Among every pharmacy’s customers are those who have trouble bringing themselves to kick the habit of that daily puff of nicotine. For community pharmacist Chan Chiew Ying, who runs a smoking cessation (SC) programme in his workplace, their success comes down to having a reason to quit. For its August issue, MIMS Pharmacist spoke to Chan to find out more about his experiences and thoughts in the field.

Tell us about your work.

In Malaysia there’s an officially organized SC program called mQuit, a collaboration between the government and the private sector. My job is actually to create a platform, to set up the SC system in my company; we have 58 branches in Malaysia, and around 1-2 pharmacists per outlet. But we only have 8 mQuit-accredited pharmacies inside.

Why so relatively few accredited?

Initially when mQuit launched, they had a fast-track program; we only had to go through one test, two courses, to get certified. The course was quite complete as well, you just finished in a few days. But the fast track is no more.

The regular course consists of three levels; an online short course and quiz; a live practical on-site simulation; and an attachment to a government SC clinic for 2 weeks. But there's some difficulty currently … we're a bit stuck at the third level, which is why you don't see many new accredited SC pharmacists.

So what I'm doing is because [our pharmacy chain] has so many pharmacists, we continually send and train the pharmacists up to the second level. When you're up to level 2, you already have the hands-on skill. Although they don't have a certificate of accreditation, hopefully by creating a platform where we manage to produce successful quitters, we'll try to see if there's another approach [to accreditation].

Why offer this platform in your pharmacy?

Because we have a difficulty in Malaysia, which is that people here do not actively come for smoking cessation programs. There are a few myths that smokers believe; one is "if I've been smoking for more than 10 years or 5 years, if I stop immediately, I'll die. I'll be having blood pressure, heart attack, stuff like that." But it's not actually true.

And the truth is, you don't just put away your cigarette immediately. You have to give yourself a buffer period of 12 weeks minimum. Our programme normally is 12 weeks, so we have 12 weeks to settle this problem. And if you follow a step-by-step reduction in smoking, you won't have any side effects because we will follow up with testing your blood pressure, your sugar level, stuff like that; so that if there's any problem, at least we can control it.

That's what the mQuit program is all about. It's not just about handling your withdrawal symptoms, it's also helping in handling your psychological needs as well.

What is it like running an SC program?

I find that if people really don't want to smoke, you don't even need 12 weeks. Around 8 weeks is enough for them to stop … What do you think is the biggest obstacle to stopping smoking? It’s not actually about handling the withdrawal symptoms, like “I cannot focus, I feel like I cannot concentrate”. That persists for just 4 weeks. After 4 weeks, the symptoms will not be as severe.

No, what’s hardest for them to get over is the habit. For example—these are a few habits that I've identified—the first habit is [taking a cigarette] after meals. You can try asking "After a meal, you feel like having a smoke, right?" Every one of them will say “yes”. Second is when they’re going to use the toilet. When they're trying to pass a bowel motion, they will try to smoke. [laughs] Yes, that’s one of the more common habits.

The third habit would be when they get stressed at work. They don't actually need to smoke, it's just that they physically, mentally feel like "I’ll feel better if I smoke." The fourth is when they're driving and they feel sleepy while driving. Lastly is when there's a festival, like Hari Raya; when they see a bunch of friends, and that ‘mood’ comes up, they also smoke.

But most people who are able to stop smoking successfully are those people who are determined, and who know why they need to stop.

Regular follow-up assessment is a key part of the SC program.

Regular follow-up assessment is a key part of the SC program.

Do smokers usually come on their own?

The ones who always get dragged there will not be successful. [laughs] Those who are, are those who come themselves, or those who realize that they are causing trouble to their family.

There are a lot of reasons people come. Some come because they want better health, but for some, it's because they want a job promotion, so they have to stop. Especially with the Army, because they need good stamina [which is affected by smoking].

Another common reason is that they want to get respect from their family members. You know how it is; if a father smokes, their daughter and their wife tend to nag them a lot, so they want to be better respected, they say.

What demographic do you usually see?

Men. Definitely men. But the one who usually asks is the [wife], bringing their husband to us. That’s the most common scenario, really. But for me, I will usually be very straightforward. I will tell them, "I don't want to waste your money, because if you force him, you’ll make him maybe practice [the programme] for 1 month, and then he’ll stop."

I think it's really important to ask them "why do you need to stop" first. They have to identify [a reason] for themselves, first. It mustn't be "because they want me to stop”, because it will not be successful, honestly speaking.

Do you find young people coming in?

No, it's always the older people. Because young people, teenagers, they smoke for the fun of being cool. Honestly speaking, they won't stop smoking, because they can't feel the [effects]. When you become an adult, you will feel that your stamina, your lungs, your breathing, the phlegm, the cough—everything comes in, and that's only when they start to get worried.

Personally, I don't really like smokers, but I'm getting better at coping with it. But for me, there's a few groups of people that mustn't smoke. First of all: doctors. In Malaysia a lot of doctors smoke, and I don't understand why. Can you imagine if you're a patient, and I tell you "you know, smoking’s not good. You should stop. It's not good for your heart,” and then I go to the back of the building and smoke? Healthcare professionals are supposed to be role models. Pharmacists, doctors. Another important group is teachers. Teachers shouldn't be smoking, but in Malaysia this is not the case.

But why is this so? Is it because our government doesn’t put in enough effort, or are people not willing to listen? Even though we impose a very high tax on tobacco in Malaysia, but still people are still buying it-- why? We have been wondering—as community pharmacists in the private sector, how can we settle this problem? We have to create more awareness.

 But there's no point just telling smokers that smoking is bad for them. Everyone knows smoking is bad. Even when you show them almost-rotten lungs [on cigarette packs], they don’t seem to feel anything. How much can you expect from telling them “smoking is not good”? For me, the most effective way is to tell them “you are hurting the people behind and beside you. And not just that; you are bringing the economy of this country down.” Do you know why? Let me ask you about a very interesting statistic. People who are smokers, what do they mostly die of?

Counseling addresses not just withdrawal symptoms but psychological needs.

Counseling addresses not just withdrawal symptoms but psychological needs.

The common answer seems like lung cancer.

Statistically, it's not. It's heart attack and stroke; what we call cardiovascular diseases. Stroke, heart attack, high blood pressure, hypertension emergencies. Most people die from that before they even develop lung cancer.

But they don't necessarily die immediately. What do they do? They go to government hospitals and get free medication. Who pays? The government is paying, and it's not cheap. And so over time, more and more smokers means more and more people with heart problems and hypertension, which means higher cost to the economy and taxpayers.

Other than that, [smoking] also causes air pollution and affects the people around. The number of babies who are admitted to the hospital for respiratory attacks and lung problems is increasing every year. You know, the most interesting thing in the hospital I used to work in was that—the kids who get admitted to the hospital, if you ask their dad, "do you smoke?" They’ll say, "oh, I always smoke outside in the garden, I don't smoke in front of my kids."

Then I'll ask them, "did you know there's a thing called third-hand smoke? It's on your hair, your body, your clothes. When you play with your kids, when they go out to the garden, will kena or not? When you go and hug your kids later, will kena or not? It follows you.”

Are there any interesting cases that stand out?

Interesting cases? Let me think … There are a lot of cases where people came back to me saying, “you said I should try this, I tried this before already, it doesn't work.” But when I asked them how they used it, [it turns out] they had been using the thing incorrectly.

For example, the [nicotine replacement] chewing gum: there's a technique to using it. But if they just use it as though it’s a normal chewing gum, of course it isn't that effective. Then sometimes when they use the [nicotine] patch, and they think the patch is not effective, then they will think that this whole [programme] does not work.

But just because the patch doesn't work doesn't mean others don't work. And so sometimes one of the challenges is that you have to explain to them that there's a lot of ways to overcome their problem. It's not just "oh no, this one failed already, then it means the whole thing doesn't work."

Another thing is that with some of the medications we're using, we have to assess the mental state of the customer first. Because there's certain medications that—if the person has certain [psychological] conditions, they shouldn't be using it, because it may cause suicidal ideation… so you really have to be careful with stuff like that.