Public Perceptions of the Ban on Tobacco Sales in San Francisco Pharmacies

Abstract

Background

In October, 2008, legislation was implemented in the city and county of San Francisco, California that banned the sale of tobacco products in pharmacies.

Objective

To characterize public awareness and perceptions of the ban on tobacco sales in San Francisco community pharmacies.

Methods

A brief, anonymous survey was used to assess public awareness and perceptions of a ban on tobacco sales approximately one year after implementation. Individuals were approached by researchers outside of chain pharmacies in San Francisco. Smokers and non-smokers were included, and participants did not have to be a customer of the pharmacy.

Results

Of 198 participants, 56% were in favor of the ban, 27% opposed it, and 17% were undecided. A greater proportion of current tobacco users (81%) than former/never users (48%) were aware of the ban (p<0.001), and a lesser proportion were supportive of the ban (21% of current users vs 65% of former/never users; p<0.001). Most current tobacco users (88% of n=43) had not considered quitting smoking as a result of the ban. The majority of consumers indicated that the ban on cigarettes sales did not influence their shopping behavior at retail pharmacies.

Conclusion

In the city and county of San Francisco, public support exists for prohibiting the sale of tobacco products in pharmacies.

INTRODUCTION

Cigarette smoking is the leading known preventable cause of death in the U.S.[1] As one of the most trusted professions,[2] pharmacists are charged with acting in the best interest of their patients’ health as delineated by their code of ethics, which states “a pharmacist promises to help individuals achieve optimum benefit from their medications, to be committed to their welfare, and…avoids…actions that compromise dedication to the best interests of patients”[3]. A substantial proportion of community pharmacies sell tobacco products, however, and this practice is in direct violation of the pharmacist’s code of ethics.

For more than four decades, the pharmacy profession has expressed opposition to tobacco sales in pharmacies. This opposition is evidenced by results from multiple research studies quantifying the opinions of individual pharmacists [4–8] and pharmacy students [4, 5]as well as resolutions or position statements issued by the International Pharmaceutical Federation [9] and the two largest professional pharmacy organizations in the U.S. (the American Pharmacists Association [10] and the American Society of Health-System Pharmacists[11]). In 2009, the American Medical Association passed a resolution opposing the sale of tobacco products in pharmacies.[12]

On 1 October 2008, the San Francisco Board of Supervisors enacted legislation in the city and county of San Francisco, California prohibiting pharmacies from selling tobacco products.[13] Supporters of the ordinance expressed the notion that a pharmacy is a place where healthcare services are rendered, and therefore these locations should not sell products known to contribute to morbidity and mortality.[14] Opponents of the ban have challenged the constitutionality of the ordinance and have expressed concerns that the ban violates equal protection laws and would result in financial harm.[15–17] Indeed, cigarette sales in traditional drug stores approached $3.5 billion in 2009.[18] To characterize public awareness and perceptions of the ban and to estimate the impact of the ban on changes in consumer shopping behavior, we administered a cross-sectional convenience survey of San Francisco residents..

METHODS

From December 2009 to February 2010, a brief, anonymous survey was conducted to assess public awareness and perceptions of the ban on tobacco sales in San Francisco pharmacies. Individuals were approached by student researchers outside of chain pharmacies in San Francisco. To attain diversity in the respondent population (e.g., age, race, sexual orientation, socioeconomic status, tobacco users), six high-volume pharmacies located in different areas of the city were targeted. Participants were at least 18 years of age, resided or worked in the city and county of San Francisco, and were able to read and answer survey questions in English. Both smokers and non-smokers were included, and participants did not have to be a patron of the pharmacy. The paper survey was self-administered, with researchers available in person if questions arose. Subjects were provided with a nominal gift (a pack of chewing gum) for their participation. The study was approved by the UCSF Committee on Human Research.

Respondents were characterized by sociodemographics and smoking history. Awareness and support of the ban was assessed by asking, “Are you aware that since October 1, 2008, San Francisco banned community pharmacies, such as Walgreens, from selling cigarettes?” and “Do you support the ban of cigarette sales in San Francisco pharmacies?” (1=strongly favor, 2=somewhat favor, 3=not sure/don’t know, 4=somewhat oppose, 5=strongly oppose). Participants reported the impact of the ban on their shopping behavior at pharmacies by indicating whether (a) they shop at them more, (b) they shop at them less, or (c) it makes no difference. Current smokers were asked to indicate whether they had considered quitting smoking because of the ban. Primary location of cigarette purchases prior to and after the ban was assessed to estimate the proportion of tobacco user respondents who purchased tobacco at a pharmacy. Current smokers also indicated the extent to which the ban has made it less convenient for them to purchase cigarettes. Finally, participants indicated whether they (a) were in favor of cigarette sales in pharmacies, (b) believed it appropriate for the government to ban cigarette sales in pharmacies, and (c) believed it is unethical for pharmacies to profit from the sale of cigarettes and the medicines used to treat diseases caused by smoking (1=strongly disagree to 5=strongly agree).

Responses were summarized using descriptive statistics. Comparisons were made using Chi-squared tests and t-tests, as appropriate. Analyses were conducted using SPSS Version 17.0 (SPSS, Inc., Chicago, IL).

RESULTS

Of 198 participants, most were male (60%) and non-Hispanic Caucasian (57%); 22% were Asian, 8% were non-Hispanic Black, and 6% were Hispanic/Latino. The average age was 43 years (SD, 16); 62% reported having a bachelor’s degree or higher, 17% had some college education, 11% had an associate’s degree, and 10% had a high school diploma or less. Sixteen percent used tobacco once or more a day, 6% used tobacco less than once a day, 22% had previously used tobacco but quit, 14% had experimented with tobacco a few times in the past, and 42% had never used tobacco.

Fifty-six percent indicated that they were aware (prior to the survey) of the ban on tobacco sales in community pharmacies. Overall, 56% were in favor of the ban, 27% opposed it, and 17% were undecided. A greater proportion of current tobacco users (81%) than former/never users (48%) were aware of the ban (X²=14.9; p<0.001), and a lesser proportion were supportive of the ban (21% of current users vs 66% of former/never users; X²=28.0; p<0.001). Most current tobacco users (88% of n=43) had not considered quitting smoking as a result of the ban.

Nineteen percent of current tobacco users reported that prior to the ban they purchased cigarettes primarily at a pharmacy. Of all respondents, most (76%) reported that the ban made no difference whether they shopped at pharmacies in San Francisco; 13% shopped at pharmacies less, and 12% shopped at pharmacies more. This differed by tobacco use status (X²=35.8; p<0.001), with 13% of non-tobacco users and 7% of users shopping at pharmacies more often, and 5% of nonusers and 40% of users shopping at pharmacies less often. Among current tobacco users, 38% believed that the ban had made it less convenient for them to purchase cigarettes.

Fewer than one fourth (23%) of respondents were in favor of cigarettes being sold in pharmacies, and 48% believed it was appropriate for the government to ban cigarette sales in pharmacies. When asked if it unethical for pharmacies to profit from the sale of cigarettes and the medicines used to treat diseases causes by smoking, 47% agreed and 32% disagreed (21% were undecided). Perceptions varied as a function of current tobacco use status [Table 1].

Table 1.

Perceptions of cigarette sales in pharmacies: current (n=43) and former or never (n=155) tobacco users.

Survey item*	Tobacco use status	Extent of agreement N (%)					Mean (SD)	t statistic and p-value
		Strongly disagree	Somewhat disagree	Not sure	Somewhat agree	Strongly agree
I am in favor of cigarettes being sold in pharmacies.	Current	7 (16)	4 (9)	11 (26)	8 (19)	13 (30)	3.4 (1.4)	−5.4 <0.001
	Former or never	73 (47)	26 (17)	31 (20)	13 (8)	12 (8)	2.1 (1.3)
It is appropriate for the government to ban cigarette sales in pharmacies.	Current	17 (40)	4 (9)	7 (16)	6 (14)	9 (21)	2.7 (1.6)	2.8 0.005
	Former or never	27 (17)	11 (7)	38 (25)	33 (21)	46 (30)	3.4 (1.4)
It is unethical for pharmacies to profit from the sale of cigarettes and the medicines used to treat diseases caused by smoking.	Current	14 (33)	6 (14)	10 (23)	9 (21)	4 (9)	2.6 (1.4)	2.9 0.004
	Former or never	27 (17)	17 (11)	32 (21)	39 (25)	40 (26)	3.3 (1.4)

^*Strongly disagree = 1, somewhat disagree = 2, not sure = 3, somewhat agree = 4, strongly agree = 5.

DISCUSSION

Most community pharmacies sell tobacco products despite the fact that they are licensed health facilities where healthcare services are provided. Research conducted in California showed that there is little professional or public support for tobacco sales in pharmacies,[4] and this research influenced the passage of legislation banning the sale of tobacco products in pharmacies in San Francisco county.[20] Because it was the first legislation of its type in the U.S., this study aimed to characterize the perceptions and opinions of the general public approximately 1 year after the ban went into effect.

Of 198 individuals surveyed, 21.7% were current tobacco users, which is higher than the 13.5% smoking prevalence reported for San Francisco.[21] Overall, our data are contradictive of retailers’ concern that implementation of bans will result in decreased clientele in community pharmacies. However because tobacco users were oversampled, the potential effect of the ban to reduce shopping frequency at retail pharmacies is likely overestimated in this study. In examining opinions of those respondents who were not neutral on the issue, there appears to be consumer support for the ban and removal of tobacco products from pharmacies

A limitation of this study is its small sample size. As a result, the statistical generalizability of our findings to the population of San Francisco and beyond is unknown. Another limitation is that our sample was highly educated, with 79% having at least some college education. Since people with a higher education level are less likely to smoke, the ban would likely have had less of an impact on respondents who did not smoke.

San Francisco was the first city to implement a ban, and it has not been without controversy.[15–17] While nearly all independently-owned pharmacies in California have long since voluntarily ceased sales of tobacco products,[14, 22, 23] tobacco sales remain ubiquitous in chain pharmacies. For decades, pharmacy chain corporations have ignored the pharmacy profession’s policies on removing tobacco from the pharmacy practice environment. Ironically, many pharmacies are now promoting health and wellness programs, including the provision of tobacco cessation counseling. Pharmacy licensing bodies, which are charged with protecting consumers and public health,[24] should consider the inherent conflict of interest that exists between the provision of healthcare services and tobacco sales and administer pharmacy licenses only to those pharmacies that are dedicated to the health and welfare of their patients and thus do not sell tobacco products. Furthermore, pharmacy licensing bodies should prohibit pharmacies that sell tobacco products from using advertising language that states or suggests that the business cares about the health of its customers. It is time for pharmacy chains to decide whether they want to be classified as (1) a convenience store that sells tobacco products or (2) a licensed healthcare establishment. In our view, and in the view of the profession and its professional organizations, the two are mutually exclusive.

CONCLUSION

Public support exists in the city and county of San Francisco for prohibiting the sale of tobacco products in pharmacies. These findings can be used as support for similar efforts in other locations.

What this paper adds.

San Francisco was the first city and county within the United States to enact legislation banning the sale of tobacco products in pharmacies. Prior to implementation of the ban, significant concern was expressed by retailers that the ban would lead to reductions in the number of clientele. In this report, we characterized public perceptions of the ban and its effect on self-reported shopping behavior at community pharmacies. The positive public support of this ban and lack of an effect on self-reported shopping behavior can serve as evidence for the creation of policies that prohibit the sale of tobacco in pharmacies globally.