ROLE OF COMMUNITY PHARMACIST IN SMOKING

CESSATION

ZAHIDA BASHIR (141177)

FACULTY OF PHARMACY

JINNAH UNIVERSITY FOR WOMEN

ROLE OF COMMUNITY PHARMACIST IN SMOKING CESSATION
1. INTRODUCTION
Smoking is a global widespread. In the Europe union smoking rate is very high. The smoking
rate in boys and girls are 13-15 years are 21.4% and 17.3 %.Smoking can cause many health
problems including cancers, cardiovascular disease, and lung diseases. Smoking also increases
the risk related with hospitalization for surgery. People who are in hospital because of a
smoking‐related illness are likely to be more interested to help to give up smoking.Community
pharmacist is only the health care professional who has regular monitoring of interaction as well
as sickness, pharmacist also play an important role in controlling smoking, all the available form
of nicotine replacement therapy (NPT) are effective in promoting smoking cessation, community
pharmacist has an important role in smoking cessation they can prevent patient by councelling to
smoker [2].The community pharmacist who council patient can control smoking cessation rate.
Smoking cessation program can improve the quality of life and the pharmacy intervention can be
cost effective, smoking cessation training to pharmacy student can built up students confidence
for counselling.Training health professionals in smoking cessation therapy has a quantifiable
effect on expert performance, but there is no strong indication that it changed clients’ smoking
behavior[3] , Pharmacy staff working on their own can make a positive contribution to the
process and outcome of smoking cessation [1].
The role of pharmacist in preventing smoking cessation are dispensing, over the counter NRT
counselling patient and other pharmaceutical smoking cessation aid, pharmacist must guide to
patient that its not good for your health. Tell the side effect of smoking. Also tell about the
disease. some previous research show that pharmacists trained to provide counselling so they can
prevent from smoking, someprescription drug are also present to prevent nicotine dependence
example of such drugs are bupropion, and cytrizine. The idea of smoking cessation services
providing by pharmacist is fresh but more popular in polish society
Bupropion has been licensed for the cure of tobacco dependence. While originally established as
an antidepressant in the US, its effectiveness in smoking cessation appears to be independent of
its antidepressant effect. Bupropion originates in sustained release tablets. The dose of bupropion
is 300 mg per day(4).
2. PHARMACIST'S ROLE IN SMOKING CESSATION
You are aware that forsaking cigarettes isn't a simple factor to try and do. It needs motivation,
will, discipline, and—help! Pharmacists area unit terribly intimate with smoking surcease and,
as attention professionals, they'll assist you in several ways; here area unit 5 of them.
i. Your pharmacist can help you develop an action plan
Smokers tend to table the time for action indefinitely.
There aren't any lack of reasons to convert oneself that the time is not right: lack of
motivation, nerve-racking time at work, illness, etc. It's true that quitting smoking could be
a nice challenge, however everybody has the power to succeed! Some people create the
error of starting the method while not initial having ready associate degree action set up.
Smoking surcease isn't a mere gesture, however rather a method that begins by responsive
queries like these:
 What can my stop date be?
 Will I quit "cold turkey" or gradually?
 Should i exploit a smoking surcease aid? If therefore, which one?
 Who around Maine am i able to raise support?
 How can I overcome my cravings?
Developing associate degree action set up will be troublesome if you do not
grasp abundant concerning smoking surcease. Your apothecary is incredibly knowledgeable
on the topic. raise him/her for methods and ways in which to extend your probabilities of
success. for example, you're a lot of doubtless to place your set up into action if you place it
down in writing.
ii. Your apothecary will assist you select a smoking surcease aid
Smoking surcease aids area unit oversubscribed over-the-counter or with a prescription
and create quitting smoking easier by reducing cravings and withdrawal
symptoms, that considerably will increase your probabilities of success. Specialists suggest the
employment of a smoking surcease aid and estimate that just one out
of twenty folks is booming in quitting smoking for goodwhile not it.
Smoking surcease aids area unit divided into 2 groups—oral treatments
and vasoconstrictor replacement therapies. the 2 oral medications that area
unitformally approved in North American nation area unit varenicline and bupropion. They
are accessible by prescription solely. Vasoconstrictor replacement therapies don't need a
prescription. It is necessary to settle on the suitable smoking surcease aid by taking under
consideration many factors, as well as your age, lifestyle, health, and medical record. As
medication consultants, pharmacists area unit well-suited to advise you and assist you to
form the most effective alternative. Among alternative things, they'll then inform
you concerning the conditions of use of the medication, aspect effects, and therefore
the warnings and precautions associated to them. With this recommendation, you'll profit the
foremost from the treatment and increase your probabilities of success.
iii. Your apothecary will impose a vasoconstrictor replacement medical aid (NRT)
As the name implies, NRTs supply a dose of vasoconstrictor to an individualwithin
the smoking surcease method aside from by the inhalation of smoke smoke. This dose helps to
cut back cravings and withdrawal symptoms like sleep disorder, nervousness,
irritability, issue concentrating, etc.
There is a good vary of NRTs within the variety of patches, chew gum, lozenges, inhalers or
sprays. These merchandise area unit thought of as first-line smoking surcease treatments as a
result of their effectiveness and safety profiles. Though they are oversubscribed over-the-
counter, these merchandise area unit reimbursed by variety of insurance firms after they area unit
prescribed. The nice news is that your apothecary will cuurently impose them to
you, therefore you do not have to be compelled to see your doctor to induce a prescription.
However, it's necessary to grasp that your apothecary can have to be compelled to meet with you
for a consultation. He/She can raise your queries and judge your scenario to confirm that you
simply area unit prescribed the most effective treatment doable. At the top of the consultation,
he/she can decide whether or not or not associate degree NRT is appropriate for you. Note that
oral treatments like varenicline and bupropion should always be prescribed by a doctor.
iv. Your apothecary will provide you with recommendation to manage your cravings
and address your withdrawal symptoms
It's well-known that cravings and withdrawal symptoms area unit what makes quitting
smoking troublesome. many of us notice it exhausting to manage them as a result of the
discomfort they cause. additionally to the employment of a smoking surcease aid, the one who
equal smoking should use alternative suggests that, tips, and solutions. luckily, there area
unit many!
There area unit many sources of data at your disposal, like the net. notice valuable tools on-
line, for example, iquitnow.qc.ca , that features a wealth of helpful data. Also, raise former
smokers to share their wining methods with you. The a lot of hip to you're, the higher your
probabilities of getting your objective.
Once again, your apothecary will play a vital role. Pharmacist’s experience and skill create them
a valuable resource. By asking them queries, you will higher perceive tobacco addiction and find
out ways in which to induce it in restraint. Straight forward tips among your
reach will generally create all the distinction. you have got the selection of a good vary of
solutions. Your apothecary will assist you discover what they are!
You will notice recommendation to assist management your smoke cravings within the following
text: Do you wish to quit smoking?
v. Your apothecary will assist you to realize your goal to quit smoking
Having others' support can create things easier and assist you to succeed. Your oldsters, friends,
and colleagues will be a major supply of motivation and support. That
said, it's additionally necessary to possess the support of a attention skilled throughout the
method, like your apothecary, whose facilitate and support you'll appreciate each step of
the approach. Pharmacists area unit involved concerning their patients' health and can lief invest
time and energy so as to assist them. The profit justifies the cost! Pharmacists area unit glad to
follow your progress and to encourage you and supply recommendation. If, throughout this
journey, you have got queries, concerns, doubts, otherwise you simply want a tiny low dose of
additional motivation, stop by to talk to them or offer them a call! There is little
question that there's nothing higher than forsaking tobacco to boost your health, well-being, and
quality of life. Your apothecary is aware of it! that's why it's powerfully best to decision upon
him/her as again and again as necessary. there is strength in numbers and you'll be able
to reckon pharmacists to affix their strength to yours, therefore you'll be able to celebrate best
victories.[5]
3. 5 A’S OF SMOKEY CESSATION
INTRODUCTION ON 5A’S

The 5 A’s advance approach is not only summarized but goal oriented way of studying and
giving the guidelines regarding the use of tobacco and their negative aspects on patients and
healthy people. It gives the guideline to the patients to give up the use of tobacco. This cessation
don’t ask the patients to quit smoking suddenly but to give it up gradually. Therefore this famous
5 A’s cessation should not be applied to the patients in very tough way and rigid and strict
manner.
Their should be leniency in helping the patient in quieting smoking. And this involves the whole
staff of the patients which can give him courage to spend life without smoking. Doctors ,
Pharmacist and other staff should make sure that the patient is ready for giving up the use of
tobacco.

Those 5A’s stands for :

i)Ask
ii)Advice
iii)Assess
iv)Assist
v) Arrange

These 5 A’s are described as follows:

i)Ask:
This involves asking the questions to the patients regarding their daily use and consumption of
tobacco as part of their vital signs like body temperature, blood pressure etc. In this the doctor
should know about the current and past routine of smoking.

ii)Advice:
In this session the doctor or the pharmacist ask the patient to give up the use of tobacco in the
manner of advise . And the quiting should be in a very clear , strong and personalized manner.
Persuade every tobacco user to quit it Expect ambivalence. Be willing to listen non-judgmentally
to his/her concerns about quitting tobacco use.
 iii)Assess:
In this session the doctor or the pharmacist determine that the patient is either ready to quit
tobacco or just forcibly doing so. How much he or she is interested in quit of tobacco.Assess
how ready the patient currently is to quit tobacco use. Readiness rulers (i.e., “On a scale of 1 to
10, where 10 is very ready
Free telephone counseling through the Maryland Quitline with an easy referral through our Fax
to Assist program

iv)Assest
For those who have successfully quit using tobacco, you can Assist by affirming their success to
support self-efficacy, and discussing any challenges to staying quit and methods to prevent
relapse.

Current Tobacco Users with High Readiness to Quit (Preparation or Action)

You can Assist by helping him/her develop a personalized quit plan with a quit date and offer an
array of effective treatment options:
 Medications and Nicotine Replacement Therapy (when medically advisable - consider
pregnancy, other medications, allergies, etc.)
 Free telephone counseling through the Maryland Quitline with an easy referral through our Fax
to Assist program
 Your local health department's cessation services programs
 Individual or group smoking cessation programs
Current Tobacco Users with Low Readiness to Quit (Precontemplation or Contemplation)
You can Assist by enhancing willingness or motivation and ability or confidence through these
methods:
 Offer personalized, relevant feedback about the importance of quitting
 Explore the individuals’ perceived pros and cons of smoking and quitting
 Discuss the 5 R’s of quitting tobacco use as follows

v)Arrange:
Follow-up is most helpful to do it within the first weeks of a quit date and can be either in person
or via telephone. During this call encourage the individual to remain quit. Discuss any obstacles
and how to overcome them. Congratulate success for those who have been able to quit. For those
who continue to use tobacco, repeated use of the 5 A’s and 5 R’s is important for supporting
motivational changes over time to move toward Action for quitting tobacco.
Some providers and settings prefer to use abbreviated forms of the 5 A’s model, such as Ask
Advise Refer(link is external), which focuses on referring patients to national tobacco quitlines
for assistance.[6]
4. TRANS THEORETICAL MODELS (TTM)
James Prochaska and Carlo DiClemente was recongnized the stages of change model.
TMM provide a structure for considerate or prevailingusing human intended behavior
modification. It has 3 establishing constructs of the model
1. The Stages of change.
2. The processes of change.
3. The context of change.

STAGES OF CHANGE
According to TMM, the behavior change can conceptualized as a series of five sequential stages
STAGE A tobacco consumer in this step……..

Precontemplation Having no thinking to leave smoking or not to quiet in near future

(i.e.…within 6 months)
Contemplation start to examine their tobacco use and want to quiet
Preparation Make a commitment to stop it (within 30 days)
Action Put his plan for stopping tobacco into action(<6 months)
Maintenance Has successfully continuously abstinence for 6 months

THE PROCESSES OF CHANGE

 Cognitive processes
 Behavioral processes

COGNITIVE PROCESSES DESCRIPTION

Consciousness-Raising
Emotional Arousal
Self-Reevaluation
Environmental Reevaluation
Knowledge about the individual and their tobacco use is
increased
Emotions about individual’s tobacco use and available
treatment are aroused
Emotion regarding to individual, especially with respect to their
tobacco used
Influence of the individual’s tobacco used on their environment
 is reassessed.
Social liberation Efforts are prepared to decrease tobacco use in society.

BEHAVIORAL PROCESSES DESCRIPTION

Self-liberation Taking a passage of deed to quit tobacco or
promising to that choice
Stimulus generalization Stimuli cause trigger back towards smoking
with, removed, or avoided
Conditioning Positive another behaviors are exchanged for
the being’s tobacco use
Reinforcement Management positive behavioral deviations are rewarded
Helping relationship Discussion with trusting person about tobacco
used

CONTEXT OF CHANGE
The context of change contains areas of effective that accompaniment ormeasurevia the stages of
change.
CONTEXT DESCRIPTION
Current life situation Current environment ( external or internal)
check i.e. level of anxiety or financial
Belief and Attitude Belief how change occur and what’s need for
change
Interpersonal Relationships Interact with other individuals
Social system Family system or social system or barriers to
change
Enduring personal Characteristics Personality Characteristics [7]

5. PHARMACOTHERAPY FOR SMOKING CESSATION

Developing cessation of smoking is among the lead intervention focused at decreasing mortality
and morbidity rate worldwide. [8] Most of the smokers are nicotine addicted. This addiction is
susceptible to remission or relapse[9]
Three are 3 approved pharmacotherapy which is available in PBS (pharmaceutical benefits
scheme)

1) Nicotine replacement therapy

2) Non nicotine therapy
a) Varenicline
b) Bupropion [10]
 NICOTINE REPLACEMENT THERAPY (NRT)
A no of formulations of NRT are available
Dosage form Efficacy
Trans dermal At steady rate these patches deliver drug
nicotine patch through skin it is used for long term therapy
it gives more compliance rate than other
NRT products but they may not properly
work against addiction by smoking so
combination therapies are used.
Nicotine nasal All the dosage forms except patches are short
spray acting Nasal sprays provide more rapid
nicotine than other dosage forms and also
reliefs acute cravings and addiction
Nicotine gum Extremely high level of nicotine is not
provided due to slow gum absorption it may
cause burning sensation and should not be
used with acidic beverages
Nicotine lozenge Nicotine from this type of formulation is
absorbed by buccal mucosa the amount of
nicotine absorbed by lozenges is greater than
absorbed by gums
Sublingual This dosage form is not used commonly it is
nicotine tablet placed under tongue where nicotine is
absorbed sublingually
Nicotine inhalers When the inhaler is puffed nicotine is
released into the mouth of the smoker it is
not deliver to the lungs or bronchi but
remains in the mouth like nicotine gum
Dose
Smokers who smoke>10
cigarettes /day should use
21mg/day patch for 6 weeks
and then 14mg/day patch for
2 weeks and finally
7mg/day patch for 2 weeks
[11]
Dose depends on the
individual condition mostly
pts are started from 1-2
doses/hr upto 40 doses/day
the pump gives 0.5 mg
nicotine/50-uL squirt
Available in 2mg and 4 mg
which provides respectively
1 and 2 mg nicotine initially
dose should starts with 1
piece every 1-2 hr for first 6
weeks then decrease to 1
piece for 2-4 hrs and finally
1 piece for 4-8 hrs [12]
It is provided in 2mg and 4
mg formulation
2 mg lozenge is used for 12
weeks and the dose is
gradually decreased
The treatment duration is 3
months each inhaler bottle
contains 10 mg of which 4
mg is delivered and 2mg is
absorbed [13]
  NON NICOTINE THERAPY

A) VARENICLINE
Varenicline decreases the nicotine withdrawl symptoms by inhibiting the binding of nicotine to
the receptor that activates the increasing effect s of nicotine which automatically increases the
nicotine dependence by this aspect varenicline is considered to reduce cigarette smoking.[14]

Safety

This drug can be used by chronic obstructive pulmonary disease (COPD ) patients safely
The main side effects include sleeping disorders, insomnia and nausea. Nausea can be reduced if
drug is used with fool or full glass of water.

Dosing

Smokers are suggested to stop smoking after one week of starting the vareniclin
The given dose is
0.5 mg daily For 3 days
0.5 mg bid daily For 4 days
1 mg bid daily For remaining 12 week of course

Evidence shows no psychiatric disorders or CVS disorders after using this drug than other FDA
approved smoking cessation drugs but it is suggested that if smoker using this drug shows any
symptoms like agitation ,behavioral changes ,depressed mood or suicidal attempt must stop the
drug and contact with consultant.[15]

B) BUPROPION
Bupropion works by increasing CNS noradrenergic and dopaminergic release

Safety

This drug is safe to use for stable patients of CVD and COPD. The side effects which are most
common are insomnia, headache, agitation and dry mouth

Dose

The common formulation used is sustained release bupropion. This drug is started before a week
of quitting date to attain steady state blood level it takes 5-7 days
The recommended course is of 12 weeks initial dose is 150 mg/day for 3 days and then 150 mg
bid thereafter. [16]
6. NON-PHARMACOLOGICAL TREATMENT FOR SMOKING
CESSATION
Community Pharmacist play a vital role in the non pharmacological treatment for smoking
cessation.Pharmacist help smokers to quit smoking by giving these non pharmacological
therapies,These non-pharmacological intervention for smoking cessation may include patient
education and advise, behavioral therapy which include both individual and group counseling,
self improvement programs and telephone counseling.[17]
 ADVISE AND EDUCATION

Community pharmacist provide education about the smoking cessation .They can provide
information about the health illness by taking cigarettes and health benefits of quitting smoking.
They educate the patient how to quit smoking.[18]
 Life style modification to minimize the stress and to improve quality of life by beginning
exercise which can improve the potential to quit smoking and prevent relapse.
 Prevent contemplation like having one cigarette won’t hurt, one cigarette ordinarily
prompts some more.
 Identify feeling or activities that raise your craving to smoke.[19][20]
 SELF IMPROVEMENT PROGRAMS

For smoking cessation self improvement program mainly comprise of electronic or printed
material. To increase motivation to stop smoking community pharmacist may provide these
printed materials to the patient and also give information on how to achieve this objective.
The self improvement programs have various advantages which may includes
 These self improvement programs are comparatively cheap.
 For recurrent quit endeavor these written materials which are given to the patients can be
used again.[17]
 TELEPHONE COUNSELING

Community pharmacist can also talk to the patient on telephone for counseling . Telephone
counseling can give information to the patient and provide support to the smokers.Telephone
counseling a well accepted methodology for the treatment of smoking cessation comprise of
both receptive(it means smoker first call to hotline) and proactive ( it means instructor start call
to smokers) approaches. Calls may utilize a format which is an organized problem solving or
give more personal tailored response. The time span of telephone contact of counselor and
smoker is comparatively short extending from 5 to 20 minutes.[21]
 CONGINITIVE BEHAVIORAL APPROACH ES

Another non pharmacological treatment for smoking cessation may include conginitive (learning
how to reduce and how to cope with negative state of mind),behavioral (change the habit to stop
or to avoid the smoking) and motivational(listening why the smoking is not essential for
us).These all information provided by the pharmacist to help the smoker to quit smoking easily.
These approaches may include both individual and group counseling. Group councelling may
involves lectures and group meetings in which community pharmacist or other health care
providers provides suggestions for preventing relapse but their cost can vary.
Concelling that is provided to the patient or smoker and bilateral telephone counseling are very
effectual than simply giving the self improvement materials and education.
Non pharmacological treatment are effective and give support to the patient who are attempting
to stop smoking.[22][23]

7. ELECTRONIC CIGARETTES
Tobacco use among adults and adolescents remains prevalent in the United States. Many
smokers wish to quit, but a number of cessation attempts are usually necessary to overcome
tobacco use. Tobacco use should be treated as a chronic condition, and the community
pharmacist must assess the patient’s readiness to quit prior to initiating pharmacotherapy.
Behavioral interventions should be utilized in the patient who is not ready to quit, and these
should be coupled with an appropriate pharmacotherapy selection once the patient is ready to
quit. Community pharmacists are well positioned to perform interventions with patients who use
tobacco.
Electronic cigarettes, also known as smokeless cigarettes, e-cigarettes, or e-cigs, are an
alternative method of consuming nicotine, the addictive chemical found in tobacco.
Manufacturers often design e-cigarettes to look like regular cigarettes, but they contain no
tobacco and don't require a match -- or any flame at all.
An e-cigarette is a battery-powered device that converts liquid nicotine into a mist, or vapor, that
the user inhales. There's no fire, no ash and no smoky smell. E-cigarettes do not contain all of the
harmful chemicals associated with smoking tobacco cigarettes, such as carbon monoxide and tar.
Manufacturers and satisfied customers say the e-cigarette is a healthier alternative to tobacco
cigarettes, which cause millions of deaths every year. Some users say e-cigs have helped reduce
their "smoker's cough," sharpened their senses of taste and smell, and even improved their sleep

ELECTRONIC CIGARETTES: A ROLE IN SMOKING CESSATION?

Electronic cigarettes (e-cigarettes) are battery-operated devices containing nicotine and other
substances (e.g., propylene glycol). E-cigarettes are growing in popularity: There were 2.4
million users in middle school and high school in 2014, and 12.6% of adult smokers have tried
them. Those most likely to use e-cigarettes are young adults (age 18-24 years) and current
smokers who attempted to quit in the past year. These devices have provoked safety concerns,
and their role in smoking cessation is heavily debated. E-cigarettes have been found to emit toxic
compounds, such as formaldehyde, via breakdown of cartridge substances (e.g., propylene
glycol, glycerin). Although they are thought to emit significantly lower levels of carcinogens
than tobacco cigarettes, they have been shown to emit toxic chemicals (e.g., diethylene glycol)
and carcinogenic impurities (e.g., N-nitrosonornicotine). Diethylene glycol, a flavoring agent
previously used to manufacture popcorn, is associated with the development of bronchiolitis
obliterans (“popcorn lung”), a severe condition involving permanent loss of lung function. study
of 51 e-cigarette flavoring juices (e-juices) found diethylene glycol in 76% of e-juices, raising
concerns over health risks different from those of combustible cigarettes. E-cigarette flavorings
have been identified as a potential harm by the American Lung Association.

The pharmacist should assess the patient’s use of e-cigarettes in place of combustible cigarettes
or as a cessation aid. Despite the lack of consistent evidence for e-cigarettes as a cessation aid,
physicians support their use 61% of the time when asked by patients who are interested in
quitting. Based on inconsistent evidence and the potential for emerging health risks, e-cigarettes
are not an appropriate cessation tool for most patients. Their use should be restricted to patients
who will not attempt any other cessation method, and patients should be apprised of the potential
harms.

COMMUNITY PHARMACISTS AS SMOKING-CESSATION TREATMENT

SPECIALISTS

As the most accessible healthcare providers, community pharmacists can support patients’
attempts to quit smoking. A systematic review of tobacco interventions by pharmacists
demonstrated that pharmacists can deliver smoking-cessation services and suggested they are
effective in helping patients successfully quit. Community pharmacists who provide smoking-
cessation services have cessation rates similar to those of other healthcare professionals. The
pharmacist should select the most appropriate therapy for the patient and counsel the patient on
how to use it correctly. It is estimated that a smoker requires eight to 11 cessation attempts, and a
Gallup poll reported that smokers average 6.1 quit attempts before achieving success. However,
recent literature indicates that the average may be as high as 30 quit attempts, noting that
previous figures may be underestimated because of the exclusion of smokers facing significant
challenges in quitting and limitations in smokers’ ability to recall lifetime quit attempts.

Pharmacists should be encouraged to perform interventions when counseling patients who are
picking up medications; even a brief intervention (3 minutes) increases patient interest and
success in quitting. Counseling interventions have been associated with greater cessation success
as the number of interventions increases. Community pharmacists should be supportive of
patients who are unsuccessful, identifying barriers and adjusting pharmacotherapy. It should be
expected that smokers will require multiple attempts, and community pharmacists should assist
in both behavioral counseling and pharmacotherapy management. All patients should be referred
to 1-800-QUIT-NOW for additional support. Pharmacists can also use the quizzes at
Smokefree.gov (e.g., a quiz on identifying stressors and how to manage them; a withdrawal quiz
to determine the degree of symptoms; and a nicotine-addiction quiz that assesses how much the
patient relies on nicotine and ways to curb cravings).
REFERENCES
1. Community pharmacy personnel interventions for smoking cessation (Review) , The
Cochrane Collaboration. Published by John Wiley & Sons, Ltd.The Cochrane Library
2008, Issue 4.
2. Silagy 2004 Silagy C, Lancaster T, Stead L, Mant D, Fowler G. Nicotine replacement
therapy for smoking cessation. Cochrane Database of Systematic Reviews 2004, Issue
3. Lancaster 2000 Lancaster T, Silagy C, Fowler G. Training health professionals in
smoking cessation. Cochrane Database of Systematic Reviews 2000, Issue 3.
4. Raw M, McNeill A, West R(1998) Smoking cessation guidelines for health
professionals. (1998) volume 55, issue 12
5. Your pharmacist's role in smoking cessation, health, health tips, © The Jean Coutu
Group (PJC) Inc.2018.
6. Maryland tobaccos resource center 2008 pg 6 ( Rollnick, Miller and Butler)
7. James O. Prochaska, Wayne F. Velicer: online pdf for trans theoretical model for
behavior change: September 1997 Volume: 12 issue: 1, page(s): 38-48

8. Mathers CD, Loncar D. Projections of global mortality and burden of disease from
2002 to 2030. PLoS Med 2006 Nov; 3(11): e442
9. McLellan AT, Lewis DC, O’Brien CP, Kleber HD. Drug dependence, a chronic
medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA
2000;284:1689-95.
10. Cahill K, Stevens S, Perera R, Lancaster T. Pharmacological interventions for smoking
cessation: an overview and network meta-analysis. Cochrane Database Syst Rev
2013;5:0.
11. Ferguson SG, Gitchell JG, Shiffman S. Continuing to wear nicotine patches after
smoking lapses promotes recovery of abstinence. Addiction. 2012 Jan 26. [Medline]
12. Etter JF, Huguelet P, Perneger TV, Cornuz J. Nicotine gum treatment before smoking
cessation: a randomized trial. Arch Intern Med. 2009 Jun 8. 169(11):1028-34

13. Piper ME, Smith SS, Schlam TR, Fiore MC, Jorenby DE, Fraser D, et al. A
randomized placebo-controlled clinical trial of 5 smoking cessation
pharmacotherapies. Arch Gen Psychiatry. 2009 Nov. 66(11):1253-62. [Medline].

14. Hays JT, Ebbert JO. Varenicline for tobacco dependence. N Engl J Med 2008;
359:2018.

15. Hajek P, McRobbie HJ, Myers KE, et al. Use of varenicline for 4 weeks before
quitting smoking: decrease in ad lib smoking and increase in smoking cessation rates.
Arch Intern Med 2011; 171:770

16. https://www.uptodate.com/contents/pharmacotherapy-for-smoking-cessation-in-adults
1 line pharmacotherapy for smoking cessation
17. Lancaster T, Stead LF. Self-help interventions for smoking cessation. Cochrane
Database Syst Rev. 2005;(3):CD00111.
18. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence:
Clinical Practice Guideline. Rockville, MD: US Dept of Health and Human Services,
Public Health Service.
19. Bergen AW, Caporaso N. Cigarette smoking. J Natl Cancer Inst 1999; 91:1365.
20. Lancaster T, Stead L, Silagy C, Sowden A. Effectiveness of interventions to help
people stop smoking: findings from the Cochrane Library. BMJ 2000; 321:355.
21. Marcus BH, Albrecht AE, King TK, et al. The efficacy of exercise as an aid for
smoking cessation in women: a randomized controlled trial. Arch Intern Med.
1999;159:1229 –1234.
22. Curry SJ. Self-help interventions for smoking cessation. J Consult Clin Psychol.
1993;61:790 – 803
23. Gonzales D, Rennard SI, Nides M, et al. Varenicline, an alpha4beta2 nicotinic
acetylcholine receptor partial agonist, vs sustained-release bupropion and placebo for
smoking cessation: a randomized controlled trial. JAMA 2006; 296:47.