Would Pharmacy Students Advocate Green Pharmacy Given Their Preference for Medicines With Environmental Impact?

Objective: To investigate the preferences among university students in Gothenburg, Sweden for medicines that have a different environmental impact with respect to effect and explore to what extent having received information about pharmaceuticals’ potential harm to the environment is associated with the stated preferences. Methods: A survey was conducted among students in different study programs at the University of Gothenburg, Sweden. In all, 704 students received oral and written information about the study at the end of a lecture and were invited to take part (response rate: 83.5%). The questionnaire contained items about medicinal environmental information and 2 scenarios with fictious medicines as options for the treatment or symptom relief of minor ailments in humans. Results: Overall, 53.3% of the students (pharmacy students: 57.8%) had received information about the environmental impact of medicines, and 79.6% (pharmacy students: 80.6%) reported that they had concerns about the consequences. Twenty percent (pharmacy students : 9.0%) named the university as an information source. The students were most satisfied overall with the least effective and most environmentally friendly medicines. Consistently, pharmacy students gave higher scores to the most environmentally harmful medicines, especially compared with medical and health care students. Pharmacy students, who, to the same extent as medical and health care students had received information about medicines’ environmental impact, were less likely to state environmentally friendly options with an inferior effect as their preferred choice. Conclusion: Pharmacy students generally rated the medicines higher than other student groups, despite being aware of the harmful effects on the environment.


Introduction
Pharmaceuticals' potential environmentally harmful properties have been of interest to environmental scientists for decades. 1,2wenty-five years ago, Halling-Sørensen and colleagues 3 published a rich review of transformation studies showing that pharmaceuticals and their residues are able to reach the environment through a myriad of pathways.More recently, seminal research has been published on how these substances can have physiological effects on living organisms, even in low concentrations, after entering nature. 4,5reen pharmacy is a concept that has evolved as a response to the increased insight into the harmful effects of pharmaceuticals. 6,7Included in the concept are measures to minimize the environmental footprint during all stages of the medicine's life cycle, from research and development via prudent prescribing and dispensing to safe disposal.The term is derived from "green chemistry" (eg, minimizing the use of ecologically hazardous reagents and designing alternate synthesis pathways) and was described in detail by Daughton 6 at the beginning of this century.
In 2016, the International Pharmaceutical Federation published a policy statement on Green Pharmacy Practice that acknowledged the impact of pharmaceuticals on the environment as a challenge of global significance. 8The federation recommended that schools of pharmacy should consider the environmental effects of medicines in their curricula and teach "green principles." 8 Other actors in the sector have published similar statements.The Pharmaceutical Group of the European Union, which represents community pharmacists in 32 European countries, calls for the exploration of "the inclusion of environmental aspects for pharmaceuticals posing a risk to or via the environment in the training of pharmacy students and continuous professional development programs as part of a One Health approach." 9The pharmaceutical industry has also, at a European level, developed a policy to minimize pharmaceutical contamination along the life cycle of the product, with a focus on extended environmental risk assessment and manufacturing effluents management. 10ence, the way forward should be to educate pharmacists about the sources and consequences of pharmaceutical pollution in theory and regarding how to put it into practice.Pharmacists, alongside other health professionals, are important mediators of environmental aspects of medicine use between academia and the public. 11Not only are they in a key position to raise awareness but they are also able to affect the patterns of use.As experts on medicines in spe, pharmacy students should be educated to assess the rationality of prescribed medicine regimes and, as suggested by International Pharmaceutical Federation, to "consider the environmental aspects of medicine use in their practice." 12Embedded in this green pharmacy perspective is not only the provision of advice on environmentally friendly options but also avoidance of recommending products with little or no benefit to the patients/customers.In Sweden, a country recognized within the European Union for its strong advocacy of measures to restrict such contamination, 11,13 the topic is, albeit with few exceptions, virtually absent from pharmacy programs' curricula.However, although there is no established commitment to incorporate environmental aspects of pharmaceutical use in Swedish pharmacy education, in recent years, there has been an increased focus on the Agenda 2030 and the Sustainable Development Goals at the university as a whole, 14 which may have led to greater attention also being paid to environmental aspects at the course level.
In a previous study, we investigated whether simple information about environmental harm would affect people's medicine choices in hypothetical situations. 15To measure how people would value environmentally friendly medicines, we designed an experimental survey where respondents were told to make trade-offs between the medicines' environmental impact and effect.Worth noting is that this does not necessarily mean that more effective medicines are more environmentally harmful.The results showed that people in Sweden are willing to forgo some of the effect if they can choose a more environmentally friendly medicine for minor ailments.As shown by Luís and colleagues 16 (2020), lay people have a tendency to perceive a lower risk with pharmaceuticals in the environment compared with experts (eg, pharmacists).At the same time, young adults seem to perceive less risk than older individuals. 17With that in mind, we aimed to investigate preferences for medicines with a different environmental impact with respect to effect among university students in Gothenburg, Sweden.More specifically, we wanted to compare the preferences among pharmacy students with those of students in other fields of study and explore to what extent having received information about pharmaceuticals' potential harm to the environment is associated with the stated preferences.

Methods
A survey was conducted on the University of Gothenburg campus during the spring semesters 2020 and 2022.Permission was obtained from the teacher responsible for the course before students were informed orally and in writing about the study and asked in connection with a lecture to participate.The target group consisted of students in pharmacy, medicine, and other health care study programs as well as students in economics, law, and social sciences.Students in all year levels were eligible for the study.A total of 704 students were present at the lectures where the recruitment took place, and the response rate was 83.5%.Consent forms and questionnaires were handed out by a project assistant and returned in separate envelopes.Completed questionnaires were treated anonymously and could not be traced back to respective student cohorts.The Swedish Ethical Review Authority stated that an ethical approval was not required according to Swedish law.
Data were collected with a paper questionnaire, which was modeled on questionnaires used in previous studies 15,17 and modified to suit the target group.The first part of the questionnaire contained items about gender, age, medicine purchased during the past 12 months, information received, and concerns about the environmental impact of medicines.In the second part, the participants were presented with 2 scenarios related to medicines used for treatment or symptom relief for minor ailments in humans.The first scenario dealt with fictitious medicines for the relief of symptoms caused by a common cold, whereas the second scenario described fictitious medicines used to reduce pain in individuals with muscle inflammation.
Succeeding each scenario, the participants were shown a table that displayed the therapeutic effect and environmental harm of the 3 medicines they were asked to consider.The proportion of patients described as symptom-free in the 2 scenarios was 90% (medicines: fluvonox and lumenoxin), 70% (medicines: oroflexol and blenasirad), and 50% (medicines: minohydren and reganolox), whereas the corresponding environmental harm for the same medicines was described as a decline in fish stocks of 40%, 20%, and 0%, respectively.A detailed description of the fictitious medicines included in the study is described in Appendix 1. Subsequently, the participants were instructed to assume that the first option was the only medicine available to them.They were then asked how satisfied they would be with this medicine under the given circumstances, considering its effect and environmental harm.Satisfaction was rated on a continuous scale from 1 to 10, where 1 = "not at all satisfied" and 10 = "extremely satisfied."The question was then repeated for the second and third options of that scenario.They were also asked to rate the 3 options as their first, second, or third preferred option.
SPSS Statistics, version 26 (SPSS Inc) was used in the analyses of the data.Pearson χ 2 tests, with subsequent Bonferroni-Holm adjusted post hoc tests, were used to examine any differences in the fields of study in relation to background variables (gender, age group, and purchase of medicines), having received information about the environmental impact of medicines, and related concerns (Table 1), as well as the choice of medicines in the 2 scenarios (Figure).The student's fields of study were categorized into 3 variables: "pharmacy," "medicine and health care," and "economics, law, and social sciences."In Sweden, there are 2 separate programs in pharmacy: pharmacy (5 years) and dispensing pharmacy (3 years).Students from both programs were included in the study and categorized as "pharmacy students."Age was categorized into 2 age groups: 19 to 24 years and 25 to 54 years.In the statistical tests, "other gender" was excluded because of the small numbers.To investigate any possible association between having received information about pharmaceuticals' potential harm to the environment and their stated preferences, Pearson χ 2 tests were conducted.Moreover, P values < .05were considered statistically significant, and mean scores were calculated for the participants' stated satisfaction with a given medicine.A 1-way analysis of variance, with subsequent Bonferroni-Holm adjusted post hoc tests, was performed to compare the mean scores in relation to field of study (Table 2).We used the Cohen criteria to determine effect size (ƞ 2 = 0.01: small effect; ƞ 2 = 0.06: medium effect; ƞ 2 = 0.14: large effect). 18Logistic regression was used to investigate the odds ratios for stating a preference for the most and least environmentally friendly medicine in relation to background variables.

Results
In total, 588 students participated in the study: 359 (61.1%) in 2020 and 229 (38.9%) in 2022.Both years included students from different programs.There was a preponderance of women (71.6%), and the mean age was 24.7 years (SD 4.86).A majority (93.6%) reported that they had purchased medicines during the past 12 months, of which the proportions were statistically similar in 2020 and 2022 (92.8% vs

92.1%
).There was no difference between the proportions who reported such purchases in relation to field of study (Table 1).Overall, 53.3% of the students had received information about the environmental impact of medicines, and 79.6% reported that they had concerns about the consequences.Table 1 shows the distribution of these results in relation to field of study.There was no difference in reported concerns between the year 2020 and 2022 (80.5% vs 78.2%).Media, including social media, followed by medicine packages/insert leaflets and friends and family were the most mentioned sources of information regarding medicines' environmental impact.As shown in Table 3, 9.0% of the pharmacy students cited the university as a source.
For both scenarios, the students stated their satisfaction with the medicines, given that this medicine was the only medicine available to them.The highest mean scores were obtained for the least effective and most environmentally friendly medicines (minohydren: 6.00; reganolox: 5.97).Correspondingly, the most effective and least environmentally friendly medicines received the lowest scores (fluvonox: 4.95; lumonexin: 5.33).For the medicines in between in terms of effect and environmental harm, the mean scores were 5.65 (oroflexol) and 5.95 (blenasirad).
One-way analysis of variances showed that there were significant differences in the distribution of scores for the medicines in the 2 scenarios across the 3 fields of study.As seen in Table 2, pharmacy students gave higher scores to the most environmentally harmful medicines (fluvonox and oroflexol; lumonexin and blenasirad) compared with the other student groups.The effect sizes were small overall (Table 2).
The figure shows how the students responded when they were asked to state their preferred choice of medicine if they had to choose between the medicines in relation to field of study.
In the cold scenario, 40.6% stated the least effective and most environmentally friendly option (minohydren) as their preferred choice, whereas the corresponding proportion for the muscle inflammation scenario (reganolox) was 34.1%.The proportions that stated a preference for the most effective and least environmentally friendly options (fluvenonox and lumonexin) were 20.7% for the cold scenario and 25.9% for the muscle inflammation scenario.As shown in Table 4, a significantly lower proportion of pharmacy students stated the most environmentally friendly medicine as their preferred choice and a significantly higher proportion stated the least environmentally friendly medicine as their preferred choice than medical and health care students.A higher proportion of medical and health care students also stated more environmentally friendly choices than economy, law, and social science students.It was also shown that age was a significant factor in their stated choices, as were reported concerns about the environmental impact of medicines (Table 4).

Discussion
This study showed that there is a certain willingness to take environmental considerations into account when choosing medicines for minor ailments among students at a Swedish university.In the design of this study, as in previous studies, 15,17 we weighed the effect against environmental harm, although this does not necessarily reflect the type of individual choices faced when choosing a medicine.One such example could, however, be diclofenac in the choice of anti-inflammatory medicine for muscle inflammation.Pharmacy students, who, to the same extent as the medical and health care students, stated that they had received information about medicines' environmental impact, were less likely to choose environmentally friendly options with an inferior effect.Although few pharmacy students cited their education as a source of information compared with medical students, a significant proportion had received information from the pharmacy, which is also a reliable source in this context.Nevertheless, the pharmacy students consistently gave environmentally harmful medicines higher scores Abbreviations: ANOVA, analysis of variance; M, mean; SD, standard deviation.a Significant mean differences between pharmacy students and medical/health care students (according to Bonferroni-Holm adjusted post hoc tests).
b Significant mean differences between medical/health students and economics, law, and social science students (according to Bonferroni-Holm adjusted post hoc tests).
c Significant mean differences between all 3 students (according to Bonferroni-Holm adjusted post hoc tests).
d Significant mean differences between pharmacy students and economics, law, and social science students (according to Bonferroni-Holm adjusted post hoc tests).
than medical and health care students, except when it came to the least environmentally harmful options.In 1 of 2 scenarios, they also gave the medicines higher scores than economics, law, and social science students.
As mentioned previously, age should be considered when studying risk perceptions. 17In the present study, students who were more than 24 years of age were more likely to state the most environmentally friendly medicines as their preferred choice than younger students.However, although there was an age effect, the analysis in Table 4 shows that the observed differences between the fields of study remained significant after adjusting for gender and age.Unsurprisingly, having concerns about the environmental impact of medicines was also a significant factor in the choice of medicine.
Compared with the results of a Swedish study based on the adult population, 15 a higher proportion of students reported that they had concerns about the environmental effects of medicines (79.6% vs 55.7%).There was also a higher proportion of students who reported having received information about medicines' environmental impact (53.3% vs 34.7%). 15It is therefore noteworthy that they were less likely to state environmentally friendly medicine choices than the general population (eg, 40.6% vs 68.2% for the most environmentally friendly medicine for the treatment of a common cold).Two possible explanations could be age, as mentioned earlier, and ongoing education.A previous Swedish study has shown that students in pharmacy and medicine hold strong beliefs in medicines' beneficial effects compared with pharmacy customers, despite a recognition that they can also be harmful and overprescribed. 19However, if students are to be perceived as experts in spe, this argument is contradicted by the study of Luís and colleagues, 16 which showed that lay people tend to perceive that pharmaceuticals pose a lower risk to the environment.
Either way, the current results imply that there is a gap between the students' environmental concerns and their willingness to take environmental considerations into account when choosing medicines.However, the reasons why students respond as they do remain to be investigated.One explanation could be that they have an individual-/ patient-based focus and thus consider that such challenges should be dealt with at the system level.Another possible explanation, although perhaps less liable, is that younger people in general are less likely to adopt preventive measures when things are put to the test, as has been seen, such as in research from the recent pandemic. 20Furthermore, the extent of social desirability bias is difficult to estimate.Environmental interest in Sweden has been stably high over the last decennium, which might make it socially desirable to report an engagement in environmental topics.However, research among students on social desirability in relation to self-reported measures of environmental attitudes and ecological behavior has shown that this does not constitute a bias. 21nly a few pharmacy students stated that they had received information about medicines' environmental impact through their education.Instead, the pharmacy was identified as the main source of such information, which may be because they had completed their internship, worked alongside studies, or been customers.This bodes well for the green pharmacy practiced in Sweden.Swedish pharmacies have received attention for their green pharmacy initiatives, which include, among others, the voluntary environmental transparency labeling of over-the-counter medicines ("well selected") and distribution of free bags and bonuses for returning unused/expired medicines for safe disposal.
Concerning limitations, social desirability bias has already been mentioned.In this study, participants were presented with a brief description of 2 scenarios for which they were asked to state their preferred choice of medicinal treatment.We included 3 variables, including ailment, therapeutic effect, and environmental harm, and stated that the risk of side effects was equal.When applying such simplified models of real-world decision-making, there is always the possibility that the people's responses do not reflect actual behavior.However, research on this intention-behavior gap shows that intentions are translated into action about half of the time and seen as a valuable and accurate predictor of behavior. 22Moreover, studies among students have shown that environmental attitudes, which greatly influences intentions, are strongly related to ecological behavior. 21With regard to environmental measures, there is evidence that increasing peoples' perception of policies' effectiveness can enhance their proenvironmental intentions and behavior and reduce the intention-behavior gap. 23If one envisions more proactive green pharmacy advocates among future pharmacists, this is a vital point.It is clear from this study that educational pathways and information received during education can have an impact on medicine preferences that can benefit the environment.
It should be noted that these results are from 1 university and cannot automatically be generalized to other universities in Sweden.Even if there is a national, common curriculum, the course content may vary.For example, Uppsala University has an elective course on pharmaceuticals in the environment that master's students in pharmacy can register for.It is also conceivable that as more research on pharmaceuticals in the environment is conducted, existing and new courses will be developed on different perspectives concerning this important area.Inspiration for strengthening the education on green pharmacy can be obtained by looking at the University of Helsinki, where they have integrated environmental aspects into all higher education in pharmaceutical and medical sciences.Percentages indicate the proportion in each group (eg, of all women or all men) who have stated this medicine as their preferred choice.What is not shown directly in the table are those who have not stated this as their first choice.Abbreviation: OR, odds ratio; CI, confidence interval.

Conclusion
As future pharmacists in various work roles, pharmacy students can play an important role in how medicines are designed, managed, and used from an environmental perspective.This study from Sweden shows that just over half of the pharmacy students knew that medicines could have a negative impact on the environment.The results also show that pharmacy students are less likely than other students to cite their education as the source of this information.Pharmacy students generally rated the medicines higher than other student groups, despite their harmful effects on the environment.Although the study examined the choice of medicines for personal use in a hypothetical setting, the results are important because personal preferences can influence how one communicates and acts in practice.To boost the further implementation and development of the green pharmacy in the Swedish pharmacy sector, it is time to enforce education so that future pharmacists have a thorough understanding of the environmental impact of their professional responsibilities.

Figure .
Figure.Preferred Choice of Medicine in the 2 Presented Scenarios in Relation to Field of Study.a Most effective and least environmentally friendly.b Moderately effective and environmentally friendly.c Least effective and most environmentally friendly.d Significant differences between medicine and health care students compared with other students according to Bonferroni-Holm adjusted post hoc tests.

Table 1
Background Information of the Study Population in Relation to Field of Study (N = 588).Significant differences in the distribution of women and men between all 3 fields of study according to Bonferroni-Holm adjusted post hoc tests.c Significant differences in age distribution between the pharmacy and the medical/health care students according to Bonferroni-Holm adjusted post hoc tests.d Significantly fewer economics, law and social science students had received information compared with pharmacy, medical, and health care students according to Bonferroni-Holm adjusted post hoc tests.
b e Insignificant differences between fields of study according to Bonferroni-Holm adjusted post hoc tests.

Table 2
One-Way ANOVA Comparing the Mean Scores of the Different Medicines Across 3 Fields of Study. 24

Table 3
Reported Source of Information About Medicines' Environmental Impact in Relation to Field of Study (N = 312) (Multiple Answers Were Possible).

Table 4
Adjusted ORs for Stating a Preference for the Most and Least Environmentally Friendly Medicine in Relation to Background Variables.