Delivering a personalised smoking cessation intervention by community pharmacists in Western Australia : a randomised controlled trial

Abstract

Background: Tobacco smoking leads to death or disability and a drain on national resources. The literature suggests that cigarette smoking continues to be a major modifiable risk factor for a variety of diseases and that smokers aged 18–30 years are relatively resistant to anti-smoking messages.Aims: This research project aimed to test a digital ageing intervention to promote smoking cessation among young adult smokers within a community pharmacy setting and explore the value of the unfunded intervention within pharmacy practice.The primary outcomes were efficacy of the intervention measured by quit attempts and nicotine dependence and the secondary outcomes were cost-effectiveness of the intervention from a health sector perspective and community pharmacy business viability.Methods: This research project was named ‘Pharmacy PAINT’ (Photo-Ageing INTervention) and was conducted in community pharmacies in Perth, Western Australia in two trials: i) a pilot study; ii) a full Randomised Controlled Trial (RCT).The research was underpinned by the Medical Research Council (MRC) – Framework for design and evaluation of complex interventions, to improve health and the complex intervention was delivered by a qualified, registered pharmacist.Young smokers, aged 18 – 30 years who randomly entered the pharmacy, either to have a prescription dispensed or purchase an OTC (Over the Counter) medication were eligible to be recruited for the research if they were English speaking and able to give informed consent, did not have beards, moustaches or facial accessories that couldn’t be removed, were available for phone survey follow-ups and were not using Nicotine Replacement Therapy (NRT) or taking nicotine dependence medications.Consenting participants were randomised into two groups: a control group and an intervention group with equal numbers in each. Allocation into the groups alternated weekly so that all participants recruited in any specific week received the same treatment.Participants in the control group received standard smoking cessation advice from a pharmacist-researcher. Participants in the intervention group received the same standard smoking cessation advice from the pharmacist-researcher but in addition, they were photographed and their images digitally aged, as a smoker and non-smoker and then invited to view the age-processed images.The intervention involved using a photo-ageing tool (APRIL® Age Progression Software, 3D age progression software based upon Canadian normative ageing data) to deliver the non-smoking message by exposing the young smokers to graphic images of the detrimental effects of smoking on their future facial appearance.Results: The pilot study recruited 50 participants, 25 allocated to the control group and 25 to the intervention group and participants were followed-up for a three-month period. The pilot study was conducted between February 2008 to December 2008 and the results informed the feasibility, recruitment strategy, outcome measure, effect size and attrition rate for the subsequent RCT.The RCT was conducted from January 2010 to June 2011 and involved 160 participants, with 80 allocated in each of the control and intervention groups. Participants were followed-up for a six-month period. At the final six-month follow-up, five (8%) in the control group declared that they had quit smoking, however, only one (1.3%) of these subjects was an objectively confirmed non-smoker (validated on carbon monoxide (CO) testing). For the intervention group, 22 (38%) declared they had quit, with 11 (13.8%) confirmed by CO testing. This difference in these proportions between groups was highly significant (p = 0.005 by Fisher’s exact test). Results for the change in nicotine dependence score using the Fagerström Scale, showed a greater proportion of the subjects in the intervention group moving to a lower smoking dependence score than the control subjects (p<0.0001).Total costs of implementing the intervention from a health sector perspective were AUD 366 or the equivalent of AUD 4.58 per participant (Table 7). With an additional 10 quitters in the intervention group compared with the control group (11 versus one respectively), the incremental cost-effectiveness ratio (ICER) was AUD 37 per additional quitter. Cost offsets of AUD 2,144 from a reduction in the health care costs of quitters resulted in the intervention potentially generating net total cost savings of AUD 1,778.Participants indicated a mean willingness to pay for the digital ageing service of AUD 20.25, which exceeded the mean cost per participant for delivering the service of AUD 4.58. This suggested the service may be viable if the customer was charged in the pharmacy if not subsidised by government. The median willingness to pay of AUD 20.00 was similar to the mean value. Ten respondents thought aspects of the service could be improved and so made the following recommendations: to also provide information on methods to quit; to also offer a support program; to also show the effects of smoking on major organs. Over 80% of participants said they would be more likely both to use the pharmacy to purchase future smoking cessation therapies and to use it more generally for other purchases. Over 80% of participants also thought their friends would be willing to pay for the service and the vast majority of participants said they would recommend photo-ageing to one or more friends who were smokers.CONCLUSION: Emphasising the link of smoking to the detrimental effects on skin and physical appearance using a personalised promotion intervention can be an effective motivator to persuade younger adult smokers to quit. This intervention can be proactively and economically delivered by a pharmacist as primary health care counselling in a community pharmacy setting.