16.2 Health Promotion: Smoking Cessation, Weight Management, Screening & Social Determinants of Health

Health Promotion: Smoking Cessation, Weight Management, Screening & Social Determinants of Health

Health promotion and disease prevention are part of the NAPRA competencies (Leadership and Stewardship, and Clinical Care). Pharmacists see patients more often than any other provider. That makes the pharmacy a natural place for smoking cessation, weight management, screening and support for people facing social barriers to health. PEBC sample items in this area test practical judgement, for example that diet and exercise prevent progression to type 2 diabetes better than any drug.

1. Smoking Cessation

Brief intervention for every tobacco user: Ask about tobacco use, Advise quitting clearly and personally, and Assist. Assisting means offering medication plus behavioural support, or referral to a quit line or program. Medication plus counselling roughly doubles to triples quit rates compared with willpower alone.

Nicotine Replacement Therapy (NRT)

• Patch: 21 mg/24 h for people smoking more than 10 cigarettes a day; 14 mg for 10 or fewer. Apply to clean, hairless skin and rotate sites. Remove at bedtime if vivid dreams or insomnia occur.
• Short-acting forms: gum, lozenge, inhaler, mouth spray. Use the 4 mg gum or lozenge if the first cigarette is within 30 minutes of waking, otherwise 2 mg.
  • Gum technique is "chew and park": chew until a peppery taste appears, then park the gum between cheek and gum, and repeat for about 30 minutes.
  • Avoid acidic drinks for 15 minutes before and during use.
• Combination NRT (a patch for baseline needs plus a short-acting form for cravings) is more effective than any single form. Doses are often higher than the package suggests for heavy smokers. Treatment usually lasts 8 to 12 weeks or more, followed by a taper.
• Safety: NRT is far safer than smoking, including in people with stable cardiovascular disease. Use caution in the first weeks after an acute coronary event. In pregnancy, behavioural support comes first; intermittent NRT forms are reasonable if needed.

Prescription and Other Options

• Varenicline (now generic in Canada) is the most effective single agent:
  • Dosing: start 1 to 2 weeks before the quit date (or use a flexible quit date): 0.5 mg daily on days 1 to 3, 0.5 mg twice daily on days 4 to 7, then 1 mg twice daily to complete 12 weeks. Take after food with water to limit nausea.
  • Renal dosing: if CrCl is below 30 mL/min, the maximum is 0.5 mg twice daily.
  • Safety: the large EAGLES trial found no significant increase in serious neuropsychiatric events compared with placebo. Patients should still report mood changes.
• Bupropion SR: 150 mg daily for 3 days, then 150 mg twice daily (at least 8 hours apart), starting 1 to 2 weeks before the quit date.
  • Contraindications: seizure disorders, current or past bulimia or anorexia, abrupt alcohol or benzodiazepine withdrawal, and MAO inhibitors within 14 days.
  • Adverse effects: insomnia and dry mouth.
• Cytisine is licensed in Canada as a natural health product for smoking cessation. It is a partial nicotinic agonist like varenicline.
• E-cigarettes may help some adults who smoke to quit or switch completely. They are not risk-free. Dual use offers little benefit, and youth vaping is a public health concern.

2. Weight Management (Obesity Canada Guideline)

• Obesity is a chronic disease. Assess its root causes, complications and weight-promoting medications:
  • antipsychotics such as olanzapine and clozapine;
  • insulin and sulfonylureas;
  • some antidepressants (mirtazapine, paroxetine);
  • corticosteroids;
  • valproate and gabapentinoids.
• Medical nutrition therapy, physical activity and psychological interventions are the foundation.
• Pharmacotherapy is an adjunct for a BMI of 30 kg/m² or more, or 27 or more with weight-related complications:
  • Semaglutide 2.4 mg weekly or liraglutide 3 mg daily (GLP-1 receptor agonists):
    • Titrate slowly to limit nausea, vomiting and constipation.
    • Watch for gallbladder disease and pancreatitis.
    • Avoid with a personal or family history of medullary thyroid carcinoma or MEN2.
    • Pregnancy: stop before a planned pregnancy.
    • Surgery: tell the surgical team, because delayed gastric emptying raises the risk of aspiration during anesthesia.
  • Naltrexone/bupropion: contraindicated with opioid use, seizure disorders and uncontrolled hypertension.
  • Orlistat 120 mg with each fat-containing meal: oily stools and fecal urgency (worse with high-fat meals). Take a multivitamin with fat-soluble vitamins at bedtime, separated from orlistat. Separate levothyroxine, and monitor cyclosporine and anticonvulsant levels.
• Unauthorized compounded or "research" GLP-1 products sold online are a safety risk. Counsel patients to use only authorized products.
• Approach conversations about weight without stigma: ask permission, use person-first language ("a person living with obesity"), and focus on health goals rather than numbers alone.

3. Screening and Lifestyle Counselling

• Pharmacy-based screening and case-finding:
  • blood pressure (standardized automated measurement, section 7.1);
  • diabetes risk (for example, the CANRISK questionnaire, and A1C where available);
  • lipids and cardiovascular risk;
  • support for organized cancer screening, such as fecal immunochemical testing for colorectal cancer, usually every 2 years from ages 50 to 74.
• Physical activity: adults should aim for at least 150 minutes of moderate to vigorous activity weekly, plus muscle strengthening twice weekly (Canadian 24-Hour Movement Guidelines).
• Alcohol: Canada's Guidance on Alcohol and Health (2023) describes 2 or fewer standard drinks a week as low risk, with risk rising steadily above that. No amount is risk-free.

4. Social Determinants of Health and Public Health Roles

• Income, housing, food security, education, racism and colonialism shape health more than health care does. Pharmacists can:
  • check drug coverage (provincial plans, NIHB, Jordan's Principle);
  • choose lower-cost equivalents;
  • connect patients with community resources;
  • use trauma-informed, culturally safe care (section 2.3).
• Harm reduction: take-home naloxone kits (no prescription needed), sterile supplies, and referral to opioid agonist therapy (section 13.2).
• Emergency preparedness: pharmacies keep continuity plans for disasters, pandemics and outages. These include backup power for vaccine refrigerators, access to patient records, and emergency supplies within provincial rules.