The tobacco epidemic represents one of the biggest public health threats affecting billions of lives (Shafey et al.,
2003). Smoking, as a result, remains to be a major cause of preventable mortality and morbidity in the developed world (Chandler and Rennard 2010).
With nicotine dependence being classified as a ‘disease’ in the World Health Organization International Classification of Diseases (ICD-10-CM Diagnosis Codes 2013), addressing individual patient needs and providing adequate treatment requires a thorough understanding of the pharmacology of addiction, specialised therapeutic knowledge and psychosocial intervention skills. Whilst many smokers are able to quit ‘cold turkey’, therapeutic services need to be tailored to meet the demands of recalcitrant smokers who cannot quit unassisted, those who have had previous unsuccessful quit attempts and highly dependent smokers with a greater prospect of relapse (Chapman and MacKenzie 2013). This necessitates that healthcare professionals be equipped with evidence-based knowledge to facilitate smoking cessation interventions.
Smoking cessation research is dynamic, and new revised guidelines suggest different approaches to those used conventionally (Zwar et al.,
2012; National Institute for Health and Clinical Excellence 2008). Current emerging recommendations debunk previous myths regarding the use of smoking cessation aids. For instance, it is now clear that nicotine replacement therapy (NRT) can be used while still smoking, with a view to cutting down as a prelude to quitting (Wennike et al.,
2003; Rennard et al.,
2006). NRT can be used beyond the recommended duration of 8 to12 weeks for as long as needed to help patients quit (Medioni et al.,
2005). In fact, NRT can be continued after smoking lapses to promote recovery of abstinence (Ferguson et al.,
2012). It is also evident that higher doses of NRT are more effective than lower doses, particularly in highly dependent smokers (Stead et al.,
2012). Furthermore, the combination of more than one form of NRT is significantly effective (Stead et al.,
2012). Indeed, NRT exhibits a wide safety profile and can be administered during pregnancy after failure of non-pharmacological interventions, in patients with cardiovascular diseases and in smokers aged 12 years and over (Schroder et al.,
2002; Coleman et al.,
2011; Thomas 2012; Hanson et al.,
2003); though many healthcare professionals would be, based on conventional wisdom, unclear or hesitant to initiate this. Hence again, it is crucial for healthcare practitioners to keep abreast in order to successfully assist smokers in quitting.
Pharmacists, among other primary healthcare professionals, can play a fundamental role in smoking cessation. They represent a highly accessible trained workforce with a wide range of therapeutic expertise. They characterise highly trusted practitioners with whom patients often consult about health and medication-related issues (Pharmacy Guild of Australia 2010). Moreover, in the last 2 decades, community pharmacies have broadened their scope of service to include, besides conventional medicine supply, a variety of specialised services, such as health screening and disease management (Schulz et al.,
2001; Monte et al.,
2009). Pharmacists are well-positioned to provide smoking cessation services within pharmacies, where smoking cessation products are stocked and retailed. They can approach a wide spectrum of patients in need of support, motivation and enhanced awareness about nicotine dependence and avenues of treatment (Li 2010). Additionally, systematic reviews, assessing the effectiveness of pharmacist-delivered smoking cessation interventions, indicated that trained community pharmacists, providing counselling and ongoing support, may have a positive effect on abstinence rates (Roughead et al.,
2003; Sinclair et al.,
2004; Dent et al.,
2007). The counselling delivered by pharmacists ranged in nature from simple advice about the importance of smoking cessation, identifying barriers to quitting and providing motivation to more intensive behavioural approaches such as providing support based on the ‘stage-of-change model’ (Sinclair et al.,
2004). Preliminary studies also suggest that pharmacy-based smoking cessation services are cost-effective (Sinclair et al.
1999; Bauld et al.,
2011).
In Australia, in 2011–12, it was estimated that nearly 20.4% of the adult male and 16.3% of the adult female population were smokers (Australian Bureau of Statistics 2013). These rates are far lower than a quarter of a century ago, and quit attempts have doubled since then (Germain et al.,
2012). In an attempt to provide disincentives to purchase tobacco products, new political and social protocols have recently been instituted countrywide. These included the implementation of the “plain” (no brand images/advertisement) packaging legislation and the raised taxes on cigarettes (Cancer Council Victoria 2012). In Australia, over-the-counter NRT and prescription-only varenicline are available. NRT patches (21 mg/24 hours and 15 mg/16 hours) and varenicline can be accessed through subsidised pricing via the Pharmaceutical Benefits Scheme, for a period of 12 weeks for the patches and up to 24 weeks for varenicline. Despite this infrastructure, little is known about the smoking cessation services provided in this sector. Published data suggest that sales of smoking cessation products have increased, but only a minority of smoking cessation product users report receiving any advice or support (Bittoun 2007; Paul et al.,
2003). Some studies have shown that smokers consistently underutilise NRT, both in terms of the number of pieces administered per day and the duration of time that treatment is used (Ferguson et al.,
2011). For instance, despite Australia’s active pharmacy practice researchers in the areas of asthma, diabetes and Home Medicines Review (Australian Government, Department of Health and Ageing 2009; 2011; The University of Sydney, Faculty of Pharmacy Faculty of Pharmacy 2005), comprehensive pharmacy-delivered smoking cessation programs have not been developed or evaluated yet. This situation may also stem from lack of positive attitudes toward pharmacist-delivered smoking cessation services and the lack of pharmacists’ skills and confidence in being able to provide these services in line with the current therapeutic guidelines. In a previous simulated patient study conducted in Sydney, authors concluded that evidence-based smoking cessation advice in pharmacies was fragile and may be compromised by commercial concerns (Chiang and Chapman 2006). Another unclear issue is whether smoking cessation is handled by pharmacy frontline staff or pharmacists. Anecdotally, it is known that often Australian pharmacy assistants may be in charge of the smoking cessation products area. To add, whilst tobacco education is common in pharmacy schools in the United States (Corelli et al.,
2005), for instance, little is known about the depth and scope of tobacco cessation content in Australian pharmacy curricula. As a result, an identification of needs, preferences and current awareness levels is crucial, as for pharmacists to perform competent smoking cessation interventions throughout their daily practice, they need to attain and demonstrate knowledge, skills and confidence in this field.
Given that early sources of knowledge that contribute to one’s professional career are generally acquired at professional courses, i.e., while undertaking a degree, it was anticipated that mapping the knowledge and attitudes of final-year pharmacy students would be an important marker of the “level of awareness” of pharmacy professionals about smoking cessation. Pharmacy students during their final year serve as a pertinent target population because of their imminent entry into the profession, recency of knowledge acquisition, possible personal smoking status or contact with peers who smoke. It may also be hypothesised that experience with providing smoking cessation services and advice should enhance the skill base of professionals and that practicing professionals would have higher awareness and more positive attitudes toward their role in smoking cessation service provision.
Aim of the study
Therefore, the aim of this study was to assess the knowledge about and attitudes toward smoking cessation in final-year pharmacy students and to compare the latter with that of practicing pharmacists and specialised smoking cessation educators. Accordingly, the overall objective of this study was to uncover underlying ‘gaps’ in pharmacy-based smoking cessation practice, aiming at investing the findings of this research in providing up-to-date education to improve smoking cessation practice.