15 Smoke in mirrors: the continuing problem of tobacco use

Sharon Connor, PharmD

Topic Area

Tobacco use

Learning Objectives

At the end of this case, students will be able to:

  • Describe the prevalence of smoking in the United States
  • List the health disparities in smoking prevalence
  • Discuss the levels of influence that impact smoking behaviors
  • Create a smoking cessation plan for an underserved patient


Smoking is the leading preventable cause of death in the United States.1 Approximately 14% of the adult population are current smokers.2 The rate of smoking continues to drop yearly, but disparities exist. The prevalence of smoking in medically underserved communities remains high, particularly among populations experiencing homelessness. Rates of cigarette smoking among homeless adults are three to four times higher than the general population.3 The rate of smoking-induced death and disease among the homeless are also disproportionately high. Despite the high rate of smoking, homeless smokers do not differ from the general population in their desire to quit.3 Smokers with substance use disorder have an even higher prevalence and smoke at five times the rate of the general population.4 Between 70-90% of individuals receiving treatment for substance use disorder smoke cigarettes.4 The impact on death rates is significant, in fact they have twice the expected rate of deaths attributable to tobacco use than in the general population.5 Like smokers who are homeless, individuals with substance use disorder are interested in quitting.5

Smoking cessation services are not always offered to these populations due to the belief that quitting is a low priority or may interfere with substance abuse recovery. The literature supports that smoking cessation does not generally adversely affect substance use outcomes.6 Effective smoking cessation services for the medically underserved are needed to reduce tobacco-related health disparities.

Pharmacists are key advocates in assisting patients toward cessation. Quit rates are higher when a pharmacist is involved. Pharmacists are accessible in most communities and nicotine replacement product are available over the counter. Nicotine replacement products will help with the physical aspects of addiction, but patients need more than just a product when trying to quit. They need assistance with behavioral modification and support. In addition, patients need a program that is tailored to their specific needs. In order enhance the delivery of services, there are pharmacist-focused materials available through the Centers for Disease Control and Prevention.7

Also needed is a setting that promotes cessation. One must consider the social determinants of health when creating a program.8 If the program fails to be comprehensive and these factors are not addressed, disparities may persist.



You are a pharmacist that volunteers in a drug and alcohol rehabilitation facility for men. Many of the men desire to quit smoking, you want to help but wonder how to optimally provide services in a facility where it seems that smoking in part of the culture.The leaders of the facility turn to you as a great asset for this need. You are ready for the challenge and hope to create a program that addresses all of the factors that influence smokers’ abilities to quit successfully. You excited to provide care to this population that smokes at a much higher rate than the general public.

CC: “I want to quit smoking!”

HPI: JS is a 54 year old white male (70 in, 80 kg) who started smoking when he was 10 years old. He is currently in a drug and alcohol rehabilitation program and heard that is it is easier to stay away from the alcohol if he quits smoking at the same time.

PMH: HTN (10 years)


  • History of substance use, in rehabilitation for excessive alcohol use
  • Patient has smoked Marlboro one pack per day for 44 years. He has tried quitting in the past, cold turkey, and his longest time staying smoke free is two weeks. He started smoking again both times because of stress. This time he would like some help and is requesting the nicotine patch. He is highly motivated to quit, he rates his motivation a 10 on a scale of 10 and is somewhat confident in his ability to quit where he rates himself an eight on a scale of 10. His biggest motivation for wanting to quit is his health and the biggest barriers or concerns about quitting are stress and being around smokers.


  • Father: alive with HTN and CAD
  • Mother: Unknown


  • Hydrochlorothiazide 25 mg PO daily


  • BP 128/88 mmHg
  • HR 64 bpm
  • BMP normal

SDH: White male, divorced and was homeless for six months before he joined the rehabilitation program. His income last year when working was $15,000. He is not currently working.

Additional context: Smoking cessation is a challenge for JS. Participants of the rehabilitation program live at the facility. The residents are not allowed to go anywhere without an escort/chaperone. Residents may smoke, but they must smoke outdoors. A smoke break is sometimes viewed as a “reward” because the patient is allowed outside of the building.

Case Questions

1. What is the prevalence of smoking in an underserved population? Those living in poverty? Those who are homeless? Those who drink alcohol or use other drugs?

2. What types of interventions have an impact on the smoking rates of individuals? On the smoking rates of communities? On the smoking rate of populations?

3. Describe how you would conduct a smoking cessation intervention for JS. How would you assess JS’s stage of change? What are the levels of intervention to consider?

4. Using the socioecological model, discuss interventions that may be helpful in lowering the smoking rate in this population in the drug and alcohol rehabilitation program. Describe individual level interventions, community level and policy level interventions that may have an impact.

Author Commentary

Guidelines for smoking cessation should be used in all populations who smoke.11,12 Smoking cessation programs have been successful in some of the hard to reach populations.13 Quitting smoking may be beneficial for other aspects of patients’ health including substance abuse.14 Pharmacists should offer smoking cessation assistance to all patients who smoke.15 Providers must consider all aspects that influence cessation rates when offering services.16 Smokers who participate in a structured smoking cessation program are more likely to quit.17

Patient Approaches and Opportunities

Nicotine is a highly addictive compound. Cigarette smoking is one of the most challenging addictions. Most smokers want to quit and those who get help have higher quit rates. Pharmacists are in an ideal position to help.

Every smoker must be asked about their smoking status and desire to quit at each visit with a health care provider. Standardized screening allows this to be automatic and ensures no patient is excluded. Ideally patients may be provided with patient-centered tools for assistance with each quit attempt. These tools must target the behavioral and physical aspects of addiction.

It is not easy to quit and there is no perfect time to quit, but services should be offered. Pharmacists are in an optimal position to assist with smoking cessation. Pharmacists are one of the most accessible health care providers and have nicotine replacement therapy readily available in most circumstances. It may require multiple attempts, but each time the patient acquires cessation skills.

Important Resources

Related chapters of interest:

External resources:

  • Healthy People 2030. Tobacco use. https://health.gov/healthypeople/objectives-and-data/browse-objectives/tobacco-use
  • Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.
  • US Preventive Services Taskforce. Interventions for tobacco smoking cessation in adults, including pregnant persons: US Preventive Services Task Force Recommendation Statement. JAMA 2021;325(3):265-279.


  1. U.S. Department of Health and Human Services. The Health Consequences of Smoking–50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. https://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf. Accessed Sept 4, 2018.
  2. Current Cigarette Smoking Among Adults in the United States. Available at: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm. Accessed February 17, 2021.
  3. Baggett TP, Rigotti NA. Cigarette smoking and advice to quit in a national sample of homeless adults. Am J of Prev Med. 2010;39:164–72.
  4. Reid MS, Fallon B, Sonne S et al. Smoking cessation treatment in community-based substance abuse rehabilitation programs. J Subst Abuse Treat.2008;35: 68-77.
  5. Richter KP, Choi WS, Alford DP. Smoking policies in U.S. outpatient drug treatment facilities. Nicotine Tob Res 2005; 7(3):475-480.
  6. Mueller SE, Petitjean SA, Wiesbeck GA. Cognitive behavioral smoking cessation during alcohol detoxification treatment: A randomized, controlled trial. Drug Alcohol Depend 2012; 126:279-285.
  7. Tips from former smokers: Healthcare providers. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/campaign/tips/partners/health/index.html. Accessed August 23, 2021.
  8. Garrett DE, Dube SR, Babb, S, McAfee T. Addressing the social determinants of health to reduce tobacco-related disparities. Nicotine Tob Res 2015;17(8):892-897.
  9. Connor SE, Cook RL, Herbert MI, Neal SM, William JT. Smoking cessation in a homeless population: There is a will but is there a way? J Gen Intern Med. 2002 May; 17(5): 369–372.
  10. McClure EA, Acquavita SP, Dunn KE, Stoller KB, Stitzer ML. Characterizing smoking, cessation services, and quit interest across outpatient substance abuse treatment modalities. J Subst Abuse Treat. 2014 Feb;46(2):194-201.
  11. Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.
  12. US Preventive Services Taskforce. Interventions for tobacco smoking cessation in adults, including pregnant persons: US Preventive Services Task Force Recommendation Statement.
    JAMA 2021;325(3):265-279.
  13. Segan, CJ, Maddox S, Borland R. Homeless Clients Benefit From Smoking Cessation Treatment Delivered by a Homeless Persons’ Program. Nicotine & Tobacco Research 2015;17 (8): 996–1001.
  14. Bobo JK, McIlvain HE, Lando HA, Walker RD, Leed-Kelly A. Effect of smoking cessation counseling on recovery from alcoholism: findings from a randomized community intervention trial. Addiction1998;93:877–87.
  15. Pharmacists: Help Your Patients Quit Smoking. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. https://www.cdc.gov/tobacco/campaign/tips/partners/health/pharmacist/index.html Accessed Sept. 4, 2018.
  16. King JL, Merten JW, Wong TJ, Pomeranz JL. Applying a Social-Ecological Framework to Factors Related to Nicotine Replacement Therapy for Adolescent Smoking Cessation. AM J Promot. 2018 Jun;32(5):1291-1303.
  17. Babb S, Malarcher A, Schauer G, Asman K, Jamal A. Quitting Smoking Among Adults-United States, 2000-2015. MMWR Weekly 2017; 65(52);1457–1464.

Glossary and Abbreviations


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Public Health in Pharmacy Practice: A Casebook Copyright © by Jordan R Covvey, Vibhuti Arya, Natalie DiPietro Mager, Neyda Gilman, MaRanda Herring, Stephanie Lukas, Leslie Ochs, and Lindsay Waddington is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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