Abstract(resumo):

Chronic non-communicable diseases (NCDs) significantly contribute to global mortality and diminished quality of life, placing a growing burden on healthcare systems. The World Health Organization has developed cost-effective strategies to manage these diseases, entitled “best buys”, by addressing major risk factors for NCDs, such as smoking, alcohol use, unhealthy diets, and physical inactivity. Pharmacies, as accessible healthcare facilities, are well-positioned to support preventive care and behaviour change, including tobacco and alcohol cessation, dietary modifications, and physical activity promotion. Legislation in some countries, like Portugal, empowers pharmacies to deliver health promotion services to the communities they serve. Strengthening collaboration between pharmacies, other healthcare services, and public health authorities can amplify the impact of these initiatives, improving population health outcomes.

Keywords(palavra-chave):

non-communicable diseases, primary care, pharmacy, healthcare, health promotion

Content(conteúdo):

Commentary

Non-communicable diseases (NCDs) are leading causes of global mortality - killing 41 million people each year (equivalent to 74% of all deaths globally), and morbidity, affecting the quality of life of a significant part of the population.1 The rising threat of these conditions has the potential to create a future society where the health impact can be a relevant burden for healthcare systems in terms of costs and management of services.2

In 2010, the World Health Organization (WHO) proposed a package of envisioned "best buys" that are a set of cost-effective (<$120,000 per disability-adjusted life-year averted), evidence-based interventions to reduce the burden of NCDs.3 Best-buys focus on the four major risk factors for NCDs (smoking, alcohol use, unhealthy diet and physical inactivity) and on four disease groups (cancer, cardiovascular disease, diabetes and chronic respiratory disease). The risk-factor-related recommended interventions include policy measures (e.g. increasing taxes), non-pharmacological measures (e.g. counselling) and pharmacological measures (e.g. availability of nicotine replacement therapy), whereas those addressing the disease groups tend to be more focused on reducing, modifying or eliminating these risk factors at the individual level and/or on health systems’ accessibility and efficiency (e.g. cervical cancer screening). Regardless of the sector where these focus, they all have the same rationale and ultimate goal, which is to contribute to progress in the nine global voluntary targets agreed in the NCD Global Monitoring Framework.4 These interventions have since their development been reviewed and updated, in 2017,5 in 2022,6 and then in 2024.7 In 2025, a new concept has been proposed, “the quick buys”, which are a subset of “best buys” that could exhibit measurable effects within 5 years. A total of 25 quick buys were chosen out of a subset of 49 pre-selected as meeting the best buy criteria in at least one country income stratum.8

Pharmacies are accessible healthcare touchpoints, often acting as the first line of contact for individuals in managing their health and can play a critical role in screening for NCDs and their risk factors, offering preventive care and health education.9 Globally, the pharmaceutical sector is aligned in the importance of tackling NCDs as part of professional development.10 The use of short and brief interventions (SBI) is recognized by WHO as an effective measure to tackle behaviour change, and can translate to significant health benefits at population level when systematically applied.11

Tobacco cessation is one of the areas where pharmacists can be involved and support people in reducing or quitting smoking, as besides the interventions from pharmacy teams, there is also a variety of effective medicines available in the pharmacy that can support people in their smoking cessation journey (considered one of the 5 quick buys).12 Tobacco cessation interventions can provide effective behavioural support to people intending to quit smoking, for example through SBI (considered a best buy).13 As smoking cessation is a behaviour that needs an intervention where people need to change, standardized interventions provided by pharmacists involving educational and motivational components seem to be a good predictor of success rates.14, 15 Further, there are also examples of smaller scale studies that support the cost-effectiveness of these interventions.16, 17

Interventions to tackle alcohol consumption are scarcely reported in the literature compared to other risk factors.18 As it is the case with SBI that address the various risk factors,19 the topic of alcohol consumption seems to be one that requires particular attention to factors such as privacy and training for pharmacists, including on communication styles.20 While there are efforts to describe initiatives in this area, using standardized tools such as AUDIT,21 there is a clear need to invest more time and resources in the interventions that primarily target alcohol consumption by engaging community pharmacies in opportunistically approach people to reduce alcohol-related harm.22 Brief psychosocial interventions have been among the 4 selected quick buys for alcohol.

Interventions focusing on healthy diet are important to support weight management and conditions associated with nutritional imbalances, leaving a door open to use nutritional approaches as a tool in healthcare and pharmacy.23, 24 The concept of “food pharmacy” - an umbrella term for programs designed to increase public access to fruits and vegetables – can be a good starting point to further explore interventions in this area.25 Pharmacy-based interventions have the potential to improve clinical outcomes as well as result in diet changes,26 and have the potential to support weight loss.27 In Portugal, pharmacies are legally allowed to provide health promotion services in pharmacies,28 including nutritional consultations in their space delivered by a registered nutritionist.29 In addition to nutritional advice and prescription exclusive to nutritionists, pharmacists may also engage in behaviour change communication (one of the 3 quick buys), as long as duly trained.

Physical activity interventions are another option to tackle risk factors in patients using pharmacy as a gateway to care, creating more active populations.30 Only one quick buy has been identified as having the potential to induce measurable effects within 5 years in the domain of physical activity and this was the brief counselling in primary healthcare. Community pharmacies are obviously embedded in primary healthcare, being thus essential that they are considered allies to achieve targets set. However, interventions to improve physical activity through community pharmacies are usually not capturing objective outcomes and often do not demonstrate specific advice targeting physical activity.31 Moreover, it has been suggested that more opportunities to promote physical activity through short and brief interventions are needed in pharmacies.32 Creating more active populations using the pharmacy as a promotion hub can be a starting point for people to focus on their health and improve their health outcomes, as observed for example through the Health Living Pharmacy schemes in England.33, 34

The scope of practice and services pharmacists can provide in the areas of prevention and public health has been increasing in the last years, opening more opportunities to link other services to the ones described above.35 Legislation in Portugal supported the value of community pharmacies as agents of healthcare promotion and service delivery since 2016.36 Pharmacies can also expand their sphere of action outreaching their community,37 for example by offering educational workshops and organize screening, early detection or awareness raising events, as long as allowed by law, as it is the case in Portugal.29 There is still need for further research to examine the relationship between intervention effectiveness and behaviour change strategies used, implementation factors, and delivery of interventions.18 Further, there is also room for policy-makers to understand the full potential these interventions can have in improving health outcomes, reducing health-related costs and promote more sustainable healthcare systems.38

Pharmacies should therefore be able to integrate health promotion and prevention services with the overall primary care offer, sharing data with healthcare providers to ensure continuity of care. Data integration needs to be seen holistically, without the traditional borders between primary and secondary care, or between public and private sectors. National coordination is essential for seamless care, which in Portugal is ensured by the Shared Services of the Ministry of Health and the Directorate-General of Health. Although much progress in health information integration has been observed in the last 5 years, there is still room for improvement. An excellent example of integration of community pharmacies in the response provided by primary healthcare, is what is currently happening for immunization against influenza and COVID-19, where pharmacists are contributing to increase vaccination coverage and even being reimbursed to do so, as long as the intervention gets recorded in the national platform for registering and managing vaccination named “Vacinas”.39

Collaboration with public health authorities can amplify the impact in local communities and support policymakers in selecting and supporting implementation of the most cost-effective interventions. The pharmacy sector needs to contribute more data, especially focusing on the cost-effectiveness of their interventions, to justify any investments made in this sector. If the government can clearly see the gains both in health and economic outcomes, then the likelihood of these services being implemented at the national level is higher, as has happened for other public health services in Portugal.40, 41 Other examples where governments supported pharmacists’ expansion of their scope of practice in different ways in several countries was during the recent COVID-19 pandemic.42

The inclusion of new services that improve health outcomes, supported and organized in partnership between the pharmacy sector, other healthcare providers, particularly in primary care, and governments, have the potential to improve the health of the population. However, one crucial aspect that often hinders progress is the low economic investment placed on prevention, which in most countries is still a small percentage of the overall health budget.43

Author contributions: All authors contributed equally to the conception, drafting, and revision of this commentary and approved its final version.?
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