Introduction

More intervention research is needed to evaluate the effectiveness of other cessation methods such as acupuncture and hypnotherapy. Tobacco dependence meets the criteria of a drug dependence disorder.₁ In most tobacco users, tolerance develops as well as a characteristic withdrawal syndrome and an inability to control future use.₂ Tobacco dependence warrants medical treatment in the same way as any other dependence disorder or other chronic disease.

Although many smokers succeed in quitting on their own, this is usually after several attempts. Over 90% of unaided quit attempts are not successful.₂, ₃ Use of appropriate pharmacotherapies could double or triple cessation rates. In India the tobacco is used in the form of patch, gutkha and cigars etc.

What's bad about smoking

The use of tobacco is associated with a myriad of problems. It is addicting and it fosters a physical and perhaps a psychological dependence. Milligram-for-milligram, nicotine (a major chemical in tobacco) is several times more addicting than heroin. It is associated with cancers of the lips, mouth, throat, larynx (voicebox), esophagus, lungs, stomach, pancreas, kidneys, bladder and uterine cervix. It damages lung and bronchial (airway) tissues directly as well as impairing their properties of self-cleansing and repair, thereby altering the dynamics and efficiency of breathing. It predisposes to atherosclerotic coronary and peripheral artery disease, angina (chest pains referable to the heart) and myocardial infarctions (heart attacks). It raises your blood pressure. It is a risk factor for osteoporosis (reduction in bone density). It can raise your susceptibility to developing peptic ulcers. If you are pregnant, it raises the risk of spontaneous abortion (miscarriage), preterm birth, low birth weight, and perinatal death. It is associated with premature aging (wrinkling) of the skin. It irritates your eyes and burns your throat and lungs. It confers an offensive odor to your hair, skin, breath, clothing and home furnishings. It stains your teeth and fingers. It can burn your skin, your clothing and your furniture. It is a fire hazard, especially when associated with drinking alcoholic beverages. It can reduce your tolerance for exercise and your overall general fitness. It is expensive. It is often offensive and potentially harmful to those around you; it can increase the incidence of asthma, pneumonia, and ear and upper respiratory infections in your nonsmoking spouse and children exposed to your smoke in the house. Some of these effects are immediate, and some are short-term, occurring in days to months. Still others are insidious in their onset and development, taking years of daily use, during which the damage is slow, yet continuous and inexorable. How the above can affect your trombone playing is obvious, especially as you develop reduced exercise tolerance and chronic obstructive lung diseases (measurable reduction in the efficiency of air exchange in the earlier stages, and chronic bronchitis and emphysema in the later stages of smoking).

Neurobiology of smoking

The great majority of regular smokers are dependent on cigarette smoking, and not simply addicted to nicotine.₈ Smoking is highly contextual and associated with certain rituals. These start with the opening of a packet, followed by the lighting process and then the sight and smell of smoke. After inhaling smoke from a modern cigarette, arterial nicotine levels increase markedly within 15 seconds.₉ This bolus of nicotine activates the brain-reward system by increasing dopamine release.₁₀ This brain reward system is a common pathway for pleasurable activities (sexual activity, eating) and most drugs of addiction.₁₁

This peak in plasma nicotine level, and the transient activation of the reward system, is followed by a gradual fall in nicotine levels into a state of withdrawal₁₂ that is, in turn, relieved by the next cigarette. Dependence arises from the temporal association of the rituals and sensory inputs with the repeated stimulation and relief of withdrawal.₁₃ This required association explains why nicotine replacement therapy (NRT) products, that deliver nicotine slowly and do not produce high plasma nicotine levels, have minimal addictive potential.₁₄

The pharmacist's role in the new smoking cessation services

Pharmacists have been shown to play an important role in smoking cessation,₁₅, ₁₇ through their opportunistic contact with people who are in good health as well those who are ill, their ability to advise people about their smoking behaviour and their expert knowledge of the role that medicines can play in improving health and reducing illness.

Opportunistic advice Pharmacists should opportunistically ask customers if they smoke (there are many appropriate triggers such as customers purchasing cough medicines, smokers' toothpaste, pregnancy tests, folic acid, etc) and where appropriate offer advice to smokers to stop.₁₈

Intermediate and specialist smoking cessation interventions The recently published updated smoking cessation guidelines₁₉ highlight the role of the pharmacist in delivering intermediate and specialist smoking cessation interventions. By combining data from two recent randomised trials in the UK, the guidelines indicated a positive effect of a structured package of behavioural support and NRT provided by pharmacists, compared with unstructured care. Community pharmacy personnel therefore have the potential to make a significant contribution to national smoking cessation rates.₂₀

Advice to quit smoking

Interventions using multiple providers from different disciplines were markedly more effective than when no provider was involved. This further indicates that healthcare workers from a range of disciplines can effectively promote smoking cessation.

Treatment formats

Self-help treatment

Nicotine replacement therapy

Other medications

Follow-up assessment and procedures

Motivational strategies

Relapse prevention

Specific populations and groups

Hospitalised patients

Patients with mental health disorders

Weight gain

Multifaceted approach

Assisting patients to quit smoking is complex and requires a systematic and multifaceted approach. The benefits of promoting smoking cessation particularly amongst hospital in-patients are well recognised not only for the individual concerned but the whole community.

There are a range of interventions and strategy alternatives that are supported by quality research-based evidence. Although they may be effective in isolation, a program of multiple interventions including appropriate pharmacotherapy with advice and support tailored to the individual, are more likely to achieve success

These interventions can only be effectively applied if there are systems in place to screen, assess and follow up patients who wish to quit smoking.

Figure 1

Consensus-based conclusions

The pharmacist has an important role to play in smoking cessation in a number of ways: through opportunistic advice, through intermediate interventions (delivering behavioural support and pharmacological treatment), In addition to recommendations based on research evidence, there are a number of recommendations, listed below, arising from reviews derived from expert opinion:

• Clinical screening systems should be expanded to include smoking status in vital signs to assist in assessment and documentation

• Continuity of abstinence should be assessed regularly throughout and on completion of treatment

• Patients not willing to undertake a smoking cessation programme at initial contact should be provided with motivational advice

• If the patient has relapsed, further intervention should be offered

• Ex-smokers no longer actively in a smoking cessation program should have the positive benefits of that decision reinforced and should be assisted with any residual problems related to smoking cessation