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

Real-World Effectiveness of Nicotine Replacement Therapy Sampling in Chinese Women of a Sex-Specific Smoking Cessation Program in Hong Kong, China

INTRODUCTION

Nicotine replacement therapy (NRT) sampling has been shown effective in increasing smoking abstinence by trials, but the real-world effectiveness in women is unknown. We examined the effectiveness of 1-week NRT sampling combined with counseling on smoking abstinence in Chinese women.

AIMS AND METHODS

A prospective study was conducted on 545 Chinese women (mean age: 37.7 years) receiving nurse-delivered smoking cessation counseling from the Women Quit program in Hong Kong from 2006 to 2023. 1-week free NRT sampling was offered to all participants. Participants were categorized based on NRT usage at 1 month: non-users (n = 255), users of < 1 week (n = 112), and 1-week users (n = 178). The primary outcome was self-reported 7-day point prevalence of abstinence (PPA) at 6 months.

RESULTS

Compared with non-users receiving counseling alone, 1-week users had higher 7-day PPA at 3- (aRR 1.66, 95% CI: 1.24 to 2.20) and 6-month (aRR 1.71, 95% CI: 1.29 to 2.25), higher 60-day (aRR 1.55, 95% CI: 1.03 to 2.33) and 150-day continuous abstinence (aRR 2.06, 95% CI: 1.33 to 3.20), and higher smoking reduction rates at 3- (aRR 1.66, 95% CI: 1.27 to 2.17) and 6-month (aRR 1.47, 95% CI: 1.07 to 2.02) follow-ups. Users of < 1 week had similar smoking abstinence and reduction rates compared with non-users (all p > .05). Higher 7-day PPA at 6 months of 1-week users was observed in lower versus higher education and income (both p for interaction < 0.05).

CONCLUSIONS

The evidence presented suggests the real-world effectiveness of 1-week NRT sampling combined with counseling for increasing smoking abstinence and reduction rates in women. This implies that encouraging sampling of NRT will improve smoking cessation outcomes, particularly for women of low socioeconomic status.

IMPLICATIONS

We found that using 1-week NRT sampling combined with counseling was associated with higher smoking abstinence and reduction rates compared with counseling alone in women receiving a quitline service. We also found that women with socioeconomic disadvantages and older age benefited more from the use of 1-week NRT sampling. These findings highlight the importance of offering and promoting the use of 1-week NRT sampling as part of smoking cessation programs for women, particularly those with lower socioeconomic status, potentially to narrow cessation disparities.

Application and utility of geographic information systems in pharmacy specific health research: A scoping review

BACKGROUND

Geographic Information Systems (GIS) are considered essential tools to analyze spatially referenced health data.

OBJECTIVES

The purpose of this scoping review is to describe how GIS is used in pharmacy specific health research.

METHODS

During July 2020, the following databases were searched: EMBASE, MEDLINE (PubMed), Web of Science and Scopus. The search strategy included terms relating to spatial analysis and pharmacy. Studies were considered eligible if they involved the use of GIS and focused on pharmacies. A narrative and tabular synthesis of the results was carried out, structured around the spatial analysis methods utilized across studies, as well as the characteristics of pharmacies evaluated in studies.

RESULTS

After a review of 6967 sources, 48 studies were included in this review. Twenty-nine studies were conducted in the United States (60.4%) and thirty-six focused on accessibility (75.0%; n = 36). Twenty-two studies investigated the relationship between sociodemographic aspects of the population and the accessibility and availability of pharmacies (45.8%). Twelve studies (25.0%) performed distance analysis and six studies (12.5%) performed geostatistical analysis. Community pharmacies were the setting evaluated most frequently, with over-the-counter selling products being the most evaluated pharmacy variable (13.3%; n = 6). Population density (58.3%; n = 28), income indicators (43.8%; n = 21) and minority community composition rates (41.7%; n = 20) were the most used population variables.

CONCLUSIONS

GIS have been increasingly used in pharmacy specific health research. Generally, research has sought to identify potential barriers to access and their effects on the population. Future research may benefit by utilizing robust spatial methods and applications across countries outside of the United States. Doing so could help to confirm the impact of sociodemographic characteristics on the availability and/or accessibility of pharmacies globally.

The differential impact of nicotine replacement therapy sampling on cessation outcomes across established tobacco disparities groups

Cigarette smoking is increasingly concentrated among marginalized populations with limited access to evidence-based cessation treatment. This includes racial/ethnic minorities, lower income individuals, those with lower educational attainment, and residents of rural areas. To reach Healthy People 2020 objectives, successful cessation interventions must narrow these disparities. Nicotine replacement therapy (NRT) sampling is an easily translatable and scalable intervention that could enhance treatment access and thus narrow disparities. The present study examined individual-level demographic moderators of the impact of NRT sampling on cessation-related behaviors including: 1) use of a cessation medication, 2) making a 24-hour quit attempt, 3) floating abstinence, and 4) 7-day point prevalence abstinence at 6-months. Study participants included N = 1245 adult smokers enrolled in the Tobacco Intervention in Primary Care Treatment Opportunities for Providers (TIP TOP) study, a recently concluded large-scale clinical trial of NRT sampling relative to standard care within 22 primary care clinics across South Carolina. Generalized linear models examined individual-level demographic moderators of treatment effect. Results suggest that NRT sampling may be more effective among some of the most disadvantaged groups of smokers, including smokers with lower income and education, as well those who live in more rural areas. The effects of NRT sampling did not differ by race. In sum, NRT sampling is a low-cost, low-burden intervention that could be disseminated broadly to reach large numbers of smokers and potentially narrow cessation disparities.

Contraceptive Desert? Black-White Differences in Characteristics of Nearby Pharmacies

OBJECTIVES

Race differences in contraceptive use and in geographic access to pharmacies are well established. We explore race differences in characteristics of nearby pharmacies that are likely to facilitate (or not) contraceptive purchase.

STUDY DESIGN

We conducted analyses with two geocode-linked datasets: (1) the Relationship Dynamics and Social Life (RDSL) project, a study of a random sample of 1003 women ages 18-19 living in a county in Michigan in 2008-09; and (2) the Community Pharmacy Survey, which collected data on 82 pharmacies in the county in which the RDSL study was conducted.

RESULTS

Although young African-American women tend to live closer to pharmacies than their white counterparts (1.2 miles to the nearest pharmacy for African Americans vs. 2.1 miles for whites), those pharmacies tend to be independent pharmacies (59 vs. 16%) that are open fewer hours per week (64.6 vs. 77.8) and have fewer female pharmacists (17 vs. 50%), fewer patient brochures on contraception (2 vs. 5%), more difficult access to condoms (49% vs. 85% on the shelf instead of behind glass, behind the counter, or not available), and fewer self-check-out options (3 vs. 9%). More African-American than white women live near African-American pharmacists (8 vs. 3%). These race differences are regardless of poverty, measured by the receipt of public assistance.

CONCLUSIONS

Relative to white women, African-American women may face a "contraception desert," wherein they live nearer to pharmacies, but those pharmacies have characteristics that may impede the purchase of contraception.

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.

Standardized Tobacco Assessment for Retail Settings (STARS): dissemination and implementation research

Objective

The Standardized Tobacco Assessment for Retail Settings (STARS) was designed to characterise the availability, placement, promotion and price of tobacco products, with items chosen for relevance to regulating the retail tobacco environment. This study describes the process to develop the STARS instrument and protocol employed by a collaboration of US government agencies, US state tobacco control programmes (TCPs), advocacy organisations, public health attorneys and researchers from the National Cancer Institute's State and Community Tobacco Control (SCTC) Research Initiative.

Methods

To evaluate dissemination and early implementation experiences, we conducted telephone surveys with state TCP leaders (n=50, response rate=100%), and with individuals recruited via a STARS download registry on the SCTC website. Website registrants were surveyed within 6 months of the STARS release (n=105, response rate=66%) and again after ∼5 months (retention rate=62%).

Results

Among the state TCPs, 42 reported conducting any retail marketing surveillance, with actual or planned STARS use in 34 of these states and in 12 of the 17 states where marketing surveillance was not previously reported. Within 6 months of the STARS release, 21% of surveyed registrants reported using STARS and 35% were likely/very likely to use it in the next 6 months. To investigate implementation fidelity, we compared data collected by self-trained volunteers and by trained professionals, the latter method being more typically in retail marketing surveillance studies. Results suggest high or moderate reliability for most STARS measures.

Conclusion

The study concludes with examples of states that used STARS to inform policy change.

A National Assessment of Medication Adherence to Statins by the Racial Composition of Neighborhoods

Adherence to statins is lower in black and Hispanic patients and is linked to racial/ethnic disparities in cardiovascular mortality. Poverty, education, and prescription coverage differentials are typically invoked to explain adherence disparities, but analyses at the level of neighborhoods and their pharmacies may provide additional insights. Among individuals filling new statin prescriptions in a national pharmacy chain (N = 326,171), we compared adherence for patients residing in mostly minority neighborhoods to those living in mainly white areas. In analyses adjusting for patient-level factors associated with poor adherence, including age, insurance, payer, prescription cost, and convenience, patients residing in black and Hispanic neighborhoods had 2-3 weeks less statin therapy over 1 year, a pattern not seen in Asian areas. In black and Hispanic neighborhoods, good adherence was associated with co-pays under $10, the use of 90-day refills, and payers other than Medicaid. Efforts to improve medication adherence for vulnerable populations may benefit from interventions at the level of local pharmacies, as well as medication benefit redesign.

Smoking cessation interventions for patients with coronary heart disease and comorbidities: an observational cross-sectional study in primary care

BACKGROUND

Little is known about how smoking cessation practices in primary care differ for patients with coronary heart disease (CHD) who have different comorbidities.

AIM

To determine the association between different patterns of comorbidity and smoking rates and smoking cessation interventions in primary care for patients with CHD.

DESIGN AND SETTING

Cross-sectional study of 81 456 adults with CHD in primary care in Scotland.

METHOD

Details of eight concordant physical comorbidities, 23 discordant physical comorbidities, and eight mental health comorbidities were extracted from electronic health records between April 2006 and March 2007. Multilevel binary logistic regression models were constructed to determine the association between these patterns of comorbidity and smoking status, smoking cessation advice, and smoking cessation medication (nicotine replacement therapy) prescribed.

RESULTS

The most deprived quintile had nearly three times higher odds of being current smokers than the least deprived (odds ratio [OR] 2.76; 95% confidence interval [CI] = 2.49 to 3.05). People with CHD and two or more mental health comorbidities had more than twice the odds of being current smokers than those with no mental health conditions (OR 2.11; 95% CI = 1.99 to 2.24). Despite this, those with two or more mental health comorbidities (OR 0.77; 95% CI = 0.61 to 0.98) were less likely to receive smoking cessation advice, but absolute differences were small.

CONCLUSION

Patterns of comorbidity are associated with variation in smoking status and the delivery of smoking cessation advice among people with CHD in primary care. Those from the most deprived areas and those with mental health problems are considerably more likely to be current smokers and require additional smoking cessation support.

A Systematic Review of Neighborhood Disparities in Point-of-Sale Tobacco Marketing

We systematically reviewed evidence of disparities in tobacco marketing at tobacco retailers by sociodemographic neighborhood characteristics. We identified 43 relevant articles from 893 results of a systematic search in 10 databases updated May 28, 2014. We found 148 associations of marketing (price, placement, promotion, or product availability) with a neighborhood demographic of interest (socioeconomic disadvantage, race, ethnicity, and urbanicity). Neighborhoods with lower income have more tobacco marketing. There is more menthol marketing targeting urban neighborhoods and neighborhoods with more Black residents. Smokeless tobacco products are targeted more toward rural neighborhoods and neighborhoods with more White residents. Differences in store type partially explain these disparities. There are more inducements to start and continue smoking in lower-income neighborhoods and in neighborhoods with more Black residents. Retailer marketing may contribute to disparities in tobacco use. Clinicians should be aware of the pervasiveness of these environmental cues.

Services provided by community pharmacies in Wayne County, Michigan: a comparison by ZIP code characteristics

OBJECTIVE

To document the availability of selected pharmacy services and out-of-pocket cost of medication throughout a diverse county in Michigan and to assess possible associations between availability of services and price of medication and characteristics of residents of the ZIP codes in which the pharmacies were located.

DESIGN

Cross-sectional telephone survey of pharmacies coupled with ZIP code-level census data.

SETTING

503 pharmacies throughout the 63 ZIP codes of Wayne County, MI.

MAIN OUTCOME MEASURES

The out-of-pocket cost for a 30 days' supply of levothyroxine 50 mcg and brand-name atorvastatin (Lipitor-Pfizer) 20 mg, availability of discount generic drug programs, home delivery of medications, hours of pharmacy operation, and availability of pharmacy-based immunization services. Census data aggregated at the ZIP code level included race, annual household income, age, and number of residents per pharmacy.

RESULTS

The overall results per ZIP code showed that the average cost for levothyroxine was $10.01 ± $2.29 and $140.45 + $14.70 for Lipitor. Per ZIP code, the mean (± SD) percentages of pharmacies offering discount generic drug programs was 66.9% ± 15.0%; home delivery of medications was 44.5% ± 22.7%; and immunization for influenza was 46.7% ± 24.3% of pharmacies. The mean (± SD) hours of operation per pharmacy per ZIP code was 67.0 ± 25.2. ZIP codes with higher household income as well as higher percentage of residents being white had lower levothyroxine price, greater percentage of pharmacies offering discount generic drug programs, more hours of operation per week, and more pharmacy-based immunization services. The cost of Lipitor was not associated with any ZIP code characteristic.

CONCLUSION

Disparities in the cost of generic levothyroxine, the availability of services such as discount generic drug programs, hours of operation, and pharmacy-based immunization services are evident based on race and household income within this diverse metropolitan county.

The impact of the tobacco retail outlet environment on adult cessation and differences by neighborhood poverty

AIMS

This study examined the impact of tobacco retail outlets on cessation outcomes over time among non-treatment-seeking smokers and assessed differences by neighborhood poverty and individual factors.

DESIGN

Observational longitudinal cohort study using geospatial data. We used generalized estimating equations to examine cessation outcomes in relation to the proximity and density of tobacco retail outlets near the home.

SETTING

Eight large Designated Media Areas across the United States.

PARTICIPANTS

A total of 2377 baseline smokers followed over three waves from 2008 to 2010.

MEASUREMENTS

Outlet addresses were identified through North American Industry Classification System codes and proximity and density measures were constructed for each participant at each wave. Outcomes included past 30-day abstinence and pro-cessation attitudes.

FINDINGS

Smokers in high poverty census tracts living between 500 m and 1.9 km from an outlet were over two times more likely to be abstinent than those living fewer than 500 m from an outlet (P < 0.05). Density within 500 m of home was associated with reduced abstinence [odds ratio (OR) = 0.94; confidence interval (CI) = 0.90, 0.98) and lower pro-cessation attitudes (Coeff = -0.07, CI = -0.10, -0.03) only in high poverty areas. In low poverty areas, density within 500 m was associated with greater pro-cessation attitudes (OR = 0.06; CI = 0.01, 0.12). Gender, education and heaviness of smoking did not moderate the impact of outlet proximity and density on cessation outcomes.

CONCLUSIONS

In the United States, density of tobacco outlets within 500 m of the home residence appears to be negatively associated with smoking abstinence and pro-cessation attitudes only in poor areas.

A systematic review of store audit methods for assessing tobacco marketing and products at the point of sale

OBJECTIVE

Over four-fifths of reported expenditures for marketing tobacco products occur at the retail point of sale (POS). To date, no systematic review has synthesised the methods used for surveillance of POS marketing. This review sought to describe the audit objectives, methods and measures used to study retail tobacco environments.

METHODS

We systematically searched 11 academic databases for papers indexed on or before 14 March 2012, identifying 2906 papers. Two coders independently reviewed each abstract or full text to identify papers with the following criteria: (1) data collectors visited and assessed (2) retail environments using (3) a data collection instrument for (4) tobacco products or marketing. We excluded papers where limited measures of products and/or marketing were incidental. Two abstractors independently coded included papers for research aims, locale, methods, measures used and measurement properties. We calculated descriptive statistics regarding the use of four P's of marketing (product, price, placement, promotion) and for measures of study design, sampling strategy and sample size.

RESULTS

We identified 88 store audit studies. Most studies focus on enumerating the number of signs or other promotions. Several strengths, particularly in sampling, are noted, but substantial improvements are indicated in the reporting of reliability, validity and audit procedures.

CONCLUSIONS

Audits of POS tobacco marketing have made important contributions to understanding industry behaviour, the uses of marketing and resulting health behaviours. Increased emphasis on standardisation and the use of theory are needed in the field. We propose key components of audit methodology that should be routinely reported.

Disparities in multiple chronic conditions within populations

Disadvantaged populations are disproportionately affected by multiple chronic conditions (MCCs), yet few studies examine the prevalence, outcomes, or effectiveness of MCC interventions in minority and socioeconomically deprived individuals and populations. An important first step in understanding MCCs, not only in such diverse population groups, but also in the general population as a whole, is to broaden the definition and scope of MCC measurement, to encompass more than the simple additive effect of clinical conditions, and to include a wide range of health and health-related aspects that interact and make up the full spectrum of multimorbidity. Only with the use of a comprehensive MCC measurement can some of the differences between the disadvantaged populations be adequately detected. Better understanding of the disparities in access to high quality health and healthcare for persons with MCCs can help guide policy and practice aimed at the prevention and amelioration of the effects of MCCs among disadvantaged groups. Indeed, disparity in MCC populations has been identified as a key goal of the U.S. Department of Health and Human Services’ Strategic Framework on MCCs. The aim of the present paper is to describe current knowledge on disparities in the population of persons with MCCs and to guide efforts for the prevention and management of MCCs in disadvantaged populations.

Journal of Comorbidity 2013;3:45–50

Consumer perceptions of the sale of tobacco products in pharmacies and grocery stores among U.S. adults

Background

Pharmacy-based tobacco sales are a rapidly increasing segment of the U.S. retail tobacco market. Growing evidence links easy access to tobacco retail outlets such as pharmacies to increased tobacco use. This mixed-mode survey was the first to employ a nationally representative sample of consumers (n = 3057) to explore their opinions on sale of tobacco products in pharmacies and grocery stores.

Results

The majority reported that sale of tobacco products should be either ‘allowed if products hidden from view’ (29.9%, 25.6%) or ‘not allowed at all’ (24.0%, 31.3%) in grocery stores and pharmacies, respectively. Significantly fewer smokers, compared to non-smokers, reported agreement on point-of-sale restrictions on sales of tobacco products (grocery stores: 27.1% vs. 59.6%, p < .01; pharmacy: 32.8% vs. 62.0%, p < .01). Opinions also varied significantly by demographic characteristics and factors such as presence of a child in the household and urban/rural location of residence.

Conclusions

Overall, a majority of consumers surveyed either supported banning sales of tobacco in grocery stores and pharmacies or allowing sales only if the products are hidden from direct view. Both policy changes would represent a departure from the status quo. Consistent with the views of practicing pharmacists and professional pharmacy organizations, consumers are also largely supportive of more restrictive policies.

The role of academic pharmacy in tobacco cessation and control

Despite decades of public health initiatives, tobacco use remains the leading known preventable cause of death in the United States. Clinicians have a proven, positive effect on patients' ability to quit, and pharmacists are strategically positioned to assist patients with quitting. The American Association of Colleges of Pharmacy recognizes health promotion and disease prevention as a key educational outcome; as such, tobacco cessation education should be a required component of pharmacy curricula to ensure that all pharmacy graduates possess the requisite evidence-based knowledge and skills to intervene with patients who use tobacco. Faculty members teaching tobacco cessation-related content must be knowledgeable and proficient in providing comprehensive cessation counseling, and all preceptors and practicing pharmacists providing direct patient care should screen for tobacco use and provide at least minimal counseling as a routine component of care. Pharmacy organizations should establish policies and resolutions addressing the profession's role in tobacco cessation and control, and the profession should work together to eliminate tobacco sales in all practice settings where pharmacy services are rendered.

Misperceptions of nicotine replacement therapy within racially and ethnically diverse smokers

Underuse of evidence-based treatment for smoking cessation, including use of nicotine replacement therapy (NRT), is widespread, particularly among minority smokers. This paper examines perceptions of NRT among and between racially and ethnically diverse groups of smokers. Nine focus groups were held among homogenous groups of African American, European American, and Hispanic smokers (N = 70). Specific themes included perceptions of: (a) the mechanism by which NRT works; (b) NRT development and regulation (ie, purpose and methods of clinical trials, Food and Drug Administration oversight, etc); (c) efficacy; (d) safety; and (e) overall cost effectiveness. Across all groups, there was a general lack of knowledge of NRT effects and its efficacy, with only moderate knowledge of the mechanism by which NRT works. Concerns about NRT safety were expressed in all groups, with particular apprehension about addictive potential and possible interactions with other medications. Among African American smokers in particular, there was strong suspicion of pharmaceutical industry and government oversight, which coincided with the consensus view that there are too many unknowns about NRT. Among Hispanic smokers, there was less suspicion of NRT but a strong cultural belief in personal responsibility for smoking cessation. Results highlight enduring misperceptions about NRT that likely undermine usage. More education about NRT is needed, not only about its efficacy and safety, but also with regard to its development and regulation. Health care professionals, many of whom are viewed as trustworthy sources of health information, have a particularly important role to promote wider use of proven cessation strategies.

Community pharmacists' involvement in smoking cessation: familiarity and implementation of the National smoking cessation guideline in Finland

BACKGROUND

Guidelines on smoking cessation (SC) emphasize healthcare cooperation and community pharmacists' involvement. This study explored the familiarity and implementation of the National SC Guideline in Finnish community pharmacies, factors relating to Guideline familiarity, implementation and provision of SC services.

METHODS

A nationwide mail survey was sent to a systematic, sample of community pharmacy owners and staff pharmacists (total n = 2291). Response rate was 54% (n = 1190). Factors related to the SC Guideline familiarity were assessed by bivariate and multivariate analysis.

RESULTS

Almost half (47%) of the respondents (n = 1190) were familiar with the SC Guideline and familiarity enhanced Guideline implementation. The familiarity was associated with the respondents' perceptions of their personal SC skills and knowledge (OR 3.8); of customers' value of counseling on nicotine replacement therapy (NRT) (OR 3.3); and regular use of a pocket card supporting SC counseling (OR 3.0). Pharmacists' workplaces' characteristics, such as size and geographical location were not associated with familiarity. In addition to recommending NRT, the pharmacists familiar with the Guideline used more frequently other Guideline-based SC methods, such as recommended non-pharmacological SC aids, compared to unfamiliar respondents.

CONCLUSIONS

SC Guideline familiarity and implementation is crucial for community pharmacists' involvement in SC actions in addition to selling NRT products. Pharmacists can constitute a potential public health resource in SC easily accessible throughout the country.