PHARMACISTS AGAINST SMOKING Final report 15/09/00 –...

S12.316638 (2001CVG2-001) Pharmacists against smoking

The European Commission has financially supported this project being a part of the ENSP Framework Project 2000.

PHARMACISTS AGAINST SMOKING Final report 15/09/00 – 15/09/01


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Project entitled: Operation of a European Tobacco Control Network 2000 Coordinated by the European Network for Smoking Prevention (ENSP) Contract S12.316638 (2001CVG2-001) Project partner: Denmark, EuroPharm Forum Smoking cessation task force Represented by Mrs Eeva Teräsalmi Project: Pharmacists against smoking Final report 15/09/00 – 15/09/01 Partners: Oesterreichische Apothekerkammer Association Pharmaceutique Belge Danish Pharmaceutical Association Association of Danish Pharmacists The Association of Finnish Pharmacies Finnish Pharmacists’ Association Conseil national de l’Ordre des Pharmaciens, France Federation des syndicats pharmaceutiques de France Federal Union of German Associations of Pharmacists (ABDA) Irish Pharmaceutical Union Federazione Ordini Farmacisti Italiani (FOFI) Federfarma, Italy Union Nationale des Pharma-ciens Luxembourgeois asbl Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie (KNMP) Associaçao Nacional das Farmacias, Portugal Ordem dos Farmaceuticos, Portugal Consejo de Farmaceuticos, Spain Swedish Pharmaceutical Society Swedish Pharmaceutical Association The National Pharmaceutical Association, United Kingdom Royal Pharmaceutical Society of Great Britain The European Commission has financially supported this project being a part of the ENSP Framework Project 2000. The Association of Finnish Pharmacies has also financially supported the project. Neither the European Commission nor any other person acting on its behalf is liable for any use made of the information contained in this report


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Table of contents Part 1 Scientific report Executive Summary 1. Introduction 2. Project description and activities

2.1 Project description 2.2. Overview of activities

3. Results 3.1 Tables of results 3.2 Response rates 3.3 Age distribution 3.4 Distribution by sex 3.5 Smoking status of pharmacists 3.6 Tobacco users 3.7 Reasons not to smoke 3.8 Non-smoking activities of pharmacists 3.9 Attitudes of pharmacists

4. Conclusion 5. Annexes

5.1 Tables of results 5.2 Questionnaire 5.3 Standard article for presenting the project in national pharmaceutical journals 5.4 Abstracts of posters 5.5 Minutes of Barcelona meeting 5.6 Programme of Kick-off seminar in Helsinki 5.7 Partner contributions

Part 2 Financial report 1. Spreadsheets 2. List of supporting documents 3. Supporting documents


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Executive Summary During the last ten years, non-smoking activities have become an important part of health promotion in community pharmacies. On top of that the broader use of nicotine replacement therapy (NRT) and the availability of NRT products over the counter has emphasized the pharmacists’ task to give their clients information and guidance concerning NRT and tobacco issues in general. No accurate information was available on how such change in the role has been perceived by the pharmacists. To gain more knowledge, a research project was developed by the EuroPharm Forum Smoking Cessation Task Force and the survey “Pharmacists against smoking” carried out in 12 European countries. The research project is part of a co-operative project between the three fora of health professionals and the Tobacco or Health Programme of WHO Regional Office for Europe aiming at reducing the prevalence of smoking among health service users and health professionals. The overall aim of the research project was to collect information about the community pharmacists’ attitudes towards tobacco dependence and their actual activities in this field. A second aim was to gain information about the pharmacists’ smoking habits to see whether that had an impact on their attitudes and activities. Such knowledge would provide the possibility to find more effective methods to reduce smoking among European people and to further develop the non-smoking activities in community pharmacies. The survey showed that the situation for non-smoking work in European community pharmacies is favourable. Community pharmacists are less frequently smokers than people in respective countries and they know the health risks of tobacco use and are aware of the risks of passive smoking. Pharmacists have a positive attitude towards non-smoking work and their knowledge on tobacco dependence in general enables their activities, although more education is required. The results also showed that pharmacists who smoke are usually not so active in their non-smoking activities and their attitudes are more negative. Nicotine replacement therapy is widely promoted in community pharmacies. As these products are in most cases sold without prescription it is of utmost importance that pharmacists can support clients who want to quit smoking with the help of NRT. The survey showed that the situation seems to be quite good, but more knowledge and written information is needed. The results can be used in national work where national guidelines on smoking cessation are written or legislative actions should be taken. The project team will continue the work on documenting and informing of pharmacists’ activities, as well as providing models for non-smoking work. The national pharmaceutical associations have an important role in ensuring the implementation of the models and encouraging their members to continue doing non-smoking activities.


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1. Introduction During the last ten years, the role of the pharmacists has widened to cover different areas in health promotion and health education. The change from dispensing activities to a more holistic view on patients and their wellbeing has been developed in different countries and in various projects. The new concept has been called clinical pharmacy and is now called pharmaceutical care. Along with the general development, the non-smoking activities have also been started in pharmacies. This has happened both in North America and in Europe. Results of different projects have been published during the 1990s, showing that activities of pharmacists are both effective and cost-effective. The change in the role of the community pharmacist in the field of health education and promotion has been very rapid. Thus it has become very important to know whether this new role has been accepted and implemented in everyday practice in pharmacies or whether we are still in an initiating phase of the changing process. We do not know how the practice has changed and what kind of service pharmacies are really giving, e.g. concerning non-smoking and smoking cessation. Are non-smoking activities in community pharmacies part of normal customer service or is it still project work, only when needed and asked for by the national organizations? The first aim of this project was to gain information about community pharmacists’ attitudes towards non-smoking activities in pharmacies and thus give answers to questions raised in the previous chapter. The second aim was to collect information about community pharmacists’ smoking habits and find out, if this had any impact on pharmacists’ attitudes. It is known from the works done by Sir Richard Doll in the 1950’s and similar research results among medical doctors by the Tobacco Control Research Centre, that health care providers, who do not smoke make better advocates for non-smoking. To get a broad view on the subject, it was decided that a European survey would by carried out so that we can make comparisons between countries as well as between those results published by different health-care professions in EU-countries. This kind of study will be carried out among medical doctors, and nurses and midwifes as well. To reach this goal, it was decided that a project ”pharmacists against smoking” would take responsibility for organizing a survey about European pharmacists’ smoking habits and their attitudes towards non-smoking work, and that the results of this study will be used to further develop the non-smoking activities in community pharmacies. It was also decided that the survey would be based on the models developed by the World Health Organization (WHO) and as described in the publication ”Smoke free Europe 3, Evaluation and Monitoring Public Health on Tobacco, September 1987. This model questionnaire developed by WHO has been used in several works done among health care professionals. It has been validated and proven to be reliable. For our purposes the model questionnaire was slightly modified to include the questions concerning the attitudes of the pharmacists. The preliminary work done between the participating pharmaceutical associations and the working group was carried out between 15.9.2000 and 30.3.2001. The dissemination of the


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questionnaires began in April 2001, with reminders sent out in June. In this report the final results are published both generally and by participating countries. The project group will use the results to further develop the work done in European community pharmacies, and the national partners will use their results for both benchmarking purposes and to develop their programmes into a European direction. National articles will be produced and education on suitable methods to be used in pharmacies will be developed. The project coordination and the leading group would like to thank the European Commission, the European Network for Smoking Prevention, WHO-EuroPharm Forum and the Association of Finnish Pharmacies for their support as well as all the project partners for their work. We have evaluated the project and are of the opinion that the main goals have been achieved, and the results can be used in the planned way. We hope that we in future can continue our co-operation with ENSP and the European Commission.


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2. Project description and activities 2.1 Project description The leading group of the project consisted of: Professional Secretary Ida Gustafsen, project administration Task force manager Eeva Teräsalmi, project coordination M.Sc. Visti Juncher, data processing Lic.Soc.Sc. Kari Djerf, statistical analysis The partners of the project are national pharmaceutical associations in 14 EU-countries: Austria, Belgium, Denmark, Finland, France, Germany, Ireland, Italy, Luxembourg, Netherlands, Portugal, Spain, Sweden and The United Kingdom. Due to legal constraints Spain and Italy could not send the addresses of pharmacists to the survey and were thus excluded from central data processing, but provided with all information. Main economical contributors have been the European Union via the European Network for Smoking Prevention (ENSP) and the Association of Finnish Pharmacies. The planning process for the survey began in 1998 in co-operation with the European Forum of Medical Associations and the European Forum of Nursing and Midwifery Associations. The common goal of these three fora was to reduce the prevalence of smoking among health care professionals and to give more effectiveness to their co-operation in the field of non-smoking activities. The project was promoted to potential partners through direct mailing, articles and congress-posters as of November 1998 and discussed with relevant partners in order to coordinate initiatives during 1999. A first meeting between the project leader and representatives from countries interested in carrying out the survey was held in Barcelona September 1999. The methodology, sampling, data processing and the questionnaire were elaborated in collaboration with the unit of Quality of Care and Technologies (QCT) in WHO, Regional Office for Europe during 1999, and the questionnaire was tested, revised and finalized after that. A kick-off seminar for participating countries was held in Helsinki on 22 September 2000. The seminar was held to ensure that administrative, financial, technical and scientific obligations were understood, and that structures and processes established would ensure the successful meeting of the obligations. In focus was the methodology of the survey, and the country representatives had the possibility to discuss with experts and get personal guidance. The survey was prepared in the participating countries in the period from October 2000 to February 2001 including translation of questionnaire and filling instructions and preparing a random sample of the addresses of community pharmacies. The national associations were provided with statistical guidance to ensure that the sampling was done correctly.


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The lists of addresses were sent to QCT during February 2001. The questionnaires were produced and disseminated in the period April 2-19.2001. In total 13975 letters with 3 questionnaires each were sent out to 12 participating EU-countries. The amount of letters sent and the numbers of community pharmacies and community pharmacists is as follows: Country No of letters No of community

pharmacies No of community pharmacists

Austria 1099 1065 4045 Belgium 1003 ~5200 7250 Denmark 287 287 913 Finland* 544 587 4080 France 1932 22640 26949 Germany 1969 21556 45465 Ireland 1107 1181 1676 Luxembourg 79 79 284 Netherlands 2183 1571 2166 Portugal 1000 2537 3759 Sweden* 772 789 5500 United Kingdom 2000 12046 24166 *Prescriptionists included, bachelor of pharmacy –degree. Source: PGEU Database 1999 The questionnaires filled in were scanned in QCT and their reliability was checked during scanning process. All duplicates were dropped – this was due to fact that in some countries one pharmacist can own more than one pharmacy and thus it is possible to get more than one letter as a pharmacy owner. To non-respondents in the five countries with the lowest response rates, i.e. Germany, Belgium, France, United Kingdom and Portugal were sent reminders as follows: Belgium 771 reminders sent on 14 June 2001 Germany 1591 reminders sent on 12-14 June 2001 France 1473 reminders sent on 14,15 and 18 June 2001 Portugal 720 reminders sent on 18-19 June 2001 United Kingdom 1461 reminders sent on 7-8 June 2001 Furthermore all national partners were encouraged to publish a general reminder in their journals or, if possible, in regular, direct mailings to all members. Partners were provided with a text for this purpose. The current situation with regard to replies was sent regularly to partners to encourage them to activate their members to send back the questionnaires. After the deadline of 31 July 2001, all answers were scanned, and the analysing and reporting phase began. This report covers both national and group results with some analysis. The more thorough analysis will continue. All results are owned by the project group under consideration of the national partners, and publishing of these preliminary results without permission is not allowed.


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2.2 Overview of activities • The survey was planned in the co-operative network with the European Forum of Medical

Associations and the European Forum of Nursing and Midwifery Associations in 1998 • The methodology, sampling, data-processing and the questionnaire were elaborated in

collaboration with the Quality of Care and Technologies WHO (QCT) in 1999 • The questionnaire was tested, revised and finalized in 1999-2000. Questionnaire enclosed. • The project was promoted to potential participants through direct mailing, articles and

posters as of November 1998. Article and poster abstract are enclosed. • The project was discussed with relevant partners like the International Pharmaceutical

Federation (representing and serving pharmacy and pharmaceutical sciences world-wide) in order to coordinate initiatives during 1999.

• The first meeting between the project leader and representatives from countries interested

in carrying out the survey was held in Barcelona in September 1999. Minutes enclosed. • A Project Group comprising project leader, contractual representative and 2 scientific

persons was established in order to facilitate cross sectional project co-ordination. • A Kick-off seminar for participating countries was held in Helsinki on 21- 22 September

2000. The seminar was held to ensure that administrative, financial, technical and scientific obligations were understood and that structures and processes established would ensure the successful meeting of the obligations. In focus was the methodology of the survey and country representatives had the possibility to discuss with experts and get personal guidance. Programme enclosed.

• A follow-up meeting was held with participating countries during the annual meeting of

EuroPharm Forum in Copenhagen on 21 October 2000. • The survey is prepared in the participating countries in the period from October 2000 –

February 2001 including translation of questionnaire and filling instructions and preparing a random sample of the addresses of community pharmacies. No activities in Italy and Spain due to legal constraints in providing addresses of members to third part.

• The questionnaires are disseminated in the period 2-19 April 2001. In total 13975 letters

with 3 questionnaires each are sent out to 12 EU countries, either to all community pharmacies or a random sample of.

• Questionnaires are returned and data entry started as of 19 April 2001.


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• Reminders incl. 1 questionnaire are disseminated in the period 7-19 June 2001 to non-

respondents in the five countries with the lowest response rates. • The analyses were made in the period from 15 July – 31 August 2001. Data entry stopped

as of 20 August. • The report was made in the period from 20 August – 10 September 2001. • The first results were presented at the annual meeting of EuroPharm Forum on 12

October 2001 (internal meeting). • The results will be published during the autumn 2001. • Evaluation meetings will hopefully be held during the autumn 2001, dependent on

available funds.


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3. Results 3.1. Tables of results Tables of results are attached in following order: 1. Replies, % of pharmacies 2. Question 16.2, Age distribution for each country 3. Question 1, Do you smoke 4. Question 8, Reasons not to smoke: I want to protect my health 5. I want to avoid unpleasant symptoms 6. I am under pressure from my colleagues 7. Smoking is unpleasant for the persons around me 8. I want to save money 9. Question 10, Is smoking permitted in the public area of the pharmacy you are working in 10. Question 11, Smoking cessation services are a normal part of my work 11. Question 6, Do you ever smoke in the public area of the pharmacy you are working in

(smokers only) 12. Question 9.1. My current knowledge is sufficient to allow me to advice a patient/customer

who wants to stop 13. Question 9.2. Smoking in pharmacies should be completely prohibited 14. Question 9.3. Pharmacists should be trained to assist patients/customers who wish to stop

smoking 15. Question 9.4. Smoking prevention and cessation should be included in the normal training

programme for pharmacists 16. Question 9.5. The legislative actions taken in our country against smoking are sufficient so

far and no more actions are needed 17. Question 12, Do you advice patients/customers to stop smoking 18. Question 13, Do you volunteer written information (e.g. Leaflets) on smoking or smoking

cessation to patients/customers 19. Question 14, Do you volunteer information about smoking cessation courses to

patients/customers who want help to stop smoking 20. Question 15, Do you actively promote nicotine replacement to your patients/customers 21. Question 16.1, Sex 22. Question 16.3, Do you live on your own 23. Question 7, When did you stop smoking 24. Question 16.4, If no in question 16.3, does anyone in your household smoke 25. Question 4, what is smoked and how much 26. Question 4.1. how much manufactured cigarettes are smoked 27. Question 4.1. filtered no info –answers 28. Question 5.1. Would you like to stop smoking 29. Question 5. Have you tried seriously to stop smoking 30. Question 5 if question 5.1 = yes 31. Smokers versus sex (rated against distribution of sex) 32. Stopped versus sex (rated against distribution of sex)


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3.2. Response rate The overall response rate was 35.5 %. Country figures are as follows: Country Pharmacies Pharmacies

replied Total number of replies

Response rate In %

AUT 1099 352 816 32.0 BEL 1003 293 443 29.2 DEN 287 146 340 50.9 DEU 1969 450 735 22.8 FIN 544 410 1352 75.3 FRA 1932 572 805 29.6 IRE 1107 424 612 38.3 LUX 79 38 76 48.1 NET 2183* 843 1017 38.6/46.6 POR 1000 344 544 34.4 SWE 722 403 1369 52.2 UNK 2000 685 858 34.4 TOTAL 13975 4960 8967 35.5 *The Netherlands was able to provide addresses for pharmacists in community pharmacies. The response rate is typical for this kind of surveys. The results from Germany might be unrepresentative but this needs further examination. Otherwise situation is acceptable for further analysis. 3.3. Age distribution Age distributions have been compared with the age distributions in corresponding countries. They represent the actual distributions. 3.4. Distribution by sex The distribution by sex is on line with the distribution by sex of pharmacists in corresponding countries. 3.5. Smoking status of pharmacists The decision whether a person is a smoker, ex-smoker or a non-smoker was based on replies to the questions 1, 2, 3, 4.1-4.5 and 7.1-7.4. The process of deduction is based on the instructions given by WHO, but because we did not have all questions in our questionnaire concerning the smoking status it was only partly possible to use their instructions. The main problem consisted of occasional smokers, who are not really classified in this survey.


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The number of smokers and non-smokers by countries and by sex are given in table 1 together with the smoking status in the same countries among adults and among some health care provider groups as presented in the National tobacco information online system (NATIONS) and in the HECOS-database. The former is provided by WHO, American Cancer Society, World Bank Group and CDC and the latter is provided by WHO- Framework on Tobacco Control. Table 1 - prevalence of smoking and tobacco use among pharmacists, populations and health professionals

Country smoking prevalence

Country Survey NATIONS HECOS Other Professions Men Women Men Women Year Men Women Men Women Profession YearAUT 24.4 14.8 30 19 1997 42 27 16 11 Physicians 1995BEL 15.0 7.8 31 26 1999 31 19 29 17 Physicians 1991DEN 19.4 9.7 32 30 1998 44 39 29 20 Physicians 1996DEU 15.2 10.1 43 30 1991 43 30 29 18 Med.Stud. 1993FIN* 20.2 6.5 27 20 1999 28 20 7 3 Physicians 1995FRA 16.8 14.5 39 27 1997 40 27 13 17 Cardiolog. 1993IRE 13.8 16.5 32 31 1998 35 34 15 15 Dentists 1990LUX 17.1 20.0 39 27 1998 32 26 12 Physicians 1991NET 17.4 6.9 37 30 1998 37 30 41 24 Med.stud. 1989POR 19.6 10.7 30 7 1996 38 15 44 - Physicians 1999SWE* 16.4 9.4 17 22 1999 21 24 38 26 Nurses 1983UNK 9.3 7.1 29 28 1997 28 27 13 5 Physicians 1995 *all consumption As can be seen from the above table, pharmacists smoke less than their respective country’s population in general. The prevalence of use of any tobacco-products is 12.8 % among pharmacists in this survey, and in some countries only 7-10% of pharmacists smoke. As seen from the results of the Nations- database, health care professionals usually smoke less than the population in general, and they have the same percentage of smokers as pharmacists. The number of those who have stopped tobacco use is approximately 35 %, with a variation between 25 % (UK, POR) and 40 % (SWE, DEU). Twenty to ten years ago the tobacco consumption among pharmacists was as usual as among basic populations. Those who stopped, can be counted as real non-smokers because in 70 % of the cases tobacco use has been stopped over 2 years ago. 3.6. Tobacco users Smokers use mainly manufactured cigarettes. In the Netherlands, cigars, hand-rolled cigarettes and pipe are used. In Sweden and Finland snuff is used, in Belgium cigarettes and in Denmark pipe, together with manufactured cigarettes (question 4.1-4.5).


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In 60 % of the countries smokers smoke more than 10 manufactured cigarettes per day. In Portugal, Luxembourg and Denmark, the people smoke even more than that. In Finland the smokers are light users with majority smoking less than 3 cigarettes per day (question 4.1) 53 % would like to stop smoking (question 5.1). The variation is ranging widely from 75 % in Ireland to 30 % in the Netherlands. 42 % have tried seriously to stop, 56 % in Sweden and UK compared to only 21 % in Luxembourg (question 5). All those who would like to stop smoking have also tried to do so (question 5 when 5.1 = yes). 3.7. Reasons not to smoke Questions 8.1 to 8.5 give reasons why not to smoke. Protection of health is main reason in every country while in other reasons not to smoke the variation between countries is bigger. To avoid unpleasant symptoms is important from 68 % in Portugal to 88 % in Sweden and Not important from 5 % in France to 14 % in Netherlands The unpleasantness to others is important from 55 % in Denmark to 86 % in Sweden and Not important from 7 % in Sweden to 30 % in Austria The want to save money is important in more than 60 % of cases in Sweden and in Finland due to the high prices of cigarettes in these countries. In Netherlands and Luxembourg under 20 % see the price as an important reason for not to smoke. Pressure from colleagues is not important which is quite natural because usually pharmacists do not smoke at pharmacies where their colleagues could have a reason to press them. It seems to be that in gathering of pharmacists, smoking is not seen as a problem or a reason to take the subject up.


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3.8. Non-smoking activities of pharmacists Questions 11 to 15 covers information about the non-smoking activities of pharmacists. Question 11. Smoking cessation services are a normal part of my work. In every country at least 50 % of pharmacists consider smoking cessation services as a normal part of their work, and in 7 countries it is over 70 % of the pharmacists. Smokers and nonsmokers differ in their opinions as shown in the following table. 73.7 % of nonsmokers and 67.3 % of smokers consider smoking cessation services as a normal part of their work. Table 2 – smoking cessation services are normal part of my work, by current smoking behaviour Smoking status Q 11 Frequency Percent Row Pct Col Pct Missing No Yes Totals No 772 1275 5735 7782 8.75 14.45 64.98 88.18 9.92 16.38 73.70 87.43 84.72 89.08 Yes 111 230 703 1044 1.26 2.61 7.97 11.84 10.63 22.03 67.34 12.57 15.28 10.92 Totals 883 1505 6438 8826 10.01 17.06 72.95 100.02 Question 12. Do you advise patients/customers to stop smoking? In Belgium, France and Portugal about 60 % of pharmacists advice patients to stop smoking while in the Netherlands, Finland and Sweden this is done only on about 20 % of cases. This result is interesting and can be seen as cultural difference between countries community pharmacy tradition. In Finland we know from other studies that pharmacists do not usually ask customers about behaviour, which can be seen as private matter, but do inform patients, when the behavioural decision has been made by the customer. Information and health education is gradually changing to more active directions. In southern Europe the tradition in pharmacies is different. Smokers and non-smokers differ in this question, which leads to the “never” and “often” -answers as can be seen in following table.


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Table 3 - do you advise patients/customers to stop smoking, by current smoking behaviour Smoking status Q12 Frequency Percent Row Pct Col Pct Missing Never

Sometimes or seldom Often Totals

No 88 331 4505 2858 7782 1.00 3.75 51.04 32.38 88.17 1.13 4.25 57.89 36.73 87.13 80.54 88.21 89.12 Yes 13 80 602 349 1044 0.15 0.91 6.82 3.95 11.83 1.25 7.66 57.66 33.43 12.87 19.46 11.79 10.88 Totals 101 411 5107 3207 8826 1.15 4.66 57.86 36.33 100.00 Question 13. Do you volunteer written information (e.g. leaflets) on smoking or smoking cessation to patients/customers, who want to stop smoking. Written information is used much, over 80 % in Finland, Germany, Austria, United Kingdom, Ireland, France, Belgium, Luxembourg; Sweden and Portugal use them sometimes or often; over 70 % in Denmark and over 60 % in Netherlands. The same 3 % difference can be seen here between smokers and non-smokers in use of written information, as was the case in question 12. Table 4 - do you volunteer written information on smoking or smoking cessation, by current smoking behaviour Smoking status Q13. Frequency Percent Row Pct Col Pct Missing Never


No 102 815 4491 2374 7782 1.16 9.23 50.88 26.90 88.17 1.31 10.47 57.71 30.51 85.71 85.25 88.25 89.18 Yes 17 141 598 288 1044 0.19 1.60 6.78 3.26 11.83 1.63 13.51 57.28 27.59 14.29 14.75 11.75 10.82 Totals 119 956 5089 2662 8826 1.35 10.83 57.66 30.16 100.00


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Question 14. Do you volunteer information about smoking cessation courses to patients/customers who wan t help to stop smoking. Information about courses is given in France, Luxembourg, United Kingdom, Ireland, Denmark, Belgium and Sweden sometimes or often in over 60 of the cases, in Austria and Germany in 57 % of the cases and in Finland, Portugal and the Netherlands from 52 to 48 % of the cases. The difference between smokers and non-smokers is about 3.5 %. Table 5 - do you volunteer information about smoking cessation courses, by current smoking behaviour? Smoking status Q14 Frequency Percent Row Pct Col Pct Missing Never


No 145 2634 3073 1930 7779 1.64 29.84 34.82 21.87 88.17 1.86 33.85 39.49 24.80 84.30 89.29 88.38 86.66 Yes 27 316 404 297 1044 0.31 3.58 4.58 3.37 11.84 2.59 30.27 38.70 28.45 15.70 10.71 11.62 13.34 Totals 172 2947 3477 2227 8823 1.95 33.42 39.40 25.24 100.01 Question 15. Do you actively promote nicotine replacement therapy to your patients/customers? NRT is promoted widely in pharmacies. In over 80 % of the cases, it is promoted often or sometimes to customers in every country, except in the Netherlands. In the Netherlands NRT is sold in druggist shops as well, and this might have some effect on the situation. Even in NRT promotion, smokers and non-smokers slightly differ, as can be seen from the following table.


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Table 6 - do you actively promote nicotine replacement therapy, by current smoking behaviour? Smoking status Q15 Frequency Percent Row Pct Col Pct Missing Never


No 150 717 3840 3075 7782 1.70 8.12 43.51 34.84 88.17 1.93 9.21 49.34 39.51 83.33 85.77 88.81 88.21 Yes 30 119 484 411 1044 0.34 1.35 5.48 4.66 11.83 2.87 11.40 46.36 39.37 16.67 14.23 11.19 11.79 Totals 180 836 4324 3486 8826 2.04 9.47 48.99 39.50 100.00 Pharmacists are very active in their daily non-smoking work, promoting nicotine replacement therapy, giving written information etc. Information on stop-smoking courses depends naturally on the situation in the country – whether courses are organized and how pharmacists are involved. 3.9. Attitudes of pharmacists Questions 9.1-9.5 measured the attitudes of pharmacists towards smoking and non-smoking activities. Question 9.1. My current knowledge about smoking is sufficient to allow me to give advice to a patient/customer, who wants to stop Pharmacists are quite satisfied with their knowledge. In Germany, Austria, United Kingdom, Denmark and Ireland, over 80 % of those who replied agree with the statement and in Belgium, France, Luxembourg and Netherlands about 80 %. In Sweden, Portugal and Finland the confidence in own knowledge is not that high. In this question the opinions of smokers and non-smokers differ. 82 % of non-smokers and 87 % of smokers agree with the statement and 9 % of non-smokers and 5 % of smokers disagree.


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Table 7 – sufficient knowledge to advise, by current smoking behaviour Smoking status Q 9.1 Frequency Percent Row Pct Col Pct Missing No opinion Disagree Agree Totals No 211 465 694 6412 7782 2.39 5.27 7.86 72.65 88.17 2.71 5.98 8.92 82.40 83.73 91.00 93.53 87.58 Yes 41 46 48 909 1044 0.46 0.52 0.54 10.30 11.82 3.93 4.41 4.60 87.07 16.27 9.00 6.47 12.42 Totals 252 511 742 7321 8826 2.85 5.79 8.40 82.95 99.99 Question 9.2. Smoking in pharmacies should be completely prohibited Over 80 % of pharmacists accept this, except for Denmark, where the percentage is 72. Smokers and non-smokers differ a lot in their opinion on this question – 15 % of smokers disagree while only 4 % of the non-smokers disagree, as can be seen in following table. Table 8 – smoking in pharmacies should be prohibited, by current smoking behaviour Smoking status Q 9.2 Frequency Percent Row Pct Col Pct Missing

No opinion Disagree Agree Totals

No 161 270 330 7021 7782 1.82 3.06 3.74 79.55 88.17 2.07 3.47 4.24 90.22 82.14 81.33 67.35 89.92 Yes 35 62 160 787 1044 0.40 0.70 1.81 8.92 11.83 3.35 5.94 15.33 75.38 17.86 18.67 32.65 10.08 Totals 196 332 490 7808 8826 2.22 3.76 5.55 88.47 100.00


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Question 9.3. Pharmacists should be trained to assist patients/customers, who wish to stop smoking Pharmacists have a positive attitude to this training; over 60 % agree with the statement except for Austria and the Netherlands. In the United Kingdom, Finland, Ireland, Germany, France and Denmark, the percentage is over 80. This is a good sign because it is well known from other studies that trained health professionals get better results in non-smoking work and are better motivated. Smokers do not have as positive attitudes as non-smokers do; the percentage of agreement is 80 % in the group of non-smokers and 73 % in the smokers group. Table 9 – pharmacists should be trained, by current smoking behaviour Smoking status Q 9.3 Frequency Percent Row Pct Col Pct Missing


No 435 688 452 6207 7782 4.93 7.80 5.12 70.33 88.18 5.59 8.84 5.81 79.76 86.83 86.65 80.57 89.05 Yes 66 106 109 763 1044 0.75 1.20 1.23 8.64 11.82 6.32 10.15 10.44 73.08 13.17 13.35 19.43 10.95 Totals 501 794 561 6970 8826 5.68 9.00 6.35 78.97 100.00 Question 9.4. Smoking prevention and cessation should be included in the normal training program for pharmacists Only 42 % of the replies from the Netherlands agree with this statement while in Germany, Luxembourg, Finland, Denmark, Belgium and Sweden more than 60 % agree, and in United Kingdom, Ireland, Austria, France and Portugal over 80 % agree. The difference between smokers and non-smokers is quite big, 73 % of nonsmokers agree and only 65 % of smokers.


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Table 10 – smoking prevention to be included in training programmes, by current smoking behaviour Smoking status Q 9.4 Frequency Percent Row Pct Col Pct Missing


No 196 1025 895 5666 7782 2.22 11.61 10.14 64.20 88.17 2.52 13.17 11.50 72.81 83.76 87.31 83.02 89.37 Yes 38 149 183 674 1044 0.43 1.69 2.07 7.64 11.83 3.64 14.27 17.53 64.56 16.24 12.69 16.98 10.63 Totals 234 1174 1078 6340 8826 2.65 13.30 12.21 71.84 100.00 Question 9.5. The legislative actions taken in our country against smoking are sufficient so far and no more actions are needed. In Finland 56 % of the respondents agree with the statement while only 10 % in Portugal. The reaction to this seems to be connected with the actual situation in the country. In Finland the tobacco law is one of the strictest in the world, while in Portugal the current situation is more liberal. On this question smokers and nonsmokers differ most. 49 % of smokers think that no more legislative actions are needed, while only 26.7 % of non-smokers support. Table 11 – legislation is sufficient and no more actions needed, by current smoking behaviour Smoking status Q 9.5 Frequency Percent Row Pct Col Pct Missing


No 205 1266 4232 2079 7782 2.32 14.34 47.95 23.56 88.17 2.63 16.27 54.38 26.72 83.67 88.28 92.93 80.18 Yes 40 168 322 514 1044 0.45 1.90 3.65 5.82 11.82 3.83 16.09 30.84 49.23 16.33 11.72 7.07 19.82 Totals 245 1434 4554 2593 8826 2.77 16.24 51.60 29.38 99.99


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4. Conclusion Based on the results of this survey, we can conclude that the situation for non-smoking work in European community pharmacies is favourable:

• Community pharmacists use much less tobacco than people in their home countries.

• Pharmacists know the health risks of tobacco products and they are also aware of the risks of passive smoking.

• Usually smoking is completely prohibited in pharmacies.

• Community pharmacists have a positive attitude towards non-smoking work and they have confidence in their own knowledge.

• Non-smoking work differs slightly in the European countries. For southern European countries it is more natural to discuss the smoking situation of a client in pre-contemplation stage, while in the northern part of Europe advice is usually given in both, the contemplation and the decision stage.

As can be seen from the results, smokers are usually more negative towards non-smoking activities, and we know from previous studies, that they are not good advocates for non-smoking activities. It is of importance that those pharmacists, who still smoke, could get more information on hazards of smoking and support in their efforts to stop. Here the national pharmaceutical organisations clearly have a task. There is a need for further education of pharmacists in tobacco issues, and this education should be part of the basic education as well. Good models already exist for continuing education, as well as for basic education, and based on these results we have to continue to get the knowledge of these models spread all over Europe. The work done in pharmacies is not well documented and usually not well known among other health care providers. These results can be used in national work where national guidelines on smoking cessation are written or legislative actions should be taken. Pharmacists have become an active part in non-smoking work. They should be supported in their work and models, which are tested as good and effective, and which should be implemented via national professional organizations. Nicotine replacement therapy is widely promoted in community pharmacies. As these products in most cases are sold without prescription, it is of utmost importance that pharmacists can support clients in quitting with the help of NRT. Based on these results, the situation seems to be quite good, but more knowledge and written information is needed.


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To work in an effective way, the healthcare team needs common goals and common ways of working. Non-smoking work is one area, where the impact might be better, if co-operation between all actors could be established. Based on these results, as well as results from surveys done among physicians, it is possible to think about a model where the 5 A’s: Ask, Advise, Assess, Assist, Arrange could be divided in the healthcare team. In this model, asking is usually done when the patient visits a medical doctor or a nurse. The smoking status is discussed, the status of change is analysed, and advice suitable to the situation is given. The task for the pharmacy is to give general advice as well as advice on the proper use of NRT, and to arrange support in the form of short check-ups at the pharmacy for those, who try to stop smoking. The project group that was established for this survey will continue its work in different task forces. The national pharmaceutical associations have an important role in implementing the models for community pharmacies, to encourage their members to continue the non-smoking work and to support their members to quit smoking. Education and information on tobacco questions should be arranged.


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5. Annexes Annex 5.1: Tables of results Annex 5.2: Questionnaire Annex 5.3: Standard article for presenting the project in national pharmaceutical journals Annex 5.4: Abstracts of posters Annex 5.5: Minutes of Barcelona meeting Annex 5.6: Programme of Kick-off seminar in Helsinki Annex 5.7: Partner contributions


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Part 2 Financial Report Spreadsheets showing Expenditure Consolidation and Details of Expenditure List of corresponding supporting documents Corresponding supporting documents

This report was produced by a contractor for Health & Consumer Protection Directorate General and represents the views of thecontractor or author. These views have not been adopted or in any way approved by the Commission and do not necessarilyrepresent the view of the Commission or the Directorate General for Health and Consumer Protection. The EuropeanCommission does not guarantee the accuracy of the data included in this study, nor does it accept responsibility for any use madethereof.

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