Sale of tobacco products in pharmacies: results and implications of an empirical study

Placement and sales of tobacco products and nicotine replacement therapy in tobacco-free and tobacco-selling pharmacies in Northern California: an observational study

OBJECTIVES

Although tobacco is the leading preventable cause of death in the USA, it is routinely sold in pharmacies. In 2008, San Francisco became the first city in the USA to pass a tobacco-free pharmacy ordinance. Over the next decade, 171 municipalities enacted similar policies, and in 2018, Massachusetts banned tobacco sales in pharmacies. Our objective was to assess the perceived effects of tobacco-free pharmacy policies on displays, sales, customer visits and counselling.

DESIGN

Observational study and survey.

SETTING

In 2017, we visited Walgreens and CVS stores in San Francisco and nearby San Jose, which allows tobacco sales, to assess placement of tobacco and over-the-counter tobacco cessation products (nicotine replacement therapy or NRT). We surveyed an employee at each site regarding the impact that tobacco-free pharmacy policies had had on customer traffic and sales of NRT.

PARTICIPANTS

We obtained display data from 72 pharmacies and collected surveys from 55 employees (76% response rate).

RESULTS

A majority of respondents at tobacco-free pharmacies (55%) reported that the policy had not affected customer visits. In comparison, 70% of respondents at tobacco-selling pharmacies believed that eliminating tobacco sales would reduce the number of customers visiting their stores. Pharmacies that were tobacco free and those that sold tobacco reported comparable displays, sales and counselling for NRT.

CONCLUSIONS

Pharmacies operating under tobacco-free policies did not report reduced customer visits. Greater awareness of this outcome could help pharmacies implement public health recommendations to eliminate tobacco sales.

Twitter users' reaction to a chain pharmacy's decision to end tobacco sales

Background

Reducing the number of tobacco outlets may help reduce smoking uptake and use; public support for such action is essential. We explored how Twitter users responded to the announcement by US pharmacy chain CVS that it was voluntarily ending tobacco sales.

Methods

We used Twitter’s application programming interface to retrieve tweets and retweets posted over an 8-day period in February 2014 that contained two trending CVS-related hashtags (#cvs and #cvsquits). We manually coded 6,257 tweets as positive, negative, or neutral.

Results

The majority of tweets were positive (56.0 %) or neutral (39.4 %).

Conclusions

There was little disapproval of CVS’s decision to end tobacco sales among Twitter users, possibly due to the voluntary nature of the decision. The level of support suggests that CVS’s image and bottom line will not suffer as a result. Further voluntary actions to end tobacco sales – which may lay the groundwork for legislation -- should be incentivized and supported.

Pharmacists' Perceptions of Tobacco Sales in an Elevated-Risk Population

Background: Policies by the American Medical Association and the American Pharmacists Association advocate for the discontinuation of tobacco sales in pharmacies, yet tobacco sales remain lucrative for pharmacies in the United States. West Virginia has the highest smoking rate (29%) and the second highest lung cancer incidence in the country. Objective: This study examined pharmacists' perceptions of tobacco sales in pharmacies and awareness of relevant policies. Methods: West Virginia pharmacists (n = 195) were surveyed to understand tobacco sales in West Virginia pharmacy, utilizing Diffusion of Innovations as a theoretical framework. Results: Eighty-one percent were community pharmacists, and 39% practiced at independent pharmacies. Sixty-two percent reported that their pharmacies did not sell tobacco. Pharmacists at independent pharmacies were more likely to be in rural areas/small towns, have decision-making control over tobacco sales, and not currently selling tobacco products. Other community pharmacists (ie, at regional and national chains) were more likely to sell tobacco products, not have decision-making control over tobacco sales, and perceive revenue loss from discontinuing tobacco sales. Other types of pharmacists (eg, hospital) estimated a greater number of patients who were smokers/tobacco users. A logistic regression showed that less perceived revenue loss was associated with greater likelihood of not selling tobacco products (all Ps < .05). Conclusions: Findings indicate a strong movement among community pharmacists to curtail the use of tobacco. Generating support for the elimination of tobacco sales and adoption of tobacco cessation initiatives in community pharmacy could help reduce smoking rates in elevated-risk populations.

Understanding community norms surrounding tobacco sales

BACKGROUND

In the US, denormalizing tobacco use is key to tobacco control; less attention has been paid to denormalizing tobacco sales. However, some localities have placed limits on the number and type of retailers who may sell tobacco, and some retailers have abandoned tobacco sales voluntarily. Understanding community norms surrounding tobacco sales may help accelerate tobacco denormalization.

METHODS

We conducted 15 focus groups with customers of California, New York, and Ohio retailers who had voluntarily discontinued tobacco sales to examine normative assumptions about where cigarettes should or should not be sold, voluntary decisions to discontinue tobacco sales, and government limits on such sales.

RESULTS

Groups in all three states generally agreed that grocery stores that sold healthy products should not sell tobacco; California groups saw pharmacies similarly, while this was a minority opinion in the other two states. Convenience stores were regarded as a natural place to sell tobacco. In each state, it was regarded as normal and commendable for some stores to want to stop selling tobacco, although few participants could imagine convenience stores doing so. Views on government's role in setting limits on tobacco sales varied, with California and New York participants generally expressing support for restrictions, and Ohio participants expressing opposition. However, even those who expressed opposition did not approve of tobacco sales in all possible venues. Banning tobacco sales entirely was not yet normative.

CONCLUSION

Limiting the ubiquitous availability of tobacco sales is key to ending the tobacco epidemic. Some limits on tobacco sales appear to be normative from the perspective of community members; it may be possible to shift norms further by problematizing the ubiquitous presence of cigarettes and drawing connections to other products already subject to restrictions.

Tobacco and alcohol sales in community pharmacies: policy statements from U.S. professional pharmacy associations

OBJECTIVE

To characterize the extent to which state and national professional pharmacy associations have implemented formal policies addressing the sale of tobacco and alcohol products in community pharmacies.

METHODS

To determine existence of tobacco and alcohol policies, national professional pharmacy associations (n = 10) and state-level pharmacy associations (n = 86) affiliated with the American Pharmacists Association (APhA) and/or the American Society of Health-System Pharmacists (ASHP) were contacted via telephone and/or e-mail, and a search of the association websites was conducted.

RESULTS

Of 95 responding associations (99%), 14% have a formal policy opposing the sale of tobacco products in pharmacies and 5% have a formal policy opposing the sale of alcohol in pharmacies. Of the associations representing major tobacco-producing states, 40% have a formal policy against tobacco sales in pharmacies, significantly more than the 8% of non-tobacco state associations with such policies.

CONCLUSION

Among national professional pharmacy associations, only APhA and ASHP have formal policy statements opposing the sale of both tobacco and alcohol in pharmacies. Most state-level professional pharmacy associations affiliated with these two national organizations have no formal policy statement or position.

Availability and range of tobacco products for sale in Massachusetts pharmacies

OBJECTIVE

New tobacco control policies have been introduced in Massachusetts which restrict tobacco product sales in pharmacies. The purpose of this investigation was to outline the scope of pharmacy involvement in the tobacco market by assessing the availability and range of tobacco products sold in Massachusetts pharmacies.

METHODS

Public listings of licenced pharmacies and tobacco retailers in Massachusetts were examined to determine the proportion of pharmacies licenced to sell tobacco, and the proportion of tobacco retailers possessing a pharmacy licence. Telephone interviews were conducted with a random sample (n=70) of pharmacies possessing a tobacco licence to assess the availability and range of tobacco products for sale. The availability of nicotine replacement therapy (NRT) products was assessed as a comparison.

RESULTS

The majority of pharmacies in Massachusetts possessed a tobacco licence (69%), and pharmacies made up 9% of licenced tobacco retailers. Among pharmacies surveyed that reported selling tobacco (90%), cigarettes were the most available tobacco product for sale (100%), followed by cigars (69%), little cigars/cigarillos (66%), moist snuff (53%), pipe tobacco (49%), roll-your-own tobacco (34%), snus (14%), dissolvable tobacco (11%) and electronic cigarettes (2%). Nearly all pharmacies selling tobacco offered the nicotine patch (100%), gum (100%) and lozenge (98%).

CONCLUSIONS

Tobacco-free pharmacy policies would affect a majority of Massachusetts pharmacies and remove a variety of tobacco products from their store shelves. Further, nearly one in ten tobacco retailers would be eliminated by prohibiting tobacco sales in Massachusetts pharmacies statewide.

Why California retailers stop selling tobacco products, and what their customers and employees think about it when they do: case studies

BACKGROUND

In California, some 40,000 retailers sell tobacco products. Tobacco's ubiquitousness in retail settings normalizes use and cues smoking urges among former smokers and those attempting cessation. Thus, limiting the number of retailers is regarded as key to ending the tobacco epidemic. In the past decade, independent pharmacies and local grocery chains in California and elsewhere have voluntarily abandoned tobacco sales. No previous studies have examined the reasons for this emerging phenomenon. We sought to learn what motivated retailers to discontinue tobacco sales and what employees and customers thought about their decision.

METHODS

We conducted case studies of seven California retailers (three grocery stores, four pharmacies) that had voluntarily ceased tobacco sales within the past 7 years. We interviewed owners, managers, and employees, conducted consumer focus groups, unobtrusively observed businesses and the surrounding environment, and examined any media coverage of each retailer's decision. We analyzed data using qualitative content analysis.

RESULTS

For independent pharmacies, the only reason given for the decision to end tobacco sales was that tobacco caused disease and death. Grocers listed health among several factors, including regulatory pressures and wanting to be seen as "making a difference." Media coverage of stores' new policies was limited, and only three retailers alerted customers. Management reported few or no customer complaints and supportive or indifferent employees. Pharmacy employees were pleased to no longer be selling a deadly product. Grocery store management saw the decision to end tobacco sales as enhancing the stores' image and consistent with their inventory of healthy foods. Focus group participants (smokers and nonsmokers) were largely unaware that retailers had stopped selling tobacco; however, almost all supported the decision, viewing it as promoting public health. Many said knowing this made them more likely to shop at the store. Most thought that advertising the store's policy was essential to generate good public relations and tobacco norm changes.

CONCLUSIONS

Voluntary retailer abandonment of tobacco sales both reflects and extends social norm changes that have problematized tobacco in California. Our findings suggest that such voluntary initiatives by retailers are welcomed by consumers and should be publicized, enhancing public health efforts.

Disparities in access to over-the-counter nicotine replacement products in New York City pharmacies

OBJECTIVES

We surveyed the availability of tobacco products and nonprescription nicotine replacement therapy (NRT) in pharmacies in New York City, stratified by the race, ethnicity, and socioeconomic status (SES) of the surrounding neighborhoods to determine whether disparities in availability existed.

METHODS

Surveyors visited a random sample of retail pharmacies to record the availability of tobacco products and nonprescription NRT. We used census data and geographic information systems analysis to determine the SES of each neighborhood. We used logistic modeling to explore relations between SES and the availability of NRT and tobacco products.

RESULTS

Of 646 pharmacies sampled, 90.8% sold NRT and 46.9% sold cigarettes. NRT and cigarettes were slightly more available in pharmacies in neighborhoods with a higher SES. NRT was more expensive in poorer neighborhoods.

CONCLUSIONS

Small disparities existed in access to nonprescription NRT and cigarettes. The model did not adequately account for cigarette access, because of availability from other retail outlets. These results may explain some of the excess prevalence of cigarette use in low-SES areas.

An evaluation of smoking cessation-related activities by pharmacists

OBJECTIVES

To (1) describe the types of smoking cessation intervention activities performed by community pharmacists and (2) assess the perceived barriers to this type of intervention.

DESIGN

Confidential mail questionnaire.

SETTING AND PARTICIPANTS

541 community pharmacists in North Carolina and 946 community pharmacists in Texas.

RESULTS

North Carolina and Texas differ with respect to the sale of cigarettes at the practice site, with North Carolina pharmacies being more likely to sell tobacco products. Overall, 555 (92.5%) respondents reported that they do not routinely ask new patients if they smoke or use tobacco products. Pharmacists described themselves as knowledgeable about smoking cessation therapies, and 42% of respondents had attended an educational program on smoking cessation. A total of 230 (39.5%) reported consistently counseling individual patients about smoking cessation treatment strategies on at least a weekly basis. Exploratory factor analysis identified four dimensions of barriers that inhibit pharmacists from engaging in smoking cessation-related activities: (1) pharmacist interpersonal characteristics, (2) practice site considerations, (3) patient characteristics, and (4) financial concerns.

CONCLUSION

Pharmacists have an opportunity to identify health risks and counsel patients about disease-preventing lifestyle changes. These findings suggest that although pharmacists believe they are qualified to perform smoking cessation interventions, they do not routinely identify smokers and they perceive several barriers to participating in such activities. Pharmacists should investigate increased involvement in smoking cessation activities for the benefit of their patients and for the potential professional and economic rewards.