An Unfortunate and Avoidable Component of American Pharmacy: Tobacco

If there was a drug contained within a delivery device provided through pharmacies that had a mortality associated with its use amounting to over 450,000 deaths in the United States and was a leading contributor to untold morbidity, would not our collective voice be heard to eliminate this product from our pharmacy milieus? The product is nicotine wrapped in the deadly delivery mechanism of cigarettes and other tobacco products.

Of the roughly 60,000 pharmacies in the United States, about 70% are chain community pharmacies or food market-based pharmacies. Tobacco is sold in almost all of these pharmacies, with the exception of a few. Traditional chains, mass merchandiser and food market-based pharmacies have been suggested to sell more tobacco products than other types of pharmacies.¹ As a percentage of total sales, tobacco products account for much less than 1%. A major inducement for some pharmacies to continue to sell cigarettes is the significant promotional funding provided by US tobacco manufacturers. This is over and above their meager tobacco sales profits.

In a replicated study of tobacco sales in pharmacies in the San Francisco area, Eule et al found that in 2003, 61% of surveyed pharmacies sold cigarettes, which was down from 89% of pharmacies selling cigarettes in 1976.² More than 8 out of 10 of the pharmacies continuing to sell cigarettes also displayed cigarette advertising.² Over-the-counter nicotine replacement (NRT) products were sold by 78% of pharmacies. Following a bizarre placement scheme, 55% of the pharmacies selling cigarettes displayed these NRT products immediately adjacent to the cigarettes.²

What do our pharmacy colleagues around the globe have to say about tobacco sales in pharmacy? In 2004, in New Orleans, the Fédération Internationale Pharmaceutique (FIP), representing pharmacists worldwide, recommended that pharmaceutical organizations diligently pursue policies stating that tobacco products are not sold in pharmacies, and that licensing bodies should not license pharmacies that are located in premises in which such products are sold. The FIP also recommended that smoking not be permitted in pharmacies.³ The Pharmaceutical Society of Australia supports the Quality Care Pharmacy Program which includes a mandatory pharmacy accreditation standard under which stocking or selling tobacco products is prohibited.⁴

Some chains allow individual store managers to make the decision to sell or not sell cigarettes. The Target Corporation pulled tobacco from shelves over a decade ago for economic reasons. The low profit margins, high potential for theft, and expensive-to-implement ordinances to control sales to minors have made selling cigarettes much less appealing to retailers. Some mass merchandisers have pulled cigarettes from shelves in 1 country while continuing to heavily promote tobacco sales in developing countries.

Most recently, the Wegmans' regional food market chain made the decision to stop selling cigarettes.⁵ In a letter to employees, CEO Danny Wegman and daughter Colleen Wegman (company president), noted: “We believe there are few of us who would introduce our children to smoking.”⁵ This action is noteworthy in and of itself, but the food market retailer is also providing smoking cessation programs for company employees.⁵

The World Health Organization (WHO) estimates that worldwide, tobacco has been estimated to have killed 100 million individuals in the past century, this total could reach 1 billion in the current century.⁶ Alarmingly, roughly 50% of the world's children live in countries that do not ban free distribution of tobacco products. Many of the cigarettes marketed and sold worldwide are from US-based tobacco manufacturers.

According to Mathers and Loncar, tobacco use is a risk factor for 6 of the 8 leading causes of death in the world (ischemic heart disease, cerebrovascular disease, lower respiratory infections, chronic obstructive pulmonary disease, tuberculosis, and trachea and bronchus lung cancers).⁷ No doubt tobacco use is a cofactor in other morbidity-inducing diseases as well.

Thirty percent of the world's smokers live in China—350 million Chinese smoke, which is more than the entire US population. There is perverse incentive for the Peoples Republic of China to encourage its citizens to smoke since tobacco sales in China are controlled by the government, netting them an estimated profit of $30 billion (US dolalrs) yearly.

The recent World Health Organization report on the global tobacco epidemic promotes an “mpower” movement, which seeks to implement 6 components⁶:

• Monitor tobacco use and prevention policies

• Protect people from tobacco smoke

• Offer to help others to quit tobacco use

• Warn about the dangers of tobacco

• Enforce bans on tobacco advertising, promotion, and sponsorship.

• Raise taxes on tobacco

Our students need to be familiar with this report, the state of tobacco-induced morbidity and mortality worldwide, and what they can do about stemming tobacco use in their practices in the future.

In ambulatory settings, US pharmacy students are learning to practice our profession, or working part time, in pharmacies that are a part of store footprints in which tobacco products are sold. Furthermore, a significant number of advanced pharmacy practice experience sites are located in places that sell tobacco products. In my mind, this is unconscionable.

US pharmacy students need an expanded worldview that includes how the world perceives pharmacists in the United States and what we do in theory and practice. All of us within our academy need to have an expanded tobacco related worldview as well. Seeing the United States as the major promoter of tobacco products worldwide and observing that a significant percentage of our educational programs are located in sites that are in tobacco-selling venues does not send a proactive message on public health promotion to the rest of the world. Dr. LEE Jong-wook, former director of the World Health Organization in 2005 noted:

Doctors, nurses, midwives, dentists, pharmacists, chiropractors, psychologists and all other professionals dedicated to health can help people change their behaviour. They are on the front line of the tobacco epidemic and collectively speak to millions of people.6 (p.37)

Now over a decade after this statement, our academia along with other pharmacy professional and trade organizations, have not done what we can and should do to optimally stem the deaths resultant from tobacco use. So, what should we do? Encourage our students upon graduation to encourage potential and current employers not to sell tobacco products. Encourage our pharmacy colleagues to stop selling tobacco products in pharmacies. Work within our preceptor programs to encourage practice sites to stop selling tobacco products. Be conscious of our connection to practice communities here and abroad, and realize the not so subtle messages we send globally by our lack of proactive public health actions, and not just via the exportation of our outstanding academic programs. Work continuously to get tobacco products out of our professional milieus. Make this an objective for inclusion in our school advisory board discussions. Work to make our university campuses smoke free. Demand that university student unions stop selling tobacco products (Why on earth does this occur?). Work with our current accrediting organization to make this a priority within its hierarchy to examine the total milieu where our pharmacy programs place students. Work with other organizations within pharmacy and public health to encourage pharmacies to “butt out” of the tobacco business once and for all, and for the well-being of all worldwide.

Finally, are there other products that can be equally as detrimental to consumers' health that pharmacists should be working to stem the sales of? Should not efforts be focused on venues selling products such as alcohol or firearms? Sadly, these additional death-inducing products also are sold in some pharmacies. Thus, stopping tobacco sales in pharmacies is just a first step of many that pharmacists should take for the betterment of our patients' health.