While the smoking cessation program is available for reimbursement to Ontario Drug Benefit (OBD) recipients who smoke, future consideration may be given to expanding program eligibility to non-ODB patients based on the experiences and outcomes of the program.

Currently, ODB recipients may enrol in the program once per year from the date of the patient’s first meeting with the pharmacist at which time they have agreed to work together on a stop smoking strategy.

A patient who smokes may self-identify his / her interest in the smoking cessation program. However, as pharmacists are in dialogue with their patients and caregivers daily for MedsCheck appointments, for front-shop questions and in fulfilling their dispensing services, there are many opportune times to talk about smoking cessation. While pharmacists already provide advice to their patients on the risks of smoking during these interactions, the opportunity may also arise when patients are indeed ready to quit smoking and decide to enrol in the smoking cessation program.

• Using the 5As algorithm¹ (Ask, Advise, Assess, Assist, Arrange) the pharmacist will guide the patient through a smoking cessation program (Refer to Appendix A)
• As with all professional pharmacy services, pharmacists will provide the smoking cessation service in an area of the pharmacy that provides a sufficient level of privacy and safety for the patient.
• All meetings with the patient must be documented to ensure program continuity. Follow-up meetings may be in person, telephone, electronic messaging or other agreed upon method of communication.
• Standardized template forms are provided as minimum standards of care to assist pharmacists with the mandatory documentation at each patient point of contact. While pharmacists may develop their own forms, the standardized template forms from the ministry must be adapted to maintain consistency of the program protocol.
• While one pharmacist may be the initial contact with the patient, any pharmacist at the designated pharmacy who has the appropriate training may meet with the patient over the course of the program. It is important however, that there is a trusting relationship between the patient and the pharmacist(s) for the duration of the program.  A one to one relationship between the patient and the counselling pharmacist may support a more successful quit attempt.

Duration of program:

• The program includes 9 points of contact including the readiness assessment whereby the patient agrees to the requirements to enrol, the first consultation meeting and the follow-up counselling sessions over a one year period or 365 days.

Readiness Assessment:

The outcome of the Readiness Assessment is that the patient agrees to enroll in the smoking cessation program and establish a quit date.

• The pharmacist provides information that fosters program awareness for the patient and asks of their willingness to quit smoking. Generally, this is an in-person interaction and may result from the MedsCheck appointment, a patient enquiry about over-the-counter nicotine replacement therapy or as a result of another process whereby the opportunity to discuss the patient’s desire to quit in the next month occurs.
• The Readiness Assessment includes a questionnaire to determine the level (rating) of the desire to quit smoking. A patient may not be ready to quit and may require more time to reflect before finally deciding to enroll.
• When the patient agrees to move forward and work with the pharmacist, the initial consultation will be arranged.
• A pharmacist and the patient may engage in a quit smoking discussion many times before a patient agrees to enrol and indicates a willingness to set a quit date.
• The readiness assessment process requires the pharmacist to document the patient's name, contact information and date of the discussion in which the patient agrees to enrolling in the program. Documentation should also outline the questions asked, the level of desire to quit smoking and the pharmacist’s name. Patients may request a copy of this record. 

Patient’s Signature:

• Patients who enrol in the Smoking Cessation program are required to establish a quit date and provide consent to the service including the method of communication whether in-person, by phone or other means; and the time(s) for the consultations.
• Patients also provide consent for sharing the readiness assessment or first consultation summary or other documentation within the circle of care².

First Consultation Meeting:

The outcome of the first consultation is to engage the patient in a dialogue about their smoking history, and to ensure the patient understands the goals and objectives of the program including their responsibilities towards success. The first consultation occurs after the pharmacist has conducted the readiness assessment, obtained patient consent for program enrolment and sharing of health information.

The pharmacist meets with the patient for the first consultation to discuss tobacco use and medication history, health risks, triggers / strategies; a quit date and consideration of pharmacotherapy.

• Patient enrolment and consent forms should be signed prior to the first consultation meeting.
• It is recommended that an in-person appointment be scheduled for the first consultation to ensure adequate time to discuss history and pharmacotherapy options.
• Patients should be provided with supporting printed education material relating to the benefits of quitting smoking and/or information pertaining to internet resources, peer groups and contact information such as the Smokers Help Line, other health care professionals, and programs to reinforce their quit smoking goals.
• The first consultation includes the development of a plan or an agreement on the chosen treatment pathway, ensuring that the patient understands the ongoing support and monitoring arrangements. Patients will use a quit smoking plan which the pharmacist is required to provide. It is a personal plan for preparing to quit smoking and what to expect regarding their process. Other quit smoking management tools including brochures, referral information to support groups and other tools and/or strategies to promote positive results should also be provided.
• The first consultation also includes the appropriate advice and documentation that it may be necessary for the pharmacist to discuss and share the patient's health information with other health care professionals (physicians, nurses) in the process of assisting with the quit smoking program. While patients have signed consent forms, best practice is that they be informed should the pharmacist provide a copy of the readiness assessment and/or first consultation or follow-up session(s) information to the physician or other health care professionals.
• Follow-up counselling sessions for the purpose of patient progress, evaluation and monitoring smoking status, addressing any concerns or issues and providing support are outlined and tentatively scheduled at the time of the first consultation.

A billing code through the ODB Health Network System is used by the pharmacist to claim reimbursement after the first consultation. Claim for reimbursement is processed once documentation of the meeting is complete and patient has signed the appropriate agreements.
PIN 93899941 = $40 – may be claimed once per year only

Follow-Up Counselling Sessions

The outcomes of the follow-up counseling sessions are to provide ongoing support for the patient by getting an update on their smoking status, addressing any concerns or issues that have arisen and to reinforce positive behaviours that the patient has used to remain smoke-free.

As noted, follow-up counselling sessions may occur in person, by telephone or other means of communication as agreed to by the patient. The location and method of communication must be included in the documentation.

All follow-up counselling sessions must be documented to ensure continuity of the program, evaluation and for the purpose of ministry auditing.

There are a total of seven follow-up counseling sessions that are billable by the pharmacist through the ministry’s Health Network System. Pharmacists may meet with their patient more often if required such as prior to the targeted quit date or other times that require support strategies and pharmacotherapy intervention; however, the program limits payment to defined parameters.

The first three or primary follow-up counselling sessions should take place within 3 weeks of the first consultation and the latter four or secondary follow-up sessions are expected to take place at intervals as agreed by the pharmacist and the patient between one to two months; between three to four months; between six to seven months and between eight to 12 months.

Suggested time-lines for follow-up counselling sessions:

Primary Follow-up sessions

• Day 3-5 (10 minutes);
• Day 7-10 (10 minutes);
• Day 14-21 (10 minutes);

Secondary Follow-up sessions

• Day 30-60 (3-5 minutes);
• Day 90-120 (3-5 minutes);
• Day 180-210 (3-5 minutes);
• Day 240-365 (3-5 minutes)

Primary Follow-up counselling sessions 1-3:

• The first 3 follow-up counselling sessions should take approximately 10 minutes and should occur within the first 3 weeks of the program being initiated.
• The sessions include a dialogue with the patient on their success / or not with the strategy chosen including identifying any potential drug therapy issues. It is a time to discuss what is working or not; ways in which the patient can overcome triggers, cravings or withdrawal symptoms. Pharmacists will optimize on the program successes and encourage continuation of those favourable outcomes. In addition, a review of biological incidents including personal, psychological or social issues if any, that prevented the patient from reaching his/her goal is part of the discussion.

A billing code for the ODB Health Network System is used by the pharmacist to claim reimbursement for each of the first three primary follow-up counselling sessions. Claim for reimbursement is processed once documentation of the meeting is complete.
PIN 93899942 = $ 15 (may be claimed three times per year only)

Secondary Follow-up counselling sessions 4-7:

• The four secondary follow-up counselling sessions are approximately 5 minutes in duration and occur as previously noted at suggested intervals following the first month.
• The sessions continue to build on the program success history and review incidents including drug therapy issues and biological incidents if any, that prevented the patient from reaching his/her goal.

A billing code for the ODB Health Network System is used by the pharmacist to claim reimbursement for each of the final (secondary) follow-up counselling sessions. Claim for reimbursement is processed once documentation of the session is complete.
PIN 93899943 = $ 10 (may be claimed four times per year only)

The 5A’s algorithm of Ask, Advise, Assess, Assist and Arrange is a smoking cessation algorithm that is commonly used by health care providers. For more information refer to the Smoking Cessation resource tools on the Ontario Pharmacists’ Association website.

Circle of Care is a commonly used term in the healthcare community that refers to the health-care providers who share patient health information; for more information regarding patient consent refer to the OCP website and the Information and Privacy Commissioner website.

¹The 5A’s algorithm of Ask, Advise, Assess, Assist and Arrange is a smoking cessation algorithm that is commonly used by health care providers. For more information refer to the Smoking Cessation resource tools on the Ontario Pharmacists’ Association website: http://www.pharmacisteducation.ca/opaCatalog218/c-139-smoking-cessation.aspx

²Circle of Care is a commonly used term in the healthcare community that refers to the health-care providers who share patient health information; for more information regarding patient consent refer to the OCP website (www.ocpinfo.com) and the Information and Privacy Commissioner website at: www.ipc.on.ca

Pharmacists are asked to document smoking cessation program results for the purpose of program evaluation.

The following results are claimed using the Ontario Drug Benefit health network system product identification numbers (PINs) for the purpose of establishing patient success in the Ontario government’s quit smoking program.  The three PINs used for program evaluation provide no remuneration. Only one of the three program evaluation PINs is claimed per patient.

Once a program evaluation PIN is claimed, no further meetings are billable for that program period.

Successful Quit:  PIN 93899944

• The successful quit PIN is claimed when a patient indicates at any time during the program that he or she has successfully quit smoking. Once the PIN is claimed, no further meetings are scheduled or billable.

Unsuccessful Quit: PIN 93899945

• The unsuccessful quit PIN is claimed when a patient indicates at any time during the program that he or she has not succeeded in quitting smoking. Once the PIN is claimed, no further meetings are scheduled.
• Pharmacist should inform patients who withdraw from the program of their eligibility to re-enroll at a later date (one year from the date of their first consultation with the pharmacist).

Unknown Status / Program Withdrawal: PIN 93899946

• The unknown status PIN is claimed when a patient cannot be reached to continue with his/her program or when a patient withdraws from the program without indicating their success in quitting smoking.

In recognition of providing professional services by community pharmacists, the Smoking Cessation program meetings are ideally conducted in the community pharmacy, in person with the patient.

A sufficient level of privacy and safety for the patient must be ensured by the pharmacist.

The Ontario government recognizes that not all interactions between the pharmacist and the patient for the smoking cessation program can be conducted in person at the pharmacy. Should a meeting occur outside the community pharmacy or by another mechanism including telephone, email or other means as arranged and agreed upon by both parties, the location and method used must be documented.

A pharmacist who provides the Smoking Cessation program is considered to be within the scope of practice of a pharmacist licensed to practice direct patient care (Part A of the Register, Ontario College of Pharmacists).

However, pharmacists are required to take a smoking cessation training program to ensure that they have a basic level of training including motivational interviewing strategies, a familiarity with more involved smoking cessation counselling and quit smoking planning. 

The training program must support the Smoking Cessation Algorithm (5 As) of Ask; Advise; Assess; Assist; Arrange. Smoking cessation programs are obtainable in Ontario through organizations including the Ontario Pharmacists' Association, the Canadian Pharmacists' Association and the Centre for Addiction and Mental Health.

Additional requirements:

• The designated manager of a pharmacy that provides a smoking cessation program must be trained in smoking cessation within six months from the time the pharmacy provides the smoking cessation service.
• A pharmacist who is trained in smoking cessation must be available during hours of operation at the pharmacy that offers a smoking cessation program.
• Training for smoking cessation must be updated at a minimum of every 5 years.
• A copy of the completed smoking cessation training program should be readily retrievable at the pharmacy for purposes of audit.

Information on the Ontario Government’s Smoke Free Ontario Strategy³ including multi-lingual fact sheets, quit smoking tips, smokers help-line, on-line group forums and other references for patients and health professionals can be provided to patients.

Other quit smoking resources:

• Canadian Cancer Society -  Smoking and Tobacco⁴
• Quit and Get Fit; Smoking and Tobacco, Ontario Lung Association⁵
• Tobacco and Smoking, Centre for Addiction and Mental Health⁶

Quit smoking help lines:

• Smoke-Free Ontario Smokers Helpline - 1-877-513-5333
• Canadian Cancer Society Smokers’ Helpline - 1-877-513-5333
• Ontario Lung Association - 1-888-344-LUNG (5864)
• Centre for Addiction and Mental Health (CAMH) Information Centre - 1-800-463-6273

Pharmacists may develop their own smoking cessation materials for patients. However, standardized template forms are provided by the Ontario Government as minimum mandatory standards of care to assist pharmacists in the documentation at each patient point of contact. While pharmacists may develop their own forms, the standardized templates from the ministry need to be adapted to maintain a consistency of the program protocol.

Templates for pharmacist’s materials are also available from the Ontario Pharmacists’ Association⁷ and the Canadian Pharmacists’ Association⁸.

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³Refer to Ontario Government’s Smoke Free Ontario resource information at http://www.mhp.gov.on.ca/en/smoke-free/

⁴Refer to Smoking and Tobacco references on the Canadian Cancer Society website: http://www.cancer.ca/Canada-wide/Prevention/Smoking%20and%20tobacco.aspx?sc_lang=en

⁵Refer to Quit and Get Fit; Smoking and Tobacco references on the Ontario Lung Association website: http://www.quitandgetfit.ca/page.aspx?pid=816

⁶Refer to Tobacco and Smoking references on the Centre for Addiction and Mental Health website: http://www.camh.net/About_Addiction_Mental_Health/AMH101/top_searched_tobacco.html

⁷Refer to Smoking Cessation resource tools on the Ontario Pharmacists’ Association website: http://www.pharmacisteducation.ca/OPA  

⁸Refer to the Quit Using and Inhaling Tobacco (Q.U.I.T.) program tools on the Canadian Pharmacists’ Association website: http://www.pharmacists.ca/content/hcp/resource_centre/practice_resources/helping.cfm

The smoking cessation program requires that pharmacists document the readiness assessment, the first consultation, the follow-up counselling sessions and whether a patient withdraws from the program. Any drug related problem identified outside of smoking cessation session must also be documented as per the standards of practice. In addition, pharmacists may incorporate quit smoking education materials and action plans as appropriate for their patients.

Each point of contact and / or meetings between the pharmacist and the patient must be documented to ensure program continuity and for the purposes of counselling, support, data analysis, evaluation and claims adjudication.

Using the ministry template forms as a minimum standard, full documentation is required of all pharmacist / patient engagement including patient readiness, patient consent and agreement terms, first consultation meeting, follow-up counselling sessions and any incidence of program withdrawal.

Follow-up meetings may be in person, telephone, electronic messaging or other agreed upon method of communication. The method and location of these meetings must be included in the documentation.

Smoking cessation documents and associated patient records including any written referrals and patient consent documentation; drug therapy information and desired outcomes / action plans; and specifics on quit smoking plans and advice offered to the patient must be retained by the pharmacist in a readily retrievable format and must be kept on site at the pharmacy for a minimum period of ten years or as indicated in O/Reg 58/11 of the Drug and Pharmacies Regulation Act.

Pharmacy records that are associated with the claims submission of professional services using the Ontario Drug Benefit Health Network System PIN mechanism are subject to audit and must be maintained in the pharmacy for a minimum of 2 years.

All documents and records relating to the Smoking Cessation program must be stored electronically (or as a hard copy) when completed and be readily available for retrieval at a later date.

Results

Patients are entitled to a copy of their readiness assessment, consent forms and any documentation from the first consultation and follow-up counselling sessions.

• Smoking Cessation claims for payment may only be submitted for ODB recipients at this time.   
• The claim submission follows the same process for submitting a claim for the MedsCheck program using a special product identification number (PIN)

Pharmacy Program Payment

PIN 93899941  $40.00 First Consultation (once per year): Readiness assessment is complete including willingness to set a quit date; patient has enrolled in the program and provided signed consent to the pharmacist for purposes sharing health information within the circle of care and for program data collection. First Quit Consultation meeting and documentation is complete.
PIN 93899942 $15.00 Primary Follow-up counselling sessions 1-3 (3 times per year = $45 total)
PIN 93899943 $10.00 Secondary Follow-up counselling sessions 4-7 (4 times per year = $40 total)

A claim for payment is made after documentation is complete and the respective smoking cessation meeting / session has occurred using the appropriate PIN; claim to be submitted on the date of service

Program Evaluation Tracking: One program evaluation PIN is claimed per patient.

PIN 93899944 $0.00 Successful Quit (once per year, if applicable)
PIN 93899945 $0.00 Un-Successful Quit (once per year, if applicable)
PIN 93899946 $0.00 Unknown Quit Status (once per year, if applicable)

A claim for evaluation is made after documentation is completed and pharmacist is made aware of the program quit status using the appropriate PIN; claim to be submitted on the date the pharmacist is made aware of the program quit status. Once a program evaluation PIN is claimed, no further meetings are billable for that program period.

By virtue of documenting the stages of the smoking cessation program by pharmacists including submitting the appropriate PIN, pharmacists are assisting in data collection for the Smoke Free Ontario Strategy.

Output measures that indicate how Ontario is meeting its smoking cessation goals may include:

• number of pharmacies that have provided a smoking cessation program
• number of ODB recipients who have enrolled in the program
• number of patients who completed the program
• quit smoking success status of patients who enrolled in the program
• number of patients who re-enrol in the program
• number of ODB recipients who used prescription therapy

Immediate and Long-term Outcomes include:

• Increased patient awareness of smoking cessation options by patients
• Improved quality of life for patients who quit smoking
• Improved patient access to health care providers and services.
• Increased partnership with community health services.
• Reduced number of adverse drug events relating to smoking.
• Reduced number of medication discrepancies.
• Reduced number of smoking related hospital emergency visits.
• Reduced number of hospital admissions that relate to smoking.
• Helps to identify best practice.
• Shared best practice information with care team.
• Builds continuous inter-professional communication.