How to talk about smoking cessation in priority populations

Case scenario

Brett is a 42-year-old man who smokes 20 cigarettes a day. He currently has no intention to quit smoking and has little interaction with the pharmacy, other than dropping off his prescriptions and picking them up.

Introduction

Tobacco smoking is one of the biggest preventable causes of death and disease in Australia.¹ While overall smoking rates in Australia continue to decline, certain
populations such as men, people with mental health conditions, and those who identify as LGBTQIA+ are reported to have higher than average levels of smoking.^1,2
For patients who wish to quit smoking, pharmacists can provide important information and support, recommend suitable over-the-counter products, and refer on to other services and support where required.³

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Epidemiology

Smoking tobacco increases the risk of many health conditions including cardiovascular disease, cancer, chronic lung disease, and diabetes.⁴ Additionally, smoking is strongly linked to an increased level of alcohol consumption (and vice versa), which can further elevate cancer risk.⁵ Daily tobacco use is also associated with increased risk of psychosis⁶ and may increase the risk of other mental illnesses⁷, including anxiety, depression,^8–10 and bipolar disorder.¹¹

While overall smoking rates in Australia continue to decline,² the National Tobacco Strategy has identified that populations such as men, the LGBTQIA+ community and people with mental illness have higher than average levels of smoking.¹²

Priority populations with higher levels of smoking

Men

In Australia, men are more likely to smoke daily than women (12.6% compared to 8.7%).¹³ It’s believed that gender differences in smoking could be attributed to a combination of physiological, cultural and behavioural factors.¹⁴

Men are less likely to seek medical help than women. Generally, men find visiting a doctor unwelcoming and tend to view general practice as a source of acute health care, rather than preventative health and advice.¹⁵ Environmental and social influences can also make it difficult for men to abstain from smoking.¹⁶

LGBTQIA+ people

In Australia, LGBTQIA+ people are 1.5 times more likely to smoke daily, compared with heterosexual people.¹ People who identify as LGBTQIA+ experience several social and psychological risk factors associated with smoking.^17,18 Evidence indicates that discrimination and minority stress experienced by LGBTQIA+ contributes to higher smoking levels in this group.¹⁹

Only 43.4% of LGBTQIA+ Australians feel accepted by healthcare providers, and only 65.5% report having a regular GP compared to 73% males and 81% females in the general population.²⁰

People with mental health conditions

Compared with the general population, people with mental illness have higher smoking rates, lower rates of cessation, and a reduced life expectancy caused by smoking, rather than their mental illness.²¹

Around 20% of people with mental illness are daily smokers.¹ Adults with mental illness are almost twice as likely to be a current smoker than those without mental health issues.² Those with severe mental illness such as schizophrenia and bipolar disorder are three times more likely to smoke than the general population.²²

Successful smoking cessation

Smoking cessation can be difficult, with one study suggesting it may take many people more than 30 attempts before succeeding.²³

In the absence of contraindications, the most successful approach to quitting smoking is behavioural therapy combined with first-line pharmacotherapy (combination nicotine replacement therapy (NRT), varenicline or bupropion) and follow-up.^24,25 Choice of pharmacotherapy should be dependent on the clinical appropriateness, the patient’s preference and efficacy. NRT combination therapy (e.g. a patch for
all day craving relief and a short-acting format like a spray for breakthrough cravings) is safe and as effective as varenicline, and more efficacious than bupropion and single use NRT.²⁵ While many NRT products are available as unscheduled medicines, varenicline
and bupropion are Schedule 4 medicines in Australia.²⁶

As many as 75% of people don’t use NRT as directed which can lead to unsuccessful quitting attempts.²¹ The optimal duration of NRT has not been established. Therapeutic Guidelines recommends at least a 12-week course,²⁴ with evidence of efficacy extending to 24 weeks.²⁴ Some patients may benefit from extended therapy to reduce relapse and improve abstinence.²⁴ However, one study found that in 61% of recent quit attempts using NRT, patients used it for only 2 weeks.²¹ Underdosing is also common, with those who want to quit not using enough NRT to obtain the best clinical effect.²⁵ Some patients may also have misconceptions about the effectiveness and safety of NRT which may hinder their willingness to use NRT or to use it correctly.

Even if motivation for quitting is high, only around 3–5% of smokers successfully quit without any help.²⁷

The role of pharmacists

Smokers report that pharmacist-assisted cessation is an appealing approach to quitting smoking.²⁸

Pharmacist Luke Vrankovich MPS, who has an interest in rural and mental health, says pharmacists are in the best position to have smoking cessation conversations with patients. ‘We have amazing rapport with most of our customers,’ he says. ‘Quitting smoking is one of the most important things people can do for their health. We owe it to them to at least try to have smoking cessation conversations.’

Pharmacists should be able to identify patients who smoke and document their tobacco use. Smokers should be given brief advice on smoking cessation, the benefits of quitting, including that it’s never too late to quit.²⁵

Pharmacists should also assess a patient’s motivation to quit. This can include discussing health concerns, incentives, perceived barriers and previous attempts to quit smoking. ²⁵

Planned follow-up increases cessation rates. Patients should be encouraged to return for follow-up within 1 week of their stop-smoking date and for additional follow-up visits to review progress.²⁵

Mr Brad Butt MPS, Founder and Lead Pharmacist for Mens Health Downunder says that ongoing support is crucial to success. ‘If we just give them the product they may or they may not have success. But if we get them to come back in a week and they’ve started smoking again, we can work through that, reassure them, and get them back on track,’ he says.

For further information on smoking cessation, please refer to:

• Supporting smoking cessation: A guide for healthcare professionals. At: www.racgp.org.au
• Australian Pharmaceutical Formulary and Handbook (APF): Nicotine replacement therapy for smoking cessation. At: https://apf.psa.org.au
• Therapeutic Guidelines. Overview of tobacco smoking and nicotine dependence. At: www.tg.org.au
• PSA’s Guidelines for pharmacists providing smoking cessation support. At: www.psa.org.au

Helping priority populations

Priority populations may experience higher levels of psychological distress, discrimination, and fear being judged that make it difficult to ask for cessation help.^29,30 Providing a safe, non-judgmental space for patients is paramount. Mr Butt says that men don’t want an overly formal situation to have a conversation about smoking.

‘One of the barriers for men is that they haven’t seen a GP for years. Sometimes they worry they’re going to get into trouble from the doctor,’ he says. ‘But there’s no reason a pharmacist can’t provide them with everything they need to quit smoking.’

Pharmacists should be aware of the stages of change for smoking cessation and which stage patients are in so they can have appropriate conversations.³¹ Research shows that even providing cessation interventions to smokers not ready to quit can be effective to increase smoking cessation.³²

Pharmacists can offer patients NRT combination therapy, as a first-line pharmacotherapy for smoking cessation.²⁵

They should also refer patients to Quitline, apps and other health professionals for smoking support, including a GP if a patient does not have a regular doctor.³³

‘Pharmacists are well-connected within a multidisciplinary team, and we know who we can refer patients to, especially patients who may not have a regular GP,’ says Mr Butt.

Conversations with LGBTQIA+ people should be sensitive, use inclusive language and respect pronouns and preferred names. Confidentiality and privacy should be always prioritised.³⁴

Community Pharmacist Mr Michael Minter, who has a special interest in providing care to marginalised communities, including the LGBTQIA+ community, says that many in the queer community, particularly the trans and gender-diverse community find walking into healthcare environments adds to their stress and anxiety.

‘With each encounter, they’re unaware of whether they’re going to experience discrimination or hostility, or misgendering which exacerbates their negative mental wellbeing. This can cause them to avoid future presentations,’ he says. People with mental illness working towards cessation need to be well-supported and monitored as they are particularly at risk of increased psychological stress and neuropsychiatric symptoms during the process of nicotine withdrawal symptoms.^25,35 They should be advised of this before quitting but reassured there are ways to manage mental health symptoms. NRT is safe and effective for people with a mental illness.²³

Extra care, monitoring and potential dose adjustment during smoking cessation is an important consideration if the patient is taking certain psychotropic (or other) medicines metabolised by CYP1A2. This is because the tar in tobacco smoke induces this enzyme and can increase metabolism of these medicines. Medicine concentrations can therefore increase if the same dose regimen is maintained once smoking is reduced or ceased.²⁵ Please refer to the APF for further information.

‘We need to acknowledge the challenges for people with mental health issues and let them know we can help and support them whether it through nicotine replacement therapy, medication, ongoing support or a combination of these things,’ says Mr Vrankovich.

Pharmacists should refer patients to their treating GP for further health management and smoking cessation support. Where possible, pharmacists should consult with the patient’s GP regarding medicine management issues in people with mental illness.³⁶

Conclusion

First-line pharmacotherapy (such as NRT combination therapy) combined with behaviour support and follow-up is the most effective approach to quitting smoking. Pharmacists play a key role in advising and supporting men, LGBTQIA+ people and those with mental illness to cease smoking.

Case scenario continued

You greet Brett and let him know you are available to support all aspects of his health, including quitting smoking whenever he is ready. You discuss the benefits of quitting, the effectiveness of NRT combination therapy, and assure him there is a lot of support available while he quits. You tell him that you’ll keep checking in with him when he comes into the pharmacy to make sure his current medications are working well, which will provide further opportunities for smoking cessation conversations.

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References

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Our author

Nerissa Bentley (she/her) is The Melbourne Health Writer, an award-winning professional health and medical writer who creates credible, evidence-based health copy for national organisations, global companies and Australian health practitioners.

Our reviewer

Brad Butt MPS is Founder and Lead Pharmacist for Men’s Health Downunder.

Luke Vrankovich MPS a pharmacist with an interest in rural and mental health.

Michael Minter is a pharmacist with a special interest in marginalised communities including the LGBTQIA+ community.