Breaking the habit: Mohamad Haniki Nik Mohamed on smoking cessation
In almost two decades of work in helping smokers kick the nicotine habit, Associate Professor Dr. Mohamad Haniki Nik Mohamed has worn many hats, ranging from service provider to trainer to policy advisor. In conjunction with World No Tobacco Day (WNTD) on the 31st of May, MIMS Pharmacist speaks to Dr. Haniki about his reasons for entering the field, as well as his work in expanding the MOH’s integrated quit-smoking service, mQuit.
How did you get started in the field of smoking cessation?
When I was doing my post-doctorate fellowship in the United States, I recruited asthmatic patients, some of whom were smokers. I told them “you know, if you’re asthmatic, you should not be smoking; it will worsen your asthma.” They asked me if there were any medications they could take to quit smoking; I said I didn’t know, because I hadn’t learned much about smoking cessation at the time.
That was towards the end of my fellowship. Upon coming back to Malaysia in 1997 I started to look up this issue and realized there were many smokers in Malaysia at the time. As a pharmacist, I wanted to help them quit smoking effectively. So I got myself trained through a range of sources—including from the Ministry of Health (MOH), local and international workshops, etc. I then put up a proposal to establish the first dedicated multidisciplinary smoking cessation clinic in Universiti Sains Malaysia (USM) in 2001.
Through this clinic, we provided the service to USM staff, students and their relatives; we also became a smoking cessation training centre at the state and national level for other HCPs. It had a good quit rate; 36% success rate after 1 to 2 years’ establishment. We were indeed thankful and proud that we clinched the best quit smoking clinic award in conjunction with the 2003 WNTD celebration for Penang.
Do you still head the clinic in USM?
No, my contract with USM ended in 2005 and I joined the International Islamic University of Malaysia (IIUM). I again spearheaded the establishment of a smoking cessation clinic to provide services to IIUM staff and students. I also participated at the quit smoking clinic (QSC) at the Hospital Tengku Ampuan Afzan (HTAA) Kuantan, particularly as part of teaching and learning.
Since there was an urgent need for equipping future and practising healthcare professionals (HCPs) with the knowledge and skills regarding smoking cessation, I collaborated with the MOH and other stakeholders, including the Malaysian Academy of Pharmacy (MAP) and Malaysian Pharmaceutical Society (MPS) to create a training program for Malaysian HCPs, particularly pharmacists, under the Certified Smoking Cessation Service Provider (CSCSP) programme. While preparing the training module, I realised that at the time there was yet a Malaysian clinical practice guidelines (CPG) on the management of tobacco use. Hence, I was appointed by the MOH to be a core team member on developing the first CPG, which we published in 2003.
The CSCSP workshops were conducted all over Malaysia; people obtained knowledge and some practical skills, particularly in behaviour and pharmacological intervention. This was followed by a one-day attachment at any of the quit smoking clinics run by the MOH. Having completed those two parts, they were certified as smoking cessation service providers.
In between this, I’m also the chairman responsible for updating the CPG for tobacco control. Remember that the first CPG came out in 2003; after that, the MOH appointed me to the chairman for the CPG on tobacco use disorders, which we published in 2016. Then the MOH also appointed me as the technical expert on e-cigarettes, smoking cessation as well as the deputy chairman for the working committee on Translating Evidence into Policy; Tobacco Control in Malaysia which we published end of last year.
That’s a lot of work!
It seems like a lot of work (laughs) but it’s not really work because it’s something which I’m passionate about, so it’s more like things done out of love.
But the CSCSP course is now available online?
Yes, as I’m getting older I don’t want to travel as much and my time is also rather restricted (laughs). We wanted to have wider coverage, so we produced the online module; all six chapters have to be passed before they can self-print the Level 1 certificate. They still have to go to a clinic for attachment in order to get Level 2 certification. When we launched the online CSCSP via the website of the Malaysian Academy of Pharmacy around 2006, we already had a pool of earlier certified providers, so new pharmacists going through the programme can opt to be attached either with a government smoking cessation clinic or with one of the existing certified providers.
We also received feedback from our HCPs who asked about the possibility of a practical exam to replace the attachment; so we came up with scenarios and assessed them using the Objective Structured Clinical Examination (OSCE) approach. This was timely as it accommodated the request from the MOH when the mQuit service was launched in 2015.
So the CSCSP’s OSCE also became part of mQuit?
Yes. The CSCSP has two levels; knowledge and practical skills. The latter can be done through attachment; a checklist of activities to complete, and the facilitator at the attachment site observing you perform counselling under supervision. There’s also the assessment via OSCE, where we give them real life scenarios to perform, and we hold it about one hour with five to six stations; it’s pretty intensive. Once they completed both levels, they are level 2 certified, meaning they can provide the service at their facility.
However, under the mQuit program, there’s another criterion to fulfil; the site or facility of their service provision must also be audited by the MOH, usually from the state health department. Once audited under mQuit, it actually allows those pharmacists to be included in the Quitline registry. The Quitline can also provide additional assistance for enrolled patients, by calling and sending reminders to them as part of monitoring and follow-up.
Being mQuit-registered also means that other stakeholders and partners can find smokers at various workplaces and refer them to you based on suitability. For example: I’m in Kuantan, I’m a mQuit service provider. A company in Kuantan has a smoke-free workplace initiative, so the company wants to send their workers to a proper smoking cessation program. So to save time and money they can refer those employees to the nearest community pharmacy instead of a government QSC.
What training challenges have you run into along the way?
The issue of renumeration. Many pharmacists providing the services—especially in the community pharmacies—they’re providing free counselling, and it’s quite laborious and intensive; each session can run up to 20 to 30 minutes. And then there’s the fact that some of the smokers may end up not buying any medication. Because the bottom line isn’t good, smoking cessation becomes a reactive service rather than a proactive one.
Previously it was thought that we couldn’t charge patients [for counselling] because of provisions under the Fees Act 1951. But when we clarified this with the MOH, they said the Fees Act isn’t imposed on pharmacists; it’s on physicians. We asked if it could be possible for mQuit-registered pharmacists to charge patients professional fees, and [the MOH] think there’s no issue. So we came up with this package; pharmacists can now charge RM100 per session if they are fully seeing the patient by themselves, and they can have at least six sessions, so they can charge RM600 for professional fees alone. On top of that, they can make a little profit from the medication.
So we hope to see more pharmacists taking up this professional service, because I believe it is the first of this kind in Malaysia; hopefully it will have a trickle effect to other pharmacist-provided services such as diabetic adherence, medication management, or other certifiable services. The Malaysian Academy of Pharmacy is looking towards such a higher level of practice for pharmacists.
How do you personally feel about the current state of mQuit?
I think it’s progressing. With the National Strategic Plan under the MOH Tobacco Control Unit, so we have a clear endgame; by 2045, we want to reduce smoking prevalence to less than 5%, and by 2025, under 15%.. But we still have a lot of work to do. Under the WHO’s Framework Convention on Tobacco Control (FCTC), there’s the 6 MPOWER strategies— i.e., Monitoring, Protecting, Offering, Warning, Enforcing and Raising taxes—and for each there’s still a lot to be done. The mQuit program is under “O”: “offering help to smokers”. It’s definitely a more systematic, integrated way to help smokers quit because people from various sectors, private and public, can now work together to facilitate a similar service whether via government clinic or community pharmacy.
Having said that, tobacco control as a whole must be also strengthened, particularly the key strategies with evidence to back them up, such as expansion of smoke-free areas and raising prices of cigarettes through tax measures. The main factor behind this epidemic is the tobacco industry. They are constantly coming up with new products to circumvent regulations; we have to be cognizant of the potential health risks these new products have. We know that all tobacco products are harmful; and we need to address all of them effectively using evidence-based approach.