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Table of Contents2ACKNOWLEDGMENTS3WHO IS SMOKING?4SMOKING CESSATION PILOT PROJECT5REACHING THE COMMUNITY6PHARMACIST’S SUPPORT7HEALTH AND WELL BEING8SUCCESSES9STEERING COMMITTEE10This report focuses on the impact of a community pharmacist operatedsmoking cessation pilot project. Under the recently proclaimedPharmaceutical Act, Manitoba pharmacists with additional training who havereceived authorization from the College of Pharmacists of Manitoba canprescribe smoking cessation medications. This project was developed in anattempt to enhance the utilization of pharmacists in preventative health caredelivery. The feasibility, impact and cost effectiveness of this pilot project arediscussed in this report in brief.All client participants completed an informed consent. All signed consentforms were secured to ensure the adherence to the Manitoba Personal HealthInformation Act.Consent forms with the linkage between participant identifiable informationand the study number were forwarded to the Principle Investigator College ofPharmacy, Faculty of Health Sciences, University of Manitoba and maintainedas per standard confidentiality protocols.Anonymity was carefully adhered to.REFERENCESAuthors:Shawn Bugden, BSc (Pharm), MSc, PharmDKevin Hamilton BSP, MScBrenna Shearer PhD, O.T. Reg. (MB)Kevin Friesen BSc (Pharm)Silvia Alessi-Severini PhDPublished by: Pharmacists Manitoba, May 2015A full copy of this report is availbale at:

AcknowledgmentsWe wish to thank the pharmacists whose participation and dedication made this project possible. This pilot projectwould not have been possible without the support of the following partners and their representatives.The pilot project received funds from the Government of Manitoba, Canadian Foundation for Pharmacy andNeighborhood Pharmacy Association of Canada. In addition, some smoking cessation product costs were covered asinsured benefits through the Employment and Income Assistance Program.Considerable in-kind support was also provided by the College of Pharmacists of Manitoba, the College of Pharmacy,University of Manitoba and Pharmacists Manitoba.COLLEGE OF PHARMACISTSOF MANITOBAwww.cphm.ca2

Who is Smoking?3rd Highest National Averageof Smokers20.5% of Manitobans SmokeMore males(23.3%) than females7% of Manitoba seniors1 in 5 people1(17.9%) smoke in Manitoba1smoke daily.2Smoking is theleading causeof preventabledeath.Smoking and tobacco use isresponsible for more than50% of lung, respiratory, andoral cancers and a substantialfactor in heart disease.2While decreases in smokingrates have been achieved inthe past decade, Manitobaexceeds the national averageof 17.3%, ranking the provincewith the third highest smokingprevalence.3 Manitoba’scurrent smoking rates warrantcontinued efforts to reducesmoking in youth and adults.2,4Not only are the smokingrates higher in Manitoba,but this rate increases inindividuals with an annualincome of less than 20,000.5It is estimated that 33% oflower socioeconomic statusCanadians are smokers.In 2010, 60% of smokersconsidered quitting and10% of those who reportedattempting to quit weresuccessful1. Between 1999and 2010 in Canada, thepercentage of people whosmoked and were seriouslyconsidering quitting increasedamong those 25 years of ageand older.13

Smoking Cessation Pilot ProjectAlthough many factors affect a patient’s quality of life, smoking cessation canarguably provide the single greatest impact in both long and short term healthbenefits. Unfortunately, tobacco is highly addictive and relapse is common. Effective,individualized strategies are required to improve the likelihood of successful abstinence.Smoking Cessation Programs Across CanadaSmoking cessation programs in Alberta, Ontario, Newfoundland, and Saskatchewan utilizepharmacists as the point of access to counsel, offer medication options, and provide follow up to those who want to stopsmoking.6-12 Most provinces across the country provide coverage for prescription medications such as bupropion andvarenicline through their drug plans according to a variety of programs and reimbursement schedules. Some jurisdictions(e.g., BC, Quebec, PEI) also provide coverage for over-the-counter (OTC) nicotine replacement products (gums andpatches).Smoking Cessation Programs in ManitobaThe role of the pharmacist in smoking cessation strategies is an underutilized resource in Manitoba. The role of thepharmacist is often an under recognized resource in smoking cessation programs. For individuals who smoke, manyfind smoking cessation overwhelming and difficult without assistance, including smoking cessation drugs and ongoingsupport and counselling. Many pharmacists have received additional knowledge and training specifically for initiating andmonitoring of smoking cessation for individual clients.During the fall of 2012, discussions ensued with the Minister of Healthy Living, Seniors and Consumer Affairs,Government of Manitoba. The intent was to open discussion on the role of the pharmacist for healthier communitiesand specifically pharmacist initiated smoking cessation.The College of Pharmacists of Manitoba, Pharmacists Manitoba, and College of Pharmacy, Faculty of Health Sciences,University of Manitoba developed a proposal for a Manitoba pharmacist initiated smoking cessation project. In 2013,the project proposal was approved and financial support was provided by the Department of Healthy Living and Seniors,Government of Manitoba, Canadian Foundation for Pharmacy and the Neighborhood Pharmacy Association of Canada.Project Objectives Assess the feasibility of a pharmacists initiated smoking cessation provincial pilot projectEnhance the role of the pharmacist in preventative health-care delivery as part of the primary health care teamReduce the number of Manitobans that smokeEvaluate the impact of the project on patient-oriented outcomesEstimate the cost effectiveness of the projectThe primary outcome of the pilot project was the self-reported smoking quit rate and smoking reduction rate at6-months.The following were the pharmacies accepted to participate in the project: Dauphin Clinic Pharmacy, 622 – 3rd Street SW, DauphinLoblaw Pharmacy 1512, 1035 Gateway Road, WinnipegLoblaw Pharmacy 1509, 80 Bison Drive, WinnipegLoblaw Pharmacy 1506, 1578 Regent Avenue,WinnipegLoblaw Pharmacy 1505, 2132 McPhillips Street,WinnipegPharmacie Dufresne, 10 – 1321 Dawson Road, PO Box229, Lorette Safeway Pharmacy, 1612 Ness Avenue, WinnipegShoppers Drug Mart 547, 43 Marion Street, WinnipegShopper’s Drug Mart 537, 2211 Pembina Highway,WinnipegShopper’s Drug Mart 2422, 777 Sherbrook Street,WinnipegTache Pharmacy, 400 Tache Avenue, WinnipegWest-Man Medical Centre Pharmacy, 146 – 6th Street,BrandonAll pharmacist participants were required to demonstrate completion of a recognized smoking cessation training project,prior experience providing smoking cessation counselling and services, as well as knowledge of and access to the targetpopulation.4

Reaching the CommunityPatient FocusA report from the Centers for Disease Control and Prevention,Best Practices for Comprehensive Tobacco Control Programs,13recommend that smoking cessation programs should betargeted to smokers that lack access to these services, such asthe uninsured or the underinsured. This group may benefit toa greater degree compared to the average population, yet theycannot afford the upfront costs associated with these types ofprograms.The pilot project target population was Manitoba residentscurrently active with Employment and Income Assistance, atleast 18 years of age or older, and interested in reducing orquitting smoking. The pilot project goal was to recruit 100While smoking at young ages leads to lifelong participants within six weeks. The initial recruitment was difficultto achieve within the six week time frame, therefore it washabits, smoking is a changeable lifestyleextended. Pharmacists successfully recruited 119 patients in 81behavior.weeks.Reaching the CommunityPharmacists actively recruited participants from within thepharmacies they were employed. Potential participantswho met the eligibility criteria either self-identified or wereapproached by the pharmacist. Potential participants wereprovided with an information sheet and consent form.Pharmacies identified staff members who were not involved inthe pilot project as resources for potential participants. Staffmembers answered any questions and ensured the participantshad an understanding of the pilot project, and the participantprovider responsibilities prior to them signing consent toparticipate in the project.Client participants received the following services that werecovered by either Employment and Income Assistance Programand/or the pilot project funding: Prescription and Over-the-Counter smoking cessationmedication and products Pharmacist support and counsellingThe Smoking Cessation Pilot Project Assessment Forms wereadapted from existing pharmacist-guided smoking cessationprogram forms. The following is a list of assessment forms thateach client completed: Quit Log Smoking CessationAssessment Form Smoking Assessment Fagerstrom ToleranceTest Quit Diary Why Do I Want to Quit? Why Test Pre-Quit Planning Health Questionnaire My Reason to QuitAre you ready toQUIT?When you’re ready to quitsmoking, your pharmacist will bethere to guide you through it.As your local medication experts, pharmacists willprovide you with the tools and knowledge to helpyou kick the butt.To learn more about how to quit smoking, talk toyour pharmacist today.Your health.Your pharmacist.Posters were provided to the pharmaciesto help promote the sponsored smokingcessation project5

Pharmacist’s Expertise and SupportPharmacists are the most accessible health care professional.14,15 Communitypharmacists provide a range of clinical services and expertise and practice inneighborhoods, towns and cities across the province.15Pharmacists are one of the most knowledgeable health care professionals inregards to smoking cessation products and strategies; knowledge achieved throughadvanced education, training and certification.7, 14,15 Because pharmacists areaccessible at the time of smoking cessation product purchase, they are ideallysituated to provide individualized therapy.During the pilot project, each participant received smoking cessation products andcounselling for three months. All costs related to over-the-counter and prescriptionsmoking cessation products, as well as compensation for pharmacist professionalcounselling services were covered by the pilot project. Prescriptions were obtainedfrom the participant’s physician when required.Preparing to QuitA Pre-Quit Log was completed by the client and returned to the pharmacist. A follow up appointment was scheduled todetermine a client’s readiness to quit smoking and the Pre-Quit planning was completed. During consultations with theirpharmacist, each client was provided with the best method and/or medication to support their quit smoking plan. Oncea Quit Date was established for the participant a Quit Day appointment was made with the participating pharmacist.Time to QuitAt the Quit Date appointment the participant received a Quit-Day-Week Plan, Quit Diary and other supportiveinformation. Each participant received a one week post quit follow-up, a one month post quit follow-up, and hada three month post quit follow-up appointment with theirparticipating pharmacist. The counselling sessions providedsupport, encouragement, and identified any challenges and waysto address them. And, equally as important, this provided anopportunity to celebrate the client’s success.Follow UpThe participants received ongoing supportive counselling on thebest time to start taking their medication, as well as ongoingmedication management advice to help adapt the products toeach participant’s lifestyle and needs.Six months following the initial Quit Day session establishedbetween the participant and pharmacist, the pharmacistperformed a follow up assessment to determine each participant’s smoking cessation or smoking reduction status.Clients who quit the project at any stage of the pilot project were contacted or attempted to be contacted by theirpharmacist.Pharmacist’s TimePharmacistsspent 275 hourscounsellingpatients6Pharmacistsscheduled 483appointmentsPharmacistspent anaverage of2.5 hourscounsellingeach patientInitialappointmentslasted onaverage 1.25hours12 patientsscheduled 1 - 6extra follow upappointments

Health and Well-BeingNicotine is considered one of the most addictive substances and many patients attempt to quit numerous times. Onaverage, participants tried to quit 4 times prior to enteringthis pilot project. Some continued to try to quit multipletimes during the project. Long term smoking was commonamong participants, with an average history of 26 years.The longer a person smoked, the less likely they were tosuccessfully quit.While only a small number of participants were able tofully quit smoking, a much larger number were able todecrease harm by reducing the number of cigarettes theysmoked.At their last follow-up appointment, 41 participantsreported they were able to reduce the amount ofcigarettes they smoked per day by an average of 16,while 4 patients restarted smoking more than they werepreviously.This reduction in smoking seems to have producedsome improvements in health. Improvements in areassuch as reduced coughing, shortness of breath, phlegmproduction and cold extremities, were reported even inthose who did not quit fully.It became evident to a number of pharmacistsinvolved in the project how critical the homesupport environment is to those wishing to quitsmoking. Some of these individuals had very realhardships in this regard and smoking cessationwas not supported at all in some cases butrather they were actually encouraged by theirfamily and friends to continue to smoke.Participants were asked to rate these symptoms at eachappointment on a scale of 0 to 3, where 0 equaled ‘nosymptoms’ and 3 equaled ‘worst ever’. Patients reportedimprovement in at least one of these areas, with 63%reporting reductions in phlegm and cough as most common. It is well established that quitting smoking is difficult andoften takes several attempts before a user is successful. Success can be measured in ways other than the completecessation of smoking. With an average reduction in daily cigarette consumption of 16, this project is still a successfulharm reduction strategy. By cutting back by more than a half a pack per day, these patients can also enjoy the benefitsof an increase in available disposable income. Given the fixed income of these patients, we have estimated a savings of 266 per month, which represents a sizable portion of the available monthly income.Now that pilot project participants are armed with more information, they may be more successful on their next attempt.Sustained efforts are required to ensure continued improvements in this difficult population.63% reportedreduction in coughand phlegm1.7% quitsmoking19% quit smokingfor 3 months30% quit smokingfor 1 month82% dropped outbefore the end ofthe project38% dropped outbefore their Quit Day41% reduced theamount of cigarettesthey smoked per dayApprox. 266/monthsaved for those whoreduced consumption ofcigarettes7

SuccessesOne of the goals of this pilot project was to testif a smoking cessation project could be deliveredto a difficult to reach population. Manitobapharmacists were able to recruit 119 patients onEmployment and Income Assistance, exceeding theinitial goal of 100 patients. Based on the smokinghistory, Fagerstrom score, comorbid mental healthconditions and other substance abuse, the projectwas successful in reaching the intended targetpopulation.Our results suggest that successful smoking cessationis difficult for Manitoba residents who are of lowersocioeconomic status. However, our successful quitrate of 1.7% is similar to that observed in a UK studycomparing pharmacist consultation with nicotinereplacement to group behavioural support.16 TheUK study success rate was 2.8% measured after oneyear, and based on up to 12 weeks of one-to-onesupport typically lasting between 5 and 15 minutes.This report provides encouraging evidence for aviable community pharmacist-run smoking cessationprogram. Quit rates similar to other programs wasdemonstrated in Manitobans who were of lowsocioeconomic status. With minor modifications, thisprogram could be expanded throughout the provinceto provide an additional access point for patients toreceive effective smoking cessation counselling.Successful abstinence from smoking can be a longjourney with multiple relapses. This project reinforcedthat smoking cessation was difficult, especially in thishard to reach population.However, these difficulties highlight the importanceof effective strategies that need to support patientsthrough multiple quit attempts and the significantclinical service that pharmacists offer to expand thenumber of access points and level of individualizedsupport required.The population in this pilot project representsa resistant, hard to reach group. Given the highsmoking rate of people with low incomes, this is animportant group to support in the quitting process.In Quebec, coverage of smoking cessation aids seemsto have been of particular advantage to low income individuals and may have contributed to a reduction of the smokingrate in Quebec from 30% to 25%.17With an average smoking history of 26 years in a highly dependent group, successful abstinence for extended periodsof time is expected to be low. Other studies that focused on the socio-economically disadvantaged have failed tohave a single patient sustain quitting longer than 12 weeks.18 Other pharmacist intervention studies in more generalpopulations have shown higher quit rates.19-22 High drop-out and lost to follow-up rates are common in addictionstudies.Smoking is the leading cause for preventable death and is responsible for 1 in 10 adult deaths. The associated morbidityrepresents a sizable strain on our health-care budget. The “price” of smoking is so high that almost all interventions tosupport smoking cessation have been shown to be cost effective.23-25An average of 470 per patient was spent supporting smoking cessation in this project. Patients that successfullyreduced the amount they smoked also benefited from a significant increase in disposable income. An economicassessment of the project suggested that the project was cost effective.Smoking cessation is difficult for everyone, however, for vulnerable populations it is evenmore so as they have many stressors in their lives. They face what seems insurmountablechallenges every day. Now that they are armed with more information, they may bemore successful on their next attempt. Sustained efforts are required to ensure continuedimprovements in this difficult population.8

Stakeholders and Steering CommitteePrinciple InvestigatorsDr. Shawn BugdenAssociate ProfessorCollege of Pharmacy, Faculty of Health SciencesUniversity of ManitobaDr. Brenna ShearerChief Executive OfficerPharmacists ManitobaSteering CommitteeDr. Silvia Alessi-Severini (Co-investigator)Associate ProfessorCollege of Pharmacy, Faculty of Health SciencesUniversity of ManitobaScott McFeetorsPresident, Pharmacists ManitobaDirector, Pharmacy OperationsLoblaw Companies Ltd.Andrew LougheadManager, Tobacco Control and Cessation UnitManitoba Health, Healthy Living and SeniorsKim McIntoshAssistant Registrar, Professional DevelopmentCollege of Pharmacists of ManitobaMurray GibsonExecutive DirectorManitoba Tobacco Reduction Alliance (MANTRA)Sheila NgProfessional Relations Chair, Pharmacists ManitobaPharmacy Practice InstructorCollege of Pharmacy, University of ManitobaJustin BatesNeighbour

The College of Pharmacists of Manitoba, Pharmacists Manitoba, and College of Pharmacy, Faculty of Health Sciences, University of Manitoba developed a proposal for a Manitoba pharmacist initiated smoking cessation project. In 2013, the project proposal was approved and financial support was provided by the Department of Healthy Living and Seniors,

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