Smoking Cessation: A Collaborative Model

JULY 01, 2006
Robert Gold, RPh, MBA

Many methods of smoking cessation are available today. The results are still less than optimal, however, especially when each method is used alone. This problem has created the need for innovative, collaborative methods in the area of tobacco cessation.

Two pharmacists working in collaboration with a registered respiratory therapist took a special interest in filling this void. This team developed a model design that incorporated spirometry and nicotine replacement therapy (NRT). The rationale behind this model was that equipping patients with objective health information provided by spirometry results, traditional NRT, and professional counseling could further improve smoking-cessation rates.

Using spirometry is a new technique in smoking cessation backed by the National Lung Health Education Program (NLHEP). Lung age and airway limitation, as well as any signs of restrictive or obstructive lung disease, can be estimated via a spirometer, a device used to measure lung health. When these results are shared with patients, higher cessation rates among smokers have been reported.1

In the recent intervention, the team created a program to implement the new model with 450 participants recruited from large clinics in southern Indiana. These clinics were typically located at hospitals or community pharmacies. Recruitment was completed using flyers and advertisements in local newspapers. All participants signed informed consent forms and were instructed on the possible risks and adverse effects of nicotine patches and spirometry. Participants could attend the smoking-cessation clinic if they were at least 18 years of age and smokers. Participants were excluded if they had any health contraindications or allergies to any component of the nicotine patches.


Each participant was required to complete 3 self-evaluations that are commonplace in smoking-cessation clinics. These self-evaluations were as follows:

  • Stages of Change (which addresses readiness to quit, precontemplation, contemplation, preparation, action, maintenance)
  • Fagerstrom Test for Nicotine Dependence (which estimates nicotine dependence—low, medium, high)
  • Center for Epidemiologic Studies Depression Scale (which evaluates depressive feelings and behaviors over the previous week—major, mild-to-moderate, or no indication of depression)

The participants'readiness to change was reviewed to customize their therapy and consultation. The Fagerstrom test was used to calculate the correct strength of NRT to be used. Depression was assessed in the study to see whether the use of bupropion hydrochloride, an antidepressant used in smoking cessation, should be considered. Each person's past medical history, medication history, current packs per day (PPD) of cigarettes smoked, and average pack years (APY) also were documented.


A respiratory therapist performed and interpreted spirometry tests and explained the results to the participants individually for ~15 minutes. All spirometry was based on the American Association of Respiratory Care guidelines and the NLHEP. The following information was recorded for each participant:

  • Forced expiratory volume in 1 second (FEV1)
  • Forced expiratory volume in 6 seconds (FEV6)
  • FEV1/FEV6 ratio
  • An estimate of lung age
  • The calculated percentage of the predicted values

Detection of restriction and obstruction of airflow was designated by a FEV1/FEV6 ratio of <0.7.

Pharmacist Counseling

Next, the participants were engaged in a 15-minute pharmacist counseling session concerning smoking cessation and the use of nicotine patches. At this session, a pharmacist also reviewed the spirometry results and stressed the lung age that was determined. The patients could objectively see their results and the effects of smoking cessation by the use of a graph comparing the FEV1 of a person who never smoked, a person who stopped smoking before 50 years of age, and a person who stopped smoking at 65 years of age. The pharmacist also assessed each patient's medication history for any drug or disease interactions. If deemed medically safe, participants were given a free 1-week supply of nicotine (Nicotrol) patches.

The pharmacist counseled each patient extensively about nicotine replacement, using materials provided with the product's packaging, including proper use, dosage, and signs of toxicity. Participants who received patches were told where to purchase more patches when the sample patches ran out. They were contacted via telephone 6 months post intervention to determine their smoking status.


During the first project, the researchers found the average lung age of participants to be >20 years older than their actual average age. Twenty percent of those enrolled had an FEV1/FEV6 of <0.7. The average PPD was 1.23, and the APY was almost 30 years. Only 268 of the 450 participants from the first venture were reached for follow-up. Upon follow-up after 6 months, 55% (n = 147) of participants were classified as "smokers," 23% (n = 62) as "cut back," and 22% (n = 59) as "ex-smokers." The majority of participants were found to be highly nicotine-dependent, based on their Fagerstrom score.

In June 2004, a second arm of the project began, utilizing a 2-week supply of nicotine patches. Patches for an additional week were supplied in the hopes of improving compliance rates. For the second program, 363 participants were recruited from southern Indiana clinics during the period from July 2004 through July 2005.

Of these 363 people, 44 participants responded to follow-up via telephone 6 months after the intervention. Their average lung age was >20 years older than the participants'actual average age. Almost 18% of the participants had an FEV1/FEV6 ratio of <0.7. The average PPD was found to be 1.22, and the APY was ~66 years. The majority of participants were found to be highly nicotine-dependent per Fagerstrom scores. After the 6- month follow-up, 45.5% (n = 20) of the participants were classified as "smokers," 11.3% (n = 5) as "cut back," and 43.2% (n = 19) as "ex-smokers."

When designing this method, the researchers aimed for a more practical approach to helping patients. Meeting with health care professionals on only 1 occasion seems to be more feasible in light of the hectic lifestyle many people have today.

The success of this 1-stop clinic approach has been an encouraging experience. Smoking-cessation rates using health care professional counseling alone are ~12%, whereas success rates with NRT alone after 6 months have ranged from 3.0% to 9.2%.2 In the first arm of this program, 22% of people had quit smoking after 6 months. The outcome rates were even higher in the second project, 43%, even with limited participation in follow-up.


Smoking contributes to many medical conditions and disease states. Outcomes from this model show the effectiveness of spirometry results as a motivational technique and further evidence of its use as an important tool in the diagnosis of abnormal airway function. The NLHEP advocates the use of spirometry, with the goal being the prevention of lung disease and promotion of lung health.3

The objective spirometry data also are good for smokers who have made multiple attempts to refrain from using tobacco. These patients learn valuable information concerning their lung function that can be used for motivation each time they try to quit smoking.

The results of these programs shed light on the effectiveness of using a pharmacist, NRT, a respiratory therapist, and spirometry within a smoking-cessation model. Patients exposed to this model now have valuable knowledge about nicotine replacement and have been presented with objective knowledge of their lung function, which may serve to improve awareness of the damage that can result from chronic obstructive pulmonary disease or other airway limitations.

Mr. Gold is a pharmacist at St. Mary's Medical Center in Evansville, Ind. He also is an affiliate associate professor of clinical pharmacy at Purdue University.

For a list of references, send a stamped, self-addressed envelope to: References Department, Attn. A. Stahl, Pharmacy Times, 241 Forsgate Drive, Jamesburg, NJ 08831; or send an e-mail request to:

The project was made possible with the support of the Indiana Tobacco Prevention and Cessation Board, NDD EasyOne Spirometers, and Pfizer Inc.