6.4 Tobacco Cessation Protocol: Training, Screening, NRT & Non-NRT Prescribing

Why this matters

Smoking cessation therapy is one of the patient care services ORS 689.645(1)(b) names for statewide drug therapy management protocols. The Board's Tobacco Cessation protocol (v. 06/2024) lets an Oregon pharmacist prescribe nicotine replacement therapy (NRT), both OTC and prescription forms, and non-NRT drugs (varenicline and bupropion SR). The MPJE tests the training requirement, the screening exclusions and the dosing logic.

Training and general requirements

• At least 2 hours of documented ACPE CE on pharmacist prescribing of tobacco cessation products before using the protocol.
• All the general prescribing rules of OAR 855-115-0330 apply: in-person assessment, care plan, notice to the primary care provider within five business days, and seven-year records.
• The patient completes the Board's Tobacco Cessation Self-Screening Patient Intake Form, and the pharmacist follows the Assessment and Treatment Care Pathway.

Screening steps that trigger referral

Choosing NRT

• Combination NRT (patch plus a short-acting form: gum, lozenge or nasal spray) is preferred.
• Starting patch dose depends on total daily nicotine, counting cigarettes, e-cigarettes and chewing tobacco:
  • 10 or fewer cigarettes per day (under about 20 mg nicotine per day): start the 14 mg/day patch.
  • More than 10 cigarettes per day (20 mg or more nicotine per day): start the 21 mg/day patch.

Screening for bupropion and varenicline

Before prescribing a non-NRT drug, the pharmacist reviews:

• Bupropion: avoid with any history of seizure, head trauma, brain surgery, stroke or epilepsy; an eating disorder (anorexia or bulimia); use of an MAOI or linezolid; or alcohol use or recent discontinuation of sedatives (seizure risk).
• Bupropion: also avoid with chronic kidney disease, liver disease, or a mental health diagnosis or treatment in the past two years.
• Varenicline: avoid, or refer if the patient still wants it, with a mental health diagnosis or treatment in the past two years, or use of an MAOI or linezolid. In the care pathway, chronic kidney or liver disease excludes bupropion but not varenicline.
• Depression screening (PHQ-2): a score of 3 or more means avoid both bupropion and varenicline and refer. NRT may still be offered.
• Suicide screening: any positive response requires immediate referral. The pharmacist calls the PCP's office, or uses a suicide crisis line after hours. Bupropion and varenicline may be prescribed only with a suicide-screening score of 0.

Standard pharmacotherapy facts (for counseling)

Behavioral support

Every pathway ends with referral to the Oregon Tobacco Quit Line (1-800-QUIT-NOW) or other cessation support, plus follow-up planning. The protocol treats counseling and support as part of the prescribing encounter, not an optional extra.

Documentation and follow-up

Each encounter produces a record under the general prescribing rules:

• The completed intake form and the pharmacist's BP reading.
• The care-pathway decisions and the product prescribed, with directions and quantity.
• The referral or Quit Line information given.
• Notice to the patient's primary care provider within five business days.

The record is kept seven years (OAR 855-104-0055). OTC nicotine products prescribed under the protocol are dispensed and labeled as prescriptions, so prescription labeling, counseling and DUR rules apply. The pharmacist plans follow-up around the target quit date: for example, adjusting NRT, stepping down patch strength, or referring if neuropsychiatric symptoms develop on varenicline or bupropion.

Exam scenario

A 42-year-old smoker of 25 cigarettes per day, with a well-controlled seizure disorder, asks for bupropion. The pharmacist measures BP at 132/84. Seizure history excludes bupropion. The pharmacist may offer combination NRT (21 mg patch plus a short-acting form), or consider varenicline if the mental health and suicide screens are negative. The pharmacist refers the patient to 1-800-QUIT-NOW, notifies the primary care provider within five business days, and documents everything for seven years. If the patient were 17, the pharmacist would refer instead of prescribing.