Journal Information
Vol. 13. Issue 6.
Pages 801-826 (November - December 2007)
Share
Share
Download PDF
More article options
Vol. 13. Issue 6.
Pages 801-826 (November - December 2007)
Full text access
Fumador internado? – A intervenção apropriada
In-patient smoker? – Providing appropriate intervention
Visits
988
Paula Pamplona1,
, Jaime Pina2
1 Assistente hospitalar graduada de Pneumologia
2 Departamento de Pneumologia do Hospital de Pulido Valente, EPE
This item has received
Article information
Abstract
Bibliography
Download PDF
Statistics
Resumo

O tabagismo é a causa de morte evitável mais frequente. Para além de provocar múltiplas doenças causadoras de internamentos, o tabagismo é também uma doença a tratar durante o internamento, não só para controlar a síndroma de abstinência do doente, sujeito a interrupção abrupta, mas também para cumprir a legislação que proíbe o uso de tabaco nos serviços de saúde, única forma eficaz de prevenir a exposição dos não fumadores ao fumo do tabaco presente no ambiente (FTA).

Tratar o fumador internado de forma apropriada é também aproveitar a janela de oportunidade para promover a cessação tabágica e não apenas a abstinência temporária.

Palavras-chave:
Cessação tabágica
internamento
serviço de saúde sem tabaco
Abstract

Tobacco use is the most avoidable cause of death. Other than provoking multiple diseases requiring hospitalisation, Tobacco Use is also a disease requiring management in the hospital setting, not only in terms of controlling the withdrawal symptoms of the patient, who has been abruptly prohibited from smoking, but also for fulfilling legislation which prohibits tobacco use in the health services, the only efficient way of preventing exposure of non-smokers to environmental tobacco smoke.

Treating the in-patient smoker in an appropriate way also provides a window of opportunity for promoting not just a temporary but a complete smoking cessation.

Key-words:
Smoking cessation
in-patient
smoke-free hospital
Full text is only aviable in PDF
Bibliografia
[1.]
An international treaty for tobacco control.[edição online] 2003. Disponível na Wide World Web: www.who.int/features/2003/08/en/
[2.]
World Bank.
Curbing the Epidemic. Governments and the economics of Tobacco Control.
World Bank, (1999),
[3.]
The World Health Organization.
The ICD-10 Classification of Mental Behavioural Disorders.
World Health Organization, (1992),
[4.]
International Classification of Diseases-9 – Clinical Modification. 2006. 9th revision.
[5.]
R. West, A. McNeill, M. Raw.
Smoking cessation guidelines for health professionals: an update.
Thorax, 55 (2000), pp. 987-999
[6.]
M. Fiore, W. Bailey, S. Cohen.
A Clinical Practice Guideline for Treating Tobacco Use and Dependence. A US Public Health Service Report.
Jama, 283 (2000), pp. 3244-3254
[7.]
European Partnership to reduce Tobacco Dependence. WHO Evidence Based Recommendations on the Treatment of Tobacco Dependence. June 2001.
[8.]
Instituto da Qualidade em Saúde. Norma de Orientação Clínica. Tratamento do uso e dependência do tabaco 2002.
[9.]
National Institute for Clinical Excellence. Guidance on the use of nicotine replacement therapy (NRT) and bupropion for smoking cessation. Technology Appraisal Guidance No. 39, Issue Date March 2002, Review Date March 2005, www.nice.org.uk.
[10.]
P. Pamplona.
Intervenção na prática clínica.
Tabagismo – do diagnóstico ao tratamento, pp. 101-136
[11.]
M.L. Borges.
Intervenção Psicológica na Dependência Tabágica.
Tabagismo – do diagnóstico ao tratamento, pp. 167-194
[12.]
B. Mendes.
Tratamento farmacológico do tabagismo.
Tabagismo – do diagnóstico ao tratamento, pp. 137-166
[13.]
C. Jiménez-Ruiz, J. Granda Orive, R. Solano, C. Valero, R. Palácios, B. Ferrero.
Recommendations on the Treatment of Tobacco Dependence.
Arch Bronconeumol, 39 (2003), pp. 514-523
[14.]
N. Rigotti, M. Munafo, M. Murphy, L. Stead.
Intervention for smoking cessation in hospitalised patients (review). Cochrane Database of Systematic Reviews.
Published by John Wiley & Sons, Ltd, (2007),
[15.]
J. Prochaska, C. DiClemente.
Stages and processes of self-change of smoking: Toward na integrative model of change.
Journal of Consulting and Clinical Psychology, 51 (1983), pp. 390-395
[16.]
J. Littell, H. Girvin.
Stages of change. A critique.
Behav Modif., 26 (2002), pp. 223-273
[17.]
Decreto lei n.° 226/83 de 27 de Maio.
[18.]
Direcção-Geral de Saúde – Circular normativa n.° 9/DES – Consumo de tabaco nas instalações dos estabelecimentos de saúde. 28 Maio 2004.
[19.]
Comissão das Comunidades Europeias. Livro verde. Por uma Europa sem fumo: opções estratégicas a nível comunitário, Janeiro 2007, pp. 1-34.
[20.]
M. Santis, C. Lucas, L. Jesus, S. Godinho, F. Domingues, A. Marques, F. Costa, A. Figueiredo.
Smoking cessation in hospital inpatients: 10 months experience.
Rev Port Pneumol, 12 (2006), pp. 50-51
[21.]
A. Cornette, I. Petitdemange, S. Briancon, C. Burlet, J.M. Polu.
Evaluation of smoking in chronic severe respiratory insufficiency patients treated with long-term oxygen at home.
Rev Mal Respir, 13 (1996), pp. 405-411
[22.]
P. Ferreira, L. Carvalho, F. Caetano, W. Videira, L. Mota, F. Oliveira.
Internamento por exacerbação da Doença Pulmonar Obstrutiva Crónica – Análise da gravidade dos doentes das exacerbações e dos critérios de internamento de acordo com o Projecto GOLD.
Boletim do HPV, XVI (2003), pp. 105-110
[23.]
D. Schuermans, F. Snoussi, E. Deschepper, M. Peys, A. Schoonis.
Counselling for smoking cessation needed in one third of hospitalised respiratory patients.
Eur Respir J, 28 (2006), pp. 838s
[24.]
M. Barrueco, C. Jiménez Ruiz, L. Palomo, M. Torrecilla, P. Romero, J. Riesco.
Veracity of smokers’ reports of abstinence at smoking cessation clinics.
Arch Bronconeumol, 41 (2005), pp. 135-140
[25.]
Martinet Y. Bohadana A, Quantificação e marcadores do tabagismo. In O Tabagismo – da prevenção à abstinência Climepsi Editores 2003:87-90
[26.]
S. Sato, K. Nishimura, H. Koyama, M. Tsukino, T. Olga, T. Hajiro, M. Mishima.
Optimal cutoff of breath carbon monoxide for assessing smoking status in patients with asthma and COPD.
Chest, 124 (2003), pp. 1749-1754
[27.]
J. Chatkin, L. Fritscher, C. de Abreu, D. Cavalet-Blanco, G. Chatkin, M. Wagner, C. Fritscher.
Exhaled carbon monoxide as a marker for evaluating smoking abstinence in a Brazilian population sample.
Prim Care Respir J, 16 (2007), pp. 36-40
[28.]
Fagerström K, Rennard S. Treatment of tobacco dependence. In Pulmonary Rehabilitaion edited by Donner C, Ambrosino N, Goldstein R. 2005: 219-28.
[29.]
T. Heatherton, L. Kozlowski, R. Frecker, K. Fagerström.
The Fagerström Test for Nicotine Dependence: a revision of the Fagerström Tolerence Questionnaire.
Br J Adicct, 86 (1991), pp. 1119-1127
[30.]
A.B.C. Robert West.
of smoking cessation – Assessment of dependence and motivation to stop smoking.
[31.]
R. Richmond, L. Kehoe, I. Webster.
Multivariate models for predicting abstention following intervention to stop smoking by general practioners.
Addiction, 88 (1993), pp. 1127-1135
[32.]
C. Jiménez-Ruiz, F. Masa, M. Miravitlles, R. Gabriel, J. Viejo, C. Villasante, V. Sobradillo.
Smoking Characteristics. Differences in attitudes and dependence between healthy smokers and smokers with COPD.
Chest, 119 (2001), pp. 1365-1370
[33.]
N. Walters, T. Coleman.
Comparasion of the smoking behaviour and attitudes of smokers who attribute respiratory symptoms to smoking with those who not.
British Journal of General Practice, 52 (2002), pp. 132-134
[34.]
M.J. Jarvis, J. Wardle, J. Waller, L. Owen.
Prevalence of hardcore smoking in England, and associated attitudes and beliefs: cross sectional study.
BMJ, 326 (2003), pp. 1061-1063
[35.]
S. Emery, E. Gilpin, C. Ake, A. Farkas, J. Pierce.
Characterizing and identifying “hard-core” smokers: implications for further reducing smoking prevalence.
Am J Public Health, 90 (2000), pp. 387-394
[36.]
American College of Chest Physicians, American Thoracic Society, Asia Pacific Society of Respirology, Canadian Thoracic Society European Respiratory Society.
Smoking and health: a physician¿s responsibility.
A statement of the joint committee on smoking and health Eur Respir J, 8 (1995), pp. 1808-1811
[37.]
M. Ward, A. Molyneux.
Smoke-free Hospitals – A practical guide from British Thoracic Society, (2005), pp. 1-21
[38.]
S. Nardini, R. Bertoletti, V. Rastelli, C. Donner.
The influence of personal tobacco smoking on the clinical practice os Italian chest physicians.
Eur Respir J, 12 (1998), pp. 1450-1453
[39.]
R. Henry, K. Ogle, L. Snellman.
Preventive Medicine: physician practices, beliefs, and perceived barriers for implementation.
Fam Med, 19 (1987), pp. 110-113
[40.]
S. Nardini.
Education and smoking cessation In: Pulmonary Rehabilitation. Edited Donner and Decramer.
Eur Respir Mon, 13 (2000), pp. 41-57
[41.]
C. Fichtenberg, S. Glantz.
Effect of smoke free workplaces on smoking behaviour: systematic review.
BMJ, 325 (2002), pp. 1-7
[42.]
P. Aveyard, R. West.
Managing smoking cessation.
[43.]
G. Lillington, L. Colm, D. Sachs.
Smoking cessation – Techniques and benefits.
Clinics in Chest Medicine, 21 (2000), pp. 199-208
[44.]
N. Rigotti.
Treatment of tobacco use and dependence.
N Engl J Med, 346 (2002), pp. 506-512
[45.]
J. Hughes, D. Hatsukami.
Signs and symptoms of tobacco withdrawal.
Arch Gen Psych, 43 (1986), pp. 289-294
[46.]
J. Hughes, Hatsukami.
Effect of nicotine on the tobacco withdrawal syndrome.
Psychopharmacology, 83 (1984), pp. 82-87
[47.]
T. Piasecki, M. Fiore, D. McCarthy, T. Baker.
Have we lost our way? The need for dynamic formulations of smoking relapse proneness.
Addiction, 97 (2002), pp. 1093-1108
[48.]
M. McBride, M. Emmons, M. Lipkus.
Understanding the potential of teachable moments: the case of smoking cessation.
Health Educ Res, 18 (2003), pp. 156-170
[49.]
M. Moller, N. Villebro, T. Pederson, H. Tonnesen.
Effect of preoperative smoking intervention on postoperative complications:a randomised clinical trial.
[50.]
Y. Lacasse, F. Maltais, R. Goldstein.
Smoking cessation in Pulmonary Rehabilitation: goal or prerequisite?.
J Cardiopulm Rehabil, 22 (2002), pp. 148-153
[51.]
K. Slama, C. Chiang, D. Enarson.
Tobacco cessation brief advice.
Int J Tuberc Lung Dis, 11 (2007), pp. 612-616
[52.]
C. Chiang, K. Slama, D. Enarson.
Associations between tobacco and tuberculosis.
Int J Tuberc Lung Dis, 11 (2007), pp. 258-262
[53.]
M. Bates, A. Khalakdina, M. Pai, L. Chang, F. Lessa, K. Smith.
Risk of tuberculosis from exposure to tobacco smoke: a systematic review and meta-analysis.
Arch Intern Med, 167 (2007), pp. 335-342
[54.]
K. Freund, R. D’Agostino, A. Belanger, W. Kannel, J. Stokes.
Predictors of smoking cessation: the Framingham Study.
American Journal of Epidemiology, 135 (1992), pp. 957-964
[55.]
N. Canga, J. De Irala, E. Vara, M. Duaso, A. Ferrer, M. Martinez-Gonzalez.
Intervention study for smoking cessation in diabetic patients: a randomized controlled trial in both clinical and primary care settings.
Diabetes Care, 23 (2000), pp. 1455-1460
[56.]
E. Gritz.
Smoking and smoking cessation in cancer patients.
British Journal of Addiction, 86 (1991), pp. 549-554
[57.]
E. Gritz, C. Carr, D. Rapkin, C. Chang, J. Beumer, P. Ward.
A smoking cessation intervention for head and neck cancer pa- tients: trial design, patient accrual, and characteristics.
Cancer Epidemiology, Biomarkers and Prevention, 1 (1991), pp. 67-73
[58.]
M. Walker, D. Vidrine, E. Gritz, R. Larsen, Y. Yan, R. Govindan, E. Fisher.
Smoking relapse during the first year after treatment for early-stage non-small-cell lung cancer.
Cancer Epidemiol Biomarkers Prev, 15 (2006), pp. 2370-2377
[59.]
Department of Health and Human Services. Health benefits of smoking cessation.
A report of the Surgeon General.
DHHS Publication No. (CDC) 90-8416, (1990),
[60.]
R. Doll, R. Peto, J. Boreham, I. Sutherland.
Mortality in relation to smoking: 50 years‘observations on male British doctors.
[61.]
N. Anthonisen, M. Skeans, R. Wise, J. Manfreda, et al.
The effects of a smoking cessation intervention on 14,5 year mortality.
Annals of Intern Med, 142 (2005), pp. 233
[62.]
US Department of Health and Human Services.
Office of the Surgeon General. The Health Consequences of smoking: A report of Surgeon General.
Rockville, MD, (2004),
[63.]
E. Gritz, D. Vidrine, A. Lazev.
Smoking cessation in cancer patients: Never too late to quit.
Evidence-based cancer care and prevention., pp. 103-140
[64.]
R. Murray, N. Anthonisen, J. Connett, R. Wise, P. Lindgren, P. Greene, M. Nides, Lung Health Study Research Group.
Effects of multiple attempts to quit smoking and relapses to smoking on pulmonary function.
J Clin Epidemiol, 51 (1998), pp. 1317-1326
[65.]
T. Eagan, A. Gulsvik, G. Eide, P. Bakke.
Remission of respiratory symptoms by smoking and occupational exposure in a cohort study.
Eur Respir J, 23 (2004), pp. 589-594
[66.]
B. Willemse, D. Postma, W. Timens, N. ten hacken.
The impact of smoking cessation on respiratory symptoms, lung function, airway hiperresponsiveness and inflammation.
Eur Respir J, 23 (2004), pp. 464-476
[67.]
T. Troosters, R. Gosselink, D. Scholier, A. Spruit, F. Pitta, M. Probst, M. Decramer.
Pulmonary Rehabilitation in smokers with COPD.- ERS.
Glasgow. ERJ, 24 (2004), pp. 667
[68.]
K. Wilson, N. Gibson, A. Willan, D. Cook.
Effect of smoking cessation on mortality after myocardial infarction; meta-analysis of cohort studies.
Arch Intern Med, 160 (2000), pp. 939-944
[69.]
J. Lightwood, S. Glantz.
Short-term economic and health benefits of smoking cessation: myocardial infarctation and stroke.
Circulation, 96 (1997), pp. 1089-1096
[70.]
R. Sargent, R. Shepard, S. Glantz.
Reduced incidence of admissions for myocardial infarction associated with public smoking ban: before and after study.
[71.]
World Health Organization Regional Office for Europe Copenhagen. European Strategy for Tobacco Control. 2002. www.euro.who.int/document/e77976.pdf. Sargent R, Shepard R, Glantz S. Reduced incidence of admissions for myocardial infarction associated with public smoking ban: before and after study. BMJ 2004; 328(7446):977-80.
[72.]
World Health Organization. The right to healthy indoor air. Report of a WHO meeting, Copenhagen, Denmark; 2000. URL http://wwweuro.who.int/air/activities/20030528_9
[73.]
J. Ockene, J. Kristeller, R. Goldberg, I. Ockene, P. Merriam, S. Barrett, P. Pekow, D. Hosmer, R. Gianelly.
Smoking cessation and severity of disease: The coronary artery smoking intervention study.
Health Psychology, 11 (1992), pp. 119-126
[74.]
R. DeBusk, N. Houston-Miller, H. Superko, C. Dennis, R. Thomas, H. Lew, W. Berger, R. Heller, J. Rompf, D. Gee, H. Kraemer, A. Bandura, G. Ghandour, M. Clark, R. Shah, L. Fisher, C. Taylor.
A case-management system for coronary risk factor modification after acute myocardial infarction.
Annals of Internal Medicine, 120 (1994), pp. 721-729
[75.]
E. Dornelas, R. Sampson, J. Gray, D. Waters, P. Thompson.
A randomized controlled trial of smoking cessation counseling after myocardial infarction.
Preventive Medicine, 30 (2000), pp. 261-268
[76.]
S. Lewis, T. Piasecki, M. Fiore, J. Anderson, T. Baker.
Transdermal nicotine replacement for hospitalized patients: A randomized clinical trial.
Preventive Medicine, 27 (1998), pp. 296-303
[77.]
N. Miller, P. Smith, R. DeBusk, D. Sobel, C. Taylor.
Smoking cessation in hospitalized patients – Results of a randomized trial.
Archives of Internal Medicine, 157 (1997), pp. 409-415
[78.]
J. Simon, S. Solkowitz, T. Carmody, W. Browner.
Smoking cessation after surgery – A randomized trial.
Archives of Internal Medicine, 157 (1997), pp. 1371-1376
[79.]
C. Taylor, N. Houston-Miller, J. Killen, R. DeBusk.
Smoking cessation after acute myocardial infarction: Effects of a nurse-managed intervention.
Annals of Internal Medicine, 113 (1990), pp. 118-123
[80.]
E. Nezami, S. Sussman, M. Pentz.
Motivation in Tobacco Use Cessation Research.
Substance Use and Misuse, 38 (2003), pp. 25-50
[81.]
T. Lancaster, L. Stead.
Self-help interventions for smoking cessation.
Cochrane Database Syst Rev, 20 (2005),
[82.]
J. Cunningham, R. Ferrence, J. Cohen, E. Adlaf.
Interest in self-help materials among a general population sample of smokers.
Addict Behav, 28 (2003), pp. 811-816
[83.]
A. Sood, J. Ebbert, R. Sood, S.R. Stevens.
Complementary treatments for tobacco cessation: a survey.
Nicotine Tob Res, 8 (2006), pp. 767-771
[84.]
S. Zhu, M. Christopher, B. Anderson, G. Tedeschi, B. Rosbrook, B. Johnson, M. Byrd, E. Gutiérrez-Terrell.
Evidence of real-world effectiveness of a telephone quitline for smokers.
N Engl J Med, 347 (2002), pp. 1087-1093
[85.]
L. Stead, R. Perera, T. Lancaster.
Telephone counselling for smoking cessation.
Cochrane Database Syst Rev, 3 (2006),
[86.]
R. Mermelstein, D. Hedeker, S. Chi Wong.
Extended Telephone Counseling for Smoking Cessation: Does content matter?.
Journal of Counsultg and Clinical Psychology, 71 (2003), pp. 565-574
[87.]
Cochrane Tobacco Addiction Group. Online www.dphpc.ox.ac.uk/cochrane_tobacco/index.html.Oxford: Department of Primary Health Care, University of Oxford.
[88.]
Andrew Molyneux.
ABC of smoking cessation – Nicotine replacement therapy BMJ, 328 (2004), pp. 454-456
[89.]
C. Sweeney, R. Fant, K. Fagerstrom, J. McGovern, J. Henningfield.
Combination nicotine replacement therapy for smoking cessation: rationale, efficacy and tolerability.
CNS Drugs, 15 (2001), pp. 453-467
[90.]
N. Schneider, M. Koury, C. Cortner, R. Olmstead, N. Hartman, L. Kleinman, A. Kim, C. Chaya, D. Leaf.
Preferences among four combination nicotine treatments Psychopharmacology, 187 (2006), pp. 476-485
[91.]
R. Murray, W. Bailey, K. Daniels, W. Bjornson, K. Kurnov, J. Connet, M. Nides, J. Kiley.
Safety of Nicotine Polacrilex Gum used by 3 094 participants in the Lung Health Study.
Chest, 109 (1996), pp. 438-445
[92.]
J. Henningfield, R. Fant, A. Buchhalter, M. Stitzer.
Pharmacotherapy for nicotine dependence.
CA Cancer J Clin, 55 (2005), pp. 281-299
[93.]
R. Fant, J. Henningfield, S. Shiffman, K. Strahs, D. Reitberg.
A pharmacokinetic crossover study to compare absorption characteristics of three transdermal nicotine patches.
Pharmacol Biochem Behav, 27 (2000), pp. 479-482
[94.]
K. Fagerström, D. Sachs.
Medical management of tobacco dependence: a critical review of nicotine skin patches.
Current Pulmonol, 16 (1995), pp. 223-238
[95.]
G. Prosise, M. Bonnet, R. Berry, M. Dickel.
Effects of abstinence from smoking on sleep and daytime sleepiness.
Chest, 105 (1994), pp. 1136-1141
[96.]
D. Wetter, M. Fiore, T. Baker, T. Young.
Tobacco withdrawal and nicotine replacement influence objective measures of sleep.
J Consult Clin Psychol, 63 (1995), pp. 658-667
[97.]
L. Staner, R. Luthringer, C. Dupont, H. Aubin.
Lagrue Sleep effects of a 24-h versus 16-h nicotine patch: A polysomnographic study during smoking cessation.
Sleep Med, 7 (2006), pp. 147-154
[98.]
N. Benowitz, S. Gourlay.
Cardiovascular Toxicity of nicotine: Implications for nicotine replacement J Am Coll Cardiol, 29 (1997), pp. 1422-1431
[99.]
R. Hubbard, S. Lewis, C. Smith, C. Godfrey, L. Smeeth, P. Farrington, J. Britton.
Use of nicotine replacement therapy and the risk of acute myocardial infarction, stroke, and death.
Tob Control, 14 (2005), pp. 416-421
[100.]
Joseph A, Norman S, Prochazcha A, Westman E, Steele B, Sherman S, Cleveland M, Antonnucio D, Hartman N, McGovern P. The Safety of Transdermal Nicotine as an Aid to Smoking Cessation in Patients with Cardiac Disease. N Engl J Med 335:1792.
[101.]
T. Meine, M. Patel, J. Washam, P. Pappas, J. Jollis.
Safety and effectiveness of transdermal nicotine patch in smokers admitted with acute coronary syndromes.
Am J Cardiol 15, 95 (2005), pp. 976-978
[102.]
D. Tashkin, R. Kanner, W. Bailey.
Smoking cessation in patients with chronic obstructive pulmonary disease.
Lancet, 357 (2001), pp. 1571-1575
[103.]
N. Rigotti, A. Thorndike, S. Regan, K. McKool, R. Pasternak, Y. Chang, S. Swartz, N. Torres-Finnerty, K. Emmons, D. Singer.
Bupropion for smokers hospitalized with acute cardiovascular disease.
Am J Med, 119 (2006), pp. 1080-1087
[104.]
J. Hughes, L. Stead, T. Lancaster.
Antidepressants for smoking cessation.
Cochrane Database Syst Rev, (2007),
[105.]
K. Cahill, L. Stead, T. Lancaster.
Nicotine receptor partial agonists for smoking cessation.
Cochran Cochrane Database Syst Rev, (2007),
[106.]
P. TØnnesen, L. Carrozzi, K. Fagerstrom, C. Gratziou, C. Jimenez-Ruiz, S. Nardini, G. Viegi, C. Lazzaro, I. Campell, E. Dagli, R. West, ERS Task Force.
Smoking cessation in patients with respiratory diseases. A high priority, integral component of therapy.
Eur Respir J, 29 (2007), pp. 390-417
[107.]
G. Keating, A. Siddiqui.
Varenicline – A review of its use as an aid to smoking cessation therapy.
CNS Drugs, 20 (2006), pp. 945-960
[108.]
L. Ranney, C. Melvin, L. Lux, E. McClain, K. Lohr.
Systematic review: smoking cessation intervention strategies for adults and adults in special populations.
Ann Intern Med, 145 (2006), pp. 845-856
Copyright © 2007. Sociedade Portuguesa de Pneumologia
Download PDF
Pulmonology
Article options
Tools

Are you a health professional able to prescribe or dispense drugs?