Renee Bittoun

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

BackgroundWith 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’.ObjectiveThis 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.SettingFinal-year pharmacy students at the University of Sydney, practicing community pharmacists and smoking cessation educators in Australia.MethodAs 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 measureTo determine areas of major clinical deficits about current evidence related to smoking cessation interventions at the pharmacy level.ResultsResponses 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.ConclusionsThe 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.

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 pregnancy

Managing smoking cessation during pregnancy is vital to the wellbeing of the fetus and the mother. Women who continue to smoke during pregnancy expose the fetus to thousands of chemicals which have been shown to cause deleterious short- and long-term effects. Although a large majority of women cease smoking early in the pregnancy, many of them relapse following delivery. Following a review of current research, an overview of the safety and efficacy of smoking cessation treatments for pregnant women will be considered. Limited research has been performed in this field; however, it can be concluded that low-dose intermittent nicotine replacement therapy is a safe treatment modality for women who smoke during pregnancy. At present there has been no research on other current smoking cessation treatments; however, we will suggest techniques to improve cessation rates and strategies to reduce relapse.

Asthma and smoking--healthcare needs and preferences of adults with asthma who smoke.

Abstract Objective: People with asthma smoke at least as much as, if not more than, people without asthma. The aim of this study was to explore the unique healthcare needs and preferences of smokers with asthma, in terms of smoking topography and initiation, perceived interplay between asthma and smoking, motivation and readiness to quit, and proposed smoking cessation techniques. Methods: Qualitative, semi-structured, in-depth telephone interviews with adult smokers who have concurrent asthma were conducted. Participants were recruited through flyers displayed at community pharmacies, general practice surgeries, university campuses, and respiratory clinics of tertiary hospitals and through an advertisement on the “Asthma Foundation” website. Recorded interviews were transcribed verbatim and analysed using NVivo®10 software (QSR International, Melbourne, Victoria, Australia). Obtained data were content-analysed for emergent themes using the ‘framework approach’. Results: Twenty-four semi-structured interviews were conducted. Most participants believed that smoking often worsens their asthma and increases the frequency and severity of their symptoms. Fear of asthma-related exacerbations and poor self-control appeared to be the major triggers for quitting smoking. Most patients reported being motivated to quit smoking; however, in many cases, determination and strong will power need to be coupled with public, social, professional, and therapeutic support to achieve and maintain success. Conclusions: Given the unique needs of people with asthma who smoke, it is imperative that evidence-based smoking cessation programs be designed and tailored to assist them in effectively quitting smoking.

Guidance for Culturally Competent Approaches to Smoking Cessation for Aboriginal and Torres Strait Islander Pregnant Women

We read with interest Passey and Sanson-Fisher’s findings from their survey with pregnant Aboriginal and Torres Strait Islander women.1 We agree entirely with their points in the Discussion that health providers lack the skill and confidence to help Aboriginal and Torres Strait Islander women tackle smoking during their pregnancy, and the need for culturally sensitive guidelines to address the barriers to cessation specific to this context. While there are no “official guidelines” of that nature in Australia, there appears to be a lack of awareness of the clinical guidelines we published in March 2014, to provide assistance to health providers in evidence-based translational approaches that are culturally competent for this target group.2 This “pragmatic guide” was developed after a systematic review of the literature,3 empirical research with Aboriginal mothers,4 and resource development with extensive engagement with Aboriginal Community Controlled Health Services and other relevant stakeholders in New South Wales, Australia.5 We took into account other published research in the area.6–8 In the development of this guide, coauthors Clarke provided a unique perspective as an Aboriginal Obstetrician, Bittoun as an internationally recognized expert in smoking cessation and health professional training, and Gould as a Tobacco Treatment Specialist, general practitioner and Indigenous health researcher. The “pragmatic guide” was presented at the Royal Australian and New Zealand College of Obstetricians and Gynaecologists’ Indigenous Women’s meeting in May 2014. This clinical guide will become the basis of a randomized controlled trial involving webinar training for general practitioners and health providers in culturally competent approaches for the target group at Aboriginal Community Controlled Health Services in 2016. It is also contributing to other e-learning packages for antenatal care providers in New South Wales. We summarize the salient points of the guide for your readers. The guide is structured according to an ABCD framework. ABC has been used in New Zealand to provide a more dynamic approach to the use of behavioral counseling and cessation assistance. A—ask; B—brief advice; C—cessation. To this we have added D—discuss the psychosocial context of smoking.2 Step D is important in this target population but could relate to any vulnerable population where smoking is highly prevalent or a social norm. However cultural competence is a key to our whole ABCD approach. ABCD includes the following evidence-based features: A—ask the woman to tell of her smoking journey using a nonconfrontational conversational approach. A multi-choice format may elicit a more accurate response to the reporting of smoking.9 We recommend using the Heaviness of Smoking Index, the strength of urges to smoke,10 and a carbon monoxide meter to assess dependence and monitor treatment response. Asking about exposure to environment tobacco smoke is important as 49% of Indigenous Australians smoke. B—brief advice: this includes the use of a visual guide to prompt discussion and educate about the stress-inducing effects of nicotine withdrawal, as an overlap between the two are reported in the target group. Pregnant Aboriginal and Torres Strait Islander women are more likely to try to “cut down” than quit, but quitting needs to be unambiguously yet sensitively encouraged. C—cessation: the “pragmatic guide” includes a nicotine replacement therapy (NRT) treatment algorithm to guide initiation in a step-wise fashion from oral NRT (safest in pregnancy), to transdermal NRT, then combination NRT (oral plus patch) if required, consistent with the Royal Australian College of General Practice updated guidelines.11 Our view is that if a woman cannot manage 1–3 days abstinence then she should be offered NRT in an expedited manner. We provide a quit plan template to help the provider work through the steps required in assisting the client to plan her quit attempt. Features of the quit plan include goal setting, problem solving, self-incentives, and social support. D—discuss the psychosocial context: this overlaps with discussion initiated for the quit plan. D acts as a reminder for the importance of the pregnant woman’s context and unique circumstances relating to smoking. The amount of family and social support can vary. The provider has a role to help the client navigate problems that can impact on smoking in pregnancy, such as financial or housing issues, and screen for domestic violence and mental health concerns, thus refer on to other services if required. We propose the ABCD approach outlined in our pragmatic guide could help standardize approaches in Australia for management of smoking in Aboriginal and Torres Strait Islander women in pregnancy. We are currently refining the guidelines with further input from Aboriginal Community Controlled Health Services and antenatal services, and developing webinar training that will potentially have geographical reach nationally.

Combat, Posttraumatic Stress Disorder, and Smoking Trajectory in a Cohort of Male Australian Army Vietnam Veterans

Background Whether trauma exposure itself or consequent posttraumatic stress disorder (PTSD) is primarily responsible for smoking and failure to quit remains unclear. Methods A cohort of male Australian Vietnam veterans (N = 388) was interviewed twice, 22 and 36 years after their return to Australia using standardized psychiatric diagnostic and health interviews and assessment of combat exposure. The smoking trajectory over time revealed a spectrum of outcomes (never smoked, early quitters, late quitters, and continuing smokers). Analysis used multivariate statistics to assess the relative contributions of combat trauma exposure and PTSD while controlling for potential confounders. Results The trajectory of smoking over time revealed that 21.9% of veterans had never smoked, 45.1% had quit smoking by the time of wave 1, 16.2% were current smokers at wave 1 who had quit by the time of wave 2, 2.8% were late adopters who were current smokers, and 13.9% were continuing smokers. Smoking was associated in single-predictor models with demographics, intelligence, combat exposure, PTSD symptom clusters and diagnosis, and alcohol disorders. Multivariate analysis revealed that PTSD, combat, and intelligence were related to the smoking spectrum but, after adding demographics and other Axis I psychiatric diagnoses, only combat remained significant. No PTSD symptom cluster uniquely predicted smoking status. Conclusions The results suggest that trauma exposure in the form of military combat may be a more robust predictor of smoking status over time than PTSD. It may be stress itself, rather than poststress disorder, that is more germane to smoking and failure to quit. Implications Exposure to traumatic stress and development of PTSD have been implicated separately in the maintenance of smoking. This longitudinal cohort study of smoking in war veterans up to three decades postwar enabled evaluation of traumatic stress exposure in combat and the course of PTSD in smoking and quitting while controlling for intelligence, background disadvantage, and other psychiatric conditions. Combat rather than PTSD emerged as more significant to smoking status, suggesting that it may be the traumatic stress itself rather than the development of a poststress disorder that is more germane to smoking in war veterans.

The four Ds deconstructed

For decades, pamphlets provided by credible government authorities have reproduced tips for quitting smoking, recommended with certainty, but with no basis in facts, findings or substantiated outcomes. The ‘four Ds’ are an example of a universally accepted set of instructions to quit smoking that has little basis in science. This anomaly is at odds with the era of evidence‐based medical interventions and should be addressed.

Ten Years of The Journal of Smoking Cessation

The advent and success of a new Journal seems to be dependent on its originality and a readership that needs and appreciates the content. It still is surprising to me personally that the Journal of Smoking Cessation (JoSC) has succeeded to such a degree since its inception 10 years ago. When I thought about a Journal for our group of the Australian Association of Smoking Cessation Professionals (AASCP), the publishers at Australian Academic Press asked whether there surely was such a journal already and that another might be redundant. When I assured them that there was no such Journal, we embarked upon an enterprise which now has great international interest and credibility. With a small startup grant from the Australian Government I was able to encourage and recruit old friends and colleagues from around the world who were all kind enough to give their names in good faith to an Editorial Board that remains the same today. Their good names and reputations greatly enhanced the credibility of the Journal and I cannot thank them enough for their faith in the Journal and its future. In particular thanks go to Michelle DiGiacomo for volunteering and continuing to volunteer an inordinate amount of time and energy supporting this endeavour.