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Come Experience What Others Already Know... The Insurance Trust
GREAT BENEFITS! Prescription Drug Coverage Dental and Orthodontic Benefits $500 Wellness Benefit Guaranteed Issue Term Life Insurance... up to $50,000 (no underwriting requirements)
Call or e-mail TODAY to schedule a time to discuss your health insurance needs.
Trevor Miller – Director of Insurance Services 404.419.8107 or email at tmiller@gpha.org Georgia Pharmacy Association Members Take Advantage of Premium Discounts Up to 30% on Individual Disability Insurance Have you protected your most valuable asset? Many people realize the need to insure personal belongings like cars and homes, but often they neglect to insure what provides their lifestyle and financial well-being - their income! The risk of disability exists and the financial impact of a long-term disability (90 days or more) can have a devastating impact on individuals, families and businesses. During the course of your career, you are 3½ times more likely to be injured and need disability coverage than you are to die. (Health Insurance Association of America, 2000) As a member of the Georgia Pharmacy Association, you can help protect your most valuable asset and receive premium discounts up to 30% on high-quality Individual Disability Income Insurance from Principal Life Insurance Company.
For more information visit www.gphainsurance.com. * Association Program subject to state approval. Policy forms HH 750, HH 702, HH 703. This is a general summary only. Additional guidelines apply. Disability insurance has limitations and exclusions. For costs and details of coverage, contact your Principal Life financial representative.
The Georgia Pharmacy Journal
2
September 2010
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Departments
Pharmacists Take Larger Role on Health Team
Pharm PAC 2010-2011 Fall Region Meeting GPhA New Members GPhA Board of Directors
Advertisers
FEATURE ARTICLES
5 9 10 17 28
7 11 12 31
Thank you to the 2009-2010 GPhA Board of Directors GPhA Member Jonathan Marquess Elected APhA Trustee GPhA Convention Wrap Up
2 2 5 5 6 9 14 12 13 16 28 32
The Insurance Trust Principal Financial Group PharmAssist Recovery Network Melvin M. Goldstein, P.C. AIP Logix, Inc. Michael T. Tarrant Design Plus Store Fixtures, Inc. GPhA Workers Compensation Pharmacists Mutual Companies Toliver & Gainer The Insurance Trust
CPE Opportunity: Tobacco Cessation Counseling: A Guide for Pharmacists GPhA Member Appointed to National MTM Board
COLUMNS
4 8
President’s Message Editorial
For an up-to-date calendar of events, log onto
www.gpha.org.
The Georgia Pharmacy Journal
3
September 2010
PRESIDENT’S MESSAGE Dale M. Coker, R.Ph., FIACP GPhA President
Anticip-a-a-tion
Pharm Pac, under the direction of former State Senator Eddie Madden. We are emptying the kitty this year, not to influence or buy votes, but to build new relationships and foster old ones among the candidates. Your Executive Vice President and lobbyists have traveled the state to hand deliver contributions and to voice the concerns of the pharmacists of Georgia on your behalf. The Academy of Independent Pharmacy has stepped up to the plate with an unprecedented $250,000 to support our political agenda.
f you’re anywhere near my age, you probably remember the ketchup commercial where the ketchup just doesn’t seem to want to come out of the bottle as Carly Simon is blurting out “Anticipation” in the background. At this time of year, when I catch that first cool afternoon breeze at the end of a another long, hot summer, my mind immediately begins to anticipate another beautiful southern fall season, with the turning of the leaves, the relief from the dog days of August, and of course, that most sacred southern event, FOOTBALL! Even though you can’t convince a die-hard, good ole’ boy DAWG fan that there are more important things in life, this fall will be one of the most important political years in recent Georgia history.
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To give you an example of some of the fruit of our political efforts this year, we were able to arrange a conference call with Republican Gubernatorial candidates Nathan Deal and Karen Handel to pose questions related to some pressing issues for Georgia pharmacists. This is an accomplishment that has never happened before. The candidates for political office are taking notice of the profession of pharmacy and the impact pharmacists can have on the elections. Now we need to do our part, not only as pharmacists, but as citizens of this country. I encourage everyone to get involved in the political process, and most importantly, get out and vote on election day. If you need information to make an informed decision on particular candidates for office, our Director of Government Affairs, Stuart Griffin, will be more than happy to share his knowledge of the candidates and their political views.
This year, the sense of anticipation is at a fever pitch for Georgia voters. In less than a month, we will be electing a new Governor, a new Secretary of State, a new Insurance Commissioner and a new Attorney General. The decisions made by those holding these positions can and will have a huge impact on the practice of pharmacy. GPhA will be expending considerable resources this year to ensure that the voice of our profession is heard loud and clear by the candidates for these offices. We want to be in a position to be at the table, no matter who is elected to these positions. As they say in political circles, if you are not at the table, you could well be on the menu. As we have learned in the not too distant past, being on the menu is not where we want to be again. Several factors are contributing to the political clout being displayed by your association this year. There is new lifeblood (and money) being pumped into the veins of The Georgia Pharmacy Journal
4
September 2010
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Thank You 2009-2010 GPhA Board of Directors of a Job Well Done Robert Bowles Eddie Madden Dale Coker Jack Dunn Robert Hatton Jim Bracewell Hugh Chancy Ashley Dukes Keith Herist Jonathan Marquess Sharon Sherrer Andy Rogers Alex Tucker Heather DeBellis Tony Singletary John Drew Bill McLeer Shobhna Butler Bobby Moody Mike Crooks Larry Batten
Chairman of the Board President President-Elect First Vice President Second Vice President Executive Vice President/CEO State-at-Large State-at-Large State-at-Large State-at-Large State-at-Large State-at-Large State-at-Large Region One President Region Two President Region Three President Region Four President Region Five President Region Six President Region Seven President Region Eight President
The Georgia Pharmacy Journal
David Gamadanis Chris Thurmond Marshall Frost Ken Eiland Renee Adamson Liza Chapman Burnis Breland Tim Short DeAnna Flores Rick Wilhoit John T. Sherrer Michael Farmer Mickey Tatum Don Davis Gina Ryan Johnson Meagan Spencer Barbee Rusty Fetterman Garrick Schenck Daniel Forrister Lance Faglie
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Region Nine President Region Ten President Region Eleven President Region Twelve President ACP Chairman AEP Chairman AHP Chairman AIP Chairman APT Chairman ASA Chairman Foundation Chairman Insurance Trust Chairman Ex Officio - President, GA Board of Pharmacy Ex Officio - Chairman, GSHP Ex Officio Mercer Ex Officio Mercer ASP Ex Officio South Ex Officio South ASP Ex Officio UGA Ex Officio UGA ASP
September 2010
Pharm PAC Enrollment Pledge Year 2010-2011
Titanium Level
Gold Level
Bronze Level
($2400 minimum pledge)
($600 minimum pledge)
($150 minimum pledge)
Michael Farmer Jeffrey L. Lurey Robert A. Ledbetter Marvin O. McCord Judson L. Mullican Mark L. Parris Fred Sharpe Jeff Sikes
Platinum Level ($1200 minimum pledge) Robert C. Bowles Bruce L. Broadrick Thomas Bryan, Jr. Hugh M. Chancy Dale Coker Billy Conley J. Ashley Dukes Stewart Flanagin Martin Grizzard Robert M. Hatton Alan M. Jones Ira Katz Harold M. Kemp Brandall Lovvorn Eddie Madden Jonathan Marquess Pam Marquess Scott Meeks Drew Miller Laird Miller Jay Mosley Tim Short
James W. Bartling Robert Cecil Liza G. Chapman Patrick M. Cook Mahlon Davidson Kevin Florence Neal Florence Amy Galloway David Gamadanis Marsha C. Kapiloff Tommy Lindsey Bobby Moody Sherri S. Moody Robert Anderson Rogers Daniel C. Royal Dean Stone Thomas H. Whitworth
Oatts Drug Company Monica M. Ali-Warren Lance P. Boles James Brown Mike Crooks Charles Alan Earnest Amanda R. Gaddy Fadeke Jafojo Allison Layne William E. Lee Ashley London William J. McLeer Houston Rogers Richard Smith Wallace Whiten Sharon B. Zerillo
Members
Silver Level ($300 minimum pledge) Renee Adamson John Colvard Al Dixon Marshall L. Frost Michael O. Iteogu Willie O. Latch Kenneth A. McCarthy Kalen Beauchamp Porter Edward Franklin Reynolds Michael T. Tarrant Brandon Ullrich Alan Voges Flynn W. Warren Oliver Whipple
(no minimum pledge) Michael’s Pharmacy Claude W. Bates Chad J. Brown Max C. Brown Lucinda F. Burroughs Waymon M. Cannon Jean N. Courson Carleton C. Crabill Alton D. Greenway J. Clarence Jackson Tracie Lunde Ralph Marett Leonard Franklin Reynolds Victor Serafy Harry Shurley William D. Whitaker Jonathon Williams
If you made a gift or pledge to Pharm PAC and your name does not appear above please, call Kelly McLendon at 404419-8116 or Ursula Hamilton at 404-419-8115. Donations made the Pharm PAC are not considered charitable donations and are not tax deductible. The Georgia Pharmacy Journal
7
September 2010
EXECUTIVE VICE PRESIDENT’S EDITORIAL Jim Bracewell Executive Vice President / CEO
2010 GPhA Annual Meeting Review he 2010 Georgia Pharmacy Association Annual Meeting and Convention by all accounts was a resounding success. The convention surveys and evaluations indicate it was perhaps the best Annual Meeting and Convention in our history.
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You said: We love some family entertainment like the hypnotist. Our response: We brought back hypnotist Kevin Lepine for a return performance.
You Said: We want more continuing education with an emphasis on quality presentations. Our response: We presented 30.5 hours of high quality continuing education.
You said: We like to hear form the Board of Pharmacy and the Legislators. Our response: We brought in the President of NCPA for a Federal report, the GA State Board of Pharmacy and your elected state pharmacy legislators for a full general session program.
You said: We want additional clinical training opportunities. Our response: We offered the APhA Certificate program in Diabetes in which the participants received 24 hours of continuing education credit and a certificate of achievement.
The attendance grew over our 2009 Convention and our numbers this year exceeded the number of attendees at our last convention in Myrtle Beach.
You said: Improve the flow of the awards portion of the Tuesday night banquet. Our response: We notified award recipients they were to receive an award and had a reserved table for them and their guests. We had many positive responses about this change.
With all this information what knowledge should a pharmacist in Georgia take away? You should immediately put the 2011 Georgia Pharmacy Association Annual Meeting and Convention on your calendar today! Saturday, June 18 through Tuesday night June 22, 2011, will be held at the most requested convention site by our members: Amelia Island Plantation, Amelia Island, FL.
You said: Move the Pharm PAC reception to a more upscale event. Our response: We moved the event to a first class venue, we added fine quality hors d’oeuvres with a classical guitarist for background music.
There is a room and space ready for you, your family and colleagues.
You said: Please improve the reception in the exhibit hall. Our response: We proved hot hors d’oeuvres, extra bars and extended time for the reception and the surveys said you liked this.
The 2011 Convention Committee is already considering new ideas and programs to keep the GPhA Annual Meeting and Convention the one must event for each pharmacist in Georgia.
You said: We love the OTC Bowl but improve the flow. Our response: We improved the game format which got high reviews on the surveys from attendees.
Save the date now for 2011 GPhA Annual Meeting and Convention, June 18- 22, 2011. I plan to see you there.
You said: We want more time for the Deans to speak. Our response: We extended the time for the Deans and included them in two general sessions instead just one.
The Georgia Pharmacy Journal
8
September 2010
FEATURED ARTICLE
GPhA Member Jonathan Marquess Elected APhA Trustee pharmacies and is President and CEO of The Institute for Wellness and Education, a disease management company in the Atlanta, Georgia, metropolitan area. Marquess graduated from Mercer University. He served as Chair of the APhA New Practitioner Committee, National President of the APhA-ASP and is a delegate in the APhA House of Delegates. President-elect designate Sobotka will succeed Marialice S. Bennett to the office of President on March 12, 2012, at the conclusion of the 2012 APhA Annual Meeting & Exposition in New Orleans. he American Pharmacists Association (APhA) released the results of its recent elections for Board of Trustees. Jenelle L. Sobotka, Pharm.D., FAPhA, of Mason, Ohio, has been chosen as 2011-2012 President-elect of the American Pharmacists Association (APhA). Also elected to serve on APhA’s Board of Trustees, beginning in March 2011, are Jonathan G. Marquess, Pharm.D., CDE, CPT, of Acworth, Georgia; and Michael A. Pavlovich, Pharm.D., of Long Beach, California. They will serve a threeyear term. Elected as Honorary President was Hazel M. Pipkin, R.Ph., of Point Venture, Texas. All will be installed at APhA’s 159th Annual Meeting & Exposition in Seattle, Washington, March 25-28, 2011.
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Jonathan G. Marquess, Pharm.D., CDE, CPT, of Acworth, Georgia who has been elected APhA Trustee is owner of three community The Georgia Pharmacy Journal
Sobotka, a graduate of the University of Iowa, previously served two terms on APhA’s Board of Trustees. She has also served on numerous other APhA Committees and as a delegate to the APhA House of Delegates. Sobotka is Director of External Relations at Procter & Gamble and was the Associate Director of the Iowa Pharmacy Association and Director of the Iowa Center for Pharmaceutical Care (ICPC). Under Sobotka’s leadership, ICPC received the 1999 APhA Foundation’s Pinnacle Award for work to advance patient care practice. She co-authored A Practical Guide to Pharmaceutical Care. Her other honors include being the recipient of the 2009 National 9
Pharmaceutical Association Foundation Excellence Award, 2008 Kappa Epsilon National Career Achievement Award, the 2005 PTCB Service Award, and the 2003 University of Iowa Rho Chi Honorary Alumni Award. APhA membership also approved a bylaws amendment for student pharmacist delegate voting rights. The bylaws amendment allows student pharmacists members who represent the APhA-Academy of Student Pharmacists in the House of Delegates to right to vote in that year’s annual election for at-large APhA Board of Trustees members and APhA President-Elect as well as any additional issues placed on the ballot from time to time. Also on the ballot were positions for APhA’s Academy of Pharmacy Practice and Management (APhAAPPM) and Academy of Pharmaceutical Research and Science (APhA-APRS). The results of these elections will be released after the candidates have been contacted.
September 2010
GPhA NEWS
GPhA Convention Wrap Up the AIP Compounding Breakfast, and the GPhF Golf Tournament and the Academy Tennis Tournament.
he GPhA Convention is always an exciting and productive time for pharmacists, but this year’s experience was particularly nice. More than 300 members gathered at the Embassy Suites Conference Center at Kingston Plantation in Myrtle Beach, South Carolina, from June 26 to 30, 2010.
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The CE for the day included: Functional Medicine and Hormone Replacement and Pain Management with Opioids, the ABCs of Metabolic Syndrome, and BLS for Healthcare Providers. We also had the Second General Session which featured the OTC Bowl.
During that time GPhA offered Continuing Education opportunities including: Quality Assurance & Continuous Quality Improvement, OTC Pain Management, MTM for Patients with Diabetes on Incretin Therapy, Addiction in the Workplace, OSHA Training, HIV/AIDS Management, Interventions for Improving Medication Adherence, and Brown Bag Patient Counseling Competition. And, that was only the first day.
That evening featured the Mercer and UGA Alumni Dinners. On Tuesday, CE included Advancing Pharmacy Practice Through Performance Management, Application of New Laws and Regulation to the Practice of Pharmacy, Emergency Preparedness for Pharmacy and Medication Therapy Management Services Update.
Also, on the first day GPhA and Insurance Trust Boards met and there was also a Pharm PAC Contributors’ reception at which the new contribution structure was announced.
The Third General session included a panel of Pharmacist Legislators who addressed state and federal government issues and how they affect pharmacy.
The second day included an Interfaith Sunrise Service, a Student Program, and Academy Business Meetings.
In the evening was the President’s Inaugural Banquet and Dessert Reception and Dance.
The CE for that day included: Immunization Update 2010, Pharmacy Law Update, and The Store Report Card: Bringing Profit Back to the Front End. There was also the First General Session where Don Yeager presented “What Makes the Great Ones Great.”
The next day GPhA held its annual business meeting at the end of which the Convention was adjourned. GPhA hopes that you all enjoyed your time in Myrtle Beach and hope that we will get to see you in Amelia Island next year.
In the evening there was a Coffee and Dessert Reception and the Kevin Lepine Hypnotist Show. On Monday there was the Council of Presidents’ Breakfast,
The Georgia Pharmacy Journal
10
September 2010
GPhA 2010 Fall Region Meetings
Eddie Madden, R.Ph., Chaiman of the Board of Directors Dale Coker, R.Ph., President Jack Dunn, R.Ph., President-Elect Robert Hatton, Pharm.D., First Vice President Pam Marquess, Pharm.D., second Vice President Jim Bracewell, Executive Vice President/CEO
Schedule of Fall 2010 Region Meetings For additional information and to RSVP go to www.gpha.org Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7 Region 8 Region 9 Region 10 Region 11 Region 12
October 5, 2010, 7:00-9:00 p.m. October 14, 2010, 6:30-9:30 p.m. October 19, 2010 October 5, 2010, 6:00-9:00 p.m. October 5, 2010 October 14, 2010 October 14, 2010, 6:00-9:00 p.m. October 12, 2010, 7:00-9:30 p.m. October 12, 2010 October 19, 2010, 6:30-9:00 p.m. October 12, 2010 October 19, 2010
South University School of Pharmacy Doublegate Country Club TBD Eagles Landing Country Club TBD TBD Adairsville Inn Holiday Inn, Waycross TBD TBD TBD TBD
Heather DeBellis Fred Sharpe John Drew Amanda Gaddyr Shobhna Butler Ashley Faulk Mike Crooks Larry Batten David Gamadanis Chris Thurmond Marshall Frost Ken Eiland
If you are not sure which region you are supposed to be in the new region webpages list the counties in each region and show a map. Just visit www.gpha.org and click on Region Webpages on the right side.
For details about the Continuing Education Program at the Spring Region Meetings and to RSVP for this event visit www.gpha.org or call GPhA at 404.231.5074. The Georgia Pharmacy Association is accredited by the Accreditation Council of Pharmacy eduction as a provider of continuing pharmacy education.
The Georgia Pharmacy Journal
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September 2010
GPHA MEMBER NEWS
Welcome to GPhA! The following is a list of new members who have joined Georgia’s premier professional pharmacy association! Ashley Jones, Augusta Perry H. Julien, Atlanta Christie Lee Keily, Ellijay Judith T. Marzullo, Marietta Sanjay Mehta, Roswell Mary Jeanne Moody, Scottsboro, AL R. Brad Mote, Mableton Stella Ngozi Okpala, Pharm.D., Fayetteville Karla L. Storey, Plum Branch, SC Laura Thompson, Pharm.D., Athens John Adam Titak, Pharm.D., Atlanta
Wayne C. Bishop, Alpharetta Joy A. Chesnut, Monroe Dudley B. Christie, Warner Robins Jennifer Cowart, North Augusta, SC Eric Steven Crowson, Marietta Carol B. Davis, Fairfax, SC Kathleen M. Edelman, Cumming Jenna Evans, Pharm.D., Eastman Ashley A. Fortney, Clayton David D. Fowler, Bennettsville, SC Walter M. Hughes, Clinton, SC
If you or someone you know wishes to join the Georgia Pharmacy Association you need only visit www.gpha.org and click “Join” at the top of the page. You can pay by credit card and your membership begins immediately. If you have any questions please call Kelly McLendon at 404-419-8116.
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COVER STORY
Pharmacists Take Larger Role on Health Team: Barney’s Pharmacy Featured in the New York Times By REED ABELSON and NATASHA SINGER Published: August 13, 2010 in The New York Times loise Gelinas depends on a personal health coach.
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At Barney’s Pharmacy, her local drugstore in Augusta, Ga., the pharmacist outlines all her medications, teaching her what times of day to take the drugs that will help control her diabetes. Ms. Gelinas, a retired nurse, also attends classes at the store once a month on how to manage her disease with drugs, diet and exercise. Since she started working with the Barney’s pharmacists, she boasts that her blood sugar, bad cholesterol and blood pressure have all decreased. “It’s my home away from home,” she says. While some of the services being offered to Ms. Gelinas resemble those found in an old-fashioned neighborhood drugstore, others reflect the expanding role of the nation’s pharmacists in ways that may benefit their customers and also represent a new source of revenue for the profession. Some health plans are even paying pharmacists to monitor patients taking regular medications for chronic illnesses like diabetes or heart disease. “We are not just going to dispense your drugs,” said David Pope, a pharmacist at Barney’s. “We are going to partner with you to improve your health as well.”
The Georgia Pharmacy Journal
At independent drugstores and some national chains like Walgreens and the Medicine Shoppe and even supermarkets like Kroger, pharmacists work with doctors and nurses to care for people with long-term illnesses. They are being enlisted by some health insurers and large employers to address one of the fundamental problems in health care: as many as half of the nation’s patients do not take their medications as prescribed, costing nearly $300 billion a year in emergency room visits, hospital stays and other medical expenditures, by some estimates. The pharmacists represent the front line of detecting prescription overlap or dangerous interaction between drugs and for recommending cheaper options to expensive medicines. This evolving use of pharmacists also holds promise as a buffer against an anticipated shortage of primary care doctors. “We’re going to need to get creative,” said Dr. Andrew Halpert, senior medical director for Blue Shield of California, which has just begun a pilot program with pharmacists at Raley’s, a local grocery store chain, to help some diabetic patients in Northern California insured through the California Public Employees’ Retirement System. Like other health plans, Blue Shield views pharmacists as having the
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education, expertise, free time and plain-spoken approach to talk to patients at length about what medicines they are taking and to keep close tabs on their well-being. The pharmacists “could do as well and better than a physician” for less
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September 2010
money, Dr. Halpert said. Some health insurers and large employers already pay for programs called medication therapy management, which typically involve face-to-face sessions between pharmacists and patients in retail stores or clinics. Pharmacists can be paid to track patients, monitoring cholesterol or blood glucose levels, for example, or prodding customers to change their diets or exercise. UnitedHealth Group has recently started working with pharmacists and health coaches at the Y.M.C.A. to counsel diabetic patients. The idea of using pharmacists in this way began to gain popularity in 2006 when some Medicare plans started covering medication therapy management programs, paying $1 to $2 a minute to pharmacists to review patients’ medicines with them; this year, about one in four people covered by Medicare Part D prescription drug plans will be eligible, according to agency estimates. For example, a Medicare Part D plan covered Ms. Gelinas’s medication management session at Barney’s pharmacy. More employers and insurers also pay for pharmacists to advise patients, a role that the new health care law encourages with potential grants for such programs. In Wisconsin, for example, community pharmacists and some health plans have banded together to create a joint program, the Wisconsin Pharmacy Quality Collaborative, to standardize medication therapy management and ensure quality care. Meanwhile Humana, which first paid for pharmacists to work with Medicare patients, expanded its coverage a few years ago. About a third of the 62,000
The Georgia Pharmacy Journal
pharmacies in its network offer these services, and the insurer says it is studying whether a pharmacist seeing a patient in person has more impact than a phone call. The advent of these services has spawned a new industry of medication therapy management companies to run clinical pharmacy programs for health insurers, contracting with pharmacists and tracking the financial and health outcomes of their services. One such company, Mirixa, founded in 2006 by the National Community Pharmacists Association, does business with more than 40,000 pharmacies nationwide. Pharmacists and others see these joint efforts as vital to remain competitive with mailorder pharmacies. One of the first places where retail pharmacists began to expand their role was Asheville, N.C., where studies validated the services. “We really positioned the pharmacist as coach,” said Fred Eckel, executive director of the state’s pharmacist group. In one recent study of 573 people with diabetes, 30 employers in 10 cities waived co-payments for diabetes drugs and supplies for those employees or family members willing to meet regularly with a pharmacist. People in the study, financed by the drug maker GlaxoSmithKline, took part in at least two sessions with pharmacists who helped them track their blood sugar, blood pressure and cholesterol levels and offered diet and exercise advice. After a year, blood pressure, blood sugar and cholesterol levels typically improved — and saved an average $593 a person on diabetes drugs and supplies. But the new relationships have stirred concerns. Federal regulators have
15
recently accused chains like Rite Aid and CVS Caremark of inadequately protecting health records. And groups like the American Academy of Family Physicians, say pharmacists should be careful not to usurp the physician’s role. “I’m concerned that people are thinking about this in terms of ‘either or,’ and that’s the wrong approach,” said Dr. Lori J. Heim, the academy’s president. “It’s an ‘and’ approach.” Michelle A. Chui, an assistant professor at the University of Wisconsin School of Pharmacy, said that pharmacists do not want to compete with doctors, but merely provide more information “so the physician has a more in-depth picture.” Still, the pharmacy business benefits. Barry S. Bryant, owner of Barney’s in Augusta, said expanding to include a wellness center where pharmacists hold medication management sessions and monthly health classes attracted more customers. Today, Barney’s fills an average of 1,000 prescriptions a day, up from 300 seven years ago, with about a third of his customers covered by Medicaid and another third by Medicare, he said. The business growth at Barney’s has even prompted Mr. Bryant and Mr. Pope to start their own education company, CreativePharmacist.com, that teaches other pharmacies how to introduce in-store services. “When we get involved with chronic care patients, their outcomes improve,” Mr. Pope said. “But, at the same time, they are improving our bottom line.”
September 2010
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Continuing Education for Pharmacists Tobacco Cessation Counseling: A Guide for Pharmacists This CPE lesson was written by Amanda Pekny, 2010 Pharm.D. Candidate, University of Nebraska College of Pharmacy, who has no financial or conflict of interest disclosures.
Goal The goal of this lesson is to assist pharmacists in developing a tobacco cessation counseling program.
Objectives At the conclusion of this lesson, successful participants should be able to: 1. implement a tobacco cessation program based on clinical practice guidelines; 2. assess the tobacco use history; 3. develop a tobacco cessation plan with the tobacco user; 4. list the physical and psychological components of nicotine addiction; and 5. identify common problems associated with quitting tobacco and suggest ways to solve them.
Introduction In January 2000, the Department of
By not meeting the Healthy People 2010 objective, a high incidence of tobaccorelated chronic diseases, productivity losses, and premature deaths continue to plague this country. Between 2000 to 2004, smoking alone resulted in more than $196 billion in annual health-related costs including smoking-attributable medical economic costs and productivity losses.2 Tobacco is the leading cause of preventable death and disease in the United States. If more comprehensive tobacco cessation programs were available to tobacco users, millions of lives and billions of dollars in tobaccorelated health care costs could be saved. Pharmacists play an integral role in health care prevention and treatment. By developing and implementing a tobacco cessation program, pharmacists can expand their role in tobacco cessation treatment and can increase patients’ quit rates.
Many cessation programs are designed to target patients who use cigarettes, however, this lesson can be used for patients who smoke or use smoke-less tobacco products. Pharmacists may choose to supplement this lesson with additional information to aid in the success of a tobacco cessation program.
Developing a Tobacco Cessation Program Using Clinical Practice Guidelines In May 2008, an updated version of the 2000 TREATING TOBACCO USE AND DEPENDENCE, a Public Health Service (PHS)-sponsored Clinical Practice Guideline was issued by the Agency for Healthcare Research and Quality (AHRQ).4 These guidelines are a collaboration of eight Federal Government and nonprofit organizations including the Centers for Disease Control and Prevention (CDC) and the National Heart, Lung, and Blood Institute (NHLBI). The guidelines suggest strategies for providing appropriate treatment for patients who use tobacco and recommends that these patients receive at least minimal treatment and counseling every time they visit a clinician. The first steps in this process (1) identification and (2) assessment of tobacco use separate patients into the following three
Health and Human Services (DHHS) published the Healthy People 2010 objectives for tobacco control in the United States. One of the 21 objectives was to reduce the adult cigarette smoking The information in this lesson helps pharmacists learn about tobacco rate to 12 percent or less by 2010. Eight cessation and provides useful years later, the Centers for Disease information for their patients. This lesson Control and Prevention (CDC) reported is divided into four pharmacist-patient that based on the current smoking trend meeting sessions: getting to know the in the United States, it was unlikely that patient; preparing for the quit date; this goal would be achieved. Data follow-up after the quit date; and analyzed from the 2008 National Health maintaining abstinence from tobacco use. Interview Survey found that 20.8 percent of Table 1 adults (46 million The “Five A’s” for Brief Intervention4 people) aged 18 years and over were current Ask about tobacco use. Identify and document tobacco use status for every patient at every visit. smokers, which was Advise to quit. In a clear, strong and personalized manner urge every tobacco user to quit. higher than, but not Assess willingness to make a For patient willing to make a quit attempt, use counseling and significantly different quit attempt. pharmacotherapy to help him or her quit. from, the 2007 estimate 1 of 19.7 percent. Assist in quit attempt. Help patient to put in place a plan to quit, with counseling and support. Arrange follow-up.
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Schedule follow-up contact, preferably within the first week after the quit date.
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treatment categories:3 1. Patients who use tobacco and are willing to quit should be treated using the five A’s (ask, advise, assess, assist, and arrange). Table 1 summarizes the “Five A’s” for brief intervention. 2. Patients who use tobacco, but are unwilling to quit at this time, should be treated with the five R’s of motivational intervention (relevance, risks, rewards, roadblocks, and repetition). Table 2 summarizes the “Five R’s” for enhancing motivation to quit using tobacco. 3. Patients who have recently quit using tobacco should be provided relapseprevention treatment. Although the above guidelines are suggested for brief intervention for a tobacco user, pharmacists can implement these strategies into their tobacco cessation counseling sessions making them more suitable for an individual patient’s needs.
significantly increased cessation rates, independent of the treatment’s intensity. 2. Two types of counseling and behavioral therapies result in higher abstinence rates (1) providing smokers with practical counseling (problemsolving skills/skills training), and (2) providing support and encouragement as part of treatment. These types of counseling elements should be included in smoking cessation interventions. Group and individual counseling was more effective than no intervention in increasing abstinence rates. Interventions were more successful when they included social support and training in general problem-solving skills, stress management, and relapse prevention. 3. The combination of counseling and medication is more effective for smoking cessation than either medication or counseling alone. Therefore, whenever feasible and appropriate, both counseling and medication should be provided to patients trying to quit smoking.
the patient at the initial meeting is important. The patient should feel comfortable and be able to express his or her thoughts and feelings without embarrassment or shame. This will make treatment, both physical and psychological, more efficacious and less problematic. The pharmacist should be informative, compassionate, an active listener, and be able to communicate to the patient in a language that is clear and understandable. The pharmacist should begin by introducing themselves and stating the purpose of the tobacco cessation counseling sessions. The intent of these sessions is to aid the patient in preparing to quit and remaining abstinent from using tobacco; providing the patient understanding about nicotine addiction; finding a suitable pharmacological treatment option; providing coping mechanisms for nicotine withdrawal; identifying and avoiding triggers; and providing useful smoking/tobacco cessation resources.
The AHRQ expert panel also made recommendations on the type and intensity of contact with a counselor to Patients should understand that First Meeting: the success of the intervention. The successfully quitting tobacco is not an Getting to Know the Patient following recommendations from the overnight process. It takes time, Introduction. Establishing a strong PHS Clinical Practice Guidelines should commitment, and planning to become relationship between the pharmacist and be implemented into a smoking or completely tobacco-free. By reassuring smokeless-tobacco cessation program:4 Table 2 1. There is a strong dose-response The “Five R’s” for Enhancing Motivation to Quit Tobacco4 relationship between the session Encourage the patient to indicate why quitting is personally relevant, being as length of person-to-person specific as possible. Motivational information has the greatest impact if it is relevant contact and successful treatment to a patient’s disease status or risk, family or social situation (e.g. having children in Relevance outcomes. Intensive interventions the home), health concerns, age, gender, and other important patient characteristics are more effective than less (e.g. prior quitting experience, personal barriers to cessation). intensive intervention and should The pharmacist should ask the patient to identify potential negative consequences be used whenever possible. Metaof tobacco use. Suggest and highlight those that seem most relevant to the patient. analysis demonstrated that when Risks The pharmacist should emphasize that smoking low-tar/low-nicotine cigarettes or interventions last for more than use of the other forms of tobacco (e.g. smokeless tobacco, cigars, and pipes) will not 10 minutes, the increase in eliminate these risks. cessation rates was much better Ask the patient to identify potential benefits of stopping tobacco use. The than when interventions did not Rewards pharmacist may suggest and highlight those benefits that seem most relevant to the involve contact with a patient. professional. However, contact The pharmacist should ask the patient to identify barriers or impediments to time with a clinician for more Roadblocks quitting and note elements of treatment (problem solving, pharmacotherapy) that than 90 minutes did not could address barriers. substantially increase abstinence The motivational intervention should be repeated every time an unmotivated rates. The number of treatment Repetition patient visits the pharmacy. Tobacco users who have failed in previous quit sessions offered is also important. attemptsbeforethey are successful. Providing four or more sessions
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Table 3 Drug Interactions with Smoking6, 7
PHARMACOKINTETIC INTERACTIONS Drug/Class
Effects After Cessation
alprazolam
Conflicting data on significance of a PK interaction. Possible decreases in serum concentrations and half-life.
caffine
Decreases clearance and increases serum concentrations. Decreases use after cessation.
chlorpromazine
Decreases clearance and increases serum concentrations. Monitor carefully when changes in smoking status occur.
flecainide
Decreases clearance and increase serum concentrations. Clinicians should be aware of the possibility of an interaction, but no specific dosage adjustment parameters are recommended.
fluvoxamine
Smokers have a 25% increase in metabolism over non-smokers. Decreases clearance and increase serum concentrations. Monitor for the desired clinical effects when changes in smoking status occur.
haloperidol
Decreases clearance and increases serum concentrations. Monitor patients carefully when changes in smoking status occur.
heparin
Mechanism unknown but increases clearance and decreases half-life has been observed with smokers. Smoking has prothrombotic effects. Active smokers may need increased dosages.
insulin
Cessation may result in decreases blood glucose or increases the subcutaneous absorption of insulin. Monitor for the desired clinical effects when changes in smoking status occur.
mexiletine
Decreases clearances and increases serum concentrations. Monitor for desired clinical effects when changes in smoking status occur.
olanzapine
Following one week of abstinence from chronic tobacco smoking, clearance may decrease. Monitor carefully when changes in smoking status occur.
propranolol
Decreases clearance and increases serum concentrations. No specific dosage adjustments are recommended. Monitor carefully for the desired clinical effects when changes in tobacco smoking status occur.
tacrine
Decreases clearance and increases serum concentrations. Monitor for desired clinical effects when changes in smoking status occur.
theophylline
Following one week of abstinence from chronic tobacco smoking, clearance may decrease by roughly 40%, leading to an increase in serum concentrations. Theophylline serum concentrations should be monitored carefully when changes in smoking status occur.
tricyclic antidepressants
Possible interaction. Decreases serum concentrations, but clinical importance is not established.
warfarin
Decreases clearance; however, this may not result in a clinically significant change in the PT or INR. Monitor patient's INR to assess the need for warfarin dosage adjustment when changes in smoking status occur.
PHARMACODYNAMIC INTRACTIONS Drug/Class
Effects After Cessation
benzodiazepines (diazepam, chlordiazepoxide)
Increases metabolism of major metabolite by up to three-fold. No specific dosage adjustment resommendations are available, but monitor patients for the desired clinical effects when changes in tobacco smoking status occur.
beta-blockers
Decreases clearance and increases serum concentrations. Blod pressure, angina and exercise tolerance are improved less by beta-blocker therapy when the patient is a smoker thatn when not smoking. Monitor carefully for the desired clinical effects when changes in tobacco smoking status occur.
corticosteroids, inhaled
Asthmatic smokers may have less of a response to inhaled corticosteroids.
opioids (propoxyphene, pentaozocine)
Increases in the therapeutic effects as hepatic enzyme activites return to normal.
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the patient that with the right tools, medication, and support provided at these meetings, the likelihood of maintaining a tobacco-free lifestyle is possible. Assessing Past Medical History of the Patient. The next step is to assess the patient by gathering background information and past medical history. Based on this information, the pharmacist can make informative recommendations to the patient’s primary care provider and assist in the selection of an appropriate tobacco cessation medication. The pharmacist should obtain the patient’s name, contact information, date of birth, gender, ethnicity, vital signs (blood pressure and pulse), height and weight. The pharmacist should ask about allergies to medications, comorbid conditions, and past surgical history. Family history of disease states, such as diabetes mellitus or coronary heart disease, is important to know as well. This information can be used to motivate the patient to stay abstinent and avoid potential health problems that can be exacerbated by tobacco use. If the patient is female, the pharmacist should ask if she is taking any contraceptives, is pregnant, or plans on becoming pregnant. Safe pharmacotherapy treatments are limited in this special population. Other populations that may need extra consideration are tobacco users with psychiatric comorbidity and/or chemical dependency and adolescent tobacco users. Tobacco cessation may increase plasma levels of some drugs to potentially toxic levels. Abstinence from smoking reverses smoking-induced CYP1A2 hepatic enzyme levels to normal, increasing plasma concentrations in patients whose dose was established while smoking.5 Certain medications are affected by tobacco smoke through pharmacokinetic (PK) or pharmacodynamic (PD) mechanisms. PK interactions affect the absorption, distribution, metabolism, or elimination of other drugs which can
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potentially cause an altered pharmacologic response. PD interactions alter the expected response or actions of other drugs.6 Therefore, a detailed list of current medications, prescribed and over-the-counter, should be obtained. Pharmacists should carefully review the dosage form, strength, and regimen of each drug and recommend adjustment and monitoring of those that are affected by smoking cessation. On the following page, Table 3 lists drugs affected by smoking cessation and dose adjustments after cessation. Assessing Tobacco Use History of the Patient. There are a variety of different questionnaires available to assess tobacco use status. The pharmacist may choose to use a questionnaire provided by a smoking cessation organization or create a customized evaluation. Regardless of which tool is utilized, the information gathered by the survey should be used to appropriately evaluate behavior and nicotine dependence. Pharmacists should be aware that patients may under-report how much tobacco they use. Prior to beginning the tobacco cessation program, patients should be asked the following questions: 1. At what age did the patient start using tobacco? For how many years? 2. Why did the patient start using tobacco? 3. How much tobacco does the patient use daily (e.g. number of cigarettes or the number of cans/pouches)? 4. When does the patient smoke/use tobacco? 5. What kinds of activities or “triggers” increase the urge to use tobacco? The Fagerström Test for Nicotine Dependence (FTND) is a standard instrument for assessing the intensity of physical addiction to nicotine.8 This selfsurvey can provide insight concerning behavior and addiction along with the use of other evaluation tools. The higher the Fagerström score, the more physically dependent the patient is to nicotine. Higher scoring patients may need additional counseling and more
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intense medication treatment(s) to successfully quit tobacco than patients with lower scores. The Fagerström Questionnaire for smoking tobacco is shown in Table 4. This questionnaire can be modified for those patients who use smokeless-tobacco. Assessing Past Quit Attempts. To some patients, talking about past quit attempts can be frustrating. The average smoker tries to quit 6 to 9 times in a lifetime.10 The patient has probably tried to stop using tobacco independently without talking to a healthcare professional. Seeking help from a smoking cessation counselor could be a last resort for some smokers who have tried numerous times to quit before but have not been successful. This topic can be a source of shame and embarrassment. However, past quit attempts are important to discuss with the patient. It is an initial starting point in determining which medications and behavior modifications worked well in the past and what did not. Patients should be asked the following questions: 1. Has the patient attempted to quit using tobacco before? How many times? 2. How long did the patient stay tobaccofree? 3. Which tobacco cessation product(s) did they use before? 4. Which product(s) worked well for the patient? Which didn’t? 5. Did the patient modify any behaviors/change routines while staying tobacco-free? 6. Why did the patient start using tobacco again? Determining the Patient’s Readiness to Quit. Understanding the patient’s readiness to quit may lead to more efficient and productive conversations during meetings. Each patient will be at a different stage of the quitting process. Some patients may need more motivation than others. Those who are less ready to quit may need to be reminded of the health benefits and financial savings associated with tobacco cessation. For patients who are highly
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motivated, the pharmacist may want to focus more time on developing a plan to quit smoking. Table 5 is a patient selfsurvey designed to help assess readiness to quit. It is based on information gathered from a national study involving both smokers and recent quitters and developed to identify motivation to quit smoking. This survey can be modified for patients who use smoke-less tobacco. The higher the score on the survey, the more ready the patient is to quit tobacco. Identifying Personal Goals for Staying Smoke-Free. The pharmacist should ask patients this important question, “Why do you want to quit?” Asking patients to provide a reason for quitting tobacco use gives them accountability for his or her actions. The patient is not only responsible for setting personal goals, but also for implementing a plan to achieve them. The pharmacist can provide helpful tools for patients to succeed. Patients should have constant reminders of their goals. For example, the patient could write his or her personal goal(s) on every handout received during cessation
meetings. This helps keep patients focused on staying tobacco-free. When it comes to actually quitting tobacco use, some patients find it hard to plan ahead and prepare for relapse or difficult situations. Giving a step-wise action plan to the patient is a good solution. In the action plan, a patient should list his or her long-term goals; short-term goals; plans to achieve these goals; what obstacles or roadblocks might be encountered and how to overcome them; and what rewards can be given for successfully achieving each goal. The pharmacist should remind the patient to take the time to thoughtfully write out an answer to each list item and bring the responses back to the next meeting for review. Keeping a Tobacco Use Log. Patients should be instructed to document his or her tobacco use for the next several days. This information provides a clearer, overall picture of the patient’s addiction to nicotine. Writing down every time the patient smokes or chews can help to
identify which emotional states and activities trigger the urge to use tobacco throughout the day. With each use, the patient should write down the following information: the date and time; the location; the activity the patient is doing while using tobacco; the patient’s current mood; and the strength of the craving for the tobacco product. A simple tobacco log sheet can be created by the pharmacist and provided to the patient. The pharmacist should instruct the patient to continue his or her normal daily routines while documenting use. The information gathered will be discussed at the next smoking cessation meeting. Selecting the Right Medication and Quit Date. It is ultimately the patient’s decision to start a tobacco cessation medication. While it is possible to quit tobacco “cold turkey”, the success rate of staying abstinent is approximately doubled with the use of pharmacotherapies.12 However, with so many products available for treatment of nicotine dependence, this can be
Table 4 Fagerstrom Test for Nicotine Dependence9 Questions
Answers
Points
1. How soon after you wake up do you smoke your first cigarette?
Within 5 minutes 6 to 30 minutes 31 to 60 minutes After 60 minutes
3 2 1 0
2. Do you find it difficult to refrain from smoking in places where it is forbidden Yes such as church, the library, or movie theaters? No
1 0
3. Which cigarette would you most hate to give up?
The first on in the morning All others
1 0
4. How many cigarettes/day do you smoke?
10 or fewer 11 to 20 21 to 30 31 or more
0 1 2 3
5. Do you smoke more frequently during the first hours after waking than during the rest of the day?
Yes No
1 0
6. Do you smoke if you are so ill that you are in bed most of the day?
Yes No
1 0
Score: 0-2: Very low addiction; 3-4: Low addition; 5: Medium addiction; 6-7: High addiction; 8-10: Very high addiction
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overwhelming for the patient. The pharmacist can aid in the selection of an appropriate therapy based on the patient’s past medical history and past quit attempts. A detailed article about the pharmacotherapy treatments of nicotine addiction for health care providers was published in the last issue of the GEORGIA PHARMACY JOURNAL. A simpler, more patient-orientated medication guide, listing the advantages and disadvantages of each drug, should be provided to the patient. The pharmacist should instruct the patient to review the medication guide, write down any additional questions about each drug, and select a drug(s) that he or she would prefer to use. Patients should be reminded that there are two parts to nicotine addiction, a physical and a behavioral component, and medications only treat the physical
addition.13 Combination therapy of both medication and counseling can significantly improve abstinence rates.4 The quit date should also be determined by the patient. The pharmacist should instruct the patient to take the time to consider which day in the near future it will be. Initially, it may take a lot of concentration and focus to stay abstinent. Therefore, the actual quit date should not be scheduled on a highly stressful day such as an upcoming wedding, graduation, or traumatic event in the patient’s life. The patient should write the date on a calendar and let his or her family and friends know when the quit date will begin. Support from family and friends may help the patient stick to the goal of staying smoke-free. Table 6 provides a quick summary to patients on
how to quit using tobacco and can be given as an additional motivational guide.
Second Meeting: Preparing for the Quit Date Assessing the Tobacco Use Log. After the patient has processed and completed the information provided in the first tobacco cessation meeting, it is time to assess the patient’s tobacco use log. The patient should have documented his or her tobacco use for at least the last three to four days and set a quit date. The tobacco use log can be discussed before, during, or after the pharmacist has presented to the patient the new material for the second cessation meeting. The pharmacist should, however, relate the new information to help solve the patient’s current tobacco use problems
Table 5 Ready to Quit Survey11 Questions
Answers
Points
I want to quit smoking for mt own personal reasons, not because I feel pressured to quit by others.
Completely Disagree Somewhat Disagree Neutral Somewhat Agree Completely Agree
1 2 3 4 5
I have a specific plan in mind to try to quit smoking.
Completely Disagree Somewhat Disagree Neutral Somewhat Agree Completely Agree
1 2 3 4 5
I am always looking for new ways to help me not smoke.
Completely Disagree Somewhat Disagree Neutral Somewhat Agree Completely Agree
1 2 3 4 5
Completely Disagree Somewhat Disagree I want to quit smoking because I worry a lot about how smoking affects my health. Neutral Somewhat Agree Completely Agree
1 2 3 4 5
Completely Disagree Somewhat Disagree Neutral Somewhat Agree Completely Agree
1 2 3 4 5
I want to quit smoking because I am tired of being a prisoner to my cigarettes.
Scale of 5 to 25: Less ready to quit (lower score); More ready to quit (higher score) The Georgia Pharmacy Journal
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and aid in the preparation of the upcoming quit date. By the end of the second meeting, the pharmacist should address why using tobacco is hard to quit; what the symptoms are of nicotine withdrawal; what the triggers are and how to manage them; what the difference is between a slip and a relapse; and what other tobacco cessation resources are available for the patient to use. The pharmacist should also determine if the patient has selected and obtained a cessation medication and if the quit date has been selected. Understanding the Physical and Psychological Addiction to Nicotine. For a successful recovery from tobacco use, it is important for patients to understand how nicotine affects the brain and why it can be difficult to quit using tobacco. A patient-oriented handout about the physical and psychological effects of nicotine should be provided to the patient to help him or her understand what to expect when quitting tobacco. Nicotine is a highly addictive, potent, and psychoactive drug.12 A single cigarette typically delivers between 1.2-3.2mg of nicotine, while other tobacco products can deliver many times that amount.12 The absorption rate of cigarette smoke from the lungs is rapid, producing with each inhalation a high concentration arterial bolus of nicotine which reaches the brain within 15 seconds, faster than by intravenous injection.15 The elimination half-life of nicotine is also short, lasting for about two hours.
However, due to the fact that the brain is a highly perfused organ, nicotine will quickly redistribute into plasma to achieve equilibrium in the body. As a result, the effective half-life of nicotine on dopamine receptors is shorter than its elimination half-life. The fast onset and short half-life of nicotine leads to frequent repeated administration to maintain raised concentrations in the brain.15
Tobacco users learn to titrate their nicotine levels throughout the day in order to avoid withdrawal symptoms, to maintain pleasure and arousal, and to modulate their mood.12 This typically leads to strong, repetitive habits and behavior rituals associated with tobacco use. For example, smokers often smoke at certain times of the day, during certain activities, in certain locations, after a meal, or under certain levels of stress.
Nicotine produces a wide range of central nervous system, cardiovascular, and metabolic effects. It activates nicotinic acetylcholine receptors (nAChRs) in the brain, and induces the releases of dopamine in the nucleus accumbens, the reward center of the brain. This effect is the same as that produced by other addictive drugs such as amphetamines and cocaine, and is thought to be a critical component in brain addiction mechanisms.15 The activation of the dopamine reward pathway gives the user a feeling of pleasure. Nicotine also causes other psychological effects such as cognitive enhancement, mood modulation, and reduction of anxiety and tension. Between administrations of tobacco, the level of dopamine declines and the tobacco user starts to experience withdrawal symptoms such as irritability and stress. The brain craves nicotine to release more dopamine to bring it back to a level of pleasure and calm.
Recognizing Nicotine Withdrawal Symptoms. Patients who have used tobacco on a regular basis will experience nicotine withdrawal symptoms if they suddenly quit using all tobacco products or if they greatly reduce their tobacco use. Because of the short half-life of nicotine, the urge to use tobacco may occur within hours of the last use. Symptoms peak about 2 to 3 days later when nicotine and its metabolites are eliminated from the body. The symptoms may last for a few days or weeks.16 Knowing what to expect and understanding that withdrawal symptoms gradually decrease with time can help the patient stay abstinent. Although, symptoms may be different for each patient, common signs of nicotine withdrawal include the following: anxiety; craving for tobacco; decreased blood pressure and heart rate; depression; difficulty concentrating; drowsiness; frustration; irritability; impatience; gastrointestinal disturbances; headache; hostility; increase in appetite and weight gain; increased in skin temperature; insomnia; and restlessness.2
Over time, tobacco users develop tolerance towards the effects of nicotine.
Table 6 Steps on How to Quit 14 1. Pick your quit date. 2. Decide how you want to quit: using medication and gradually cutting back or quitting at once. 3. Thow it away! Throw away everything related to smoking, including cigarettes, ashtrays, lighters, and matches. 4. Get support. Start to build a support network (family and friends) and keep them updated and involved with your progress. 5. After quit date arrives, don’t smoke or chew. If you do have slip, recommit to quitting right away. Remember your long-term goals and the rewards for not using tobacco (health, financial, family). 6. Track your progress. Keep a record of your progress. Note any questions you may want to ask for the next meeting. 7. Remember to keep trying!
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A list of these common signs can be a useful tool for the patient. The pharmacist can also encourage the patient to think of these withdrawal symptoms as a positive process in which his or her body is ridding itself of nicotine. Identifying Triggers and Coping Techniques. Repetitive habits and behavior rituals associated with tobacco use are eventually incorporated into the nicotine addiction. These behavior rituals are closely coupled with sensory aspects of smoking.15 For example, for a patient who smokes, each puff of nicotine delivered to the brain is linked to the sight of the packet and the smell of the smoke. The activity that the patient is doing at the time becomes the reason to use tobacco. The reward of smoking is associated with the activity. This accounts for smokers’ widespread concern that if they stopped smoking they would not know what to do with their hands, and for the ability of smoking related cues or “triggers” to evoke strong cravings.15 Treatment for the psychological addiction to nicotine is accomplished by
breaking triggers through behavior modification. This is done by modifying the patient’s behaviors, changing routines, and learning how to deal with stressful issues without using tobacco as a coping mechanism. Table 7 provides examples of common triggers and ways to avoid them. This table can be modified for patients who use smoke-less tobacco. Based on the patient’s comments on the tobacco log and past smoking history, the pharmacist should have the patient complete a trigger log which identifies the patient’s own triggers and how the patient will manage them. This log should be displayed somewhere visible so that the patient will be reminded of what to do when the trigger occurs. One of the most difficult times to avoid using tobacco is when the patient wakes up in the morning. During the night, the patient has become deprived of nicotine. Nicotine blood concentration levels drop close to those of non-smokers.15 The first cigarette or pinch of chewing tobacco releases dopamine in the brain and gives the patient a strong sense of pleasure and calmness. The pharmacist
should advise patients to change their morning routines to avoid the urge to use tobacco. The pharmacist can also provide patients a list of activities to do instead of smoking which may help patients occupy their time and stay focused on their longterm goals. For example, suggested activities could include starting a new hobby; going to the movies, library, or a bookstore; doing some spring cleaning around the house; chewing sugarless gum; drinking water; or starting an exercise program. Visual reminders of the patient’s personal goals may also help with overcoming strong cravings. Patients can writedowntheir personal goals or reasons why they want to quit on pieces of paper and place them in areas that trigger the urge to use tobacco. For example, patients can place the paper in the plastic sleeve in their cigarette packs or on the dashboard of their car. Understanding the Difference between a Slip and a Relapse. Quitting tobacco permanently can be challenging for many tobacco users. In fact, few people never
Table 7 Common Triggers and How to Manage Them17, 18 Triggers
Suggested Coping Techinques
Being around others who smoke.
Go to places where smoking isn’t allowed. Tell friends who smokke you are trying to quit.
Feeling bored.
Find new ways to occupy your time. Read, walk, start a new hobby.
Drinking alcohol.
Avoid alcohol while you are trying to stop smoking.
Feeling hungry.
Have a healthy snack or drink water. Exercise can also help.
Drinking Coffee
Switch to tea, or hold your cup in the hand you used to hold your cigarette in.
Talking on the telephone.
Put something else in your hand, like a pen, straw, doodle on a scratch pad.
Watching television.
Do not sit in your usual chair. Keep popcorn or low-fat healthy sncks on hand.
Finishing a meal.
Brush your teeth after eating. Take a walk.
Feel nervous, stressed, or anxious.
Try relaxation techniques.
Waking up in the morning.
Usually the toughest time for smokers. Take a shower, eat breakfast, exercise, or brush your teeth as soon as you get up. CHANGE your routine.
Driving to and from work.
Play music, take a different route, carpool with a nonsmoker. or walk to work if possible. Spend the money to detail your car before the chosen quit day so there will not be temptations from the smell of tobacco.
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slip at all.19 However, turning a slip into a relapse is the under control of the patient. It is important for the pharmacist to explain what the difference is between a slip and a relapse. A slip is a one-time mistake that is quickly corrected while a relapse is going back to using tobacco.16 A slip is not a failure. The patient can still successfully quit. If the patient uses tobacco, he or she should stop using again right away and recommit to quitting. The pharmacist should ask the patient to write down the reason(s) for the slip and what he or she could have done differently. The pharmacist should encourage the patient not to become discouraged. The patient can use this information to make a stronger attempt at quitting the next time the troubling situation occurs.
an individual patient’s needs, Table 9 however, can be challenging. Examples of Rewards for Staying Tobacco Each patient counseled will Free4 be uniquely different. Improved health Patients will be at different stages of the quitting Food will taste better process. This could be the Improved sense of smell first attempt at quitting Save money tobacco or one of many attempts to quit. Some Feel better about yourself patients will be more Home, car, clothing, and breath will smell better motivated to try anything Can stop worrying about children new while others will need more encouragement and Set a good example for children guidance. Each patient’s Have healthier children comprehension level for understanding and Not worry about exposing others to smoke processing information will taking the prescribed medication(s). also be different. Therefore, it is important that resources provided by the This meeting should address the patient’s concerns and provide the patient with pharmacist are not only customized to additional motivation to stay abstinent Providing Additional Tobacco Cessation address the patient’s current situation, from tobacco. This meeting should be Resources to the Patient. There are many but also written in a language that the used to answer the patient’s questions tobacco cessation resources available patient will understand. about the tobacco cessation through professional organizations, federal or state funded quitting programs, An excellent resource for pharmacists can medication(s) he or she is taking, how and online web sites. Pharmacists have be found on the Rx for Change web site.20 the patient is feeling mentally and emotionally, any triggers or slips that he Registration is free and gives access to access to vast amounts of useful or she has experienced since the quit information, which when provided to the many educational tools and resources date, and any additional roadblocks that including presentations, handouts, and patient, can assist in further are preventing the patient from staying large group materials for patient understanding of tobacco cessation. tobacco-free. The pharmacist can suggest educational use. In addition, there are Selecting the right information to meet ways to manage difficult triggers and comprehensive video review the material presented from Table 8 training sessions available to previous meetings. The pharmacist Examples of Health Risks Related to Tobacco pharmacists and pharmacy 4 should review the difference between a students. These videos Use slip and a relapse and that successfully provide examples of RISKS quitting tobacco takes commitment, situations that pharmacists concentration, planning, and time. may encounter while Acute
Shortness of breath, exacerbation of asthma, harm to pregnancy, infertility, increased serum carbon monoxide.
Long-term
Heart attack and strokes, lung and other cancers (larynx, oral cavity, pharynx, esophagus, pancreas, bladder, cervix), chronic obstructive pulmonary disease (chronic bronchitis and emphysema), long-term disability and need for extended care.
Increase risk of lung cancer and heart disease in spouses; higher rates of smoking by children of tobacco users; Environmental increase risk for low birth weight, SIDA, asthma, middle ear disease and respiratory infections in children of smokers.
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counseling patients about tobacco cessation.
Third Meeting: Follow-up after the Quit Date Addressing the Patient’s Concerns. The next meeting with the patient should take place after the patient’s quit date. The patient should have been refraining from using tobacco products for some time and should be
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Understanding the Health Risks Associated with Continued Tobacco Use. In the United States, tobacco use is responsible for nearly 1 in 5 deaths.2 As a result of smoking or exposure to secondhand smoke, more than 440,000 premature deaths and 5.1 million years of potential life was lost each year between 2000-2004.21 During that period, smoking-attributable health care expenditures totaled an estimated $100 billion annually, up $24 billion from $75.5 billion spend during 1999-2001.2 Cigarette smoking substantially increases
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the risk of cardiovascular diseases such as stroke, sudden death, and heart attack; nonmalignant respiratory diseases including emphysema, asthma, chronic bronchitis, and chronic obstructive pulmonary disease; lung cancer; and other cancers such as mouth, pharynx, larynx, esophagus, stomach, pancreas, uterus, cervix, kidney, ureter, and bladder.3 The risk of developing lung cancer is about 23 times higher in male smokers and 13 times higher in female smokers compared to lifelong nonsmokers.2 Smokeless tobacco users have a four-fold greater risk of oral cancer than nonusers. The risk increases up to 50-fold for long term users.22 Half of all those who continue to smoke will die from smoking-related diseases.2 Exposure to environmental tobacco smoke (i.e. secondhand smoke) has been cited as the cause of 3,400 lung cancer deaths and 46,000 heart disease deaths in nonsmoking adults in the United States every year.2 Children exposed to environmental smoke have a higher risk of respiratory infection, asthma, and middle ear infections than those who are not exposed.3 Sudden infant death syndrome (SIDS) occurs more often in infants whose mothers smoked during pregnancy than in offspring of nonsmoking mothers.3 Smoking during pregnancy also reduces fetal growth and increases the risk of ectopic pregnancy and spontaneous abortion.3 A pharmacist should discuss the health consequences associated with continued tobacco use and how they can be prevented by tobacco cessation. Table 8 from the PHS Clinical Practice Guidelines summarizes the health risks related to tobacco use. Understanding the Rewards of Staying Tobacco-free. The patient may need more motivation to resist the temptation of using tobacco again. Table 9 from the PHS Clinical Practice Guidelines provides other examples of rewards for staying tobacco-free. Besides decreasing
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the risk of morbidity and mortality, patients will also save money when they quit tobacco. The pharmacist can provide the patient a tobacco cost calculator and examples of items that can be bought with the potential money saved by quitting tobacco. For example, the national average in 2008 was $4.26/pack of cigarettes. For a pack-aday smoker, by not buying cigarettes the patient could save enough money to purchase: a portable DVD player (worth over $250) in just two months; a flatscreen TV (worth $750) in only six months; or a 4-day cruise for two people (worth over $1,500) in one year.23 In addition to improving health and saving money, the patient can also spend less time smoking and gain more time to do something more enjoyable or productive. The pharmacist can help the patient figure out how much time is saved. On average the smoking time for one cigarette is five minutes.21 By multiplying this number by how many cigarettes the patient smokes per day, the patient can calculate how many minutes are gained per day, month, or year. The pharmacist can then encourage the patient to write down and think about what he or she can do with the money saved and the time gained from not using tobacco. For example, the patient could start a new hobby which could help with avoiding triggers and tobacco use.
Fourth Meeting: Maintaining Abstinence from Tobacco Use Addressing Roadblocks and How to Overcome Them. The last and final meeting with the patient should be reserved to tie-up any loose ends from the previous tobacco cessation sessions. The pharmacist should evaluate the patient’s current progress and address any additional problems or roadblocks that are interfering with complete tobacco cessation. The pharmacist should assess the patient’s medication use and adherence, reinforcing that a full
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course of therapy is necessary to assure maximal benefit while the patient continues to make behavioral changes. The pharmacist should also review any important topics from previous meetings which will help keep the patient motivated. The patient should be reminded to stay focused on the longterm goal, to utilize any handout or resources that have been provided, and to remember the reasons why to quit. Table 10 provides common roadblocks encountered by patients and possible actions that clinicians can take to solve the problem. Completing and Evaluating the Tobacco Cessation Program. Congratulations should be offered to the patient for completing the tobacco cessation program. Patients should feel a sense of pride for the effort and commitment that they have shown to become tobacco-free. Patients should also reflect on the last four sessions as a learning experience and should use the information in their daily lives. At the end of the final meeting, the pharmacist can provide the patient a certificate of achievement. This certificate can recognize the patient’s dedication to quitting tobacco and hope for further success, and a longer, healthier, and smoke-free life. This final meeting should include a patient evaluation about the tobacco cessation program. The pharmacist should explain that completing the questionnaire will help make improvements to the program for the benefit of future patients. Questions listed on the survey could include the following: 1. How would you describe your health before you quit tobacco? 2. How would you describe your health now after you quit tobacco? 3. What activities do you think were helpful in quitting tobacco? 4. What activities do you think were not helpful in quitting tobacco? 5. What was the hardest tobacco trigger to manage/overcome?
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6. What advice will you take with you from completing this program? 7. What advice would you give to other tobacco users trying to quit?
Conclusion Pharmacists understand the pathophysiology and pharmacotherapy involved in the treatment and recovery from nicotine addiction. With this knowledge, pharmacists can guide the
patient in preparing to quit and remaining abstinent from using tobacco, finding a suitable pharmacological treatment option, providing coping mechanisms for nicotine withdrawal, identifying and avoiding triggers, and providing useful smoking/tobacco cessation resources.
a successful tobacco cessation program, increase patient quit rates, and expand their role in tobacco treatment. With more tobacco cessation programs, the U.S. government’s objective to reduce the adult tobacco use rates, prevent premature deaths, and reduce tobaccorelated health care costs, may become a reality.
Using the right tools and resources, pharmacists can develop and implement
Table 10 Addessing Problems Encountered by Former Smokers4 Problems
Responses
Lack of support for cessation
• Schedule follow-up visits or telephone calls with the patient. • Urge the patient to call the national Quitline network (1-800-QUIT-NOW) or other local Quitline. • Help the patient identify sources of support within his or her environment. • Refer the patient to an appropriate organization that offers cessation counseling or support.
Negative mood or depression • If significant, provide counseling, prescribe appropriate medications, or refer the patient to a specialist. Strong or prolonged withdrawal symptoms
• If the patient reports prolonged craving or other withdrawal symptoms, consider extending the use of an approved pharmacotherapy or adding/combing pharmacologic medications to reduce strong withdrawal symptoms.
Weight gain
• Recommend starting or increasing physical activity. • Reassure the patient that some weight gain after quitting is common and usually is self-limiting. • Emphasize the health benefits of quitting relative to the health risks of modest weight gain. • Suggest low-calorie substitutes such as sugarless chewing gum, vegetables, or mints. • Maintain the patient on medication known to delay weight gain (e.g. bupropion SR, NRTs –particularly 4mg nicotine gum- and lozenge). • Refer the patient to a nutritional counselor or program.
Smoking lapses
• Suggest continued use of medications, which can reduce the likelihood that a lapse will lead to a full relapse. • Encourage another quit attempt or a recommitment to total abstinence. • Reassure that quitting may take multiple attempts, and use the lapse as a learning experience. • Provide or refer for intensive counseling.
References 1. Prevalence of current smoking among adults aged 18 years and over: United States, 1997-June 2008. Center for Disease Control and Prevention (CDC) Web site. http://www.cdc.gov/nchs/data/nhis/earlyrelease/200812_08.pdf; Accessed on January 25, 2010. 2. American Cancer Society. Cancer Facts & Figures 2009. Atlanta: American Cancer Society; 2009. 3. Doering, PL. Substance-related disorders: alcohol, nicotine, and caffeine. In: Dipiro, JT, Talbert RL, Yee GC, Matzke, GR, Wells BG, Posey, LM, eds. Pharmacotherapy A Pathophysiological Approach. 6th ed. New York, NY: McGraw-Hill; 2005:1198-1205. 4. Fiore MC, Jaen MC, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. A Clinical Practice Guideline. Washington, DC: US Dept of Health and Human Services. Public Health Service; 2008. 5. Schaffer SD, Yoon S, Zadezensky I. A review of smoking cessation: potentially risky effects on prescribed medications. J Clin Nurs. 2009;18(11):1533-1540. 6. Rx For Change: Drug Interactions With Smoking. The Regents of the University of California, University of Southern California, and Western University of Health Sciences. http://www.ashp.org/Import/PRACTICEANDPOLICY/PublicHealthResourceCenters/TobaccoCessation/DrugInteractionswithSmoking.aspx. 1999. Accessed January 11, 2010. 7. Clinical Pharmacology Web site. Drug Interaction Report. http://www.clinicalpharmacologyip.com.library1.unmc.edu:2048/Forms/Reports/intereport.aspx. Accessed January 27, 2010. 8. Rustin, TA. Assessing nicotine dependence. Am Fam Physician 2000;62:579-84,591-2. http://www.aafp.org/afp/20000801/579.html. Accessed January 12, 2010. 9. Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The Fagerström Test for Nicotine Dependence: a revision of the Fagerström Tolerance Questionnaire. Br J Addict. 1991;86(9):1119-1127. 10. U.S. Department of Health and Human Services. Women and Smoking: A Report of the Surgeon General. Rockville (MD): US Department of Health and Human Services, Public Health Service, Office of the Surgeon General, 2001.
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11. Are Your Patients Who Smoke Ready to Quit? Pfizer. Printed in USA/July 2009. 12. Nicotine abuse and dependence: medical topics. MD Consult Web site. September 19,2007. http://www.mdconsult.com.library1.unmc.edu:2048/das/pdxmd/body/0/0?type=med&eid=9-u1.0-_1_mt_6080329. Accessed January 20, 2009. 13. Klingemann,T. Redefining “cold turkey”: a new way of looking at an old method. PowerPoint presentation presented at: Olson Center for Women’s Health; May 20, 2008; Omaha, NE. 14. Beat the Pack. Program Launch/Reasons to Quit Week 1: How to Quit. Pfizer. Printed in USA/August 2008. 15. Jarvis MJ. ABC of smoking cessation: why people smoke. BMJ. 2004; 328(7434):277-9 16. American Cancer Society. Guide to quitting smoking. http://www.cancer.org/docroot/ped/content/ped_10_13x_guide_for_quitting_smoking.asp. November 23, 2009. Accessed on January 19, 2010. 17. Saunder, K. Toolkit for Tobacco Cessation Counseling: Triggers. Handout for patients. 18. American Lung Association 19. Beat the Pack. Coping With the Urge to Smoke Week 2: What to Do if You Slip. Pfizer. Printed in USA/August 2008. 20. Rx for Change. University of California, San Francisco. http://rxforchange.ucsf.edu/. Accessed February 5, 2010. 21. Centers for Disease Control and Prevention. Smoking-attributable mortality, years of potential life lost, and productivity losses-united states, 2000-2004. MMWR Morb Mortal Wkly Rep. 2008;57(45): 1226-1228. 22. University of Iowa: Hospitals and Clinics. Health topics: smokeless tobacco. http://www.uihealthcare.com/topics/medicaldepartments/cancercenter/smokelesstobacco/index.html. May 2007. Accessed January 24, 2010. 23. Understanding the potential benefits of quitting smoking. Pfizer. Printed in the USA/November 2008.
GPhA Member Appointed to National MTM Advisory Board onathan G. Marquess Pharm.D., CDE, CPT was appointed to the National MTM Advisory Board which held its inaugural meeting June 7-8, 2010. The diverse group is charged with focusing on key issues related to the advancement of Medication Therapy Management (MTM) services for payors, providers and other stakeholders.
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Lawyer and Pharmacist Leroy Toliver, Pharm.D., R.Ph., J.D. • Professional Licensure Disciplinary Proceedings • Medicaid Recoupment Defense • Challenges in Medicaid Audits • OIG List Problems • SCX or Other Audits Leroy Toliver has been a Georgia Registered Pharmacist for 38 years. He has been a practicing attorney for 29 years and has represented numerous pharmacists and pharmacies in all types of cases. Collectively, he has saved his clients millions of dollars.
“The board is well-positioned to discuss the critical issues related to MTM services during this dynamic time,” said Sherri Cohmer, Director of Medicare & Commercial Clinical Pharmacy Programs at Humana and a National MTM Advisory Board member. “The broad perspectives offered by the advisory board members will help us all to envision the short and long-term positioning of MTM services within the larger health care picture.” Through MTM services, pharmacists at local independent and chain pharmacies receive alerts and information concerning medication use patterns, as well as guidance on working with patients and doctors to fix potential drug complications. The retailers receive service fees in order to free-up pharmacist time to perform MTM activities. In 2010, the federal government placed increased emphasis on the services by requiring Medicare plans to offer more robust MTM programs.
Toliver and Gainer, LLP 942 Green Street, SW Conyers, GA 30012-5310 altoliver@aol.com 770.929.3100
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Continuing Education for Pharmacists Quiz and Evaluation Tobacco Cessation Counseling: A Guide for Pharmacists 1. According to the PHS Clinical Practice Guidelines, what is the minimum amount of time health care professionals should interact with patients to increase cessation rates? a. 5 minutes b. 10 minutes c. 25 minutes d. 90 minutes
6. What questionnaire can be used to determine the patient’s willingness to quit tobacco? a. Fagerström Test b. Ready to Quit Survey c. General Sociology Smoking Survey d. Why Do I Smoke? Quiz 7. Which center of the brain is activated by nicotine and is thought to be a critical component in brain addiction mechanisms? a. corpus callosum b. nucleus accumbens c. hypothalamus d. medulla oblongata
2. According to PHS Clinical Practice Guidelines, tobacco cessation is more effective when a. medication is provided only b. counseling is provided only c. medication and counseling are provided d. no medication and counseling are provided
8. What is the main difference between a slip and a relapse? a. A slip is a one-time mistake that is quickly corrected; a relapse is returning to using tobacco. b. A slip is returning to using tobacco; a relapse is a one-time mistake that is quickly corrected. c. A slip is a failure; a relapse is not a failure. d. A slip is not a failure but the patient will never successfully quit; a relapse is a failure.
3. Which medication does NOT interact with cigarette smoking? a. beta-blockers b. caffeine c. olanzapine d. sertraline 4. What questionnaire is a standard instrument used to assess the intensity of physical addiction? a. Fagerström Test b. Ready to Quit Survey c. General Sociology Smoking Survey d. Why Do I Smoke? Quiz
9. Tobacco use is responsible for how many deaths in the United States? a. 0 in 5 deaths c. 2 in 5 deaths b. 1 in 5 deaths d. 3 in 5 deaths 10. Which of the following is NOT a reward for staying tobacco-free as listed in the PHS Clinical Practice Guidelines? a. Improved health b. Save money c. Have negative mood or depression d. Set a good example for childrend.
5. How many times does the average smoker attempt to quit tobacco in his or her lifetime? a. 1 to 2 times b. 3 to 5 times c. 6 to 9 times d. 10 to 15 times
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Journal CPE Answer Sheet The Georgia Pharmacy Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. No financial was received for this activity. This article was originally published by the Nebraska Pharmacists Association under UAN#128-000-10-057-H04-P Participants should not seek duplicate credit. This article in reprinted with permission from the Nebraska Pharmacists Association.
Tobacco Cessation Counseling: A Guide for Pharmacists This lesson is a knowledge-based CPE activity and is targeted to pharmacists. GPhA code: J10-09 ACPE#: 0142-9999-10-009-H04-P Contact Hours: 2.0 (0.20 CEU) Release Date: 09/01/2010 Expiration Date: 09/01/2013 1. Select one correct answer per question and circle the appropriate letter below using blue or black ink (no red ink or pencil.) 2. Members submit $4.00, Non-members must include $10.00 to cover the cost of grading and issuing statements of credit/ Please send check or money order only. Note: GPhA members will receive priority in processing CE. Statements of credit for GPhA members will be emailed or mailed within four weeks of receipt of the course quiz. 1. 2. 3. 4. 5.
A A A A A
B B B B B
C C C C C
D D D D D
6. A B C D 7. A B C D 8. A B C D 9. A B C D 10. A B C D
Activity Evaluation: must be completed for credit Please rate the following items on a scale from 1 (poor) to 5 (excellent)as to how well the activity: 1. Met my educational needs: 2. Relates to pharmacy practice: 1 3. Achieves the stated learning objectives: 4. Faculty presented the information: 5. Teaching methods conveyed information: 6. Post-test aided in assessing my grasp of the information: 7. Avoided any bias or commercial bias: 1 8. How long did it take to complete this activity?
1 2 3 4 5 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 2 3 4 5 _______________________
A passing grade of 70% is required for each examination. A person who fails the exam may resubmit the quiz only once at no additional charge. Please check here if you are indicating a change of address ___ Phone #: _______________________________ Name: ____________________________________________________________________________ License Number(s) and State(s): ___________________ Email Address: ___________________________ Address: __________________________________________________________________________ City: _________________ State: __________ Zip: __________ Remove this page from the Journal and mail this completed quiz and evaluation to: GPhA, 50 Lenox Pointe NE, Atlanta, GA 30324. The Georgia Pharmacy Journal
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2010 - 2011 GPhA BOARD OF DIRECTORS
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The Georgia Pharmacy Journal® (GPJ) is the official publication of the Georgia Pharmacy Association, Inc. (GPhA). Copyright © 2010, Georgia Pharmacy Association, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical including by photocopy, recording or information storage retrieval systems, without prior written permission from the publisher and managing editor. All views expressed in bylined articles are the opinions of the author and do not necessarily express the views or policies of the editors, officers or members of the Georgia Pharmacy Association.
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