approximately 0.1%) and it should not be prescribed to patients with a current seizure disorder or any history of seizures. In clinical trials of bupropion for smoking cessation no seizures were reported. Allergic reactions occur at a rate of approximately 3% and minor adverse effects are common including dry mouth and insomnia.

Effectiveness of a pharmacist-based smoking-cessation program and its impact on quality of life

We conducted a prospective, open-label trial to evaluate the effectiveness of a pharmacist-based, comprehensive, smoking-cessation program with 31 self-referred subjects. A secondary goal was to measure changes in health-related quality of life (HRQOL) during the cessation attempt. The program consisted of weekly, 1-hour group sessions over 12 weeks. It incorporated nicotine replacement therapy (patch, gum) with extensive behavior modification counseling. Trained pharmacists served as program facilitators. Smoking cessation was chemically verified at 3 and 6 months by exhaled carbon monoxide. The patients' HRQOL was measured using the smoking-cessation quality of life questionnaire at baseline, 2 weeks, and 1, 2, 3, and 6 months. Chemically verified abstinence rates at 3 and 6 months were 42% (13 patients) and 26% (8 patients), respectively. Among patients who quit, vitality, mental health, and self-control significantly improved during the 3-month program. Six-month cessation rates were modest, although HRQOL improved within 3 months of abstinence.