Tobacco harm reduction and vaping cessation: New opportunities for pharmacist skills

On May 31, 2023, the World Health Organization (WHO) and public health champions around the world will come together to celebrate World No Tobacco Day (WNTD). Across the globe, opinions and approaches to vaping are a constantly moving target as countries attempt to navigate this relatively new space of balancing tobacco harm reduction for smokers while minimizing the uptake by youth. Australia requires a prescription to obtain e-cigarettes[1] and has recently banned recreational use of e-cigarettes in public places. Great Britain wants to achieve a goal of 5% population smoking rate by 2030[2] and has recently announced free vape starter kits along with behavioural support to any person who wants to quit smoking cigarettes. New Zealand has a smoke-free goal for its citizens by 2025. Their three-pronged approach is to restrict sales of combustible tobacco products to anyone born in 2009 or above, reducing tobacco retailers by 95%, and by reducing cigarettes nicotine content to below addictive content.[3] USA has made it illegal for any retailers to sell tobacco products, including e-cigarettes and vapes, to anyone under the age of 21.[4] Canada’s Tobacco Strategy (CTS) is the current federal strategy to address tobacco use in Canada and is designed to help achieve the target of less than 5% tobacco use by 2035. Currently, approximately 48,000 Canadians die every year from a tobacco-related disease. The legal maximum concentration of nicotine in commercially available vaping products is restricted to 20mg/mL[5][6] Read: What should healthcare professionals do about youth vaping? With an ever-expanding scope of practice, pharmacists are often the first point of contact for any patient seeking help for their health concerns. Almost 70% of smokers say they want to quit.[7] With vaping rates on the rise, and evolving areas regarding tobacco harm reduction, it can be challenging to navigate the gray while assisting patients with these new options. Pharmacists for a Smoke Free Canada (PSFC) have released a new tool called the PSFC e-cig Nicotine Estimator. It was developed for healthcare practitioners to estimate the daily amount of nicotine vaped (mg/day) from an ENDS (Electronic Nicotine Delivery System) which is also called an e-cig, electronic cigarette or vape. This tool will help pharmacists navigate the emerging areas of tobacco harm reduction and vaping cessation. 1) PSFC e-cig Nicotine Estimator Form 2) PSFC e-cig Nicotine Estimator (mg) Downloadable Excel Tool 3) PSFC e-cig Nicotine Estimator (%) Downloadable Excel Tool Jane Ling, president of PSFC, and Dr. Leslie Phillips, PSFC VP (N.L.) have authored the tool and provided an accompanying short video webinar to explain how to use the PSFC e-cig Nicotine Estimator. Learning objectives include: Describe the basic components of e-cigarettes, explain how they work, and identify the basic types of e-cigarettes currently available Apply a systematic process to estimate the amount of nicotine a person is vaping on a daily basis (mg/day), using factors such as device type, e-liquid concentration, and frequency of use Use a case-based scenario to estimate the daily nicotine amount vaped in various e-cigarettes Pharmacists are in a unique position to make a significant positive impact on patient health with providing smoking cessation counselling and in some provinces, smoking cessation prescribing. Many provinces and some third-party plans also remunerate pharmacists for smoking cessation counselling services across Canada including: Green Shield $125 annually[8] Ontario $125 annually[9] Saskatchewan $360 annually[10] Alberta $140 annually[11] Manitoba $280 annually[12] Tobacco addiction is a chronic relapsing disease and is a risk factor for many chronic diseases including diabetes, hypertension, COPD, heart disease.[13] Smoking cessation is one of the most impactful and cost-effective preventative interventions in healthcare.[13] On average, it can take several quit attempts, but in each quit attempt patients learn strategies, become more knowledgeable and move towards success. Quitting smoking is challenging for any patient but with pharmacists by their side assisting them on their long and winding road, it can greatly improve their chances of success. Read: Pharmacists for a Smoke Free Canada now offers an e-cigarette nicotine estimator Pharmacists are: the most accessible healthcare provider [14] one of the most trusted healthcare professionals an expert in medication management and treatment choices PSFC have developed several tools, algorithms and videos to help pharmacists assist people on their journey to a smoke-free life. By using a combination of strategies including the 3A’s (Ask, Advise, Act) as well as motivational interviewing to gather patient history, pharmacists can work with patients to implement an effective, clinically suitable and sustainable smoking cessation plan. These PSFC resources can be found online: Canadian Pharmacist Smoking Cessation Pharmacotherapy Algorithm PSFC Algorithm Initial Tool PSFC Algorithm Follow Up Tool PSFC Patient Quit Tool Algorithme pharmacothérapie pour l’abandon tabagique PCSF Algorithme d’évaluation initiale PCSF Algorithme de suivi PCSF Plan d’abandon pour le patient Tobacco Harm Reduction and Vaping Cessation are two new emerging areas where patients are asking pharmacists for help. PSFC were part of the development committees of both: 1) Lower Risk Nicotine Use Guidelines (LRNUG) - The Health Canada/CAMH Nicotine is an extremely addictive substance that can be difficult to quit completely. For patients currently using or thinking of using nicotine products, LRNUG outlines modifiable behaviours and recommendations on the use of alternative nicotine products such as e-cigarettes. Pharmacists can share this Evidence Brief and Quick Tips page as a way to initiate conversation with patients who are looking to improve their health. 2) Vaping Cessation Resource Guide - CAMH These guidelines provide considerations for approaches to vaping cessation. For example, in addition to asking all patients if they are smokers, all patients should be asked if they vape, and consider that some patients may use both. Take into account patient preference, their personal goals, and smoking history when developing a treatment plan. With patients paying attention to their lung health now more than ever, pharmacists can help them navigate the changing landscape of smoking, tobacco harm reduction and vaping cessation. With all these new tools, pharmacists are poised to be leaders in assisting patients on their journey to a healthier smoke-free life. No-one needs to be left behind. REFERENCES [1] Evans & Lowrey. (May 1, 2023) Health minister launches war on vaping, Medicare reforms. https://www.abc.net.au/news/2023-05-02/vapes-recreational-use-banned-government-crackdown/102290248 Accessed May 15, 2023 [2] Department of Health and Social Care, U.K. Smokers urged to swap cigarettes for vapes in world first scheme. https://www.gov.uk/government/news/smokers-urged-to-swap-cigarettes-for-vapes-in-world-first-scheme#:~:text=As%20part%20of%20the%20world,smoking%20rates%20to%205%25%20or Accessed May 15, 2023 [3] Dennis Normile. (Dec 9, 2022) The final puff: Can New Zealand quit smoking for good? https://www.science.org/content/article/final-puff-can-new-zealand-quit-smoking-good [4] FDA Products. E-Cigarettes, Vapes, and other ENDS https://www.fda.gov/tobacco-products/products-ingredients-components/e-cigarettes-vapes-and-other-electronic-nicotine-delivery-systems-ends#:~:text=It%20is%20illegal%20for%20a,cigarettes%20%E2%80%93%20to%20anyone%20under%2021 Accessed May 15, 2023 [5] Government of Canada. Canada's Tobacco Strategy. https://www.canada.ca/en/health-canada/services/publications/healthy-living/canada-tobacco-strategy.html Accessed May 15, 2023 [6] Government of Canada. Regulating tobacco and vaping products: Vaping products regulations. https://www.canada.ca/en/health-canada/services/smoking-tobacco/vaping/product-safety-regulation.html Accessed May 15, 2023 [7] Babb S, Malarcher A, Schauer G, Asman K, Jamal A. Quitting Smoking Among Adults—United States, 2000–2015. Morbidity and Mortality Weekly Report 2017;65(52):1457-64 Accessed May 18, 2023 [8] Green Shield Canada: Guide to Pharmacist Health Coaching – Smoking Cessation Program https://www.providerconnect.ca/Carriers/GreenShield/SmokeCessationPdf/en_CA/SmokingCessationWorksheet.pdf Accessed May 15, 2023 [9] Health Canada. Pharmacy Smoking Cessation Program. https://www.health.gov.on.ca/en/pro/programs/drugs/smoking/ Accessed May 15, 2023 [10] Pharmacy Association of Saskatchewan. What is PACT? https://skpharmacists.ca/what-is-pact/ Accessed May 15, 2023 [11] Compensation Guide - Alberta Blue Cross. https://www.ab.bluecross.ca/pdfs/83443_compensation_guide.pdf Accessed May 15, 2023 [12] Pharmacists Manitoba. Expression of Interest: Manitoba Smoking Cessation Social Impact Bond https://www.pharmacistsmb.ca/sib/expression-of-interest.html#:~:text=Starting%20April%201%2C%202022%2C%20participating,thereby%20reducing%20health%20care%20costs Accessed May 15, 2023 [13] S. Department of Health and Human Services. Smoking Cessation. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2020 Accessed May 18, 2023 [14] Valliant SN, Burbage SC, Pathak S, Urick BY. Pharmacists as accessible health care providers: quantifying the opportunity. J Manag Care Spec Pharm. 2022 Jan;28(1):85-90. doi: 10.18553/jmcp.2022.28.1.85. PMID: 34949110; PMCID: PMC8890748. Accessed May 18, 2023

Tobacco harm reduction and vaping cessation: New opportunities for pharmacist skills

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