How pharmacists can support efforts to quit smoking

Quitting smoking benefits health at every age, reducing risks ranging from cardiovascular disease to cancer, adding up to 10 years to life expectancy, and protecting coworkers, family members and friends from secondhand smoke.^[1] From an employer’s perspective, when employees stop smoking, it can improve employee health, increase productivity, reduce costs, enhance job satisfaction and result in a better corporate image.^[2]

However, quitting smoking can be very difficult and many people don’t succeed on their first attempt. Underscoring that point, Mark Twain is said to have quipped, “Giving up smoking is the easiest thing in the world. I know because I’ve done it thousands of times.”

That said, 70.6% of Canadians who smoked at some point in the past have succeeded in quitting. Many of those who haven’t yet kept trying, with 44.5% of people who currently smoke saying they had attempted to stop within the past year. Quit attempts don’t tend to skew towards men, towards women or to a specific age range. Everyone’s trying.^[3]

And, with every attempt to quit, people learn something new about their strengths, temptations and smoking patterns, and they can often identify areas for improvement that make the next attempt easier and more likely to be successful. As they move forward on this journey, it helps to draw on all available resources – and that can include a supportive pharmacist.

Manitoba has formalized pharmacists’ role in smoking cessation into the Quit Smoking with Your Manitoba Pharmacist program. Launched in April 2022, it’s the province’s first health-related program funded by a social impact bond. Any Manitoban 18 or older who wants to quit smoking can access counselling sessions at their local pharmacy, along with up to $100 in prescribed medications and nicotine replacement therapies over the course of a year.

In other provinces, there may not be a formal program in place – but pharmacists can still play a critical part in helping smokers quit. For example, pharmacists can:

• Help people choose non-prescription nicotine replacement therapies from among multiple formulations that include patches, gum, mists and inhalers
• Offer counsel on how to use medications and deal with side effects, and explain why it’s important to comply with recommended doses
• Provide tips, strategies and resources that empower people with practical steps and actions

Perhaps most importantly, pharmacists can offer non-judgemental support at every stage of the journey – support that helps people who want to quit smoking understand they are not alone in the effort.

Getting started

Sometimes, people approach pharmacists with their intention to quit smoking. Other times, pharmacists can plant the seed of the idea by asking, “Do you smoke?” If they say yes, pharmacists can ask for permission to take the conversation further by saying something like, “Are you willing to briefly discuss your tobacco use?” If there’s agreement, pharmacists have an opportunity to ask, “What do you think about quitting?”

If someone has already been considering quitting but hasn’t taken any steps towards that goal, simply raising the topic in a healthcare setting may set them on a course towards smoking cessation. If they haven’t thought much about it, a pharmacist pointing out that quitting can improve underlying conditions such as asthma and hypertension may be the nudge they need. Whether or not someone has a pre-existing condition, the pharmacist can provide a handout listing multiple reasons to quit as motivation.

Having a plan is essential to strengthen someone’s commitment to smoking cessation. Once someone has decided to give it a try, a pharmacist can encourage them to:

• P – pick a quit day
• L – let friends, family and coworkers know you plan to quit
• A – anticipate triggers (see below) and avoid, find alternatives or adjust to deal with them
• N – access nicotine addiction medication if appropriate

Pharmacists can also provide education and direct people towards vetted websites on multiple relevant topics.

For example, it’s important for people to be aware of withdrawal symptoms and learn how to manage them – an area where pharmacists have plenty of expertise to share. Knowing you may experience restlessness and boredom, anxiety and depression, stress, headaches, cough, fatigue and insomnia, digestive problems, trouble concentrating and weight gain means you’ll be more likely to accept these symptoms and ride them out.

In addition, pharmacists can provide psychological support and offer suggestions to deal with stress. These may include practising relaxation techniques, deep breathing, exercising, reducing or eliminating caffeine, and organizing days to avoid tension – especially on and immediately after the quit day.

Asking “What do you think will work for you?“ is a good way for pharmacists to get the information they need to tailor their approach and start people off on the path towards a life free of smoking.

Dealing with cravings

The first three days are often the most difficult for people who are quitting smoking. That’s when nicotine withdrawal symptoms generally peak. After that, the intensity of symptoms generally drops through the first month.

However, cravings may continue. They’re often the longest-lasting and strongest withdrawal symptom, and they’re hard to manage without some external support. Checking in with a pharmacist can help people stay on track, and the pharmacist can also share steps that have helped others, such as the five D’s:

• Delay – promise yourself you won’t smoke for two minutes
• Deep breathe – immediately take several deep breaths
• Drink – take a sip of cold water or unsweetened juice (e.g., grapefruit juice) or crunch a small piece of ice
• Do something else – get completely away from the situation that may be prompting you to want to smoke
• Dial-a-buddy – phone a friend for support

Pharmacists can also encourage people to create a list of specific reasons they want to quit that they can refer to when they feel a craving – for example, feeling better, getting healthier, sparing loved ones from secondhand smoke and saving money. This can help people stay focused on their goal so they can more easily stare down their cravings.

Managing triggers

Triggers are the situations that tempt people to smoke. They’re different for everyone, but may include activities such as leaving work or school, speaking on the phone, drinking alcohol or coffee, driving, and feeling angry or stressed. It’s important for people who are quitting smoking to identify their specific triggers so they can recognize the moments when they might slip and plan ahead to break the association.

Again, having a healthcare professional on their side can help people implement strategies to deal with triggers. Some approaches that may be helpful include:

• Write down as many triggers as possible
• Plan to manage the two or three strongest triggers by avoiding them for a while or deciding how you’ll cope with them
• Find other things to keep your hands and mouth busy at the times when you usually smoked, such as chewing gum, or jump into another activity you enjoy
• Remind yourself that just one puff can lead to another so it’s important to avoid even one drag
• Reward yourself for milestones or small successes such as an hour, a day or a week without smoking
• Stay focused on quitting smoking, without adding other goals (such as losing weight) at the same time
• Consider a treatment, such as medicine, a support hotline or a support group if you are having trouble managing triggers

Support is critical to managing triggers, whether that comes from family, friends, a support group or a pharmacist. Calling a support hotline – a pharmacist can provide the number – can also be very helpful in the midst of struggling against a trigger.  

Moving on from slips

It’s essential for anyone quitting smoking to understand the difference between a slip (a one-off lapse) and a relapse (resuming regular smoking), because acting quickly after a slip can stop it from progressing to a relapse. If a slip happens, it can be very helpful to reach out for support right away.

Pharmacists, in particular, can offer professional reassurance that a slip isn’t a sign of failure or a reason to become discouraged. They can emphasize that it’s simply a brief return to an old behaviour that doesn’t instantly turn someone into a smoker again. And they can encourage people to see a slip as a reminder to refocus on the goal of quitting smoking. 

It can help to think of a slip as “losing the battle but not the war.” What’s critical, pharmacists can remind people, is to try to figure out why the slip happened and make a plan for the next time something similar occurs. Then set the slip aside and pick up where you left off. 

Other strategies that can help people move on from slips include:

• Curbing temptations to smoke by making yourself wait two hours – then decide whether you really need the tobacco product
• Take a fresh look at your list of reasons to quit smoking and remember why you wanted to stop in the first place – then take control again
• Think of other situations in the past when you were tempted to smoke but didn’t – then remind yourself how strong you were then, and that you can be as strong again

A good overall strategy when quitting smoking is to make it hard to smoke. That means avoiding places where you can easily ask someone for a tobacco product, and not buying a pack to have on hand just in case.

Unless someone returns to regular smoking, it’s generally a good idea to continue medication or nicotine replacement therapy despite a slip – and pharmacists are trusted experts in medication who can recommend this. Making sure physiological aspects are addressed helps people who have slipped focus on managing the psychological side of cravings and triggers, and get back on track. 

Being accessible

Pharmacists are well positioned to provide advice related to smoking cessation because they are one of the most readily accessible healthcare providers. People can simply walk into a pharmacy or call their pharmacist when they need to talk. They don’t have to make an appointment. They can choose a time that works for them. They can drop by or pick up the phone as often as they wish. 

Pharmacists can also quickly connect people to other healthcare professionals if help is needed outside their scope of practice, and they can steer people towards excellent resources provided by organizations such as the Canadian Lung Association, Canadian Cancer Society, Heart and Stroke Foundation of Canada, Smokers’ Helpline, Health Canada and provincial smoking cessation programs.

From recommending medications and nicotine replacement therapy to offering regular follow-ups, psychological support and resources, pharmacists can be strong partners in the process to quit smoking. In the end, their most significant contribution may be to help people see there is a clear path forward, support is all around, and that a commitment to quit smoking will lead to success.

A smoking cessation roadmap for employers

A good starting point for employers who are interested in helping employees quit smoking is Health Canada’s guide to Smoking Cessation in the Workplace, which includes an employee needs assessment survey, calculation of workplace costs associated with smoking, checklist for assessing smoking cessation programs, and a range of educational handouts for employees.