Tobacco cessation counseling: Pharmacists’ opinions and practices

Tobacco cessation counseling: Pharmacists’ opinions and practices

Patient Education and Counseling 61 (2006) 152–160 www.elsevier.com/locate/pateducou Tobacco cessation counseling: Pharmacists’ opinions and practice...

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Patient Education and Counseling 61 (2006) 152–160 www.elsevier.com/locate/pateducou

Tobacco cessation counseling: Pharmacists’ opinions and practices Karen Suchanek Hudmon a,*, Alexander V. Prokhorov b, Robin L. Corelli c a

Department of Epidemiology and Public Health, Yale University School of Medicine, 60 College Street, Room 431, PO Box 208034, New Haven, CT 06520-8034, USA b Department of Behavioral Science, The University of Texas, M.D. Anderson Cancer Center, Houston, TX, USA c Department of Clinical Pharmacy, University of California at San Francisco School of Pharmacy, San Francisco, CA, USA Received 27 December 2004; received in revised form 27 February 2005; accepted 6 March 2005

Abstract Objective: As a key interface between patients and the health-care community, pharmacists are uniquely positioned to promote tobacco cessation. The objectives of this study were to: (a) characterize pharmacists’ past training and current activities in provision of tobacco interventions, attitudes toward assisting patients with quitting, and interest in receiving specialized training for tobacco cessation counseling; and (b) identify predictors of pharmacists’ counseling for tobacco cessation. Methods: A 10-page survey was mailed to all licensed pharmacists in four California counties. Results: Returned surveys (n = 1168; 54.2% response) indicated that fewer than 8% of pharmacists have received formal training for tobacco cessation counseling, and current levels of counseling are low. Key predictors of cessation counseling include practice setting, pharmacists’ race/ethnicity, perceived pros of counseling, and self-efficacy for counseling. Of 715 pharmacists who have direct patient contact, 93% indicated that receiving specialized tobacco cessation counseling training would increase their counseling quality, and 70% indicated that it would increase the number of patients counselled. Eighty-eight percent reported interest in receiving specialized training to obtain these skills. Conclusion: Although few pharmacists have received formal training in tobacco cessation and counseling activities currently are low, there is substantial professional interest in further developing this role. Practice implications: Provision of comprehensive training that focuses on promoting self-efficacy for counseling likely will increase pharmacists’ tobacco cessation counseling activities. # 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Smoking cessation; Tobacco cessation; Patient counseling; Pharmacist

1. Introduction Health-care providers are uniquely positioned to serve as a cornerstone for the nation’s tobacco prevention and cessation efforts, having both access to quitting aids and commanding a level of respect that renders them particularly influential in advising patients on health-related issues. To date, physicians have received the greatest attention in the scientific community as providers of tobacco cessation treatment. Less attention has been paid to other health-care providers in the community, such as pharmacists, yet of all health professionals, pharmacists are the most easily accessed by the public and thus are ideally situated to * Corresponding author. Tel.: +1 203 785 7367; fax: +1 203 785 6279. E-mail address: [email protected] (K.S. Hudmon).

initiate behavior change among patients or complement the efforts of other providers. Unlike most other clinicians, advice from a pharmacist does not require an appointment or medical insurance; as such, pharmacists have the opportunity to reach and assist underserved populations, which often suffer from a disproportionately higher incidence of tobacco-related diseases [1]. Furthermore, because three nicotine replacement therapy (NRT) formulations—the nicotine gum, lozenge, and transdermal patch—are available without a prescription the U.S., the pharmacist might be the only health professional to come into contact with many tobacco users prior to or during their quit attempts. The idea of having pharmacists counsel patients for tobacco cessation is not new ([2–15]). While the impact of pharmacists on quit rates has yet to be confirmed in metaanalyses, preliminary results from controlled trials appear

0738-3991/$ – see front matter # 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2005.03.009

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favorable [16]. Pharmacists have proven to be cost-effective components of tobacco cessation programs [17,18], and research shows that receiving specialized training for providing tobacco cessation counseling increases pharmacists’ likelihood of discussing tobacco use with their patients and promotes greater patient satisfaction with the pharmacists’ counseling sessions [10]. Given the opportunity to engage in community-based tobacco outreach and education, Williams et al. [19] found pharmacists to be willing and interested in participating in this type of activity. The pharmacist is a logical provider for tobacco cessation counseling; however, most studies have found that pharmacists do not routinely discuss tobacco use with their patients [4,14,19–22]. In an effort to gain information to determine whether training programs are needed to equip pharmacists with the knowledge and skills necessary to take an active role in reducing the prevalence of tobacco use, we conducted a cross-sectional survey to characterize the pharmacists’ role in tobacco cessation and determine factors associated with provision of cessation counseling.

2. Methods

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preceded by a cover letter and consent form. The cover letter listed six state and national pharmacy organizations that encouraged pharmacists’ participation (see Acknowledgements). Participation required written informed consent, which was submitted with the completed survey. The survey instrument and study procedures were approved by an institutional review board for the protection of human subjects. The survey administration methods [23] included (a) a notification postcard at 1 week, (b) the 10-page survey with a $ 5 bill, (c) a reminder postcard at +1 week, (d) a replacement survey with reminder note to nonresponders at +2 weeks, and (e) a replacement survey with reminder note to nonresponders at +4 weeks. All postage was prepaid. 2.3. Study measures 2.3.1. Sociodemographics and practice setting The respondent population was characterized by sex, race/ethnicity, age, smoking status, employment status, and professional experience (education, practice setting, and whether the respondent’s current position involves patient interaction).

2.1. Study population A publicly available listing of names and addresses for all licensed pharmacists (n = 2364) in four Northern California counties (Alameda, Merced, San Francisco, San Mateo) was obtained from the State of California Department of Consumer Affairs. These counties were selected to provide representation of urban, suburban, and rural practice environments. Because many of the opinions that we were assessing pertained to the pharmacy profession in general, we chose not to limit our study to specific practice settings. 2.2. Survey development and data collection procedures A survey instrument was constructed and reviewed by nine experts, including tobacco researchers, faculty members at schools of pharmacy, and practicing pharmacists. Although the survey was primarily descriptive in nature, elements of theory were woven throughout the survey, including scales assessing self-efficacy for counseling and perceived pros and cons for counseling as predictors of selfreported tobacco cessation counseling activities. Based on responses received from a pilot survey sent to a randomly selected subset of the study population (n = 150), the survey was revised and administered in 1999–2000 to the remainder of the population (n = 2219, including pharmacists from the subset of 150 who had moved and forwarding addresses were available). Skip patterns were incorporated into the survey to account for the wide variety of pharmacy practice settings, some of which involved patient interaction and some of which did not. The final survey was 10 pages,

2.3.2. Current practice behaviors The survey instrument was created just prior to introduction of the 5 A’s treatment model (Ask about tobacco use, Advise tobacco users to quit, Assess readiness to quit, Assist with quitting, Arrange with quitting) [24]; therefore the 4 A’s model (Ask, Advise, Assist, Arrange) intervention framework proposed by the National Cancer Institute [25] was used. Using this model, we assessed the extent to which pharmacists (a) ask patients whether they use tobacco, (b) advise tobacco users to quit, (c) assist patients with quitting, and (d) arrange a follow-up visit with those patients who were counselled for cessation. Because patients receiving prescription medications commonly receive a level of care above that which is received by consumers purchasing nonprescription medications (for example, a patient profile is maintained and new medications can be screened for potential drug–drug interactions and contraindications), our survey items (for Ask and Assist) were constructed to capture potential differences for these two patient populations. Additionally, pharmacists rated their perceived self-efficacy for counseling (12 items, Cronbach alpha = 0.94; one factor accounting for 61.0% of the variance); perceived pros (8 items, Cronbach alpha = 0.86) and cons (7 items, Cronbach alpha = 0.70) of counseling (2 factors accounting for 45.4% of the variance); perceived effectiveness of the pharmacist in helping patients to quit on a 5-point scale (poor = 1, fair = 2, average = 3, good = 4, excellent = 5); and reported the number of patients whom they had counselled for cessation in the past month. Survey items for our newly developed self-efficacy, pros, and cons scales are presented in Appendix A.

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2.3.3. Counseling for nonprescription NRT use In assessing perceived barriers to counseling for nonprescription NRT, respondents rated their perception of the extent to which 15 specific barriers (Table 2) precluded or prevented pharmacist counseling activities (rating scale: not at all important = 1, slightly important = 2, fairly important = 3, very important = 4, extremely important = 5). These items focused primarily on systems-related barriers to counseling, as opposed to the perceived cons scale, which focused primarily on pharmacists’ perceptions of their role in helping patients quit. Respondents also indicated whether they believed their primary practice setting had adequate facilities for providing private counseling for tobacco cessation. 2.4. Other measures In addition, we inquired about the perceived effectiveness of pharmacists in helping patients to quit, past training for tobacco cessation counseling, interest in receiving specialized training for cessation, and perceptions of how cessation training would influence their practice. Finally, we assessed perceptions regarding whether the pharmacy profession should be more or less active in tobacco prevention and cessation activities.

statistics and cross-tabulations to describe the respondents, their opinions, and their counseling behaviors. Total scores were computed for the pros, cons, and self-efficacy scales, and the pros and cons scores were converted to t-scores for analysis. Logistic regression was conducted according to backward stepwise procedures described by Hosmer and Lemeshow [26], identifying factors associated with tobacco cessation counseling behavior of pharmacists who were currently working in a practice setting that involved patient interaction (n = 715). Factors that were considered include age, sex, race/ethnicity (dichotomized as white or nonwhite), smoked 100 or more cigarettes in lifetime, years in practice, education (doctor of pharmacy [Pharm.D.] or not), type of practice setting (community or other), previous training for tobacco cessation counseling, perceived pros of counseling, perceived cons of counseling, self-efficacy for counseling, and perceptions regarding adequacy of facilities for cessation counseling (adequate or inadequate). The dichotomous dependent variable in these regression analyses was reported cessation counseling of four or more patients per month (coded 1) versus fewer than four per month (coded 0). A p value of <0.05 was considered significant for retention in the final model.

3. Results 2.5. Data handling and analysis 3.1. Study population All survey responses were double-keyed (entered twice) to ensure accurate data entry. Statistical analyses, conducted using SPSS version 10.1.3, involved simple summary

Of the 2219 pharmacists to whom we mailed a survey, return mail indicated that 63 had moved outside of the

Table 1 Respondent characteristics (n = 1168) Characteristic

Category

Numbera

Percent of responses

Sex

Male Female Asian or Pacific Islander Caucasian African American Hispanic or Latino Others BS or BA MS or MA Doctorate in pharmacy (Pharm.D.) Residency Doctorate other than Pharm.D. Pharmacy-related position Patient contact as part of pharmacy-related positionc Retired Traditional chain pharmacy Independently owned pharmacy Hospital Health maintenance organization Other pharmacy-related position Range: 23–90

604 559 646 451 15 14 23 708 76 722 175 39 955 715 122 334 130 307 157 213 Average: 46.7

51.9 48.1 56.2 39.3 1.3 1.2 2.0 60.6 6.5 61.8 15.0 3.3 81.8 74.9 10.4 35.0 13.6 32.1 16.4 22.3 S.D.: 13.6

Race/ethnicity

Educationb

Employmentb

Practice settingb,c

Age in years a b c

Values might not sum to 1168 because of missing data. Categories are not mutually exclusive; therefore, totals exceed 100%. Of 955 pharmacists working in a pharmacy-related position.

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selected counties or had moved with no forwarding address. Of the remaining 2156 pharmacists in the study population, we received 1168 completed surveys (54.2% response). Table 1 summarizes key characteristics of respondents. 3.2. Current practice behaviors Of 715 respondents for whom direct patient interaction is part of their pharmacy-related position, 26.8% reported that they do not counsel any patients for tobacco cessation during a typical month. The median number of patients counselled per month was 4.0. Nearly half (48.1%) of the 519 pharmacists who practice in settings where nonprescription NRT are available for purchase estimate that fewer than 20% of patients purchasing these products from their workplace receive counseling by a pharmacist. On average, most (37.7%) pharmacists estimated that they spend between 1 and 2 min per patient counselled on use of nonprescription NRT; 5.0% spend less than 30 s, 21.3% spend 30 s to 1 min, 32.5% spend 3–5 min, and 3.5% spend more than 5 min. The primary barrier to counseling patients for nonprescription NRT most often cited by pharmacists was that they were not aware when the products were being purchased; this barrier was perceived to be either fairly (21.6%), very (26.5%), or extremely important (30.8%) by 78.9% of respondents (mean item score, 3.54; S.D., 1.35). Other important barriers to counseling for nonprescription NRT are presented in Table 2. When asked to rate whether the need for more training for counseling for an addiction is an important barrier, 21.8% reported that it was not at all important; 17.9% rated it as slightly important, 21.4% fairly important, 22.8% very important, and 16.1% extremely important. More than half (51.6%) of respondents who directly interact with patients as part of their practice felt that they had inadequate facilities for providing private tobacco cessation counseling.

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Fig. 1 presents the pharmacists’ responses to questions regarding implementation of the Ask, Advise, Assist, and Arrange practice model [25]; these statistics pertain to past-month counseling behavior among 715 pharmacists who have direct interaction with patients as part of their routine practice activities. Responses suggest low levels of tobacco cessation intervention activity. For example, most survey respondents (52.5%) had not assessed the tobacco use status of any prescription patients in the preceding month. 3.3. Predictors of tobacco cessation counseling activities In bivariate analyses among the 715 respondents for whom direct patient interaction is part of their pharmacyrelated position, the following factors were associated with the dichotomous dependent variable (providing tobacco cessation counseling to four or more patients per month versus fewer than four per month) at p < 0.20 and thus were entered into the multivariate logistic regression analyses: race/ethnicity of the pharmacist ( p = 0.003), whether the pharmacist perceived that s/he had adequate counseling facilities for private counseling for tobacco cessation ( p = 0.008); perceived effectiveness of counseling by a pharmacist for helping patients to quit ( p = 0.04), past formal training for tobacco cessation counseling ( p = 0.004); perceived pros of counseling ( p < 0.001), perceived cons of counseling ( p < 0.001); self-efficacy for tobacco cessation counseling ( p < 0.001); and practice setting ( p < 0.001). Sex, age, ever smoking (100 or more cigarettes in lifetime), years practiced, and whether the respondent had received a Pharm.D. degree were unrelated ( p > 0.20) to counseling. Table 3 shows results of the final model. Variables include the race/ethnicity of the pharmacist (white more likely to counsel than non-white),

Table 2 Barriers to providing counseling for nonprescription NRT productsa Barrier

Mean (S.D.)b

% Reported as ‘‘very’’ or ‘‘extremely’’ important

Not always aware when nonprescription patches or gum are being bought Not enough time for OTC patch and gum counseling Pharmacy is not adequately staffed Burdened with pharmacy paperwork and other technical duties Lower priority for OTC patch and gum counseling versus other duties Lack of ongoing pharmacist-patient relationship with most OTC customers Need more training for counseling for an addiction Difficult to show value of counseling Lack of patients’ expectations or acceptance of pharmacists as counselors for tobacco cessation Need more training for patch and gum knowledge Not reimbursed for OTC patch and gum counseling Lack of private area for counseling Location of patches and gum is not always convenient to the pharmacist Pharmacy management does not encourage counseling for OTC patches and gum Dislike counseling patients for tobacco cessation

3.54 3.50 3.39 3.29 3.16 3.09 2.94 2.85 2.77

(1.35) (1.28) (1.36) (1.44) (1.31) (1.41) (1.39) (1.40) (1.34)

57.3 56.9 52.8 51.0 44.1 44.3 38.9 36.0 30.6

2.67 2.60 2.60 2.36 2.30 1.65

(1.37) (1.59) (1.43) (1.42) (1.43) (1.02)

30.7 33.1 28.3 23.6 23.4 7.1

a b

Among 519 pharmacists who have direct contact with patients in practice settings where NRT is stocked for purchase. Rating scale: 1 = not at all important, 2 = slightly important, 3 = fairly important, 4 = very important, 5 = extremely important.

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Fig. 1. Pharmacists’ counseling for tobacco cessation—Ask, Advise, Assist, Arrange: reports of past-month behavior (n = 715).

practice setting (community pharmacists more likely to counsel than other settings), perceived pros of counseling (higher perceived pros is associated with higher frequency of counseling), and self-efficacy for counseling (higher selfefficacy is associated with higher frequency of counseling). Although prior formal training for tobacco cessation counseling was not included in the final model, t-tests indicated that prior training is positively associated with both the perceived pros of counseling ( p < 0.001) and selfefficacy ( p < 0.001) and inversely associated with the perceived cons of counseling ( p = 0.007). As anticipated, the perceived pros and cons of counseling scale scores were inversely related (r = 0.38, p < 0.01), and the self-efficacy scale scores were positively correlated with the perceived pros scores (r = 0.46, p < 0.01) and negatively correlated with the perceived cons scores (r = 0.28, p < 0.01).

Table 3 Binary logistic regression model predicting tobacco cessation counseling activitiesa Predictor variableb

Odds ratio

95% confidence interval

Pharmacists’ race/ethnicity [non-white] Self-efficacy for counseling Practice setting [not community pharmacy] Perceived pros of counseling (t-scores)

1.71 1.63 1.49

1.21, 2.43 1.30, 2.05 1.06, 2.10

1.05

1.03, 1.07

3.4. Pharmacists’ perceived role in tobacco control and training for tobacco cessation counseling When pharmacists who worked in a position that involved direct contact with patients (n = 715) were asked to rate pharmacists’ effectiveness in assisting patients with quitting, the distribution was as follows: 6.3% poor, 16.4% fair, 37.3% average, 31.4% good, and 8.5% excellent. Of all respondents (n = 1168), 82.3% believed that the profession should be more active in preventing the onset of tobacco use, and 86.4% believed that the profession should become more active in assisting tobacco users with quitting. However, results indicated that of respondents employed in a pharmacyrelated position that involves direct patient interaction (n = 715), only 8.9% have received formal training for tobacco cessation counseling (7.5% of all respondents). Of these pharmacists, 87.5% expressed an interest in receiving formal training; 70.2% indicated that the training would increase the number of patients that they counsel; and 93.5% indicated that the training would increase the quality of the assistance that they provide to patients. When asked the maximum number of hours they would be willing to spend to be trained for comprehensive tobacco cessation counseling through a ‘‘live’’ continuing education program or workshop, the response distribution was as follows: 1–2 h, 25.7%; 3–4 h, 37.1%; 5–6 h, 11.0%, and 7–8 h, 15.0% (11.1% were not interested in a live training).

a

Among 715 pharmacists who report patient contact as part of pharmacyrelated position. Dependent variable is counsels fewer than four patients per month (coded 0) versus counsels more than four patients per month (coded 1). b Referent group indicated in brackets for categorical variables. Perceived pros of counseling and self-efficacy for counseling were treated as continuous variables.

4. Discussion Our survey of 1168 licensed pharmacists in northern California suggests that pharmacists do not routinely engage in tobacco cessation counseling activities. To our knowl-

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edge, this is the largest US-based study evaluating pharmacists’ practices and opinions related to tobacco cessation. Fewer than 4% of respondents who have direct patient care responsibilities routinely (more than 80% of the time) ask their patients about tobacco use. This finding is lower but comparable to the 7.5–12.2% rate observed in previous studies of pharmacists [14,19,22]. Because identifying tobacco users is a crucial step in the treatment of tobacco use and dependence, systematic changes in the pharmacy practice environment are necessary if pharmacists are to assume a more significant role in the provision of cessation services. For example, routine use of pharmacy computer system software to document smoking status (similar to the procedure for documenting drug allergies) could screen for potential smoking–medication interactions and serve as a prompt for the pharmacist to engage in cessation activities [27]. Given that pharmacists might be the only health-care provider with an opportunity to counsel patients who opt to use nonprescription NRT products, a primary goal of our survey was to characterize factors that we thought would impact the pharmacist’s ability to serve this role. Nearly half (49%) of pharmacists reported that fewer than one-fifth of patients who purchase nonprescription NRT agents receive counseling in their practice setting, and the primary barrier to provision of counseling for nonprescription NRT is that pharmacists are not aware of when the products are being purchased. It is possible that even simple and inexpensive changes within the pharmacy, such as relocating the NRT products to behind the pharmacy counter, or in close proximity, could result in more frequent tobacco cessation counseling interventions [28]. Approximately half of respondents who interact with patients as part of their practice felt that they had inadequate facilities for providing private counseling for tobacco cessation, however this situation likely improved with the privacy regulations of the U.S. Health Insurance Portability and Accountability Act (HIPAA). Although prior research has demonstrated that receiving specialized tobacco cessation training leads to an increased frequency of cessation counseling among healthcare professionals in general [29], it has yet to be demonstrated whether reimbursement for this cognitive service, and what level of reimbursement, would be needed to further enhance pharmacists’ cessation activities. While most pharmacists currently are not being utilized as a resource for quitting, patients perceive the pharmacy to be a convenient place to receive cessation counseling [21], and an estimated 63% of nonprescription NRT users believe that receiving advice or assistance from a pharmacist would either probably (46%) or definitely (17%) increase a smoker’s likelihood of being able to quit [20]. Indeed, 46% of quitters reported that they would be either very or extremely likely to meet with a pharmacist for one-on-one counseling if a nominal ($10) co-payment were required; this percentage increased to 68% if the service was to be provided at no cost [20].

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Significant predictors of tobacco cessation counseling included the perceived pros of counseling, the perceived confidence in tobacco cessation counseling abilities (selfefficacy), and the pharmacist’s racial/ethnic background. Our data reveal that receiving formal training increases clinicians’ likelihood of counseling, but in multivariate regression analysis, self-efficacy for counseling outweighs our prior training variable. As such, we infer that tobacco training programs focusing on enhancing confidence in counseling will be most effective in increasing the number of patients counselled. The racial/ethnic differences in counseling that we identified are difficult to explain. While the majority of our respondents were of Asian or Pacific Islander origin, we did not assess the racial/ethnic background of patients whom they served. If pharmacists of Asian or Pacific Islander origin choose to practice in communities comprised primarily of Asian or Pacific Islander patients, one would expect lower levels of tobacco cessation counseling because the prevalence of smoking is lower in these populations [30]. In our regression analyses, we combined all non-White participants, because these subgroups exhibited very similar odds ratios for counseling. Further investigation of this finding is warranted. While few pharmacists have received formal training for tobacco cessation counseling, and few currently address tobacco use with their patients, the vast majority of respondents believed that the profession should be more active in tobacco cessation activities. Nearly 90% expressed interest in receiving specialized tobacco cessation training. Seventy percent believe that formal training will increase the number of patients whom they counsel for quitting and 93% believe training will increase the quality of their counseling for tobacco cessation. Because training increases cessation counseling interventions [10,29,31], efforts should be made to provide comprehensive, evidence-based training to practicing pharmacists through continuing education programs and to students through required pharmacy school coursework [32]. At a minimum, pharmacists (particularly those who are not trained to provide cessation counseling) should ask about tobacco use, advise patients to quit, and refer these patients to a toll-free quitline (e.g., 1-800-QUITNOW). Indeed, schools of pharmacy across the United States are taking steps toward equipping their students with tobacco cessation counseling skills through the dissemination and adoption of the Rx for Change: Clinician-assisted Tobacco Cessation curriculum [33–35]. This curriculum, which has been taught to more than 10,000 pharmacy students over the past 5 years, equips students with the knowledge and skills to provide comprehensive cessation counseling. It is reasonable to assume that this program, along with other recent initiatives since the administration of our survey, have led to increases in pharmacists’ tobacco cessation counseling activities. Currently ongoing activities, such as the newly created (October 2004) Pharmacy Partnership for Tobacco Cessation (sponsored by the Robert

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Wood Johnson Foundation and the University of California San Francisco Smoking Cessation Leadership Center), brings together key leaders within the profession to create, implement, and evaluate a national action plan that aims to enhance the tobacco cessation counseling role of pharmacists in all practice environments.

continuing education programs. At a minimum, pharmacists should routinely screen for tobacco use among patients and refer tobacco users to local resources for quitting, such as smoking cessation groups or toll-free quitlines.

Acknowledgements 5. Conclusion As an important interface and communication link between the health-care system and tobacco users, pharmacists are uniquely positioned to assist patients with quitting. However, our data suggest a lack of tobacco cessation counseling activity by pharmacists. Although few pharmacists have received formal training for providing support for cessation, there is substantial professional interest in further developing this role, and our data suggest that this training will yield an increase in tobacco cessation counseling activities.

6. Practice implications Given that the average American household visits a community pharmacy 15 times each year [36], the potential for pharmacist-assisted tobacco cessation is enormous and could have a substantial impact in reducing the prevalence of tobacco use. Nationwide, more than 50,000 community pharmacies employ approximately 136,773 pharmacists [37]; if each of these pharmacists successfully assisted just 1 tobacco user in quitting each month, this would result in more than 1.6 million quitters annually. Additionally, pharmacists are employed in various other settings, including health maintenance organizations, hospitals, and clinics. Comprehensive counseling from a pharmacist not only provides patients with information and social support for their quit attempts, but also could improve the poor compliance rates commonly observed with NRT treatment regimens [38–40]. Furthermore, because pharmaceutical aids for cessation are available primarily through pharmacies, and because pharmacists might be the only health-care provider with an opportunity to provide cessation interventions to the under-insured and patients who opt to use nonprescription NRT, it is imperative that pharmacists receive formal training for tobacco cessation counseling. Training programs should focus on highlighting the pros of counseling and promoting self-efficacy for counseling, such as through role playing or the use of standardized patients. To ensure that all future pharmacists are equipped with stateof-the-art knowledge and skills for promoting cessation, schools of pharmacy should ensure that all graduates achieve competency in addressing this key risk factor for disease and death. Furthermore, employers and national, state, and local pharmacy organizations are encouraged to support the training of licensed pharmacists through evidence-based

This study was funded by the University of California Tobacco-related Disease Research Program grant 7IT-0169 to K. Hudmon. The authors acknowledge the following organizations for permitting use of their name in the survey cover letter: California State Board of Pharmacy, American Pharmacists Association, California Pharmacists Association, California Society of Health-systems Pharmacists, American Society of Consultant Pharmacists, and California Pharmacy Partnership of the California Medical Association Foundation. Bruce A. Berger, Ph.D., R.Ph., Carlo C. DiClemente, Ph.D., Janet Brigham, Ph.D., Ellen R. Gritz, Ph.D., James Krebs, Pharm.D., Lisa A. Kroon, Pharm.D., Helen E. Smith-Holland, Ph.D., R.Ph., David M. Suchanek, R.Ph., and Jeff Taylor, Ph.D. reviewed the survey instrument. Ruth Krasnow provided data management support, and Liv Trondsen coordinated survey administration and data coding. Judith DePue, Ed.D. and Jeff Taylor, Ph.D. provided previously tested study measures that facilitated our survey and scale development.

Appendix A. Scale items A.1. Self-efficacy for tobacco cessation counseling How much confidence do you have in the following aspects of tobacco cessation counseling? Please circle one number for each item, using the response options shown below. 1 = Not at all confident, 2 = not very confident, 3 = moderately confident, 4 = very confident, 5 = extremely confident. How confident are you that you: a. Know the appropriate questions to ask patients when providing counseling? b. Have the skills needed to counsel for an addiction? c. Can provide motivation to patients who are trying to quit? d. Have the skills to monitor and assist patients throughout their quit attempt? e. Have the skills to assist patients who seem to be in a hurry? f. Have sufficient therapeutic knowledge of the pharmaceutical products for tobacco cessation? g. Can create consumer awareness of why pharmacists should ask questions about tobacco use? h. Know when a referral to a physician is necessary?

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i. Are able to apply sensitive methods of suggesting tobacco cessation to patients who use tobacco? j. Are able to provide adequate counseling when time is limited? k. Can help recent quitters learn how to cope with situations or triggers that might rekindle old tobacco use habits? l. Can provide counseling to patients who are not interested in quitting?

[2]

[3]

[4]

A.2. Pros and cons of tobacco cessation counseling How much do you agree or disagree with the following statements in terms of your decision to counsel tobacco users? Please circle one number for each item, using the response options shown below. 1 = Strongly disagree; 2 = disagree; 3 = not sure; 4 = agree; 5 = strongly agree. a. It is important for me to counsel, because people can buy nicotine patches or gum without seeing a physician (pro). b. It is difficult for me to get people to quit using tobacco (con). c. Counseling for cessation is not an efficient use of my time (con). d. Patients thank me when I provide advice for stopping tobacco use (pro). e. My counseling will increase a patient’s likelihood of quitting (pro). f. Tobacco counseling improves my relationship with patients (pro). g. Pharmacy management is pleased with my level of patient care when I provide tobacco cessation counseling (pro). h. Helping with tobacco cessation makes me feel useful to patients (pro). i. I find counseling patients about tobacco to be frustrating (con). j. Patients appreciate it when I provide tobacco cessation counseling (pro). k. I find tobacco cessation counseling to be a thankless task (con). l. Lack of reimbursement makes me less likely to counsel for cessation (con). m. As a pharmacist, I play an important role in countering tobacco use (pro). n. I have insufficient time to provide tobacco cessation counseling (con). o. If patients can’t quit using tobacco on their own, there is little that I can do (con).

[5]

[6]

[7]

[8] [9]

[10]

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[13]

[14]

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[17] [18]

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