British Columbia Pharmacy Association (BCPhA) Clinical Service Proposal Pharmacist-Led Smoking Cessation Services

Transcription

1 British Columbia Pharmacy Association (BCPhA) Clinical Service Proposal Pharmacist-Led

2 Introduction Tobacco-related illnesses are the leading cause of preventable death in BC. Each year more than 6,000 British Columbians die from tobacco use, despite the province having the lowest smoking rate in Canada. Smoking kills more people in British Columbia than all other drugs, motor vehicle collisions, murder, suicide and HIV/AIDS combined. 1 The economic impact of tobacco use is equally significant, costing the province s economy approximately $2.3 billion annually, including $605 million in health care costs. 2 BC has been making significant progress in helping residents to stop using tobacco. Changes in tobacco legislation and policies, recent media campaigns and initiatives such as QuitNow and HealthLink BC, combined with the launch of the BC Smoking Cessation Program, are all evidence-based interventions that have helped lower the province s smoking rate. This multi-faceted cessation strategy has been key to BC successfully reducing tobacco use, but the province s strategy should not end there; more needs to be done. BC can reduce smoking rates even further by developing the most comprehensive and effective smoking cessation program in Canada. To achieve this goal, BC should expand access to smoking cessation services outside traditional physician office settings to include community-based, pharmacist-led cessation programs that are proven to help smokers quit smoking. What Is the Scope of the Problem? Approximately 550,000 British Columbians smoke tobacco and most of them (70 per cent) want to quit. 2 In the past year approximately 190,000 smokers in BC received nicotine replacement therapies (NRT) or prescription smoking cessation drugs through the BC Smoking Cessation Program. 3 Furthermore, since the QuitNow program began, it has had more than 20,000 contacts with individuals and more than 11,000 people have registered for QuitNow web, text and telephone support. While these are both positive signs that more British Columbians are attempting to quit, they also indicate that the majority of them are doing so without formal support. Among smokers who attempt to quit, only a small proportion succeed without repeated attempts. Studies of those attempting to quit by themselves suggest that success rates after six to 12 months are three to five per cent. 4 All types of NRT have been shown to increase the chances of success rates by per cent 5. Smoking cessation drugs further increase the success rates. 6 Evidence shows that drug therapy and behavioural interventions in health care settings further increase the odds of success in quitting. 7 This includes direct support provided intensively in settings such as family physician offices, emergency rooms and walk-ins, as well as community pharmacies. 8 Not all

3 smokers in BC are the same and their needs are different. Therefore, to ensure equitable access and better likelihood of success, they should receive help in a variety of settings. What Role Can Pharmacists Play? Currently, the role of pharmacists in the BC Smoking Cessation Program is limited to dispensing NRT and prescription smoking cessation drugs. Unlike in other jurisdictions, smokers in BC are not offered a structured, pharmacist-led, smoking cessation program. Other health care systems, including the Ontario Ministry of Health and the National Health Service in the UK, recognize that community pharmacists are ideally positioned to provide the direct, structured support smokers need to quit. Pharmacists are front-line health care professionals who serve local communities and play an important role in educating patients about their health. They are regarded by Canadians as one of the most trusted professions and, to the benefit of smokers, are among the most easily accessible health care professionals. 9 Pharmacists then are well-placed to advise smokers on the appropriate use of their NRT and to regularly monitor their cessation progress. Pharmacist-led tobacco interventions have been proven to help smokers quit. 10 Evidence shows that pharmacist-led cessation programs can lead to quit rates that are five to 11 per cent higher than rates among those attempting to quit without a structured program. 11 In the UK, for example, pharmacists are credited with facilitating at least 100,000 of the NHS s 500,000 quit attempts. 12 Expanding BC s cessation services to include pharmacist-led programs would benefit the province by addressing the current gap in support services for smokers. An annual survey of outpatient visits determined that more than 70 per cent of smokers visit a physician annually, with most reporting wanting to quit. 13 However, 32 per cent of patient charts did not include information about tobacco use, while 80 per cent of identified smokers had no documentation of cessation assistance. 14 This suggests that current physician-led cessation programs are not adequately meeting the demand for support services. Clearly, British Columbians who want to quit smoking need better access to cessation programs. Pharmacist-led smoking cessation programs would provide these smokers with the increased access to the comprehensive and effective cessation support services they need to successfully quit smoking.

4 How Can This Benefit the Patient? There is strong evidence to demonstrate the benefit to smokers of pharmacist-led smoking cessation programs. Pharmacist-led programs provide smokers with: Access Pharmacist-led cessation services offer smokers choice and maximize accessibility. 15 An increased number of convenient settings where smokers have access to cessation support services improves the odds that their quit attempts will be successful. Medication Expertise The support of community pharmacists, who have medication expertise and are familiar with smokers NRT needs, medication history and chronic conditions helps ensure that smokers use cessation medications that are right for their individual medical needs. The proper, safe and effective use of cessation medications by smokers, with the support of their pharmacist, ensures the avoidance of medication complications that can often lead to costly hospitalizations. Ongoing Counselling Cessation services led by pharmacists provide smokers with ongoing counselling support, which is widely recognized as being a vital and effective part of a smoking cessation program. Ongoing counselling has been found to increase smoking-cessation rates by 50 per cent. 16 Pharmacist-led smoking cessation treatments lower smoking rates and save lives and money. The immediate and long-term health benefits of quitting smoking are well documented, from reducing the risk of heart disease to preventing respiratory infections and chronic lung diseases, to reducing postoperative complications. 7 Quitting smoking also reduces the risk of cancers, which is significant considering that smoking is responsible for 30 per cent of all cancer-related deaths and more than 85 per cent of lung cancer-related deaths. 17 Smoking cessation also benefits non-smokers, reducing complications from second-hand smoke, especially in children who suffer higher rates of asthma and respiratory infections. Children are also half as likely to start smoking if their parents have successfully quit. 7 It is estimated that if the average smoker in BC quit, he or she could gain back 4.2 years of life that would be lost if through continued smoking and that, by retirement age, he or she could avoid spending more than $152,000 on cigarettes. 18 Smoking Cessation Facts If 10 per cent of BC smokers quit, BC would save $2.9 billion $8,533 in direct health care costs are avoided for every smoker who quits If pharmacists can assist 5 per cent of smokers trying to quit, BC could avoid $68 million in health care costs

5 How Can This Benefit the Health Care System? Pharmacist-led smoking cessation programs have been successfully implemented in a number of health care systems and delivered benefits in several ways: Cost Effectiveness Pharmacist-led smoking cessation programs have been shown to be costeffective alternatives to self-directed quit attempts. 19 In the US, comparisons of community pharmacy-based smoking cessation programs with self-directed quit attempts found the incremental cost-effectiveness of the pharmacist-led program to be US$844 to US$1,662 per life year saved (depending on the smoker s age). 20 Analysis in the UK determined that pharmacistled cessation programs had a lower cost per quality-adjusted life year gained (benefits quitters 15 receive) compared with self-directed quit attempts and group services. Further evaluations of community pharmacy-based cessation programs that included counselling meetings for smokers determined that the cost-effectiveness of using pharmacists compares favorably with other disease prevention medical interventions, such as screening for hypertension or hypercholesterolemia. 21 Health Care Savings Smoking cessation programs led by pharmacists produce health care savings. In the US, a pharmacist-led smoking cessation program run by the Department of Veterans Affairs showed a 16 per cent quit rate, with annual savings of $691,200 and a net cost benefit of $551, In BC, a pharmacist-led smoking cessation program could help an additional five to 11 per cent of smokers quit, potentially resulting in $68-$150 million in avoided health care costs. If approximately eight per cent 4,5 of smokers using NRT and 15 per cent 6 using prescription smoking cessation drugs successfully quit, the result would be around 16,000 successful quitters. The costs of NRT and prescription smoking cessation drugs for every unsuccessful quit attempt range from $240-$340, respectively, for a standard 12-week treatment. In the past year, more than 80 per cent of all NRT issued as part of the BC Smoking Cessation Program was picked up at community pharmacies. This translates to 120,000 smokers picking up NRT from their pharmacist and 40,000 smokers picking up prescription smoking cessation drugs, at a significant cost to the province. A pharmacist-led cessation program providing improved patient access to follow-up counselling could help reduce these NRT and cessation drug costs, which would contribute to the Province avoiding health expenditures of $1.37 billion.

6 BCPhA s Proposal The BCPhA proposes that the Government of BC collaborate with community pharmacy to develop and implement a pharmacy-led smoking cessation program, funded by the Ministry of Health, to provide British Columbians with the improved access, medication expertise and ongoing counselling they need to successfully quit smoking. The cessation program would be modelled after the Ontario Pharmacy Cessation Program. 23 Similar to the program in Ontario, the BC program would consist of an initial patient assessment to determine readiness to quit. For patients ready to quit, the assessment would be followed by a consultation to document the patient s smoking habits/history and previous quit attempts and to determine a plan to quit. Patients agreeing to further consultations with their pharmacist would be eligible for further structured smoking cessation consultations. Consultations and regular follow-up with the patient would be documented to ensure program continuity. Ideally, the consultations would take place when NRT or prescription smoking cessation drugs are picked up from the pharmacy. The BCPhA also proposes that the program include a minimum of three and a maximum of eight consultation sessions, each lasting longer than three minutes, which have been shown to increase the chances of prolonged abstinence. 24 This approach is supported by evidence from Ontario, where pharmacist-led smoking cessation interventions with three consultations were shown to result in a higher quit rate when compared with a single consultation intervention (27.7 per cent vs. 18 per cent) 25. The model of intervention should be based on the Five As (ask, advise, assess, assist, arrange), as recommended by the Canadian Action Network for the Advancement, Dissemination, and Adoption of Practice-Informed Tobacco Treatment (CAN ADAPTT) and as implemented in the Ontario Smoking Cessation Program. Other techniques such as FRAMES (feedback about personal risk, responsibility of patient, advice to change, menu of strategies, empathetic style, promote self-efficacy) could also be explored. Pharmacists would be required to complete training on smoking cessation counselling prior to participating in the BC program. The program would be operated over a defined period and be regularly evaluated to assess its clinical impact and cost effectiveness. Pharmacists could also be included in program evaluation by entering into PharmaNet the patient s quit status at the end of a 12-week course of NRT or smoking cessation therapy. The BCPhA and Ministry of Health would collaborate on developing program evaluations and documentation requirements to ensure financial accountability. The BCPhA s proposed program is summarized in the figure below. If the proposed service was offered to each patient who picked up NRT or prescription smoking cessation drugs in 2011/12 (160,000

7 patients) with an average cost of $100 per patient, it would generate a potential net cost avoidance of $ million dollars to the health care system, based on the increased number of smokers who would quit smoking. Pharmacist-Led Smoking Cessation Program Remuneration Model Point of Contact Description Outcomes Remuneration ASK client if he/she smokes If the client is NOT ready to make a quit attempt or does not want further consultation services: Provide client with information. Assessment ADVISE smoker to quit ASSESS patient readiness to make a quit attempt now If the client is ready to make a quit attempt and set a quit date: Proceed to or schedule First Consultation. $0 First Consultation Follow-up Consultation(s) Maximum 8 annually. ASSIST the client in making a quit attempt ARRANGE for follow-up contact, either in person or via telephone Set a quit date Create quit plan Provide practical counselling Provide handouts or refer to other community supports Determine quit status Assess pharmacotherapy use Discuss triggers and strategies to overcome them Document: $50 $15 Program Evaluation Document patient s success status with the program Patient succeeded in quitting smoking Patient did not succeed in quitting smoking Patient did not indicate whether he/she quit smoking $5 The BC Smoking Cessation Program has significantly improved access to NRT and prescription smoking cessation products. However, the program lacks the face-to-face, ongoing support from a health care professional that evidence shows smokers need to successfully kick their habit. A pharmacist-led smoking cessation program in BC would address this shortfall, expand access to cessation services, improve the odds of successful quit attempts and result in significant savings in health care cost.

8 1 BC Ministry of Health Tobacco Control Program. 2 Office of the Premier, Ministry of Health. BC rolls out program to help smokers quit [news release]. September 27, Retrieved from www2.news.gov.bc.ca/news_releases_ /2011prem htm 3 Office of the Premier, Ministry of Health. Celebrating the anniversary of the Smoking Cessation Program. [news release]. October 24, Retrieved from www2.news.gov.bc.ca/news_releases_ /2012hlth pdf 4 Hughes JR, Keely J, Naud S. Shape of the relapse curve and longterm abstinence among untreated smokers. Addiction 2004; 99:29 38.Retrieved from 5 Stead LF, Perera R, Bullen C,Mant D, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD DOI: / CD pub3. 6 Wu P, Wilson K, Dimoulas P, Mills EJ. Effectiveness of smoking cessation therapies: a systematic review and meta-analysis. BMC Public Health 2006, 6:300 doi: / Smoke-Free Ontario Scientific Advisory Committee. Evidence to Guide Action: Comprehensive Tobacco Control in Ontario. Toronto, ON: Ontario Agency for Health Protection and Promotion, Dent LA, Harris KJ, Noonan CW. Tobacco interventions delivered by pharmacists: a summary and systematic review. Pharmacotherapy 2007; 24(2): Ipsos Reid Canada Public Opinion Poll. What Do Pharmacists, Doctors, Soldiers, Pilots and Teachers Have in Common? They re among the Most Trusted Professions in Canada Khan K, Anderson JR, Du J, Tinker D, Bachyrycz AM, Namdar R. Smoking Cessation and Its Predictors: Results from a Community-Based Pharmacy Tobacco Cessation Program in New Mexico. Ann Pharmacother 2012; 46: Sinclair HK, Bond CM, Stead LF. Community pharmacy personnel interventions for smoking cessation. Cochrane Database of Systematic Reviews Brock T, Taylor D, Wuliji T. Curbing the Tobacco Pandemic: The Global Role for Pharmacy. The school of Pharmacy, University of London Ferketich AK, Khan Y, Wewers ME. Are physicians asking about tobacco use and assisting with cessation? Results from the national ambulatory medical care survey (NAMCS). Prev Med 2006; 43(6): Ferketich AK, Khan Y, Wewers ME. Are physicians asking about tobacco use and assisting with cessation? Results from the national ambulatory medical care survey (NAMCS). Prev Med 2006; 43(6): NB: THIS IS THE SAME AS REF #13 15 Bauld L, Boyd KA, Briggs AH, Chesterman J, Ferguson J, Judge K, Hiscock R. One-Year Outcomes and a Cost-Effectiveness Analysis for Smokers Accessing Group-Based and Pharmacy-Led Cessation Services - Nicotine & Tobacco Research, Volume 13, Number 2 (February 2011) Canadian National Organisation of Occupational Therapists Position Statement: The Role of Health Professionals in Tobacco Cessation (Joint Statement)(June 2011) Developed jointly with the Canadian Association of Occupational Therapists, the Canadian Counselling and Psychotherapy Association, the Canadian Dental Hygienists Association, the Canadian Medical Association, the Canadian Nurses Association, and the Canadian Physiotherapy Association. 17 Centers for Disease Control and Prevention. The health consequences of smoking: a report of the Surgeon General. Dept. of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, GA Bridge J., Turpin B. The cost of smoking in British Columbia and the economics of tobacco control executive summary. February Retrieved from

9 19 Kahende JW, Loomis BR, Adhikari B, Marshall L. A Review of Economic Evaluations of Tobacco Control Programs. International Journal of Environmental Research and Public Health 20 Tran MT, Holdford DA, Kennedy DT, Small RE. Modeling the cost-effectiveness of a smoking-cessation program in a community pharmacy practice. Pharmacotherapy 2002, 22, Crealey GE, McElnay JC, Maguire TA, O Neill C. Costs and effects associated with a community pharmacy-based smokingcessation programme. Pharmacoeconomics 1998, 14, Gasdek Manolakis P, Skelton JB. Pharmacists' Contributions to Primary Care in the United States Collaborating to Address Unmet Patient Care Needs: The Emerging Role for Pharmacists to Address the Shortage of Primary Care Providers*. American Journal of Pharmaceutical Education 2010; December 15; 74(10): S7. 23 Pharmacy Smoking Cessation Program Ontario Ministry of Health and Long Term Care. September 1, Retrieved from 24 CAN-ADAPTT. Canadian Smoking Cessation Clinical Practice Guideline: Summary Statements. Toronto, Canada: Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment, Centre for Addiction and Mental Health Pharmacy Smoking Cessation Program Ontario Ministry of Health and Long Term Care. September 1, Retrieved from