Jennifer Butler, B.Sc.(Pharm)

According to Health Canada, 12% of Canadians aged 15 or older currently smoke cigarettes, putting them at risk of developing lung cancer, heart disease, respiratory illnesses and more (Faisal, 2024; Health Canada, 2022). Even more concerning, their 2023-2024 report on alcohol and drug use amongst students shows that 15% of students in grades 7 to 12 report to have used non-cannabis e-cigarettes or vapes within the previous 30-days (Health Canada, 2025). 

The social-ecological model, first described by McLeroy et. al. in 1988, provides a framework that describes the 5 levels of influence on health and behaviour: intrapersonal, interpersonal, organizational, community and public policy (King et al., 2018; McLeroy et al., 1988). In this essay, I will discuss how smoking and smoking cessation are impacted at each level of this model. Additionally, given that pharmacists are well-positioned to promote smoking cessation, I will outline opportunities for pharmacists and pharmacy organizations to address the relevant factors at each level to support these efforts.

Figure: visual depiction of a social-ecological model to describe levels of pharmacy intervention on smoking cessation

Intrapersonal Level

There are many factors at the intrapersonal level that impact smoking. People who smoke often cite perceived benefits, such as pleasure, arousal, enhanced vigilance, reduced anxiety or depression, reduced hunger, and more. Some people use smoking as a means of socialization. Patients’ health literacy & behaviours, their knowledge of the health impacts of smoking, the perceived risks or effectiveness of nicotine replacement therapy (NRT) also play a significant role (Han & Son, 2022; Obieche et al., 2021; Zhou et al., 2021). 

Patients who wish to quit smoking may experience concerns regarding withdrawal symptoms or potential weight gain. Additionally, managing internal and habitual triggers associated with smoking—such as nicotine cravings, stress management, and personal routines linked to smoking, like drinking coffee, driving, or eating—may be viewed as a significant challenge (Zhou et al., 2021).

Pharmacists have several means through which they can address intrapersonal barriers to smoking cessation. First, they are able to assess and encourage patients who smoke to quit through education and motivational interviewing. As primary care providers, pharmacists are able to dispel misinformation about smoking, increase the knowledge of the benefits of quitting and provide general health promotion. Additionally, pharmacists can utilize the technique of motivational interviewing to help patients address concerns such as stress management, as well as confronting internal and habitual cues. 

Second, pharmacists can assess patients for NRT and smoking cessation therapy. Smoking cessation products increase the likelihood of remaining smoke-free by reducing withdrawal symptoms (Faisal, 2024). Due to the wide availability of products, such as oral medication, patches, gum & lozenges, inhalers, and mouth sprays, pharmacists have the opportunity to tailor a patient’s therapy to their preferences, lifestyle and specific needs. 

Finally, as scopes of pharmacy practice continue to expand, many pharmacists, including some in Manitoba, have the authority to prescribe both prescription and non-prescription smoking cessation products to patients, thereby reducing barriers related to accessibility (College of Pharmacists of Manitoba, n.d.). 

Interpersonal Level

Interpersonal relationships with family, friends and other networks within a person’s life play important roles in a patient’s smoking journey. However, at times these relationships can be viewed as a double-edge sword, as the beliefs and influence of those around a person can either help or hinder their efforts to quit smoking (Obieche et al., 2021; Tramonti et al., 2021). While some people may encourage and support a patient on this endeavour, others may create resistance through peer pressure or simply by smoking around them (Obieche et al., 2021; Zhou et al., 2021). 

Pharmacists have the opportunity to have a positive impact by cultivating strong patient-provider relationships, thereby gaining high levels of trust and consideration from patients for their opinions and advice. While nurturing such relationships takes time and energy, pharmacists enable themselves to successfully reach patients, particularly those who were previously not ready to quit. Furthermore, through motivational interviewing, pharmacists can reframe a patient’s mindset and present potential positive impacts of smoking cessation on interpersonal relationships. For instance, they could emphasize that quitting smoking may enhance one’s exercise tolerance, enabling them to engage more actively in play with their children. 

Organizational Level

Factors influencing smoking cessation at an organizational level include elements such as smoking policies in workplaces, schools, and other public venues, the availability of designated smoking areas, and the frequency of smoking breaks (Obieche et al., 2021). 

At the organizational level, pharmacists can enhance smoking cessation rates by increasing the visibility of smoking cessation resources. This can be achieved by strategically placing advertisements within the pharmacy that promote smoking cessation products and services, providing accessible information such as educational brochures or pamphlets, and prominently displaying over-the-counter NRT where patients can easily self-select.

Community Level

Factors that can positively impact smoking cessation at a community level include media influences, local smoking cessation campaigns, and reduced levels of social acceptability of smoking (King et al., 2018; Obieche et al., 2021).

While individual pharmacists can have a direct impact here, positive impact on smoking cessation at the community level is more readily achieved by local pharmacy organizations. Pharmacy advocacy organizations can use their platform to create and promote smoking cessation resources, campaigns and programs. For instance, in 2022, Pharmacists Manitoba, in partnership with the Government of Manitoba and Shoppers Drug Mart, launched a 3-year smoking cessation program aimed at helping Manitobans who are ready to quit smoking by providing pharmacist-led clinical services and coverage for smoking cessation products (Government of Manitoba, n.d.). At a national level, the Canadian Pharmacist Association has created a comprehensive toolkit to assist individual pharmacists and pharmacies who are providing smoking cessation services at their locations (Faisal, 2024).

Policy Level

At the policy level, smoking cessation can be promoted through measures such as the taxation of tobacco products, public bans on smoking and restrictions on the sale of tobacco, including regulations related to location and age (Obieche et al., 2021). 

Once again, pharmacy organizations play a major role at this level. Pharmacy advocacy organizations can call for reimbursement of smoking cessation services provided by pharmacists, thereby securing their availability and sustainability. Furthermore, pharmacy regulators can build frameworks that authorize pharmacists to prescribe for smoking cessation products, which allows patients to acquire prescription-only medications without having to see a second provider, as well as take advantage of existing drug coverage. In Manitoba, the College of Pharmacists has a pathway by which pharmacists can become authorized to prescribe for smoking cessation therapies, including the prescription-only medication, Varenicline (College of Pharmacists of Manitoba, n.d.). 

Concluding Thoughts

By organizing the factors impacting smoking and smoking cessation within a social-ecological model, as demonstrated here, pharmacists and pharmacy organizations can effectively strategize to promote smoking cessation by tackling factors at all levels. Pharmacists are well-equipped to address individual patients’ personal and interpersonal barriers to quitting, as well as creating a pharmacy environment conducive to quitting. Simultaneously, pharmacy organizations can promote smoking cessation through member education and support, community and governmental advocacy and expanding the scope of practice. By embracing this multi-level approach, our profession can play a pivotal role in reducing smoking rates, improving public health, and ultimately saving lives.

References

College of Pharmacists of Manitoba. (n.d.). Prescribing Drugs for Smoking Cessation. College of Pharmacists of Manitoba. Retrieved March 7, 2025, from https://cphm.ca/practice-education/prescribing-smoking-cessation/

Faisal, S. (2024). Break the Habit: A Pharmacist’s Toolkit for Smoking Cessation Counselling. Canadian Pharmacists Journal / Revue Des Pharmaciens Du Canada, 157(6), 285–285. https://doi.org/10.1177/17151635241290111

Government of Manitoba. (n.d.). Quit Smoking with your Manitoba Pharmacist. Province of Manitoba – DepartmentName. Retrieved March 3, 2025, from https://www.gov.mb.ca/DepartmentURL/pagename.html

Han, G., & Son, H. (2022). A systematic review of socio-ecological factors influencing current e-cigarette use among adolescents and young adults. Addictive Behaviors, 135, 107425. https://doi.org/10.1016/j.addbeh.2022.107425

Health Canada. (2022, December 19). Smoking in Canada: What we know [Research]. https://www.canada.ca/en/health-canada/services/smoking-tobacco/surveys-statistics-research/smoking-what-we-know.html

Health Canada. (2025, March 3). Alcohol and Drug Use among Students in Canada, 2023–24 [Surveys]. https://www.canada.ca/en/health-canada/services/canadian-student-tobacco-alcohol-drugs-survey/2023-2024-key-findings.html

King, J. L., Merten, J. W., Wong, T.-J., & Pomeranz, J. L. (2018). Applying a Social–Ecological Framework to Factors Related to Nicotine Replacement Therapy for Adolescent Smoking Cessation. American Journal of Health Promotion, 32(5), 1291–1303. https://doi.org/10.1177/0890117117718422

McLeroy, K. R., Bibeau, D., Steckler, A., & Glanz, K. (1988). An Ecological Perspective on Health Promotion Programs. Health Education Quarterly, 15(4), 351–377. https://doi.org/10.1177/109019818801500401

Obieche, O., Lee, M., & Salehi, N. (2021). Exploring attitudes towards smoking behaviour and cessation among hospitalised smokers via a socio-ecological framework: A scoping review. Addictive Behaviors, 122, 107040. https://doi.org/10.1016/j.addbeh.2021.107040

Tramonti, F., Giorgi, F., & Fanali, A. (2021). Systems thinking and the biopsychosocial approach: A multilevel framework for patient‐centred care. Systems Research & Behavioral Science, 38(2), 215–230. https://doi.org/10.1002/sres.2725Zhou, S., Levinson, A. H., Zhang, X., Portz, J. D., Moore, S. L., Gore, M. O., Ford, K. L., Li, Q., & Bull, S. (2021). A Pilot Study and Ecological Model of Smoking Cues to Inform Mobile Health Strategies for Quitting Among Low-Income Smokers. Health Promotion Practice, 22(6), 850–862. https://doi.org/10.1177/1524839920942214