Introduction

Smoking is the leading preventable cause of death in the United States.¹ Approximately 14% of the adult population are current smokers.² The rate of smoking continues to drop yearly, but disparities exist. The prevalence of smoking in medically underserved communities remains high, particularly among populations experiencing homelessness. Rates of cigarette smoking among homeless adults are three to four times higher than the general population.³ The rate of smoking-induced death and disease among the homeless are also disproportionately high. Despite the high rate of smoking, homeless smokers do not differ from the general population in their desire to quit.³ Smokers with substance use disorder have an even higher prevalence and smoke at five times the rate of the general population.⁴ Between 70-90% of individuals receiving treatment for substance use disorder smoke cigarettes.⁴ The impact on death rates is significant, in fact they have twice the expected rate of deaths attributable to tobacco use than in the general population.⁵ Like smokers who are homeless, individuals with substance use disorder are interested in quitting.⁵

Smoking cessation services are not always offered to these populations due to the belief that quitting is a low priority or may interfere with substance abuse recovery. The literature supports that smoking cessation does not generally adversely affect substance use outcomes.⁶ Effective smoking cessation services for the medically underserved are needed to reduce tobacco-related health disparities.

Pharmacists are key advocates in assisting patients toward cessation. Quit rates are higher when a pharmacist is involved. Pharmacists are accessible in most communities and nicotine replacement product are available over the counter. Nicotine replacement products will help with the physical aspects of addiction, but patients need more than just a product when trying to quit. They need assistance with behavioral modification and support. In addition, patients need a program that is tailored to their specific needs. In order enhance the delivery of services, there are pharmacist-focused materials available through the Centers for Disease Control and Prevention.⁷

Also needed is a setting that promotes cessation. One must consider the social determinants of health when creating a program.⁸ If the program fails to be comprehensive and these factors are not addressed, disparities may persist.

Case

CC: “I want to quit smoking!”

HPI: JS is a 54 year old white male (70 in, 80 kg) who started smoking when he was 10 years old. He is currently in a drug and alcohol rehabilitation program and heard that is it is easier to stay away from the alcohol if he quits smoking at the same time.

PMH: HTN (10 years)

SH:

• History of substance use, in rehabilitation for excessive alcohol use
• Patient has smoked Marlboro one pack per day for 44 years. He has tried quitting in the past, cold turkey, and his longest time staying smoke free is two weeks. He started smoking again both times because of stress. This time he would like some help and is requesting the nicotine patch. He is highly motivated to quit, he rates his motivation a 10 on a scale of 10 and is somewhat confident in his ability to quit where he rates himself an eight on a scale of 10. His biggest motivation for wanting to quit is his health and the biggest barriers or concerns about quitting are stress and being around smokers.

FH:

• Father: alive with HTN and CAD
• Mother: Unknown

Medications:

• Hydrochlorothiazide 25 mg PO daily

Labs:

• BP 128/88 mmHg
• HR 64 bpm
• BMP normal

SDH: White male, divorced and was homeless for six months before he joined the rehabilitation program. His income last year when working was $15,000. He is not currently working.

Additional context: Smoking cessation is a challenge for JS. Participants of the rehabilitation program live at the facility. The residents are not allowed to go anywhere without an escort/chaperone. Residents may smoke, but they must smoke outdoors. A smoke break is sometimes viewed as a “reward” because the patient is allowed outside of the building.

Case Questions

1. What is the prevalence of smoking in an underserved population? Those living in poverty? Those who are homeless? Those who drink alcohol or use other drugs?

Smoking rates are higher in underserved populations. In fact, according to the Centers for Disease Control, 25% of those who live in poverty smoke compared to 14% of those who have incomes above the federal poverty level. When looking at other factors, 41% those with a GED are smoke cigarettes. Approximately two-thirds of adults who are homeless are current smokers. The numbers are even more concerning when looking at patients who suffer from alcohol addition, where close to 90% use tobacco. The highest rate is reported among those with substance abuse disorder where there are report of up to 97% of the population being current smokers.

2. What types of interventions have an impact on the smoking rates of individuals? On the smoking rates of communities? On the smoking rate of populations?

At the individual level, according to the Agency for Healthcare Research and Quality Treating Tobacco Use and Dependence Guidelines, providers should ask patients of their smoking status at each visit. Assistance with quitting should be offered to all smokers who wish to quit. Smoking cessation strategies should include counseling and/or medications but medication alone or counseling alone are also acceptable. Smokers should be offered both since quit rates improve when using counseling and medication in combination unless there is a special consideration such as pregnant women or adolescents.

At the community level, organizations have implemented community-based smoking cessation initiatives such as the American Lung Association’s Freedom From Smoking and the American Cancer Society’s Fresh Start program. Strategies such as community-based smoking cessation interventions disseminated in partnership with community organizations has shown to be beneficial among urban African American smokers. Policy level interventions could include the expansion of insurance coverage for proven smoking cessation treatments. Standardized packaging to packs of cigarettes may to reduce the appeal. Smoking bans in indoor spaces make it easier for those who are quitting to abstain. An increase in taxes results in an increase in cost and may impact smoking rates.

3. Describe how you would conduct a smoking cessation intervention for JS. How would you assess JS’s stage of change? What are the levels of intervention to consider?

JS is in the contemplation stage of change. He is ready to quit but has not yet made a plan. You should provide support and materials that align with JS’s stage of change. JS is highly motivated to quit. You may wish to consider an intervention to increase his confidence. Since JS is interested in the nicotine patch, the Agency for Healthcare Research and Quality Treating Tobacco Use and Dependence Guidelines recommend nicotine replacement for eight weeks starting with the 21 mg per day nicotine patch and tapering down over eight weeks. In order to increase the chance of a successful quit attempt, individual counseling on his quit day and follow-up within two weeks would be beneficial. Since stress was the trigger for JS’s relapse, you may wish to provide some strategies for managing stress such as deep breathing techniques. Behavior modification is an important aspect of a successful quit attempt. You should work with JS to create a behavioral modification plan.

Since JS is in a substance abuse rehabilitation facility, it is likely that a majority of the people living there are current smokers. It is best to discuss temptations and strategies for behavior modification to avoid the situations where he is likely to smoke. If many of the clients at the facility wish to quit, typically 70% of current smokers want to quit, you may consider working with the rehabilitation facility staff on a policy change regarding smoking at the facility.

4. Using the socioecological model, discuss interventions that may be helpful in lowering the smoking rate in this population in the drug and alcohol rehabilitation program. Describe individual level interventions, community level and policy level interventions that may have an impact.

A socioecological approach includes considering all of the levels of influence in JS’s smoking habits and behaviors. Individual factors may include those associated with income, stress and substance abuse history. Interpersonal factors may include social ties such as being around other smokers. In the case of JS, his social network will likely include substantial numbers of other smokers, which limits opportunities for change. Organizational factors may include living conditions in the rehabilitation facility. Community factors may include exposure to tobacco advertising and ready availability of tobacco products. Policy level or society factors include regulatory efforts prohibiting smoking in public places, taxation policies and restrictions on advertising.

Author Commentary

Smoking is the leading preventable cause of death in the United States.¹ Although the number of adults who smoke continues to decrease, disparities exist in smoking rates.⁸ Certain population continue to smoke at much higher rates than the general population.⁸ Despite the higher rates of smoking, these populations have a desire to quit.^9,10Guidelines for smoking cessation should be used in all populations who smoke.¹¹ Smoking cessation programs have been successful in some of the hard to reach populations.¹² Quitting smoking may be beneficial for other aspects of patients’ health including substance abuse.¹³ Pharmacists should offer smoking cessation assistance to all patients who smoke.¹⁴ Providers must consider all aspects that influence cessation rates when offering services.¹⁵ Smokers who participate in a structured smoking cessation program are more likely to quit.¹⁶

Patient Approaches and Opportunities

Nicotine is a highly addictive compound. Cigarette smoking is one of the most challenging addictions. Most smokers want to quit and those who get help have higher quit rates. Pharmacists are in an ideal position to help.

Every smoker must be asked about their smoking status and desire to quit at each visit with a health care provider. Standardized screening allows this to be automatic and ensures no patient is excluded. Ideally patients may be provided with patient-centered tools for assistance with each quit attempt. These tools must target the behavioral and physical aspects of addiction.

It is not easy to quit and there is no perfect time to quit, but services should be offered. Pharmacists are in an optimal position to assist with smoking cessation. Pharmacists are one of the most accessible health care providers and have nicotine replacement therapy readily available in most circumstances. It may require multiple attempts, but each time the patient acquires cessation skills.