Smoking cessation support in community pharmacies: is the association of smoking and eye disease an additional tool to increase uptake?

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IJPP 2008, 16: 251–256© 2008 The AuthorsReceived November 4, 2007Accepted March 28, 2008DOI 10.1211/ijpp.16.4.0007ISSN 0961-7671

Smoking cessation support in community pharmacies: is the association of smoking and eye disease an additional tool to increase uptake?

Judith Thornton, Perihan Torun, Richard Edwards, Annie Harrison,

Simon P. Kelly, Roger A. Harrison and Arpana Verma

Abstract

Objective Community pharmacists have a central role in provision of smoking-cessation support.Evidence is growing that tobacco smoking is associated with development and progression ofseveral potentially blinding eye diseases. As part of an ongoing programme of raising awareness ofthis link, we investigated whether community pharmacists are aware of this association and incor-porate relevant advice into their smoking-cessation guidance. Setting Two-thousand and eighty community pharmacists in north west England, UK. Method A postal self-completion questionnaire asked pharmacists about their current practicewith regard to smoking habits of their clients. Data were extracted and entered onto a database forstatistical analyses. Key findings The response rate was 50.5%; 685 (65.2%) pharmacists asked clients about smokinghabits; the most common situation was when clients complained of respiratory symptoms. Of thesepharmacists, 52.7% always/usually recommended that smokers should stop and 37.2% always/usuallyassessed motivation to succeed. Help provided by pharmacists included brief advice on smokingcessation, leaflets, more structured support, referral to smoking-cessation services, and nicotinereplacement therapies. The most common reason why pharmacists did not ask about smoking waslack of time (83.1%); 52.0% were aware of the causal association of smoking with eye disease, and19.8% of those who asked about smoking habits mentioned this association when discussing smokingcessation. Conclusion Our study shows that community pharmacists are actively involved in smoking cessa-tion. Many pharmacists are aware of the causal association between smoking and eye disease, butfew are actively counselling patients about the eye heath risks of smoking. Community pharmacistscould include this information in their advice to clients who smoke, as an additional means topromote smoking cessation.

In the UK, one of the main tobacco control interventions in the national strategy ‘SmokingKills’ was comprehensive smoking cessation services. These were introduced by theNational Health Service (NHS) in Health Action Zones (areas in England with greaterconcentrations of deprived populations) in 1999–2000 and throughout all health authoritiesin 2000–2001. National guidance states that these should target disadvantaged smokers andareas.1 Community pharmacists are healthcare professionals who have regular contact withlarge numbers of people in health and in sickness. They are ideally placed to support healthylifestyles and, thus, have been proposed as having a central role in provision of smoking-cessation support.2,3 Pharmacists have been shown to increase smoking-cessation ratesthrough using a structured smoking-cessation intervention.4 A document published jointlyby the National Institute of Health and Clinical Excellence, the Royal Pharmaceutical Societyof Great Britain and PharmacyHealthLink, Helping smokers to stop: advice for pharmacistsin England, provides pharmacists with guidance needed to help smokers to stop.5 All phar-macists were made aware of this document in 2005 through the Pharmaceutical Journal.6

Pharmacists in the UK are able to provide cessation advice opportunistically during routine

Introduction

Clinical Epidemiology and Public Health Unit, University of Manchester, UK

Judith Thornton, honorary research fellow Perihan Torun, research associate Annie Harrison, trials assistant Arpana Verma, clinical lecturer in public health

School of Community Medicine, University of Manchester, Manchester, UK

Roger A. Harrison, course unit leader

Department of Public Health, University of Otago, Wellington, New Zealand

Richard Edwards, senior lecturer in epidemiology

Ophthalmology Department, Bolton Hospitals NHS Trust, Bolton, UK

Simon P. Kelly, consultant ophthalmologist

Correspondence: Judith Thornton, Clinical Epidemiology and Public Health Unit, University of Manchester, Manchester M13 9PT, UK. E-mail: [email protected]

Acknowledgements: Professor Karen Hassel and Dr Liz Seston, Centre for Pharmacy Workforce Studies, School of Pharmacy and Pharmaceutical Sciences, University of Manchester, for providing the sample of North West community pharmacists. Lesley Patterson, Clinical Epidemiology and Public Health Unit, University of Manchester, for her help in preparing and posting the questionnaires.

The study was funded by Bolton Hospitals NHS Trust and University Hospital of South Manchester NHS Foundation Trust.

IJPP16(4).book Page 251 Thursday, June 19, 2008 11:52 AM

252 The International Journal of Pharmacy Practice, August 2008

consultations such as prescription handling, minor ailmentservices, and purchase of over-the-counter medicines, and cansupply both nicotine replacement therapies over-the counterand bupropion on prescription. Pharmacists may also referpatients to NHS smoking-cessation services for additionalsupport and follow-up.

Tobacco smoking is a major risk factor for many chronicdiseases,7 but the effects of smoking on the eye are not wellrecognised. There is growing evidence from epidemiologystudies and systematic reviews that tobacco smoking is asso-ciated with development and/or progression of eye disease, mostnotably age-related macular degeneration8,9 and cataract,10 butalso thyroid eye disease,11 and other eye diseases such asretinal ischaemia, anterior ischaemic optic neuropathy andtobacco–alcohol amblyopia.12 We suspected that awarenessof this link was little known and having attention drawn to thethreat smoking poses to sight is a potent stimulus to quit.

We developed a programme of work involving a multidis-ciplinary team which comprised NHS clinical ophthalmolo-gists and public health academics; links were developed withthe Royal College of Ophthalmologists and a local campaigningcharity North West Action on Smoking and Health (NWASH).The programme aims were: first, to raise awareness of thelink between smoking and eye disease and advocate changesin relevant policies, and second, to investigate and promotechange in professional practice so that smokers are identifiedand routinely offered smoking-cessation advice/support ineyecare settings. We developed a programme of research andeducation, targeting policy makers, healthcare professionals,the public and patients. We reviewed evidence about thecausal link between smoking and eye disease, researchedcurrent awareness of the link in patients and the public,researched current practice of eyecare health professionalsincluding ophthalmologists and optometrists, produced healtheducation materials, and campaigned for policy changes.13

As part of this investigational programme, we investigatedthe current practice of community pharmacists in identifyingsmokers and providing smoking-cessation advice, andwhether they are aware of the association between smokingand eye disease and incorporate relevant advice into theirsmoking-cessation guidance.

As part of a 2005 census of pharmacists, the Centre for Phar-macy Workforce Studies, School of Pharmacy and Pharma-ceutical Sciences, University of Manchester identifiedpharmacists from the Royal Pharmaceutical Society of GreatBritain (RPSGB) and assigned their field of practice (forexample, community, hospital, industry or academia).14 Fromthis database, we identified all community pharmacists (definedas pharmacists working in community retail pharmacies)including those with both full-time, part-time or locumemployment, with registered addresses in north west Englandas defined as the NW Strategic Health Authority area (Cheshire,Cumbria, Greater Manchester, Lancashire and Merseyside).

A self-completion questionnaire (available on request)was developed to ask pharmacists about their current practicewith regard to smoking habits of their clients. Responses

were mostly categorical but some free text responses wereincluded for more qualitative data. The questionnaire includeditems on the following:

• how long pharmacists had been in practice and the levelof familiarity with their clients (estimated proportion ofclients who they recognised or were familiar with)

• how often pharmacists asked about smoking status andadditional questions about current smoking and smokinghistory, e.g. duration, intensity, and quitting history

• how often pharmacists offered advice and assistance topeople who wanted to stop, and the type of support offered

• reasons for not asking about smoking status (where relevant) • awareness of association between smoking and eye disease • how often pharmacists discussed the association between

smoking and eye disease during consultations about stoppingsmoking, and used a leaflet on smoking and eye disease

• views about the need for further education and trainingabout the effects of smoking on eyes.

We piloted the questionnaire with two community pharma-cists from outside the north west region. We tested theirunderstanding of individual questions in the questionnaireand the acceptability of the questionnaire. As a result wemodified the sequencing and wording of some questions toimprove clarity. The responses from these pharmacists werenot included in the results. The final questionnaire included16 items and took about 10 minutes to complete. The ques-tionnaire and covering letter were posted to 2273 namedpharmacists with a reply-paid envelope for questionnairereturn; after 4 weeks, non-responders were sent a reminderletter with a second copy of the questionnaire. Data wereextracted and entered onto an Access database for statisticalanalysis using Open-Epi.15

The University Research Ethics Committee reviewed theproject and granted a waiver as it was a survey of professionalpractice. The project was registered with the trusts sponsoringthe work using the Pan-Manchester Research NotificationForm.

Out of 2273 questionnaires, 90 responses were received statingthe questionnaire was not applicable to the pharmacist it wassent to, as they had died, retired, were no longer practising ascommunity pharmacists or had moved from the north west. Atotal of 1056 completed questionnaires were returned but afurther five were excluded as their respondents had movedfrom the north west. Of the 1127 non-responders we double-checked with the 2007 register of pharmacists and found 98were no longer practising or based in the north west. In total,2080 questionnaires were valid and we received 1051 validreplies, giving a response rate of 50.5%.

The duration of practice as a community pharmacist variedfrom newly qualified (12.1%) to more than 40 years (5.3%).The greatest number of respondents had been practising for11–30 years (48.3%); 60.9% of respondents were aware ofHelping smokers to stop: advice for pharmacists in England,5

and 25.7% claimed to have read this guidance.

Methods

Results


August 2008, The International Journal of Pharmacy Practice 253

Overall, 685 (65.2%) community pharmacists reportedthat they asked clients about their smoking habits; nine phar-macists (0.9%) did not answer this question; of the 685 whodid, most did so sometimes (71.8%) or rarely (10.9%), though14.2% did so most of the time or every time (Table 1). Theproportion of pharmacists asking clients about their smokinghabits varied from 57% to 76% between pharmacists groupedby number of years of practice. There was no clear trendbetween groups, with the highest proportion asking aboutsmoking among pharmacists who had been practising for6–10 years (75.9%, 95% confidence interval (CI) 68.8% to82.1%), and the lowest (56.7%, 95% CI 49.2% to 64.0%)among pharmacists with 31–50 years of practice. The propor-tion of pharmacists asking clients about smoking habitsincreased with pharmacists’ familiarity with their clients. Theproportions asking about smoking were: 55.0% (95% CI52.8% to 66.3%) of pharmacists who recognised 1–25% ofclients; 59.7% (95% CI 52.8% to 66.3%) of those who recog-nised 26–50% of clients; 66.8% (95% CI 61.4% to 71.8%) ofpharmacists who recognised 50–75% of clients; and 70.0%(95% CI 63.7% to 75.7%) of those who recognised more than75% of their clients.

An open unprompted question in the questionnaire askedthe pharmacists to list consultations when they would initiatea discussion about smoking habits of clients (Table 2). Forthe 502 pharmacists who replied, the most common situation

was when clients complained of asthma, chronic obstructivepulmonary disease (COPD) or respiratory symptoms (87.8%).Only 6.2% discussed smoking when providing general healthand lifestyle advice. Some pharmacists (2.6%) would also askclients who appeared to be smokers (for example, clothessmelling of tobacco smoke).

Using an open question, pharmacists were asked whatquestions they asked clients about smoking habits. For the 592pharmacists who responded to this question, the commonestadditional questions asked about smoking included quantityof cigarettes smoked (88.9% of pharmacists), duration ofsmoking (35.8%), triggers and patterns for smoking (41.9%),craving for cigarettes (36.8%), previous quit attempts(34.0%), and if they wanted to try to stop (37.7%). Morerarely asked were the reasons for smoking (11.7%), and asso-ciated habits (3.9%).

Of the 685 pharmacists who stated that they asked clientsabout smoking habits, 52.7% always or usually recommendedthat smokers should stop, and 37.3% always or usuallyassessed the clients’ motivation to succeed (Table 1). However,there was some discrepancy in the replies, because 86.3% ofpharmacists claimed to give further advice and assistancemost of the time or every time. In other consultations wherepharmacists initiated discussion about smoking habits, onlyfour (0.8%) of 502 who responded stated that they discussedthe risks of smoking during consultations about eye disease.A range of smoking-cessation help and advice was offered toclients by the community pharmacists. Among pharmacistswho asked clients about smoking or offered advice on howto stop, this included brief advice on smoking cessation(90.9%), with leaflets (71.7%) or more structured support(55.3%), and clients were often referred to smoking-cessationservices (67.3%). Pharmacists also offered nicotine replacementtherapies and/or dispensed bupropion (90.5%).

In a prompted question, the most common reason whypharmacists felt unable to ask clients about smoking routinelywas lack of time; this reason was given by 498 of 599 whoresponded (83.1%). Other reasons included: lack of privacyin the pharmacy (18.5%); no training (20.5%); forgetting toask (24.5%); worry about offending clients (38.7%) or of losingbusiness (8.2%); and concern that asking about smoking habitswas irrelevant for pharmacy clients (4.0%) or was not the roleof the pharmacist (3.2%).

When we assessed the primary aim of our project, over half(52.0%) of the 1051 community pharmacists were aware ofthe causal association of smoking with eye disease. However,

Table 1 Smoking cessation practice among pharmacists who asked about smoking behaviour of clients (n = 685)

Never n (%) Rarely n (%) Sometimes n (%) Most times n (%) Every time n (%)

How often did these pharmacistsask about smoking

– 75 (10.9) 492 (71.8) 84 (12.3) 13 (1.9)

How often did these pharmacists advise to stop smoking

6 (0.9) 37 (5.4) 267 (39.0) 243 (35.5) 118 (17.2)

How often did these pharmacists assess motivation to stop

25 (3.6) 107 (15.6) 283 (41.3) 197 (28.8) 58 (8.5)

How often did these pharmacists offer advice and assistance

2 (0.3) 15 (2.2) 64 (9.3) 147 (21.5) 444 (64.8)

How often did these pharmacists mention eye disease risk

302 (44.1) 234 (34.2) 86 (12.6) 37 (5.4) 12 (1.8)

Table 2 Specific consultations where pharmacists ask aboutsmoking habits; unprompted responses (n = 502)

Consultation n (%)

Respiratory symptoms, asthma and chronic obstructive pulmonary disease (COPD)

441 (87.8)

Medicines use review 182 (36.3) Cardiovascular disease 107 (21.3) Screening/monitoring 55 (11.0) Diabetes mellitus 44 (8.8) General health/lifestyle advice 31 (6.2) Weight problems 19 (3.8) Pregnancy/parenthood 17 (3.4) Signs of smoking 13 (2.6) Contraception 5 (1.0) Eye disease 4 (0.8) Other 34 (6.8)



only 19.8% of those who asked about smoking habits men-tioned this association at least sometimes when discussingsmoking cessation with clients (Table 1). In the unpromptedquestion about which consultations were ones where pharma-cists initiated discussion about smoking habits, only four (0.8%)of 502 who responded stated that they discussed the risks ofsmoking during consultations about eye disease (Table 2). Ofpharmacists who asked about smoking, 5.1% handed out aleaflet on smoking and eye disease when advising on smokingcessation. Most pharmacists (91.1%) wanted to improvetheir knowledge about the association between smoking andeye disease, and 965 (91.8%) felt that training would bebeneficial (Table 3).

In our study, almost two-thirds (65.2%) of community pharma-cists reported that they asked clients about their smoking habits.Counselling for smoking cessation by pharmacists was promptedby a number of situations, most commonly during consultationsabout respiratory symptoms and conditions, and during medi-cines use reviews. Help provided by pharmacists included briefadvice on smoking cessation, leaflets, more structured support,referral to smoking-cessation services and nicotine replacementtherapies. The most common reason why pharmacists did notask about smoking was lack of time (83.1%). A total of 52.0% ofpharmacists was aware of the causal association of smoking witheye disease, but only 19.8% of those who asked about smokinghabits mentioned this association.

The main limitation to the survey was that, in spite offollow-up letters and questionnaires, the response rate wasonly moderate. However, this may be typical for a postal surveyof a professional group, for example, the response rate in asurvey of ophthalmologists was 54%.16 It is possible that therespondents were systematically different in their knowledge,beliefs and practice in asking about smoking and providingsmoking-cessation advice from non-responders. Furthermore,some of the response rates for questions within the question-naire were low, for example, only half the respondents repliedto the open question about the consultations in which they

asked clients about smoking habits. One would have expectedmore pharmacists to ask patients with cardiovascular diseaseabout their smoking habits. Another limitation is that likemany studies of professional practice, the survey relies onself-reported data. Research asking pharmacy clients abouttheir experience of being asked about smoking, and perhapseven observational studies, would provide additionalinformation and validation data for these findings.

However, strengths of this survey included the inclusion inthe sampling frame of all community pharmacists in the northwest of England. The inclusion of all types of pharmacists isimportant, as practice may differ between different settings,for example, a part-time locum pharmacist working across anumber of different city-centre pharmacies may not have theopportunity to develop a relationship with clients that allowsdetailed questioning about smoking habits, in contrast with apharmacist in a single rural pharmacy who knows his/herclients more closely. An interesting finding in our study wasthat pharmacists who recognised, or were familiar with, manyclients were more likely to ask about smoking habits. Thesurvey included full-time, part-time and locum pharmacists inindependent pharmacies or pharmacies that form part of amultiple chain. All levels of age, professional experience andseniority were included, from newly qualified to semi-retired.The north west comprises pharmacies in both urban and ruralsettings. Therefore, the results are likely to be generalisable toother community pharmacists in the UK.

This is the first survey to examine knowledge of the asso-ciation of smoking and eye disease and smoking cessationpractice among UK community pharmacists. Previous surveyshave examined practice in Australia,17 the USA,18,19 andCanada,20 and all found a high interest among pharmacists inpromoting smoking cessation but did not examine awarenessof smoking and eye disease. In the Australian study, confidenceemerged as the most important predictor of smoking-cessationactivities, followed by the fear of alienating patients.17 AnAmerican study identified four dimensions of barriers that inhibitpharmacists from engaging in smoking-cessation-related activi-ties: pharmacist interpersonal characteristics, practice site con-siderations, patient characteristics, and financial concerns.18

The Canadian study found that more than half of pharmacistsquestioned did not participate in smoking-cessation activities,for a range of reasons including insufficient education andpreparation, unsuitable environments for counselling patients,lack of time and/or management support.20

Patients with existing eye diseases or at risk of developingeye disease should be advised to stop smoking, as smoking ces-sation is likely to slow or stop progression of at least three eyediseases and improve the outcome of treatment.8,10,11 How-ever, in previous studies we showed that although patients andteenagers had little awareness of the association of smokingwith eye disease,21,22 fear of blindness could be a strongermotivation factor for quitting smoking than fear of other morerecognised diseases such as lung cancer and cardiovasculardisease. Preliminary data on the impact of television advertise-ment campaigns on a call to national quitlines in Australia andNew Zealand23,24 demonstrates that the link between smokingand blindness acts as a powerful stimulus for smokers to quit.

Although 52% of the pharmacists in our study wereaware of the causal association of smoking with eye disease,

Discussion

Table 3 Community pharmacists’ opinions on need for further knowl-edge or training on the association between smoking and eye disease(n = 1051)

Stronglydisagree n (%)

Disagree n (%)

Neither agree nordisagree n (%)

Agreen (%)

Stronglyagree n (%)

Need to improveknowledge ofsmoking andeye disease

4 (0.4) 14 (1.3) 63 (6.0) 533 (50.7) 425 (40.4)

Whether training on smoking and eye disease would be beneficial

2 (0.2) 12 (1.1) 61 (5.8) 562 (53.5) 403 (38.3)


August 2008, The International Journal of Pharmacy Practice 255

and 19.8% of those who asked about smoking habits statedthat they mentioned this association when discussing smok-ing cessation with clients, disappointingly few (0.8%) statedthat they discussed the risks of smoking during consulta-tions about eye disease, a much lower proportion than forother common conditions. It is encouraging that a highpercentage of pharmacists were aware of the associationbetween smoking and eye disease. Possibly this is as a resultof recent publications highlighting this risk, including areport in the British Medical Journal,9 a subsequent newsreport in the Pharmaceutical Journal (6 March 2004), andconsiderable associated media interest. But only one-fifth ofpharmacists specifically discussed the association at leastsometimes with clients when discussing smoking. Disap-pointingly few mentioned asking about smoking duringconsultations about eye disease, though this finding wasfrom an unprompted open question, and pharmacists mayhave only reported the most common occasions that theyasked about smoking.

However, findings from specific surveys of eyecare healthprofessionals showed that this information was little used. Asurvey of UK community optometrists found that few rou-tinely enquire about smoking habits among new and existingpatients, or provide smoking-cessation advice and support;10.7% of optometrists always or most times mentioned theassociation between smoking and eye disease during consul-tations, and 46.1% sometimes mentioned the association.25

As for community pharmacists, the most common barrier tosmoking-cessation interventions by optometrists was lack oftime. In a survey of UK hospital consultant ophthalmologists,40% claimed to always or usually advise patients to stopsmoking, and 61% always or usually mentioned eye diseaseas a reason to quit.16

In conclusion, our study shows that many communitypharmacists are aware of the causal association betweensmoking and eye disease, but few are actively counsellingpatients about the eye-health risks of smoking and the need tostop smoking. Pharmacists might more actively include thisinformation in their smoking-cessation advice as an addi-tional health-promotional factor, as this novel informationcould help increase smoking-cessation rates. Relevantinformation could be incorporated into training materials forpharmacists, and most pharmacists in the survey expressed awish to increase their knowledge and have some trainingabout the association of smoking with eye disease. A fewpharmacists reported using a leaflet describing the associationbetween smoking and eye disease. The leaflet, Smoking andblindness, from the charity NorthWest Action on Smokingand Health, aims to highlight the ocular effects of smoking topatients and the public. The leaflet has been forwarded to allUK ophthalmologists and optometrists and has also beenmade available to UK specialist ophthalmic pharmacists. It isalso available for free downloading (www.nwash.co.uk).

1 NHS Executive. New NHS smoking cessation services (HSC1999/087). London: Department of Health; 1999.

2 Department of Health. A vision for pharmacy in the new NHS.London: Department of Health; 2003. http://www.dh.gov.uk/en/Consultations/Closedconsultations/DH_4068353 (accessedMarch 31, 2008).

3 Department of Health. Choosing health through pharmacy: aprogramme for pharmaceutical public health 2005–2015. London:Department of Health; 2005. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/docu-ments/digitalasset/dh_4107496.pdf (accessed March 31, 2008).

4 Sinclair HK, Bond CM, Stead, LF. Community pharmacypersonnel interventions for smoking cessation (Cochranereview). The Cochrane Library Issue 1. Oxford: UpdateSoftware; 2004.

5 McRobbie H, McEwan A. Helping smokers to stop: advice forpharmacists in England. London: National Institute for Healthand Clinical Excellence, Royal Pharmaceutical Society of GreatBritain and PharmacyHealthLink; 2005.

6 Editorial: Stop smoking document offers practice points forpharmacists. Pharm J 2005;275:(7364):267. http://www.pjonline.com/Editorial/20050827/society/p267stopsmoking.html(accessed March 31, 2008).

7 Scientific Committee on Tobacco and Health. Report of theScientific Committee on Tobacco and Health. London: TheStationery Office; 1998.

8 Thornton J, Edwards R, Mitchell P et al. Smoking andage-related macular degeneration: a review of association. Eye2005;19:935–44.

9 Kelly SP, Thornton J, Lyratzopoulos G, Edwards R, Mitchell P.Smoking and blindness – Strong evidence for the link, but publicawareness lags. Br Med J 2004;328:537–8.

10 Kelly SP, Thornton J, Edwards R, Sahu A, Harrison R. Smokingand cataract: review of causal association. J Cataract RefractSurg 2005;31:2395–404.

11 Thornton J, Kelly SP, Harrison RA, Edwards R. Cigarettesmoking and thyroid eye disease: a systematic review. Eye2007;21:1135–45.

12 Solberg Y, Rosner M, Belkin M. The association between ciga-rette smoking and ocular diseases. Surv Ophthalmol 1998;42:535–47.

13 Thornton J, Edwards R, Harrison RA et al. ‘Smoke gets in youreyes’: a research-informed professional education and advocacyprogramme. J Public Health 2007;29:142–6.

14 Hassell K, Seston L, Eden M. Pharmacy workforce census2005: main findings. London: Royal Pharmaceutical Society ofGreat Britain; 2006.

15 Dean AG, Sullivan KM, Soe MM. OpenEpi: open sourceepidemiologic statistics for public health, Version 2.2. www.OpenEpi.com (accessed March 31, 2008).

16 Sahu A, Edwards R, Harrison RA, Thornton J, Kelly SP.Attitudes and behaviour of ophthalmologists to smoking cessa-tion. Eye 2008;22:246–50.

17 Edwards D, Freeman T, Gilbert A. Pharmacists’ role in smokingcessation: an examination of current practice and barriers to ser-vice provision. Int J Pharmacy Pract 2006;14:315–17.

18 Williams DM, Newsom JF, Brock TP. An evaluation of smokingcessation-related activities by pharmacists. J Am Pharm Assoc(Wash) 2000;40:366–70.

19 Hudmon KS, Prokhorov AV, Corelli RL. Tobacco cessationcounseling: pharmacists’ opinions and practices. Patient EducCouns 2006;61:152–60.

20 Ashley MJ, Victor JC, Brewster J. Pharmacists’ attitudes, roleperceptions and interventions regarding smoking cessation fromfour Canadian provinces. Chronic Dis Can 2007;1/2:20–8.

21 Bidwell G, Sahu A, Edwards R et al. Perceptions of blindnessrelated to smoking: a hospital-based cross-sectional study. Eye2005;19:945–8.

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22 Moradi P, Thornton J, Edwards R et al. Teenagers’ perceptionsof blindness related to smoking – novel message to a vulnerablegroup. Br J Ophthalmol 2007;91:605–7.

23 Carroll T, Rock B. Generating Quitline calls during Australia’sNational Tobacco Campaign: effects of television advertise-ment execution and programme placement. Tob Control 2003;12:ii40–4.

24 Wilson N, Hodgen E, Mills J et al. Journal article on smokingand blindness prompts significantly more calls to the Quitline.N Z Med J 2002;115:199–200.

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Smoking cessation support in community pharmacies: is the association of smoking and eye disease an additional tool to increase uptake?