the georgia pharmacy journal: september 2010

The Georgia Pharmacy Journal September 20102

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F E A T U R E A R T I C L E S

5 Thank you to the 2009-2010 GPhA Board of Directors

9 GPhA Member Jonathan Marquess Elected APhA Trustee

10 GPhA Convention Wrap Up

17 CPE Opportunity: Tobacco Cessation Counseling: A Guide for Pharmacists

28 GPhA Member Appointed to National MTM Board

C O L U M N S

4 President’s Message

8 Editorial

For an up-to-date calendarof events, log onto www.gpha.org.

14Pharmacists Take Larger Role on Health Team

Departments7 Pharm PAC 2010-201111 Fall Region Meeting12 GPhA New Members31 GPhA Board of Directors

Advertisers2 The Insurance Trust2 Principal Financial Group5 PharmAssist Recovery Network5 Melvin M. Goldstein, P.C.6 AIP9 Logix, Inc.14 Michael T. Tarrant12 Design Plus Store Fixtures, Inc.13 GPhA Workers Compensation16 Pharmacists Mutual Companies28 Toliver & Gainer32 The Insurance Trust

P R E S I D E N T ’ S M E S S A G E


If you’re anywhere near my age, you probablyremember the ketchup commercial where the ketchupjust doesn’t seem to want to come out of the bottle as

Carly Simon is blurting out “Anticipation” in thebackground. At this time of year, when I catch that firstcool afternoon breeze at the end of a another long, hotsummer, my mind immediately begins to anticipateanother beautiful southern fall season, with the turning ofthe leaves, the relief from the dog days of August, and ofcourse, that most sacred southern event, FOOTBALL!Even though you can’t convince a die-hard, good ole’ boyDAWG fan that there are more important things in life,this fall will be one of the most important political years inrecent Georgia history.

This year, the sense of anticipation is at a fever pitch forGeorgia voters. In less than a month, we will be electing anew Governor, a new Secretary of State, a new InsuranceCommissioner and a new Attorney General. Thedecisions made by those holding these positions can andwill have a huge impact on the practice of pharmacy.GPhA will be expending considerable resources this yearto ensure that the voice of our profession is heard loudand clear by the candidates for these offices. We want tobe in a position to be at the table, no matter who is electedto these positions. As they say in political circles, if you arenot at the table, you could well be on the menu. As wehave learned in the not too distant past, being on themenu is not where we want to be again.

Several factors are contributing to the political clout beingdisplayed by your association this year. There is newlifeblood (and money) being pumped into the veins of

Pharm Pac, under the direction of former State SenatorEddie Madden. We are emptying the kitty this year, notto influence or buy votes, but to build new relationshipsand foster old ones among the candidates. Your ExecutiveVice President and lobbyists have traveled the state tohand deliver contributions and to voice the concerns ofthe pharmacists of Georgia on your behalf. The Academyof Independent Pharmacy has stepped up to the plate withan unprecedented $250,000 to support our politicalagenda.

To give you an example of some of the fruit of ourpolitical efforts this year, we were able to arrange aconference call with Republican Gubernatorial candidatesNathan Deal and Karen Handel to pose questions relatedto some pressing issues for Georgia pharmacists. This is anaccomplishment that has never happened before. Thecandidates for political office are taking notice of theprofession of pharmacy and the impact pharmacists canhave on the elections. Now we need to do our part, notonly as pharmacists, but as citizens of this country. Iencourage everyone to get involved in the politicalprocess, and most importantly, get out and vote onelection day. If you need information to make an informeddecision on particular candidates for office, our Directorof Government Affairs, Stuart Griffin, will be more thanhappy to share his knowledge of the candidates and theirpolitical views.

Dale M. Coker, R.Ph., FIACPGPhA President

Anticip-a-a-tion

5The Georgia Pharmacy Journal September 2010

PharmAssist Recovery Network

The PharmAssist Network continuesto provide advocacy, intervention and

assistance to the impairedpractitioners, students and techniciansin the state. If you or anyone you

know needs assistance, please call thehotline number:

PharmAssist Hotline Number(24 hours / 7 days a week)

404-362-8185(All calls are confidential)

Robert Bowles Chairman of the BoardEddie Madden PresidentDale Coker President-ElectJack Dunn First Vice PresidentRobert Hatton Second Vice PresidentJim Bracewell Executive Vice President/CEOHugh Chancy State-at-LargeAshley Dukes State-at-LargeKeith Herist State-at-LargeJonathan Marquess State-at-LargeSharon Sherrer State-at-LargeAndy Rogers State-at-LargeAlex Tucker State-at-LargeHeather DeBellis Region One PresidentTony Singletary Region Two PresidentJohn Drew Region Three PresidentBill McLeer Region Four PresidentShobhna Butler Region Five PresidentBobby Moody Region Six PresidentMike Crooks Region Seven PresidentLarry Batten Region Eight President

David Gamadanis Region Nine PresidentChris Thurmond Region Ten PresidentMarshall Frost Region Eleven PresidentKen Eiland Region Twelve PresidentRenee Adamson ACP ChairmanLiza Chapman AEP ChairmanBurnis Breland AHP ChairmanTim Short AIP ChairmanDeAnna Flores APT ChairmanRick Wilhoit ASA ChairmanJohn T. Sherrer Foundation ChairmanMichael Farmer Insurance Trust ChairmanMickey Tatum Ex Officio - President, GA Board of

PharmacyDon Davis Ex Officio - Chairman, GSHPGina Ryan Johnson Ex Officio MercerMeagan Spencer Barbee Ex Officio Mercer ASPRusty Fetterman Ex Officio South Garrick Schenck Ex Officio South ASPDaniel Forrister Ex Officio UGALance Faglie Ex Officio UGA ASP

Thank You 2009-2010 GPhA Board of Directors of a Job Well Done


Titanium Level($2400 minimum pledge)Michael FarmerJeffrey L. LureyRobert A. LedbetterMarvin O. McCordJudson L. MullicanMark L. ParrisFred SharpeJeff Sikes

Platinum Level($1200 minimum pledge)Robert C. BowlesBruce L. BroadrickThomas Bryan, Jr.Hugh M. ChancyDale CokerBilly ConleyJ. Ashley DukesStewart FlanaginMartin GrizzardRobert M. HattonAlan M. JonesIra KatzHarold M. KempBrandall LovvornEddie MaddenJonathan MarquessPam MarquessScott MeeksDrew MillerLaird MillerJay MosleyTim Short

Gold Level($600 minimum pledge)James W. BartlingRobert CecilLiza G. ChapmanPatrick M. CookMahlon DavidsonKevin FlorenceNeal FlorenceAmy GallowayDavid GamadanisMarsha C. KapiloffTommy LindseyBobby MoodySherri S. MoodyRobert Anderson RogersDaniel C. RoyalDean StoneThomas H. Whitworth

Silver Level($300 minimum pledge)Renee AdamsonJohn ColvardAl DixonMarshall L. FrostMichael O. IteoguWillie O. LatchKenneth A. McCarthyKalen Beauchamp PorterEdward Franklin ReynoldsMichael T. TarrantBrandon UllrichAlan VogesFlynn W. WarrenOliver Whipple

Bronze Level($150 minimum pledge)Oatts Drug CompanyMonica M. Ali-WarrenLance P. BolesJames BrownMike CrooksCharles Alan EarnestAmanda R. GaddyFadeke JafojoAllison LayneWilliam E. LeeAshley LondonWilliam J. McLeerHouston RogersRichard SmithWallace WhitenSharon B. Zerillo

Members(no minimum pledge)Michael’s PharmacyClaude W. BatesChad J. BrownMax C. BrownLucinda F. BurroughsWaymon M. CannonJean N. CoursonCarleton C. CrabillAlton D. GreenwayJ. Clarence JacksonTracie LundeRalph MarettLeonard Franklin ReynoldsVictor SerafyHarry ShurleyWilliam D. WhitakerJonathon Williams

Pharm PAC Enrollment

Pledge Year 2010-2011

If you made a gift or pledge to Pharm PAC and your name does not appear above please, call Kelly McLendon at 404-419-8116 or Ursula Hamilton at 404-419-8115. Donations made the Pharm PAC are not considered charitabledonations and are not tax deductible.

The 2010 Georgia Pharmacy Association AnnualMeeting and Convention by all accounts was aresounding success. The convention surveys and

evaluations indicate it was perhaps the best Annual Meetingand Convention in our history.

You Said: We want more continuing education with anemphasis on quality presentations.Our response:We presented 30.5 hours of high qualitycontinuing education.

You said:We want additional clinical training opportunities.Our response:We offered the APhA Certificate program inDiabetes in which the participants received 24 hours ofcontinuing education credit and a certificate of achievement.

You said: Improve the flow of the awards portion of theTuesday night banquet.Our response: We notified award recipients they were toreceive an award and had a reserved table for them and theirguests. We had many positive responses about this change.

You said:Move the Pharm PAC reception to a more upscaleevent.Our response:We moved the event to a first class venue, weadded fine quality hors d’oeuvres with a classical guitarist forbackground music.

You said: Please improve the reception in the exhibit hall.Our response:We proved hot hors d’oeuvres, extra bars andextended time for the reception and the surveys said youliked this.

You said:We love the OTC Bowl but improve the flow.Our response:We improved the game format which got highreviews on the surveys from attendees.

You said:We want more time for the Deans to speak.Our response:We extended the time for the Deans andincluded them in two general sessions instead just one.

You said:We love some family entertainment like thehypnotist.Our response:We brought back hypnotist Kevin Lepine for areturn performance.

You said:We like to hear form the Board of Pharmacy andthe Legislators.Our response:We brought in the President of NCPA for aFederal report, the GA State Board of Pharmacy and yourelected state pharmacy legislators for a full general sessionprogram.

The attendance grew over our 2009 Convention and ournumbers this year exceeded the number of attendees at ourlast convention in Myrtle Beach.

With all this information what knowledge should apharmacist in Georgia take away? You should immediatelyput the 2011 Georgia Pharmacy Association Annual Meetingand Convention on your calendar today!

Saturday, June 18 through Tuesday night June 22, 2011, willbe held at the most requested convention site by ourmembers: Amelia Island Plantation, Amelia Island, FL.

There is a room and space ready for you, your family andcolleagues.

The 2011 Convention Committee is already consideringnew ideas and programs to keep the GPhA Annual Meetingand Convention the one must event for each pharmacist inGeorgia.

Save the date now for 2011 GPhA Annual Meeting andConvention, June 18- 22, 2011.

I plan to see you there.

E X E C U T I V E V I C E P R E S I D E N T ’ S E D I T O R I A L

Jim BracewellExecutive Vice President / CEO


2010 GPhA Annual Meeting Review

The American PharmacistsAssociation (APhA) releasedthe results of its recent

elections for Board of Trustees.Jenelle L. Sobotka, Pharm.D., FAPhA,of Mason, Ohio, has been chosen as2011-2012 President-elect of theAmerican Pharmacists Association(APhA). Also elected to serve onAPhA’s Board of Trustees, beginningin March 2011, are Jonathan G.Marquess, Pharm.D., CDE, CPT, ofAcworth, Georgia; and Michael A.Pavlovich, Pharm.D., of Long Beach,California. They will serve a three-year term. Elected as HonoraryPresident was Hazel M. Pipkin, R.Ph.,of Point Venture, Texas. All will beinstalled at APhA’s 159th AnnualMeeting & Exposition in Seattle,Washington, March 25-28, 2011.

Jonathan G. Marquess, Pharm.D.,CDE, CPT, of Acworth, Georgia whohas been elected APhA Trustee isowner of three community

pharmacies and is President andCEO of The Institute for Wellnessand Education, a diseasemanagement company in theAtlanta, Georgia, metropolitan area.Marquess graduated from MercerUniversity. He served as Chair of theAPhA New Practitioner Committee,National President of the APhA-ASPand is a delegate in the APhA Houseof Delegates.

President-elect designate Sobotkawill succeed Marialice S. Bennett tothe office of President on March 12,2012, at the conclusion of the 2012APhA Annual Meeting & Expositionin New Orleans.

Sobotka, a graduate of the Universityof Iowa, previously served two termson APhA’s Board of Trustees. She hasalso served on numerous other APhACommittees and as a delegate to theAPhA House of Delegates. Sobotka isDirector of External Relations atProcter & Gamble and was theAssociate Director of the IowaPharmacy Association and Director ofthe Iowa Center for PharmaceuticalCare (ICPC). Under Sobotka’sleadership, ICPCreceived the 1999APhA Foundation’sPinnacle Award forwork to advancepatient care practice.She co-authored APractical Guide toPharmaceutical Care.Her other honorsinclude being therecipient of the 2009National

Pharmaceutical AssociationFoundation Excellence Award, 2008Kappa Epsilon National CareerAchievement Award, the 2005 PTCBService Award, and the 2003University of Iowa Rho Chi HonoraryAlumni Award.

APhA membership also approved abylaws amendment for studentpharmacist delegate voting rights.The bylaws amendment allowsstudent pharmacists members whorepresent the APhA-Academy ofStudent Pharmacists in the House ofDelegates to right to vote in thatyear’s annual election for at-largeAPhA Board of Trustees membersand APhA President-Elect as well asany additional issues placed on theballot from time to time.

Also on the ballot were positions forAPhA’s Academy of PharmacyPractice and Management (APhA-APPM) and Academy ofPharmaceutical Research and Science(APhA-APRS). The results of theseelections will be released after thecandidates have been contacted.


F E A T U R E D A R T I C L E

GPhA Member Jonathan Marquess Elected APhA Trustee


G P h A N E W S

The GPhA Convention is always an exciting andproductive time for pharmacists, but this year’sexperience was particularly nice. More than 300

members gathered at the Embassy Suites Conference Centerat Kingston Plantation in Myrtle Beach, South Carolina,from June 26 to 30, 2010.

During that time GPhA offered Continuing Educationopportunities including: Quality Assurance & ContinuousQuality Improvement, OTC Pain Management, MTM forPatients with Diabetes on Incretin Therapy, Addiction in theWorkplace, OSHA Training, HIV/AIDS Management,Interventions for Improving Medication Adherence, andBrown Bag Patient Counseling Competition. And, that wasonly the first day.

Also, on the first day GPhA and Insurance Trust Boards metand there was also a Pharm PAC Contributors’ reception atwhich the new contribution structure was announced.

The second day included an Interfaith Sunrise Service, aStudent Program, and Academy Business Meetings.

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 theFirst General Session where Don Yeager presented “WhatMakes the Great Ones Great.”

In the evening there was a Coffee and Dessert Reception andthe Kevin Lepine Hypnotist Show. On Monday there was the Council of Presidents’ Breakfast,

the AIP Compounding Breakfast, and the GPhF GolfTournament and the Academy Tennis Tournament.

The CE for the day included: Functional Medicine andHormone Replacement and Pain Management with Opioids,the ABCs of Metabolic Syndrome, and BLS for HealthcareProviders. We also had the Second General Session whichfeatured the OTC Bowl.

That evening featured the Mercer and UGA AlumniDinners.

On Tuesday, CE included Advancing Pharmacy PracticeThrough Performance Management, Application of NewLaws and Regulation to the Practice of Pharmacy,Emergency Preparedness for Pharmacy and MedicationTherapy Management Services Update.

The Third General session included a panel of PharmacistLegislators who addressed state and federal governmentissues and how they affect pharmacy.

In the evening was the President’s Inaugural Banquet andDessert Reception and Dance.

The next day GPhA held its annual business meeting at theend of which the Convention was adjourned.

GPhA hopes that you all enjoyed your time in Myrtle Beachand hope that we will get to see you in Amelia Island nextyear.

GPhA Convention Wrap Up


GPhA 2010 GPhA 2010

Fall Region MeetingsFall Region Meetings

Eddie Madden, R.Ph., Chaiman of the Board of DirectorsDale Coker, R.Ph., PresidentJack Dunn, R.Ph., President-ElectRobert Hatton, Pharm.D., First Vice PresidentPam Marquess, Pharm.D., second Vice PresidentJim Bracewell, Executive Vice President/CEO

Schedule of Fall 2010 Region MeetingsFor additional information and to RSVP go to www.gpha.orgRegion 1 October 5, 2010, 7:00-9:00 p.m. South University School of Pharmacy Heather DeBellisRegion 2 October 14, 2010, 6:30-9:30 p.m. Doublegate Country Club Fred SharpeRegion 3 October 19, 2010 TBD John DrewRegion 4 October 5, 2010, 6:00-9:00 p.m. Eagles Landing Country Club Amanda GaddyrRegion 5 October 5, 2010 TBD Shobhna ButlerRegion 6 October 14, 2010 TBD Ashley FaulkRegion 7 October 14, 2010, 6:00-9:00 p.m. Adairsville Inn Mike CrooksRegion 8 October 12, 2010, 7:00-9:30 p.m. Holiday Inn, Waycross Larry BattenRegion 9 October 12, 2010 TBD David GamadanisRegion 10 October 19, 2010, 6:30-9:00 p.m. TBD Chris ThurmondRegion 11 October 12, 2010 TBD Marshall FrostRegion 12 October 19, 2010 TBD Ken Eiland

For details about the Continuing Education Program at the Spring RegionMeetings and to RSVP for this event visit www.gpha.org or call GPhA at404.231.5074.

The Georgia Pharmacy Association is accredited by the Accreditation Council of Pharmacy eduction as aprovider of continuing pharmacy education.

If you are not sure which region you are supposed to be in the new region webpages list the counties ineach region and show a map. Just visit www.gpha.org and click on Region Webpages on the right side.


G P H A M E M B E R N E W S

Wayne C. Bishop, AlpharettaJoy A. Chesnut, Monroe

Dudley B. Christie, Warner RobinsJennifer Cowart, North Augusta, SC

Eric Steven Crowson, MariettaCarol B. Davis, Fairfax, SC

Kathleen M. Edelman, CummingJenna Evans, Pharm.D., Eastman

Ashley A. Fortney, ClaytonDavid D. Fowler, Bennettsville, SCWalter M. Hughes, Clinton, SC

Ashley Jones, AugustaPerry H. Julien, Atlanta

Christie Lee Keily, EllijayJudith T. Marzullo, Marietta

Sanjay Mehta, RoswellMary Jeanne Moody, Scottsboro, AL

R. Brad Mote, MabletonStella Ngozi Okpala, Pharm.D., Fayetteville

Karla L. Storey, Plum Branch, SCLaura Thompson, Pharm.D., AthensJohn Adam Titak, Pharm.D., Atlanta

Welcome to GPhA!The following is a list of new members who have joined Georgia’s premier

professional pharmacy association!

If you or someone you know wishes to join the Georgia Pharmacy Association you need only visitwww.gpha.org and click “Join” at the top of the page. You can pay by credit card and your membershipbegins immediately. If you have any questions please call Kelly McLendon at 404-419-8116.

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Eloise Gelinas depends on apersonal health coach.

At Barney’s Pharmacy, her localdrugstore in Augusta, Ga., thepharmacist outlines all hermedications, teaching her what timesof day to take the drugs that will helpcontrol her diabetes.

Ms. Gelinas, a retired nurse, alsoattends classes at the store once amonth on how to manage her diseasewith drugs, diet and exercise. Since shestarted working with the Barney’spharmacists, she boasts that her bloodsugar, bad cholesterol and bloodpressure have all decreased. “It’s myhome away from home,” she says.

While some of the services beingoffered to Ms. Gelinas resemble thosefound in an old-fashionedneighborhood drugstore, others reflectthe expanding role of the nation’spharmacists in ways that may benefittheir customers and also represent anew source of revenue for theprofession. Some health plans are evenpaying pharmacists to monitorpatients taking regular medications forchronic illnesses like diabetes or heartdisease.

“We are not just going to dispenseyour drugs,” said David Pope, apharmacist at Barney’s. “We are goingto partner with you to improve yourhealth as well.”

At independent drugstores and somenational chains like Walgreens and theMedicine Shoppe and evensupermarkets like Kroger, pharmacistswork with doctors and nurses to carefor people with long-term illnesses.

They are being enlisted by somehealth insurers and large employers toaddress one of the fundamentalproblems in health care: as many ashalf of the nation’s patients do nottake their medications as prescribed,costing nearly $300 billion a year inemergency room visits, hospital staysand other medical expenditures, bysome estimates.

The pharmacists represent the frontline of detecting prescription overlapor dangerous interaction betweendrugs and for recommending cheaperoptions to expensive medicines. Thisevolving use of pharmacists also holdspromise as a buffer against ananticipated shortage of primary caredoctors.

“We’re going to need to get creative,”said Dr. Andrew Halpert, seniormedical director for Blue Shield ofCalifornia, which has just begun apilot program with pharmacists atRaley’s, a local grocery store chain, tohelp some diabetic patients inNorthern California insured throughthe California Public Employees’Retirement System.

Like other health plans, Blue Shieldviews pharmacists as having the

education, expertise, free time andplain-spoken approach to talk topatients at length about whatmedicines they are taking and to keepclose tabs on their well-being. Thepharmacists “could do as well andbetter than a physician” for less


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Pharmacists Take Larger Role on Health Team:Barney’s Pharmacy Featured in the New York Times

By REED ABELSON and NATASHA SINGERPublished: August 13, 2010 in The New York Times


money, Dr. Halpert said.

Some health insurers and largeemployers already pay for programscalled medication therapymanagement, which typically involveface-to-face sessions betweenpharmacists and patients in retailstores or clinics. Pharmacists can bepaid to track patients, monitoringcholesterol or blood glucose levels, forexample, or prodding customers tochange their diets or exercise.UnitedHealth Group has recentlystarted working with pharmacists andhealth coaches at the Y.M.C.A. tocounsel diabetic patients.

The idea of using pharmacists in thisway began to gain popularity in 2006when some Medicare plans startedcovering medication therapymanagement programs, paying $1 to$2 a minute to pharmacists to reviewpatients’ medicines with them; thisyear, about one in four people coveredby Medicare Part D prescription drugplans will be eligible, according toagency estimates. For example, aMedicare Part D plan covered Ms.Gelinas’s medication managementsession at Barney’s pharmacy.

More employers and insurers also payfor pharmacists to advise patients, arole that the new health care lawencourages with potential grants forsuch programs. In Wisconsin, forexample, community pharmacists andsome health plans have bandedtogether to create a joint program, theWisconsin Pharmacy QualityCollaborative, to standardizemedication therapy management andensure quality care.

Meanwhile Humana, which first paidfor pharmacists to work with Medicarepatients, expanded its coverage a fewyears ago. About a third of the 62,000

pharmacies in its network offer theseservices, and the insurer says it isstudying whether a pharmacist seeinga patient in person has more impactthan a phone call.

The advent of these services hasspawned a new industry of medicationtherapy management companies torun clinical pharmacy programs forhealth insurers, contracting withpharmacists and tracking the financialand health outcomes of their services.One such company, Mirixa, foundedin 2006 by the National CommunityPharmacists Association, doesbusiness with more than 40,000pharmacies nationwide. Pharmacistsand others see these joint efforts asvital to remain competitive with mail-order pharmacies.

One of the first places where retailpharmacists began to expand their rolewas Asheville, N.C., where studiesvalidated the services. “We reallypositioned the pharmacist as coach,”said Fred Eckel, executive director ofthe state’s pharmacist group.

In one recent study of 573 people withdiabetes, 30 employers in 10 citieswaived co-payments for diabetes drugsand supplies for those employees orfamily members willing to meetregularly with a pharmacist. People inthe study, financed by the drug makerGlaxoSmithKline, took part in at leasttwo sessions with pharmacists whohelped them track their blood sugar,blood pressure and cholesterol levelsand offered diet and exercise advice.After a year, blood pressure, bloodsugar and cholesterol levels typicallyimproved — and saved an average$593 a person on diabetes drugs andsupplies.

But the new relationships have stirredconcerns. Federal regulators have

recently accused chains like Rite Aidand CVS Caremark of inadequatelyprotecting health records.

And groups like the AmericanAcademy of Family Physicians, saypharmacists should be careful not tousurp the physician’s role. “I’mconcerned that people are thinkingabout this in terms of ‘either or,’ andthat’s the wrong approach,” said Dr.Lori J. Heim, the academy’s president.“It’s an ‘and’ approach.”

Michelle A. Chui, an assistantprofessor at the University ofWisconsin School of Pharmacy, saidthat pharmacists do not want tocompete with doctors, but merelyprovide more information “so thephysician has a more in-depthpicture.”

Still, the pharmacy business benefits.Barry S. Bryant, owner of Barney’s inAugusta, said expanding to include awellness center where pharmacistshold medication management sessionsand monthly health classes attractedmore customers.

Today, Barney’s fills an average of1,000 prescriptions a day, up from 300seven years ago, with about a third ofhis customers covered by Medicaidand another third by Medicare, hesaid.

The business growth at Barney’s haseven prompted Mr. Bryant and Mr.Pope to start their own educationcompany, CreativePharmacist.com,that teaches other pharmacies how tointroduce in-store services.

“When we get involved with chroniccare patients, their outcomesimprove,” Mr. Pope said. “But, at thesame time, they are improving ourbottom line.”

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GoalThe goal of this lesson is to assistpharmacists in developing a tobaccocessation counseling program.

ObjectivesAt the conclusion of this lesson,successful participants should be able to:1. implement a tobacco cessationprogram based on clinical practiceguidelines;2. assess the tobacco use history;3. develop a tobacco cessation plan withthe tobacco user;4. list the physical and psychologicalcomponents of nicotine addiction; and5. identify common problems associatedwith quitting tobacco and suggest waysto solve them.

IntroductionIn January 2000, the Department ofHealth and Human Services (DHHS)published the Healthy People 2010objectives for tobacco control in theUnited States. One of the 21 objectiveswas to reduce the adult cigarette smokingrate to 12 percent or less by 2010. Eightyears later, the Centers for DiseaseControl and Prevention (CDC) reportedthat based on the current smoking trendin the United States, it was unlikely thatthis goal would be achieved. Dataanalyzed from the 2008 National HealthInterview Survey foundthat 20.8 percent ofadults (46 millionpeople) aged 18 yearsand over were currentsmokers, which washigher than, but notsignificantly differentfrom, the 2007 estimateof 19.7 percent.1

By not meeting the Healthy People 2010objective, a high incidence of tobacco-related chronic diseases, productivitylosses, and premature deaths continue toplague this country. Between 2000 to2004, smoking alone resulted in morethan $196 billion in annual health-relatedcosts including smoking-attributablemedical economic costs and productivitylosses.2

Tobacco is the leading cause ofpreventable death and disease in theUnited States. If more comprehensivetobacco cessation programs wereavailable to tobacco users, millions oflives and billions of dollars in tobacco-related health care costs could be saved.Pharmacists play an integral role inhealth care prevention and treatment. Bydeveloping and implementing a tobaccocessation program, pharmacists canexpand their role in tobacco cessationtreatment and can increase patients’ quitrates.

The information in this lesson helpspharmacists learn about tobaccocessation and provides usefulinformation for their patients. This lessonis divided into four pharmacist-patientmeeting sessions: getting to know thepatient; preparing for the quit date;follow-up after the quit date; andmaintaining abstinence from tobacco use.

Many cessation programs are designed totarget patients who use cigarettes,however, this lesson can be used forpatients who smoke or use smoke-lesstobacco products. Pharmacists maychoose to supplement this lesson withadditional information to aid in thesuccess of a tobacco cessation program.

Developing a TobaccoCessation Program UsingClinical Practice GuidelinesIn May 2008, an updated version of the2000 TREATING TOBACCO USE AND

DEPENDENCE, a Public Health Service(PHS)-sponsored Clinical PracticeGuideline was issued by the Agency forHealthcare Research and Quality(AHRQ).4 These guidelines are acollaboration of eight FederalGovernment and nonprofit organizationsincluding the Centers for DiseaseControl and Prevention (CDC) and theNational Heart, Lung, and BloodInstitute (NHLBI). The guidelinessuggest strategies for providingappropriate treatment for patients whouse tobacco and recommends that thesepatients receive at least minimaltreatment and counseling every time theyvisit a clinician. The first steps in thisprocess (1) identification and (2)assessment of tobacco use separatepatients into the following three


Continuing Education for PharmacistsTobacco Cessation Counseling: A Guide for PharmacistsThis CPE lesson was written by Amanda Pekny, 2010 Pharm.D. Candidate, University of Nebraska College of Pharmacy, who has nofinancial or conflict of interest disclosures.

Ask about tobacco use. Identify and document tobacco use status for every patient at every visit.

Advise to quit. In a clear, strong and personalized manner urge every tobacco user to quit.

Assess willingness to make aquit attempt.

For patient willing to make a quit attempt, use counseling andpharmacotherapy to help him or her quit.

Assist in quit attempt. Help patient to put in place a plan to quit, with counseling and support.

Arrange follow-up. Schedule follow-up contact, preferably within the first week after the quit date.

Table 1The “Five A’s” for Brief Intervention4

**T

T


treatment categories:3

1. Patients who use tobacco and arewilling to quit should be treated using thefive A’s (ask, advise, assess, assist, andarrange). Table 1 summarizes the “FiveA’s” for brief intervention.2. Patients who use tobacco, but areunwilling to quit at this time, should betreated with the five R’s of motivationalintervention (relevance, risks, rewards,roadblocks, and repetition). Table 2summarizes the “Five R’s” for enhancingmotivation to quit using tobacco.3. Patients who have recently quit usingtobacco should be provided relapse-prevention treatment.Although the above guidelines aresuggested for brief intervention for atobacco user, pharmacists can implementthese strategies into their tobaccocessation counseling sessions makingthem more suitable for an individualpatient’s needs.

The AHRQ expert panel also maderecommendations on the type andintensity of contact with a counselor tothe success of the intervention. Thefollowing recommendations from thePHS Clinical Practice Guidelines shouldbe implemented into a smoking orsmokeless-tobacco cessationprogram:4

1. There is a strong dose-responserelationship between the sessionlength of person-to-personcontact and successful treatmentoutcomes. Intensive interventionsare more effective than lessintensive intervention and shouldbe used whenever possible. Meta-analysis demonstrated that wheninterventions last for more than10 minutes, the increase incessation rates was much betterthan when interventions did notinvolve contact with aprofessional. However, contacttime with a clinician for morethan 90 minutes did notsubstantially increase abstinencerates. The number of treatmentsessions offered is also important.Providing four or more sessions

significantly increased cessation rates,independent of the treatment’s intensity.2. Two types of counseling andbehavioral therapies result in higherabstinence rates (1) providing smokerswith practical counseling (problem-solving skills/skills training), and (2)providing support and encouragement aspart of treatment. These types ofcounseling elements should be includedin smoking cessation interventions.Group and individual counseling wasmore effective than no intervention inincreasing abstinence rates. Interventions were more successful whenthey included social support and trainingin general problem-solving skills, stressmanagement, and relapse prevention. 3. The combination of counseling andmedication is more effective for smokingcessation than either medication orcounseling alone. Therefore, wheneverfeasible and appropriate, both counselingand medication should be provided topatients trying to quit smoking.

First Meeting:Getting to Know the PatientIntroduction. Establishing a strongrelationship between the pharmacist and

the patient at the initial meeting isimportant. The patient should feelcomfortable and be able to express his orher thoughts and feelings withoutembarrassment or shame. This will maketreatment, both physical andpsychological, more efficacious and lessproblematic. The pharmacist should beinformative, compassionate, an activelistener, and be able to communicate tothe patient in a language that is clear andunderstandable. The pharmacist shouldbegin by introducing themselves andstating the purpose of the tobaccocessation counseling sessions. The intentof these sessions is to aid the patient inpreparing to quit and remainingabstinent from using tobacco; providingthe patient understanding about nicotineaddiction; finding a suitablepharmacological treatment option;providing coping mechanisms fornicotine withdrawal; identifying andavoiding triggers; and providing usefulsmoking/tobacco cessation resources.

Patients should understand thatsuccessfully quitting tobacco is not anovernight process. It takes time,commitment, and planning to becomecompletely tobacco-free. By reassuring

Relevance

Encourage the patient to indicate why quitting is personally relevant, being asspecific as possible. Motivational information has the greatest impact if it is relevantto a patient’s disease status or risk, family or social situation (e.g. having children inthe home), health concerns, age, gender, and other important patient characteristics(e.g. prior quitting experience, personal barriers to cessation).

Risks

The pharmacist should ask the patient to identify potential negative consequencesof tobacco use. Suggest and highlight those that seem most relevant to the patient.The pharmacist should emphasize that smoking low-tar/low-nicotine cigarettes oruse of the other forms of tobacco (e.g. smokeless tobacco, cigars, and pipes) will noteliminate these risks.

RewardsAsk the patient to identify potential benefits of stopping tobacco use. Thepharmacist may suggest and highlight those benefits that seem most relevant to thepatient.

RoadblocksThe pharmacist should ask the patient to identify barriers or impediments toquitting and note elements of treatment (problem solving, pharmacotherapy) thatcould address barriers.

RepetitionThe motivational intervention should be repeated every time an unmotivatedpatient visits the pharmacy. Tobacco users who have failed in previous quitattemptsbeforethey are successful.

Table 2The “Five R’s” for Enhancing Motivation to Quit Tobacco4


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 statusoccur.

flecainide Decreases clearance and increase serum concentrations. Clinicians should be aware of the possibility of aninteraction, but no specific dosage adjustment parameters are recommended.

fluvoxamine Smokers have a 25% increase in metabolism over non-smokers. Decreases clearance and increase serumconcentrations. 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 smokingstatus occur.

heparin Mechanism unknown but increases clearance and decreases half-life has been observed with smokers. Smokinghas prothrombotic effects. Active smokers may need increased dosages.

insulin Cessation may result in decreases blood glucose or increases the subcutaneous absorption of insulin. Monitorfor the desired clinical effects when changes in smoking status occur.

mexiletine Decreases clearances and increases serum concentrations. Monitor for desired clinical effects when changes insmoking status occur.

olanzapine Following one week of abstinence from chronic tobacco smoking, clearance may decrease. Monitor carefullywhen 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 insmoking status occur.

theophyllineFollowing 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 monitoredcarefully 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. Monitorpatient's INR to assess the need for warfarin dosage adjustment when changes in smoking status occur.

PHARMACOKINTETIC INTERACTIONS

Table 3Drug Interactions with Smoking6, 7

PHARMACODYNAMIC INTRACTIONS

Drug/Class Effects After Cessation

benzodiazepines(diazepam,chlordiazepoxide)

Increases metabolism of major metabolite by up to three-fold. No specific dosage adjustment resommendationsare available, but monitor patients for the desired clinical effects when changes in tobacco smoking status occur.

beta-blockersDecreases clearance and increases serum concentrations. Blod pressure, angina and exercise tolerance areimproved less by beta-blocker therapy when the patient is a smoker thatn when not smoking. Monitor carefullyfor 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.


the patient that with the right tools,medication, and support provided atthese meetings, the likelihood ofmaintaining a tobacco-free lifestyle ispossible.

Assessing Past Medical History of thePatient. The next step is to assess thepatient by gathering backgroundinformation and past medical history.Based on this information, thepharmacist can make informativerecommendations to the patient’sprimary care provider and assist in theselection of an appropriate tobaccocessation medication. The pharmacistshould obtain the patient’s name, contactinformation, date of birth, gender,ethnicity, vital signs (blood pressure andpulse), height and weight. Thepharmacist should ask about allergies tomedications, comorbid conditions, andpast surgical history. Family history ofdisease states, such as diabetes mellitus orcoronary heart disease, is important toknow as well. This information can beused to motivate the patient to stayabstinent and avoid potential healthproblems that can be exacerbated bytobacco use. If the patient is female, thepharmacist should ask if she is taking anycontraceptives, is pregnant, or plans onbecoming pregnant. Safepharmacotherapy treatments are limitedin this special population. Otherpopulations that may need extraconsideration are tobacco users withpsychiatric comorbidity and/or chemicaldependency and adolescent tobaccousers.

Tobacco cessation may increase plasmalevels of some drugs to potentially toxiclevels. Abstinence from smoking reversessmoking-induced CYP1A2 hepaticenzyme levels to normal, increasingplasma concentrations in patients whosedose was established while smoking.5

Certain medications are affected bytobacco smoke through pharmacokinetic(PK) or pharmacodynamic (PD)mechanisms. PK interactions affect theabsorption, distribution, metabolism, orelimination of other drugs which can

potentially cause an alteredpharmacologic response. PD interactionsalter the expected response or actions ofother drugs.6 Therefore, a detailed list ofcurrent medications, prescribed andover-the-counter, should be obtained.Pharmacists should carefully review thedosage form, strength, and regimen ofeach drug and recommend adjustmentand monitoring of those that are affectedby smoking cessation. On the followingpage, Table 3 lists drugs affected bysmoking cessation and dose adjustmentsafter cessation.

Assessing Tobacco Use History of thePatient. There are a variety of differentquestionnaires available to assess tobaccouse status. The pharmacist may choose touse a questionnaire provided by asmoking cessation organization or createa customized evaluation. Regardless ofwhich tool is utilized, the informationgathered by the survey should be used toappropriately evaluate behavior andnicotine dependence. Pharmacists shouldbe aware that patients may under-reporthow much tobacco they use. Prior tobeginning the tobacco cessationprogram, patients should be asked thefollowing questions: 1. At what age did the patient start usingtobacco? For how many years?2. Why did the patient start usingtobacco?3. How much tobacco does the patientuse daily (e.g. number of cigarettes or thenumber of cans/pouches)?4. When does the patient smoke/usetobacco? 5. What kinds of activities or “triggers”increase the urge to use tobacco?

The Fagerström Test for NicotineDependence (FTND) is a standardinstrument for assessing the intensity ofphysical addiction to nicotine.8 This self-survey can provide insight concerningbehavior and addiction along with theuse of other evaluation tools. The higherthe Fagerström score, the morephysically dependent the patient is tonicotine. Higher scoring patients mayneed additional counseling and more

intense medication treatment(s) tosuccessfully quit tobacco than patientswith lower scores. The FagerströmQuestionnaire for smoking tobacco isshown in Table 4. This questionnaire canbe modified for those patients who usesmokeless-tobacco.

Assessing Past Quit Attempts. To somepatients, talking about past quit attemptscan be frustrating. The average smokertries to quit 6 to 9 times in a lifetime.10

The patient has probably tried to stopusing tobacco independently withouttalking to a healthcare professional.Seeking help from a smoking cessationcounselor could be a last resort for somesmokers who have tried numerous timesto quit before but have not beensuccessful. This topic can be a source ofshame and embarrassment. However,past quit attempts are important todiscuss with the patient. It is an initialstarting point in determining whichmedications and behavior modificationsworked well in the past and what did not.Patients should be asked the followingquestions: 1. Has the patient attempted to quitusing tobacco before? How many times?2. How long did the patient stay tobacco-free?3. Which tobacco cessation product(s)did they use before?4. Which product(s) worked well for thepatient? Which didn’t?5. Did the patient modify anybehaviors/change routines while stayingtobacco-free?6. Why did the patient start usingtobacco again?

Determining the Patient’s Readiness toQuit.Understanding the patient’sreadiness to quit may lead to moreefficient and productive conversationsduring meetings. Each patient will be at adifferent stage of the quitting process.Some patients may need moremotivation than others. Those who areless ready to quit may need to bereminded of the health benefits andfinancial savings associated with tobaccocessation. For patients who are highly


motivated, the pharmacist may want tofocus more time on developing a plan toquit smoking. Table 5 is a patient self-survey designed to help assess readinessto quit. It is based on informationgathered from a national study involvingboth smokers and recent quitters anddeveloped to identify motivation to quitsmoking. This survey can be modified forpatients who use smoke-less tobacco.The higher the score on the survey, themore ready the patient is to quit tobacco.

Identifying Personal Goals for StayingSmoke-Free. The pharmacist should askpatients this important question, “Whydo you want to quit?” Asking patients toprovide a reason for quitting tobacco usegives them accountability for his or heractions. The patient is not onlyresponsible for setting personal goals, butalso for implementing a plan to achievethem. The pharmacist can providehelpful tools for patients to succeed.Patients should have constant remindersof their goals. For example, the patientcould write his or her personal goal(s) onevery handout received during cessation

meetings. This helps keep patientsfocused on staying tobacco-free.

When it comes to actually quittingtobacco use, some patients find it hard toplan ahead and prepare for relapse ordifficult situations. Giving a step-wiseaction plan to the patient is a goodsolution. In the action plan, a patientshould list his or her long-term goals;short-term goals; plans to achieve thesegoals; what obstacles or roadblocksmight be encountered and how toovercome them; and what rewards can begiven for successfully achieving each goal.The pharmacist should remind thepatient to take the time to thoughtfullywrite out an answer to each list item andbring the responses back to the nextmeeting for review.

Keeping a Tobacco Use Log. Patientsshould be instructed to document his orher tobacco use for the next several days.This information provides a clearer,overall picture of the patient’s addictionto nicotine. Writing down every time thepatient smokes or chews can help to

identify which emotional states andactivities trigger the urge to use tobaccothroughout the day. With each use, thepatient should write down the followinginformation: the date and time; thelocation; the activity the patient is doingwhile using tobacco; the patient’s currentmood; and the strength of the craving forthe tobacco product. A simple tobaccolog sheet can be created by thepharmacist and provided to the patient.The pharmacist should instruct thepatient to continue his or her normaldaily routines while documenting use.The information gathered will bediscussed at the next smoking cessationmeeting.

Selecting the Right Medication and QuitDate. It is ultimately the patient’sdecision to start a tobacco cessationmedication. While it is possible to quittobacco “cold turkey”, the success rate ofstaying abstinent is approximatelydoubled with the use ofpharmacotherapies.12 However, with somany products available for treatment ofnicotine dependence, this can be

Questions Answers Points

1. How soon after you wake up do you smoke your first cigarette?

Within 5 minutes6 to 30 minutes31 to 60 minutesAfter 60 minutes

3210

2. Do you find it difficult to refrain from smoking in places where it is forbiddensuch as church, the library, or movie theaters?

YesNo

10

3. Which cigarette would you most hate to give up? The first on in the morningAll others

10

4. How many cigarettes/day do you smoke?

10 or fewer11 to 2021 to 3031 or more

0123

5. Do you smoke more frequently during the first hours after waking thanduring the rest of the day?

YesNo

10

6. Do you smoke if you are so ill that you are in bed most of the day? YesNo

10

Score: 0-2: Very low addiction; 3-4: Low addition; 5: Medium addiction; 6-7:High addiction; 8-10: Very high addiction Score:

Table 4Fagerstrom Test for Nicotine Dependence9


overwhelming for the patient. Thepharmacist can aid in the selection of anappropriate therapy based on thepatient’s past medical history and pastquit attempts. A detailed article about thepharmacotherapy treatments of nicotineaddiction for health care providers waspublished in the last issue of the GEORGIA

PHARMACY JOURNAL. A simpler, morepatient-orientated medication guide,listing the advantages and disadvantagesof each drug, should be provided to thepatient. The pharmacist should instructthe patient to review the medicationguide, write down any additionalquestions about each drug, and select adrug(s) that he or she would prefer touse. Patients should be reminded thatthere are two parts to nicotine addiction,a physical and a behavioral component,and medications only treat the physical

addition.13 Combination therapy of bothmedication and counseling cansignificantly improve abstinence rates.4

The quit date should also be determinedby the patient. The pharmacist shouldinstruct the patient to take the time toconsider which day in the near future itwill be. Initially, it may take a lot ofconcentration and focus to stayabstinent. Therefore, the actual quit dateshould not be scheduled on a highlystressful day such as an upcomingwedding, graduation, or traumatic eventin the patient’s life. The patient shouldwrite the date on a calendar and let his orher family and friends know when thequit date will begin. Support from familyand friends may help the patient stick tothe goal of staying smoke-free. Table 6provides a quick summary to patients on

how to quit using tobacco and can begiven as an additional motivational guide.

Second Meeting:Preparing for the Quit DateAssessing the Tobacco Use Log. After thepatient has processed and completed theinformation provided in the first tobaccocessation meeting, it is time to assess thepatient’s tobacco use log. The patientshould have documented his or hertobacco use for at least the last three tofour days and set a quit date. Thetobacco use log can be discussed before,during, or after the pharmacist haspresented to the patient the new materialfor the second cessation meeting. Thepharmacist should, however, relate thenew information to help solve thepatient’s current tobacco use problems

Questions Answers Points

I want to quit smoking for mt own personal reasons, not because I feel pressuredto quit by others.

Completely DisagreeSomewhat DisagreeNeutralSomewhat AgreeCompletely Agree

12345

I have a specific plan in mind to try to quit smoking.


12345

I am always looking for new ways to help me not smoke.


12345

I want to quit smoking because I worry a lot about how smoking affects my health.


12345

I want to quit smoking because I am tired of being a prisoner to my cigarettes.


12345

Table 5Ready to Quit Survey11

Scale of 5 to 25: Less ready to quit (lower score); More ready to quit (higher score) Score:


and aid in the preparation of theupcoming quit date. By the end of thesecond meeting, the pharmacist shouldaddress why using tobacco is hard toquit; what the symptoms are of nicotinewithdrawal; what the triggers are andhow to manage them; what the differenceis between a slip and a relapse; and whatother tobacco cessation resources areavailable for the patient to use. Thepharmacist should also determine if thepatient has selected and obtained acessation medication and if the quit datehas been selected.

Understanding the Physical andPsychological Addiction to Nicotine. Fora successful recovery from tobacco use, itis important for patients to understandhow nicotine affects the brain and why itcan be difficult to quit using tobacco. Apatient-oriented handout about thephysical and psychological effects ofnicotine should be provided to thepatient to help him or her understandwhat to expect when quitting tobacco.

Nicotine is a highly addictive, potent, andpsychoactive drug.12 A single cigarettetypically delivers between 1.2-3.2mg ofnicotine, while other tobacco productscan deliver many times that amount.12

The absorption rate of cigarette smokefrom the lungs is rapid, producing witheach inhalation a high concentrationarterial bolus of nicotine which reachesthe brain within 15 seconds, faster thanby intravenous injection.15 Theelimination half-life of nicotine is alsoshort, lasting for about two hours.

However, due to the fact that the brain isa highly perfused organ, nicotine willquickly redistribute into plasma toachieve equilibrium in the body. As aresult, the effective half-life of nicotine ondopamine receptors is shorter than itselimination half-life. The fast onset andshort half-life of nicotine leads tofrequent repeated administration tomaintain raised concentrations in thebrain.15

Nicotine produces a wide range ofcentral nervous system, cardiovascular,and metabolic effects. It activatesnicotinic acetylcholine receptors(nAChRs) in the brain, and induces thereleases of dopamine in the nucleusaccumbens, the reward center of thebrain. This effect is the same as thatproduced by other addictive drugs suchas amphetamines and cocaine, and isthought to be a critical component inbrain addiction mechanisms.15 Theactivation of the dopamine rewardpathway gives the user a feeling ofpleasure. Nicotine also causes otherpsychological effects such as cognitiveenhancement, mood modulation, andreduction of anxiety and tension.Between administrations of tobacco, thelevel of dopamine declines and thetobacco user starts to experiencewithdrawal symptoms such as irritabilityand stress. The brain craves nicotine torelease more dopamine to bring it backto a level of pleasure and calm.

Over time, tobacco users developtolerance towards the effects of nicotine.

Tobacco users learn to titrate theirnicotine levels throughout the day inorder to avoid withdrawal symptoms, tomaintain pleasure and arousal, and tomodulate their mood.12 This typicallyleads to strong, repetitive habits andbehavior rituals associated with tobaccouse. For example, smokers often smoke atcertain times of the day, during certainactivities, in certain locations, after ameal, or under certain levels of stress.

Recognizing Nicotine WithdrawalSymptoms. Patients who have usedtobacco on a regular basis will experiencenicotine withdrawal symptoms if theysuddenly quit using all tobacco productsor if they greatly reduce their tobaccouse. Because of the short half-life ofnicotine, the urge to use tobacco mayoccur within hours of the last use.Symptoms peak about 2 to 3 days laterwhen nicotine and its metabolites areeliminated from the body. Thesymptoms may last for a few days orweeks.16 Knowing what to expect andunderstanding that withdrawal symptomsgradually decrease with time can help thepatient stay abstinent. Although,symptoms may be different for eachpatient, common signs of nicotinewithdrawal include the following:anxiety; craving for tobacco; decreasedblood pressure and heart rate;depression; difficulty concentrating;drowsiness; frustration; irritability;impatience; gastrointestinal disturbances;headache; hostility; increase in appetiteand weight gain; increased in skintemperature; insomnia; and restlessness.2

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 therewards 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!

Table 6Steps on How to Quit 14


A list of these common signs can be auseful tool for the patient. Thepharmacist can also encourage thepatient to think of these withdrawalsymptoms as a positive process in whichhis or her body is ridding itself ofnicotine.

Identifying Triggers and CopingTechniques. Repetitive habits andbehavior rituals associated with tobaccouse are eventually incorporated into thenicotine addiction. These behavior ritualsare closely coupled with sensory aspectsof smoking.15 For example, for a patientwho smokes, each puff of nicotinedelivered to the brain is linked to thesight of the packet and the smell of thesmoke. The activity that the patient isdoing at the time becomes the reason touse tobacco. The reward of smoking isassociated with the activity. Thisaccounts for smokers’ widespreadconcern that if they stopped smokingthey would not know what to do withtheir hands, and for the ability ofsmoking related cues or “triggers” toevoke strong cravings.15

Treatment for the psychologicaladdiction to nicotine is accomplished by

breaking triggers through behaviormodification. This is done by modifyingthe patient’s behaviors, changingroutines, and learning how to deal withstressful issues without using tobacco as acoping mechanism. Table 7 providesexamples of common triggers and waysto avoid them. This table can bemodified for patients who use smoke-lesstobacco.

Based on the patient’s comments on thetobacco log and past smoking history, thepharmacist should have the patientcomplete a trigger log which identifiesthe patient’s own triggers and how thepatient will manage them. This logshould be displayed somewhere visible sothat the patient will be reminded of whatto do when the trigger occurs.

One of the most difficult times to avoidusing tobacco is when the patient wakesup in the morning. During the night, thepatient has become deprived of nicotine.Nicotine blood concentration levels dropclose to those of non-smokers.15 Thefirst cigarette or pinch of chewingtobacco releases dopamine in the brainand gives the patient a strong sense ofpleasure and calmness. The pharmacist

should advise patients to change theirmorning routines to avoid the urge to usetobacco.

The pharmacist can also provide patientsa list of activities to do instead ofsmoking which may help patients occupytheir time and stay focused on their long-term goals. For example, suggestedactivities could include starting a newhobby; going to the movies, library, or abookstore; doing some spring cleaningaround the house; chewing sugarlessgum; drinking water; or starting anexercise program.

Visual reminders of the patient’s personalgoals may also help with overcomingstrong cravings. Patients canwritedowntheir personal goals or reasonswhy they want to quit on pieces of paperand place them in areas that trigger theurge to use tobacco. For example,patients can place the paper in the plasticsleeve in their cigarette packs or on thedashboard of their car.

Understanding the Difference between aSlip and a Relapse.Quitting tobaccopermanently can be challenging for manytobacco users. In fact, few people never

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 assoon 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 themoney to detail your car before the chosen quit day so there will not be temptations from the smell oftobacco.

Table 7Common Triggers and How to Manage Them17, 18


slip at all.19 However, turning a slip into arelapse is the under control of thepatient. It is important for the pharmacistto explain what the difference is betweena slip and a relapse. A slip is a one-timemistake that is quickly corrected while arelapse is going back to using tobacco.16 Aslip is not a failure. The patient can stillsuccessfully quit. If the patient usestobacco, he or she should stop usingagain right away and recommit toquitting. The pharmacist should ask thepatient to write down the reason(s) forthe slip and what he or she could havedone differently. The pharmacist shouldencourage the patient not to becomediscouraged. The patient can use thisinformation to make a stronger attemptat quitting the next time the troublingsituation occurs.

Providing Additional Tobacco CessationResources to the Patient. There are manytobacco cessation resources availablethrough professional organizations,federal or state funded quitting programs,and online web sites. Pharmacists haveaccess to vast amounts of usefulinformation, which when provided to thepatient, can assist in furtherunderstanding of tobacco cessation.Selecting the right information to meet

an individual patient’s needs,however, can be challenging.Each patient counseled willbe uniquely different.Patients will be at differentstages of the quittingprocess. This could be thefirst attempt at quittingtobacco or one of manyattempts to quit. Somepatients will be moremotivated to try anythingnew while others will needmore encouragement andguidance. Each patient’scomprehension level forunderstanding andprocessing information willalso be different. Therefore, it isimportant that resources provided by thepharmacist are not only customized toaddress the patient’s current situation,but also written in a language that thepatient will understand.

An excellent resource for pharmacists canbe found on the Rx for Change web site.20

Registration is free and gives access tomany educational tools and resourcesincluding presentations, handouts, andlarge group materials for patienteducational use. In addition, there are

comprehensive videotraining sessions available topharmacists and pharmacystudents. These videosprovide examples ofsituations that pharmacistsmay encounter whilecounseling patients abouttobacco cessation.

Third Meeting:Follow-up after theQuit DateAddressing the Patient’sConcerns. The next meetingwith the patient should takeplace after the patient’s quitdate. The patient shouldhave been refraining fromusing tobacco products forsome time and should be

taking the prescribed medication(s).This meeting should address the patient’sconcerns and provide the patient withadditional motivation to stay abstinentfrom tobacco. This meeting should beused to answer the patient’s questionsabout the tobacco cessationmedication(s) he or she is taking, howthe patient is feeling mentally andemotionally, any triggers or slips that heor she has experienced since the quitdate, and any additional roadblocks thatare preventing the patient from stayingtobacco-free. The pharmacist can suggestways to manage difficult triggers andreview the material presented fromprevious meetings. The pharmacistshould review the difference between aslip and a relapse and that successfullyquitting tobacco takes commitment,concentration, planning, and time.

Understanding the Health RisksAssociated with Continued Tobacco Use.In the United States, tobacco use isresponsible for nearly 1 in 5 deaths.2 As aresult of smoking or exposure tosecondhand smoke, more than 440,000premature deaths and 5.1 million years ofpotential life was lost each year between2000-2004.21 During that period,smoking-attributable health careexpenditures totaled an estimated $100billion annually, up $24 billion from$75.5 billion spend during 1999-2001.2

Cigarette smoking substantially increases

AcuteShortness of breath, exacerbation ofasthma, harm to pregnancy, infertility,increased serum carbon monoxide.

Long-term

Heart attack and strokes, lung and othercancers (larynx, oral cavity, pharynx,esophagus, pancreas, bladder, cervix),chronic obstructive pulmonary disease(chronic bronchitis and emphysema),long-term disability and need for extendedcare.

Environmental

Increase risk of lung cancer and heartdisease in spouses; higher rates ofsmoking by children of tobacco users;increase risk for low birth weight, SIDA,asthma, middle ear disease and respiratoryinfections in children of smokers.

Table 8Examples of Health Risks Related to Tobacco

Use4

Improved health

Food will taste better

Improved sense of smell

Save money

Feel better about yourself

Home, car, clothing, and breath will smell better

Can stop worrying about children

Set a good example for children

Have healthier children

Not worry about exposing others to smoke

RISKS

Table 9Examples of Rewards for Staying Tobacco

Free4


the risk of cardiovascular diseases such asstroke, sudden death, and heart attack;nonmalignant respiratory diseasesincluding emphysema, asthma, chronicbronchitis, and chronic obstructivepulmonary disease; lung cancer; andother cancers such as mouth, pharynx,larynx, esophagus, stomach, pancreas,uterus, cervix, kidney, ureter, andbladder.3 The risk of developing lungcancer is about 23 times higher in malesmokers and 13 times higher in femalesmokers compared to lifelongnonsmokers.2 Smokeless tobacco usershave a four-fold greater risk of oral cancerthan nonusers. The risk increases up to50-fold for long term users.22 Half of allthose who continue to smoke will diefrom smoking-related diseases.2

Exposure to environmental tobaccosmoke (i.e. secondhand smoke) has beencited as the cause of 3,400 lung cancerdeaths and 46,000 heart disease deaths innonsmoking adults in the United Statesevery year.2 Children exposed toenvironmental smoke have a higher riskof respiratory infection, asthma, andmiddle ear infections than those who arenot exposed.3 Sudden infant deathsyndrome (SIDS) occurs more often ininfants whose mothers smoked duringpregnancy than in offspring ofnonsmoking mothers.3 Smoking duringpregnancy also reduces fetal growth andincreases the risk of ectopic pregnancyand spontaneous abortion.3

A pharmacist should discuss the healthconsequences associated with continuedtobacco use and how they can beprevented by tobacco cessation. Table 8from the PHS Clinical PracticeGuidelines summarizes the health risksrelated to tobacco use.

Understanding the Rewards of StayingTobacco-free. The patient may needmore motivation to resist the temptationof using tobacco again. Table 9 from thePHS Clinical Practice Guidelinesprovides other examples of rewards forstaying tobacco-free. Besides decreasing

the risk of morbidity and mortality,patients will also save money when theyquit tobacco. The pharmacist canprovide the patient a tobacco costcalculator and examples of items that canbe bought with the potential moneysaved by quitting tobacco. For example,the national average in 2008 was$4.26/pack of cigarettes. For a pack-a-day smoker, by not buying cigarettes thepatient could save enough money topurchase: a portable DVD player (worthover $250) in just two months; a flat-screen TV (worth $750) in only sixmonths; or a 4-day cruise for two people(worth over $1,500) in one year.23

In addition to improving health andsaving money, the patient can also spendless time smoking and gain more time todo something more enjoyable orproductive. The pharmacist can help thepatient figure out how much time issaved. On average the smoking time forone cigarette is five minutes.21 Bymultiplying this number by how manycigarettes the patient smokes per day, thepatient can calculate how many minutesare gained per day, month, or year.The pharmacist can then encourage thepatient to write down and think aboutwhat he or she can do with the moneysaved and the time gained from not usingtobacco. For example, the patient couldstart a new hobby which could help withavoiding triggers and tobacco use.

Fourth Meeting:Maintaining Abstinence fromTobacco UseAddressing Roadblocks and How toOvercome Them. The last and finalmeeting with the patient should bereserved to tie-up any loose ends fromthe previous tobacco cessation sessions.The pharmacist should evaluate thepatient’s current progress and addressany additional problems or roadblocksthat are interfering with completetobacco cessation. The pharmacistshould assess the patient’s medicationuse and adherence, reinforcing that a full

course of therapy is necessary to assuremaximal benefit while the patientcontinues to make behavioral changes.The pharmacist should also review anyimportant topics from previous meetingswhich will help keep the patientmotivated. The patient should bereminded to stay focused on the long-term goal, to utilize any handout orresources that have been provided, andto remember the reasons why to quit.Table 10 provides common roadblocksencountered by patients and possibleactions that clinicians can take to solvethe problem.

Completing and Evaluating the TobaccoCessation Program. Congratulationsshould be offered to the patient forcompleting the tobacco cessationprogram. Patients should feel a sense ofpride for the effort and commitment thatthey have shown to become tobacco-free.Patients should also reflect on the lastfour sessions as a learning experience andshould use the information in their dailylives. At the end of the final meeting, thepharmacist can provide the patient acertificate of achievement. Thiscertificate can recognize the patient’sdedication to quitting tobacco and hopefor further success, and a longer,healthier, and smoke-free life.

This final meeting should include apatient evaluation about the tobaccocessation program. The pharmacistshould explain that completing thequestionnaire will help makeimprovements to the program for thebenefit of future patients. Questionslisted on the survey could include thefollowing:1. How would you describe your healthbefore you quit tobacco?2. How would you describe your healthnow after you quit tobacco?3. What activities do you think werehelpful in quitting tobacco?4. What activities do you think were nothelpful in quitting tobacco?5. What was the hardest tobacco triggerto manage/overcome?


6. What advice will you take with youfrom completing this program?7. What advice would you give to othertobacco users trying to quit?

ConclusionPharmacists understand thepathophysiology and pharmacotherapyinvolved in the treatment and recoveryfrom nicotine addiction. With thisknowledge, pharmacists can guide the

patient in preparing to quit andremaining abstinent from using tobacco,finding a suitable pharmacologicaltreatment option, providing copingmechanisms for nicotine withdrawal,identifying and avoiding triggers, andproviding useful smoking/tobaccocessation resources.

Using the right tools and resources,pharmacists can develop and implement

a successful tobacco cessation program,increase patient quit rates, and expandtheir role in tobacco treatment. Withmore tobacco cessation programs, theU.S. government’s objective to reducethe adult tobacco use rates, preventpremature deaths, and reduce tobacco-related health care costs, may become areality.

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 prolongedwithdrawal symptoms

• If the patient reports prolonged craving or other withdrawal symptoms, consider extending the use of anapproved pharmacotherapy or adding/combing pharmacologic medications to reduce strong withdrawalsymptoms.

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 –particularly4mg 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.

Table 10Addessing Problems Encountered by Former Smokers4

References1. 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 ofHealth 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 ofHealth 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.clinicalpharmacology-ip.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 ToleranceQuestionnaire. 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 andHuman Services, Public Health Service, Office of the Surgeon General, 2001.


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):277-916. 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.

Jonathan G. Marquess Pharm.D., CDE, CPT was appointed to the National MTM Advisory Board which held itsinaugural meeting June 7-8, 2010. The diverse group is charged with focusing on key issues related to theadvancement of Medication Therapy Management (MTM) services for payors, providers and other stakeholders.

“The board is well-positioned to discuss the critical issues relatedto MTM services during this dynamic time,” said Sherri Cohmer,Director of Medicare & Commercial Clinical PharmacyPrograms at Humana and a National MTM Advisory Boardmember. “The broad perspectives offered by the advisory boardmembers will help us all to envision the short and long-termpositioning of MTM services within the larger health carepicture.”

Through MTM services, pharmacists at local independent andchain pharmacies receive alerts and information concerningmedication use patterns, as well as guidance on working withpatients and doctors to fix potential drug complications. Theretailers receive service fees in order to free-up pharmacist timeto perform MTM activities. In 2010, the federal governmentplaced increased emphasis on the services by requiring Medicareplans to offer more robust MTM programs.

GPhA Member Appointed to National MTM Advisory Board

Lawyer and Pharmacist Leroy Toliver, Pharm.D., R.Ph., J.D.

• Professional LicensureDisciplinary Proceedings• Medicaid Recoupment Defense• Challenges in Medicaid Audits• OIG List Problems• SCX or Other Audits

Leroy Toliver has been a Georgia RegisteredPharmacist for 38 years. He has been a practicingattorney for 29 years and has represented numerouspharmacists and pharmacies in all types of cases.Collectively, he has saved his clients millions of

dollars.

Toliver and Gainer,LLP

942 Green Street, SWConyers, GA [email protected]


Continuing Education for PharmacistsQuiz 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 careprofessionals should interact with patients to increasecessation rates?

a. 5 minutesb. 10 minutesc. 25 minutesd. 90 minutes

2. According to PHS Clinical Practice Guidelines,tobacco cessation is more effective when

a. medication is provided onlyb. counseling is provided onlyc. medication and counseling are provided d. no medication and counseling are provided

3. Which medication does NOT interact withcigarette smoking?

a. beta-blockersb. caffeinec. olanzapined. sertraline

4. What questionnaire is a standard instrument usedto assess the intensity of physical addiction?

a. Fagerström Testb. Ready to Quit Surveyc. General Sociology Smoking Surveyd. Why Do I Smoke? Quiz

5. How many times does the average smoker attemptto quit tobacco in his or her lifetime?

a. 1 to 2 timesb. 3 to 5 timesc. 6 to 9 timesd. 10 to 15 times

6. What questionnaire can be used to determine thepatient’s willingness to quit tobacco?

a. Fagerström Testb. Ready to Quit Surveyc. General Sociology Smoking Surveyd. Why Do I Smoke? Quiz

7. Which center of the brain is activated by nicotineand is thought to be a critical component in brainaddiction mechanisms?

a. corpus callosumb. nucleus accumbensc. hypothalamusd. medulla oblongata

8. What is the main difference between a slip and arelapse?

a. A slip is a one-time mistake that is quicklycorrected; a relapse is returning to using tobacco.

b. A slip is returning to using tobacco; arelapse 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.

9. Tobacco use is responsible for how many deaths inthe United States?

a. 0 in 5 deaths c. 2 in 5 deathsb. 1 in 5 deaths d. 3 in 5 deaths

10. Which of the following is NOT a reward forstaying tobacco-free as listed in the PHS ClinicalPractice Guidelines?

a. Improved healthb. Save moneyc. Have negative mood or depressiond. Set a good example for childrend.


J o u r n a l C P E A n s w e r S h e e t

The Georgia Pharmacy Association is accredited by the Accreditation Council for Pharmacy Education as a providerof continuing pharmacy education. No financial was received for this activity. This article was originally published bythe Nebraska Pharmacists Association under UAN#128-000-10-057-H04-P Participants should not seek duplicatecredit. This article in reprinted with permission from the Nebraska Pharmacists Association.

Tobacco Cessation Counseling: A Guide for PharmacistsThis lesson is a knowledge-based CPE activity and is targeted to pharmacists.GPhA code: J10-09ACPE#: 0142-9999-10-009-H04-PContact Hours: 2.0 (0.20 CEU)Release Date: 09/01/2010Expiration Date: 09/01/20131. Select one correct answer per question and circle the appropriate letter below using blue or black ink (no red ink orpencil.)2. Members submit $4.00, Non-members must include $10.00 to cover the cost of grading and issuing statements ofcredit/ 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. A B C D 6. A B C D2. A B C D 7. A B C D3. A B C D 8. A B C D4. A B C D 9. A B C D5. A B C D 10. A B C D

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1. Met my educational needs: 1 2 3 4 5 2. Relates to pharmacy practice: 1 2 3 4 5 3. Achieves the stated learning objectives: 1 2 3 4 5 4. Faculty presented the information: 1 2 3 4 5 5. Teaching methods conveyed information: 1 2 3 4 5 6. Post-test aided in assessing my grasp of the information: 1 2 3 4 5 7. Avoided any bias or commercial bias: 1 2 3 4 5 8. How long did it take to complete this activity? _______________________

A passing grade of 70% is required for each examination. A person who fails the exam may resubmit the quiz only onceat no additional charge.

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PharmacySonny Rader Ex Officio - Chairman, GSHPGina Ryan Johnson Ex Officio MercerJill Augustine Ex Officio Mercer ASPRusty Fetterman Ex Officio South Olivia Santoso Ex Officio South ASPSukh Sarao Ex Officio UGARobb Hutherson Ex Officio UGA ASP

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