Pharmacists’ Impact on Tobacco Cessation Initiatives at WVU Medicine

Marc Phillips, PharmD CPHQ
Pharmacy Quality Specialist
WVU Medicine
Morgantown, WV

Rebekah Matuga, PharmD CPHQ
Ambulatory Pharmacy Manager
WVU Medicine
Morgantown, WV

Kelsea Seago, PharmD
PGY2 Oncology Pharmacy Resident
WVU Medicine
Morgantown, WV

Although the smoking rate among the general U.S. population decreased from 20.9% in 2005 to 14% in 2017, the smoking rate among people with cancer remains elevated.^1,2 This disparity was recently highlighted by the National Cancer Institute (NCI) Cancer Moonshot in an effort to increase cessation resources for the cancer population.

The NCI initiative, known as the Cancer Center Cessation Initiative (C3I), has offered funding to a total of 42 cancer centers across the nation for the creation or expansion of smoking-cessation treatment programs. To support the overarching mission of ensuring that every cancer patient who smokes is provided with adequate cessation support, each C3I participating site is required to develop a plan to continue cessation efforts after the conclusion of the 2-year funding period.² Sustainability is an important aspect of the C3I because the initiative also draws attention to the fact that historically, less than half of all patients diagnosed with cancer were engaged in a conversation regarding cessation, treated with cessation medications, or referred elsewhere for cessation support.²

Yet another disparity in smoking rates is seen in certain regions of the United States (for example, in Appalachia and the state of West Virginia). According to the Centers for Disease Control and Prevention, 26% of West Virginians smoked in 2017, the highest percentage in any state and 12% above the national average.¹ Furthermore, in 2016 West Virginia had the second highest rate of smokeless tobacco use: 8.5%.³ Recognition of these statistics, which may be associated with a deficiency in care, has allowed WVU Medicine to independently capitalize on the intentions of the C3I through internal initiatives to increase tobacco cessation among all patients, including patients with cancer.

Our efforts to improve access to tobacco cessation resources began when the West Virginia Hospital Association Honors Program established “increased access to tobacco cessation” as a requirement for designation as a Silver Honors facility in 2018. This requirement fueled the administrative support needed to enact meaningful change at our hospital and across the entire WVU Medicine system. To tackle this issue, we wanted to leverage our electronic medical record (EMR) to refer patients to our state’s Quit Line, provide tobacco-cessation medications, and provide eventual outpatient referral to tobacco-cessation clinics. Our EMR vendor pointed us to similar programs in other academic medical centers, which we emulated in our program.

Identification of a physician champion in the early stages was critical in order to vet the program and then engage physicians as the project progressed. We found ours in Samantha Minc, a vascular surgeon in our Heart and Vascular Institute (HVI). While the information technology (IT) team was busy in spring 2018 with building the program in the EMR, Dr. Minc helped us decide which services to include in the program pilot and develop education for providers. Education was provided by service line and included information on the program workflow, tobacco-cessation options, and outpatient referral opportunities. The IT team’s work building the program was completed in early summer 2018. The program was rolled out initially to services located in the HVI, then to our academic medicine services, and finally system-wide during the summer. Our program relies on a Best Practice Alert (BPA), which alerts the provider that a patient was designated a smoker during the nursing staff’s initial assessment for inpatient admissions. This alert fires only after the patient has been in a nonintensive-care-unit bed for 24 hours. The BPA suggests that the provider discuss tobacco cessation and provides the mechanism for sending that referral, ordering tobacco cessation medications, and, as of early 2019, referring the patient to outpatient tobacco-cessation services.

The program has been widely accepted and used by our providers since its launch. Our BPA has fired on 45.54% of all admissions since its inception, and we are currently seeing a 13.5% referral rate to the Quit Line throughout the system. These referrals have been hindered because of administrative requirements on the Quit Line side, but we have initiated a fix that we hope will be in place by the end of the first quarter of 2019. In order to expand the program’s reach beyond the inpatient stay, we have tied outpatient referral orders to both a tobacco-cessation clinic located in our Mary Babb Randolph Cancer Center (MBRCC) and a pharmacist-led group class housed in our Family Medicine Clinic.

The two smoking-cessation programs (offered at MBRCC and the Family Medicine Clinic) are similarly structured as a free 5- to 6-week tobacco-cessation support group offered to patients and caregivers alike. Both series focus on overcoming barriers to cessation, identifying and preparing for a patient-designated quit date, and providing support for sustaining cessation after the quit date has passed. Medications proven to assist with successful cessation are individualized for each participant. Classes are led by various providers, including pharmacists, all of whom have earned the Certified Tobacco Treatment Specialist (CTTS) designation.

The CTTS certification is issued by the Council for Tobacco Treatment Training Programs (CTTTP) to healthcare providers who have completed and passed an accredited training program designed to provide education about tobacco addiction and nicotine withdrawal symptoms, causes and consequences of tobacco use, and guidance on individualizing effective treatments for all forms of tobacco and nicotine use. Certification for many of these providers was obtained onsite through a program developed by the WVU School of Dentistry, one of only 20 programs in the nation to gain accreditation through CTTTP and the first dental school to join the list in 2017.⁴

In addition to these group therapy options, other ongoing initiatives at MBRCC are aimed at improving tobacco-cessation rates among our oncology patients. Screening for tobacco use has been incorporated into the WVU Cancer Institute’s Cellular Therapy Survivorship Clinic, a pharmacist-driven clinic at MBRCC for patients who have undergone hematopoietic cell transplantation. Patients in this clinic are continually assessed for initiation or continuation of tobacco use, and patients using any form of tobacco are encouraged to consider cessation. One of the board-certified oncology pharmacists who see patients in the survivorship clinic has also obtained CTTS training. When a patient in the clinic has been identified as being ready to tackle cessation, a separate appointment for tobacco cessation is arranged for more focused, individualized counseling and support.

Outside of the survivorship clinic, other providers in MBRCC are able to give a referral for pharmacist-led tobacco cessation services for interested patients. Patients seen for tobacco cessation are scheduled for a 45- to 60-minute initial session to identify barriers to cessation, assess prior quit attempts, and discuss pharmacotherapy options through motivational interviewing techniques. Through a collaborative practice agreement, pharmacists are able to prescribe pharmacotherapy based on the individual patient’s preferences and comorbidities and then follow up with the patient as appropriate, according to their preferences and needs.

Regardless of CTTS designation, oncology pharmacists are often in an ideal position to address tobacco use. It is imperative that we as pharmacists discuss with our patients any interactions between various chemotherapies and smoking, such as the potential for decreased concentrations of bendamustine, erlotinib, irinotecan, and pomalidomide in patients who smoke.^5-7 In addition, screening for tobacco use is easily incorporated into initial counseling sessions for patients who are undergoing cancer treatment. Cessation counseling may be offered if the patient screens positive for tobacco use, or a referral to a local cessation clinic or support group can be given. Follow-up sessions with patients undergoing treatment can also be used to continue encouraging or monitoring cessation.

As evidenced through efforts at WVU Medicine, pharmacists play a vital role in the battle against tobacco use by implementing institutional quality improvement initiatives, seeking additional training through CTTTP, or simply starting the conversation with a cancer patient. The NCI’s Cancer Moonshot C3I accented the need for increased attention, resources, and time dedicated to supporting cancer patients on their journey to cessation. This program can be a driver of change to decrease smoking rates and improve oncology outcomes in cancer centers across the nation.

References

1. Centers for Disease Control and Prevention. Current cigarette smoking among adults in the United States. Smoking and Tobacco Use, 2017. Accessed February 2019.
2. Croyle RT, Morgan GD, Fiore MC. Addressing a core gap in cancer care—the NCI Moonshot Program to help oncology patients stop smoking. N Engl J Med. 2019;380(6):512-515.
3. Centers for Disease Control and Prevention. Smokeless tobacco use in the United States. Smoking and Tobacco Use, 2016. Accessed February 2019.
4. Sheffer CE, Payne T, Ostroff JS, et al. Increasing the quality and availability of evidence-based treatment for tobacco dependence through unified certification of tobacco treatment specialists. J Smok Cessat. 2016;11(4):229-235.
5. Bendeka (bendamustine) [prescribing information]. North Wales, PA: Teva Pharmaceuticals USA Inc.; July 2018.
6. O’Malley M, King AN, Conte M, Ellingrod VL, Ramnath N. Effects of cigarette smoking on metabolism and effectiveness of systemic therapy for lung cancer. J Thorac Oncol. 2014;9(7):917-926.
7. Pomalyst (pomalidomide) [prescribing information]. Summit, NJ: Celgene Corporation; March 2018.