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Pharmacy Promotion of Tobacco Use Among Children in Massachusetts
Pharmacy Promotion of Tobacco Use Among Children in Massachusetts OJ 100 pharmacies surveyed) 95 sold tobacco) 81 were willing to illegally sell cigarettes to
minors) and one-half displayed tobacco ads. by Linda J. Brown and Joseph R. DiFranza, MD
Abstract The role played by phannacies in the promotion and distribution of tobacco to children was assessed in a survey of 100 phannacies. Of the 100 surveyed, 95 sold tobacco products, 50 advertised tobacco, 42 advertised the cigarette brands that are most appealing to children, and 23 displayed the Camel cartoon adveltisen1ents that have been identified as being targeted specifically at children. Candy tobacco products were sold in 220/0 of the pharmacies. Of the phannacies selling tobacco, 81 0/0 were willing to sell it to n1inors illegally. The five phannacies that did not carry tobacco products were independent stores. When compared to chain pharmacies , independent pharn1acies more frequently advertised tobacco (p < 0.05) but were not more likely to sell it to children. The authors contend that phannacists who sell tobacco violate the profession'S Adult smokers are declining by one miUion each year, and teenagers and Code of Ethics and play an ilnportant role preteenagers represent 90% of the tobacco industry's replacement smokers. in the promotion of tobacco use among children.
Introduction With the number of American adult smokers declining by one million each year, the tobacco industry Inust recruit replacement smokers to maintain its economic viability.l ,2 The tobacco industry's advertising methods and distribution Vol. NS32, No.5
May 19921421
systen1 are key factors in recruItIng teenagers and preteenagers who represent 90% of the industry's replacement sn1okers.3-6 Our purpose was to study the policies and practices of pharmacies to detern1ine the degree to which pharInacies participate in the tobacco industry'S promotion of AMERICAN PHARMACY
tobacco use among youths. Children's attitudes, images, and behaviors regarding tobacco are strongly and adversely influenced by tobacco advertising. 3,4,7-11 Even candy tobacco products are harmful because they provide young children with their first opportunity to mimic smoking behavior.12 Children who play with candy cigarettes are three times more likely to try smoking than children who do not. 12 Because tobacco is detrimental to health, many health organizations in the United States are working for a ban on all tobacco advertising. 14,15 It has been banned or severely
Easy access to a supply of tobacco appears to be the most important factor fostering tobacco use among teenagers.
restricted in dozens of countries, and the sale of candy tobacco has been banned in Australia's Capital Territory.13 Although tobacco advertising works to create a demand for tobacco among children, easy access to a supply of tobacco now appears to be the most important factor fostering tobacco use among teenagers. 5 In one community, teenage smoking rates dropped by 69% when active law enforcement put an end to illegal sales of tobacco to minors. 5 Merchants who sell tobacco to minors might therefore be the cause of two-thirds of adolescent tobacco use. In recognition of the need to keep tobacco out of the hands of children, 46 states and the District of Columbia have made it illegal to supply children with tobacco. 16 In Massachusetts, the law prohibits the sale of tobacco to children less than 18 years old and requires tobacco retailers to post warning signs explaining the law. 17 In this study, we sought to determine whether or not pharmacies sell tobacco, advertise tobacco , sell candy tobacco products, or illegally sell tobacco to children.
Methods The study was conducted during the summer of 1991. One hundred pharmacies were selected from the Massachusetts registration list to provide a sample representative of urban, suburban, and rural areas. Pharmacies not AMERICAN PHARMACY
open to the general public were excluded. Five underage buyers (ages 13 to 16, boys and girls) conducted sham purchases as follows. The buyer asked the sales clerk for cigarettes. When payment was requested, the buyer indicated that he or she did not have enough money and left the pharmacy. Buyers were truthful about their age if asked, and made no attempt to appear older. We recorded whether or not each pharmacy: (1) stocked tobacco products, (2) was willing to sell to children, (3) posted state-mandated warning signs, (4) promoted cigarette brands most popular with children (Marlboro, Camel, Newport, and Kool) or had any other tobacco ads, and (5) stocked candy or gum fashioned to resemble tobacco products. Statistical comparisons were conducted using the Yates corrected chi square.
Results Of the 100 pharmacies surveyed, 40 were chain pharmacies and 60 were independently operated. Of the 100, only five , all independents, had a policy of not selling tobacco products. Of those that did sell tobacco, 810/0 (77/ 95) were willing to illegally sell cigarettes to underage buyers, and 580/0 (55/ 95) did not post the warning signs mandated by state law. Among the 40 pharmacies posting the signs, 75% (30/ 40) were still willing to sell tobacco to children. Independent pharmacies who sold tobacco did not differ from the chain pharmacies in their willingness to sell tobacco to minors (780/0 [43 / 55] versus 850/0 [34 / 40] respectively, p > 0.05). One-half of the pharmacies displayed tobacco advertisements, and 42 displayed advertisements for the brands most popular with children. Twenty-three displayed Camel cartoon advertisements that have been shown to effectively target children down to the age of three years. 3,4 Independent pharmacies were more likely to display tobacco advertisements (600/0 [36 / 60]) than were the chain stores (35% [14/ 40], p < 0.05). The independents were twice as likely to display advertisements for the cigarette brands most popular with children (530/0 [32 / 60] versus 250/0 [10 / 40], p < 0.05). No correlation was found between the presence of these advertisements and the willingness of the pharmacy to sell tobacco to the underage buyer. Candy tobacco products were sold in 22 of the 100 pharmacies surveyed. No differences were noted between the independent and the chain pharmacies concerning the sale of candy tobacco products. Of the 22 pharmacies that sold these products, 910/0 (20/ 22) were willing to sell real tobacco products to children compared to 780/0 (57/73) of the pharmacies that did not sell candy tobacco products (p = 0.1). Interestingly, the five pharmacies that did not stock tobacco products also did not stock candy tobacco products. May
1992/422
Vol. NS32, No.5
D iscussion The Code of Ethics of the American Pharmaceutical Association (APhA) states, "A pharmacist should never knowingly condone the dispensing, promoting, or distributing of drugs .. .that lack therapeutic value for the patient. ,, 18 In 1970, APhA declared that "mass display of cigarettes in pharmacies is in direct contradiction to the role of the pharmacy as a public health facility. "19 In 1971, this stand was strengthened with the recommendation that tobacco products not be sold in pharmacies.20 Despite an ethical and professional mandate to forego tobacco sales, only 50/0 of the pharmacies we surveyed had done so. Our survey was limited to pharmacies in Massachusetts and may not be representative of pharmacies nationwide. We are confident, however, that pharmacies that do not sell tobacco are the exception rather than the rule. Our data on illegal sales are consistent with that available from five smaller surveys performed in other states.21 - 25 Combining results from the six studies reveals that 680/0 (184/ 270) of tobacco-selling pharmacies illegally sold tobacco to children. Previous studies have shown that children frequently tum to pharmacies as a source of tobacco products. In one survey, 420/0 of 10th-grade smokers indicated that they had purchased cigarettes from a pharmacy at least once, and 290/0 reported buying most of their cigarettes from pharmacies. 21 A similar study of Canadian children found that pharmacies are the primary source of tobacco for 200/0 of smokers 11 to 15 years old, and 340/0 of 16-year-old smokers.26 Overall, pharmacies were found to be the second most common place for children to purchase tobacco; only comer stores were more often used. 26 Since the illegal sale of tobacco to children may be responsible for two-thirds of adolescent tobacco use,5 and since pharmacies are responsible for a significant proportion of these illegal sales, pharmacies involved in tobacco sales contribute profoundly to the burden of disease among children. It is possible that a significant portion of current adult smokers also became addicted to cigarettes that were illegally sold to them at pharmacies when they were children. To discourage smokers from quitting, tobacco companies have always maintained that tobacco has not been shown to be harmful. In the 1940s the R.J. Reynolds Tobacco Company hoped to assuage smokers' fears with the slogan, "More Doctors Smoke Camels Than Any Other Brand. ,,27 Today they continue to imply that uncertainty exists in the medical profession about the negative health effects of smoking. 28,29 In 1989, 25 years after the first Surgeon General's report on smoking, "Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service," 450/0 of smokers still believed that there is a safe level of smoking, and 21% believed that smoking was either dangerous only for some people or not dangerous at all. 30 We believe that pharmacists who sell real or candy tobacco are VoL NS32, No.5 May 1992/423
reinforcing the tobacco industry'S deception that smoking is not dangerous. Those who display tobacco advertising are actively participating in that deception. Although APhA's Code of Ethics states, "The pharmacist should hold the health and safety of patients to be of first consideration," 18 concern over a potential loss of revenue is too often the primary consideration when deciding whether to sell tobacco. 31 However, tobacco is a low margin item that ties up a large amount of capital in inventory. 31 Of Canadian pharmacists who have discontinued tobacco sales, 21 % report an increase in profits, and only 2010 report a long-term decrease. 32 Pharmacists, by selling and promoting tobacco, and especially by selling it to children, playa major role in the tobac-
Pharmacies that sea and promote tobacco products playa major role in the nicotine addiction of children.
co industry'S efforts to promote nicotine addiction among children. Pharmacists who sell and promote tobacco are violating their professional code of ethics, and those who sell it to children are violating "the law" as well. Pharmacists in Quebec and Ontario have initiated bans on tobacco sales in all pharmacies. 33 ,34 Pharmacists who are employed by others may not enjoy the same freedom to forego tobacco sales as do their independent counterparts. However, all pharmacists can obey the law, and all can follow the example of their Canadian colleagues by working through their professional organizations to sponsor legislation to ban the sale of tobacco in pharmacies. Linda j. Brown is a medical student, University ofMassachusetts Medical School; joseph R. DiFranza, MD, is associate professor of family medicine, Department ofFamily and Community Medicine, University of Massachusetts Medical Center. Acknowledgments: Ib is p roject was supported by grants from the University of Massachusetts Medical Center and Doctors Ought to Care.
AMERICANPHARMACY
References 1. Pierce JP, Fiore MC, Novotny TE, et al. Trends in cigarette smoking in the United States-projections to the year 2000. JAMA. 1989;261:61-5. 2. DiFranza JR, Tye JB. Who profits from tobacco sales to children? JAMA. 1990;263:2784-7. 3. Fischer PM, Schwartz MP, Richards JW, et al. Brand logo recognition by children aged 3 to 6 years, Mickey Mouse and Old Joe the Camel. JAMA. 1991;266:3145-8. 4. DiFranza JR, Richards JW, Paulman PM, et al. RJR Nabisco's cartoon camel promotes camel cigarettes to children. JAMA. 1991;266:3149-53. 5. Jason LA, Ji PY, Anes MD, et al. Active enforcement of cigarette control laws in the prevention of cigarette sales to minors. JAMA. 1991;266:3159-61. 6. Kandel DB, Logan JA. Patterns of drug use from adolescence to young adulthood: I. Periods of risk for initiation, continued use and discontinuation. Am J Pub Health. 1984;74:660-6. 7. Aitken PP, Leathar DS, O'Hagan FJ. Children's awareness of cigarette advertisements and brand imagery. Brit J Addict. 1987;82:615-22. 8. Charlton A. Children's advertisement-awareness related to their views on smoking. Health Educ J. 1986;45(2):75-8. 9. Aitken PP, Leathar DS, Squair SI. Children's awareness of cigarette brand sponsorship of sports and games in the UK. Health Educ Res. 1986;1 (3):203-11. 10. Goldstein AO, Fischer PM, Richards JW, et al. Relationship between high school student smoking and recognition of cigarette advertisements. J Pediatr. 1987;110:488-91. 11. Chapman S, Fitzgerald B. Brand preference and advertising recall in adolescent smokers: some implications for health promotion. Am J Pub Health. 1982;72(5):491-4. 12. Klein JD, Forehand B, Oliveri J, et al. Candy cigarettes: do they encourage children's smoking? Pediatrics. 1992:89(1 ):27-31. 13. Health or tobacco. An end to tobacco advertising and promotion. Toxic Substances Board, New Zealand, 1989. 14. Media advertising for tobacco products. American Medical Association Board of Trustees Report. JAMA. 1986;255(8):1033. 15. Blasi V, Monaghan HP. The first amendment and cigarette advertising. JAMA. 1986;256:502-9. 16. DiFranza JR, Norwood BD, Garner DW, et al. Legislative efforts to protect children from tobacco. JAMA. 1987;257:3387-9. 17. Massachusetts General Laws, chapter 270, sections 6 and 7. 18. American Pharmaceutical Association, Code of Ethics, July 1981, Washington, DC. 19. Committee Reports. JAm Pharm Assoc. 1970;NS10(6):357. 20. Committee Reports. JAm Pharm Assoc. 1971;NS11(5):270. 21. Forster JL, Klepp K-I, Jeffrey RW. Sources of cigarettes for 10th graders in two Minnesota cities. Health Educ Res. 1989;4:45-50. 22. Skretney MT, Cummings M, Sciandra R, et al. An intervention to reduce the sale of cigarettes to minors. NY State J Med. 1990;90:54-5. 23. Hoppock KC, Houston TP. Availability of tobacco products to minors. J Fam Pract. 1990;30: 174-6. 24. Forster JL, Hourigan M, Weigum J. The movement to restrict children's access to tobacco in Minnesota. Presented at the Surgeon General's Interagency Committee on Smoking and Health, May 31, 1990. 25. Altman DG, Foster V, Rasemick-Douss L, et al. Reducing the illegal sale of cigarettes to minors. JAMA. 1989;261 :80-3. 26. Students and tobacco, the 1990 Nova Scotia Council on Smoking and Health Survey, final report. Nova Scotia Council on Smoking and Health, March 1991, p. 20. 27. Blum A. When "more doctors smoked Camels," cigarette advertising in the journal. NY State J Med. 1983;83(13):1347-52. 28. RJR ordered by FTC to show cause in MR FIT case. Mealey's Litigation Reports: Tobacco. Mealey Publications, April 1989;4(4):7-8.
Advertising Woos Children to Smoking Surgeon General Antonia Novello, MD, has joined the American Medical Association (AMA) in calling on R.J. Reynolds and other tobacco companies to stop using advertising that appeals to children. AMA recently held a press conference publicizing a study showing that Reynolds' "Old Joe Camel," a cartoon character used in advertising Carn.,els cigarettes since 1988, was correctly identified by 300/0 of three-year-olds and 91% of six-year-olds. The study, by Paul Fischer, MD, et al. showed that children ~ecognized Old Joe Camel from exposure to billboards, movies, tee shirts, toys, and candy. "The tobacco and advertising industries are attempting to take hostage the most vulnerable in our population--our nation's youth," Novello said. "While cigarette companies claim that they do not intend to market to children, the reality is that this argument becomes irrelevant if advertising affects what children know," Novello said. "Did you ever imagine that six-year-alds are as familiar with Old Joe as with Mickey Mouse?" Surveys before 1988 indicated little preference for Camels among young people, Novello said. Recent surveys show that in some communities, 25% or more of young smokers are now buying Camels; since 1986, its market share has increaseQ,230% among the youngest group of smokers. Also actively battling the health consequences of smoking is the National Cancer Institute (NCl). In 1990, NCI spent $47 million to fight smoking, according to NCI's director Samuel Broder, MD, but the tobacco companies spent 80 times that amount promoting smoking, and about 3,000 teenagers take up smoking each day .. In 1989, a Reynolds' ad that appeared in Rolling Stone magazine offered dating advice to young men. The back page of the ad suggested that to get a free pack of cigarettes "even if you don't like to redeem coupons," they should ask a friend or "a kind looking stranger" to redeem the coupon for them. As Broder asked, who "would feel compelled to ask a 'kind looking stranger' to redeem a coupon for free merchandise-unless, of course, they were underage?"
29. Warner KE. Selling Smoke: Cigarette Advertising and Public Health. Washington DC: American Public Health Association, 1986. 30. Imperial Tobacco Ltd. Continual Market Assessment Study, quoted by Dr. Jeffrey Harris in Exhibit AG-196, p. 43, RJR-MacDonald and Imperial Tobacco Ltd. v. Attorney General of Canada. Quebec Superior Court, 1989.
33. Quebec to limit sale of tobacco. Wall Street Journal, February 21, 1991:A10.
31. Cunningham G. You can do without discounting, tobacco. Drug Merchandizing. February 1988;72-3.
34. Hall C. Pharmacists want to ban tobacco sales in drug stores. Ottawa Citizen, October 18, 1990:A1.
Report, April 1987, TR# 72428.
32. Health and Welfare Canada, Survey of Level 3 Pharmacists, Summary
AMERICAN PHARMACY
May 1992/424 Vol. NS32, No.5
minors) and one-half displayed tobacco ads. by Linda J. Brown and Joseph R. DiFranza, MD
Abstract The role played by phannacies in the promotion and distribution of tobacco to children was assessed in a survey of 100 phannacies. Of the 100 surveyed, 95 sold tobacco products, 50 advertised tobacco, 42 advertised the cigarette brands that are most appealing to children, and 23 displayed the Camel cartoon adveltisen1ents that have been identified as being targeted specifically at children. Candy tobacco products were sold in 220/0 of the pharmacies. Of the phannacies selling tobacco, 81 0/0 were willing to sell it to n1inors illegally. The five phannacies that did not carry tobacco products were independent stores. When compared to chain pharmacies , independent pharn1acies more frequently advertised tobacco (p < 0.05) but were not more likely to sell it to children. The authors contend that phannacists who sell tobacco violate the profession'S Adult smokers are declining by one miUion each year, and teenagers and Code of Ethics and play an ilnportant role preteenagers represent 90% of the tobacco industry's replacement smokers. in the promotion of tobacco use among children.
Introduction With the number of American adult smokers declining by one million each year, the tobacco industry Inust recruit replacement smokers to maintain its economic viability.l ,2 The tobacco industry's advertising methods and distribution Vol. NS32, No.5
May 19921421
systen1 are key factors in recruItIng teenagers and preteenagers who represent 90% of the industry's replacement sn1okers.3-6 Our purpose was to study the policies and practices of pharmacies to detern1ine the degree to which pharInacies participate in the tobacco industry'S promotion of AMERICAN PHARMACY
tobacco use among youths. Children's attitudes, images, and behaviors regarding tobacco are strongly and adversely influenced by tobacco advertising. 3,4,7-11 Even candy tobacco products are harmful because they provide young children with their first opportunity to mimic smoking behavior.12 Children who play with candy cigarettes are three times more likely to try smoking than children who do not. 12 Because tobacco is detrimental to health, many health organizations in the United States are working for a ban on all tobacco advertising. 14,15 It has been banned or severely
Easy access to a supply of tobacco appears to be the most important factor fostering tobacco use among teenagers.
restricted in dozens of countries, and the sale of candy tobacco has been banned in Australia's Capital Territory.13 Although tobacco advertising works to create a demand for tobacco among children, easy access to a supply of tobacco now appears to be the most important factor fostering tobacco use among teenagers. 5 In one community, teenage smoking rates dropped by 69% when active law enforcement put an end to illegal sales of tobacco to minors. 5 Merchants who sell tobacco to minors might therefore be the cause of two-thirds of adolescent tobacco use. In recognition of the need to keep tobacco out of the hands of children, 46 states and the District of Columbia have made it illegal to supply children with tobacco. 16 In Massachusetts, the law prohibits the sale of tobacco to children less than 18 years old and requires tobacco retailers to post warning signs explaining the law. 17 In this study, we sought to determine whether or not pharmacies sell tobacco, advertise tobacco , sell candy tobacco products, or illegally sell tobacco to children.
Methods The study was conducted during the summer of 1991. One hundred pharmacies were selected from the Massachusetts registration list to provide a sample representative of urban, suburban, and rural areas. Pharmacies not AMERICAN PHARMACY
open to the general public were excluded. Five underage buyers (ages 13 to 16, boys and girls) conducted sham purchases as follows. The buyer asked the sales clerk for cigarettes. When payment was requested, the buyer indicated that he or she did not have enough money and left the pharmacy. Buyers were truthful about their age if asked, and made no attempt to appear older. We recorded whether or not each pharmacy: (1) stocked tobacco products, (2) was willing to sell to children, (3) posted state-mandated warning signs, (4) promoted cigarette brands most popular with children (Marlboro, Camel, Newport, and Kool) or had any other tobacco ads, and (5) stocked candy or gum fashioned to resemble tobacco products. Statistical comparisons were conducted using the Yates corrected chi square.
Results Of the 100 pharmacies surveyed, 40 were chain pharmacies and 60 were independently operated. Of the 100, only five , all independents, had a policy of not selling tobacco products. Of those that did sell tobacco, 810/0 (77/ 95) were willing to illegally sell cigarettes to underage buyers, and 580/0 (55/ 95) did not post the warning signs mandated by state law. Among the 40 pharmacies posting the signs, 75% (30/ 40) were still willing to sell tobacco to children. Independent pharmacies who sold tobacco did not differ from the chain pharmacies in their willingness to sell tobacco to minors (780/0 [43 / 55] versus 850/0 [34 / 40] respectively, p > 0.05). One-half of the pharmacies displayed tobacco advertisements, and 42 displayed advertisements for the brands most popular with children. Twenty-three displayed Camel cartoon advertisements that have been shown to effectively target children down to the age of three years. 3,4 Independent pharmacies were more likely to display tobacco advertisements (600/0 [36 / 60]) than were the chain stores (35% [14/ 40], p < 0.05). The independents were twice as likely to display advertisements for the cigarette brands most popular with children (530/0 [32 / 60] versus 250/0 [10 / 40], p < 0.05). No correlation was found between the presence of these advertisements and the willingness of the pharmacy to sell tobacco to the underage buyer. Candy tobacco products were sold in 22 of the 100 pharmacies surveyed. No differences were noted between the independent and the chain pharmacies concerning the sale of candy tobacco products. Of the 22 pharmacies that sold these products, 910/0 (20/ 22) were willing to sell real tobacco products to children compared to 780/0 (57/73) of the pharmacies that did not sell candy tobacco products (p = 0.1). Interestingly, the five pharmacies that did not stock tobacco products also did not stock candy tobacco products. May
1992/422
Vol. NS32, No.5
D iscussion The Code of Ethics of the American Pharmaceutical Association (APhA) states, "A pharmacist should never knowingly condone the dispensing, promoting, or distributing of drugs .. .that lack therapeutic value for the patient. ,, 18 In 1970, APhA declared that "mass display of cigarettes in pharmacies is in direct contradiction to the role of the pharmacy as a public health facility. "19 In 1971, this stand was strengthened with the recommendation that tobacco products not be sold in pharmacies.20 Despite an ethical and professional mandate to forego tobacco sales, only 50/0 of the pharmacies we surveyed had done so. Our survey was limited to pharmacies in Massachusetts and may not be representative of pharmacies nationwide. We are confident, however, that pharmacies that do not sell tobacco are the exception rather than the rule. Our data on illegal sales are consistent with that available from five smaller surveys performed in other states.21 - 25 Combining results from the six studies reveals that 680/0 (184/ 270) of tobacco-selling pharmacies illegally sold tobacco to children. Previous studies have shown that children frequently tum to pharmacies as a source of tobacco products. In one survey, 420/0 of 10th-grade smokers indicated that they had purchased cigarettes from a pharmacy at least once, and 290/0 reported buying most of their cigarettes from pharmacies. 21 A similar study of Canadian children found that pharmacies are the primary source of tobacco for 200/0 of smokers 11 to 15 years old, and 340/0 of 16-year-old smokers.26 Overall, pharmacies were found to be the second most common place for children to purchase tobacco; only comer stores were more often used. 26 Since the illegal sale of tobacco to children may be responsible for two-thirds of adolescent tobacco use,5 and since pharmacies are responsible for a significant proportion of these illegal sales, pharmacies involved in tobacco sales contribute profoundly to the burden of disease among children. It is possible that a significant portion of current adult smokers also became addicted to cigarettes that were illegally sold to them at pharmacies when they were children. To discourage smokers from quitting, tobacco companies have always maintained that tobacco has not been shown to be harmful. In the 1940s the R.J. Reynolds Tobacco Company hoped to assuage smokers' fears with the slogan, "More Doctors Smoke Camels Than Any Other Brand. ,,27 Today they continue to imply that uncertainty exists in the medical profession about the negative health effects of smoking. 28,29 In 1989, 25 years after the first Surgeon General's report on smoking, "Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service," 450/0 of smokers still believed that there is a safe level of smoking, and 21% believed that smoking was either dangerous only for some people or not dangerous at all. 30 We believe that pharmacists who sell real or candy tobacco are VoL NS32, No.5 May 1992/423
reinforcing the tobacco industry'S deception that smoking is not dangerous. Those who display tobacco advertising are actively participating in that deception. Although APhA's Code of Ethics states, "The pharmacist should hold the health and safety of patients to be of first consideration," 18 concern over a potential loss of revenue is too often the primary consideration when deciding whether to sell tobacco. 31 However, tobacco is a low margin item that ties up a large amount of capital in inventory. 31 Of Canadian pharmacists who have discontinued tobacco sales, 21 % report an increase in profits, and only 2010 report a long-term decrease. 32 Pharmacists, by selling and promoting tobacco, and especially by selling it to children, playa major role in the tobac-
Pharmacies that sea and promote tobacco products playa major role in the nicotine addiction of children.
co industry'S efforts to promote nicotine addiction among children. Pharmacists who sell and promote tobacco are violating their professional code of ethics, and those who sell it to children are violating "the law" as well. Pharmacists in Quebec and Ontario have initiated bans on tobacco sales in all pharmacies. 33 ,34 Pharmacists who are employed by others may not enjoy the same freedom to forego tobacco sales as do their independent counterparts. However, all pharmacists can obey the law, and all can follow the example of their Canadian colleagues by working through their professional organizations to sponsor legislation to ban the sale of tobacco in pharmacies. Linda j. Brown is a medical student, University ofMassachusetts Medical School; joseph R. DiFranza, MD, is associate professor of family medicine, Department ofFamily and Community Medicine, University of Massachusetts Medical Center. Acknowledgments: Ib is p roject was supported by grants from the University of Massachusetts Medical Center and Doctors Ought to Care.
AMERICANPHARMACY
References 1. Pierce JP, Fiore MC, Novotny TE, et al. Trends in cigarette smoking in the United States-projections to the year 2000. JAMA. 1989;261:61-5. 2. DiFranza JR, Tye JB. Who profits from tobacco sales to children? JAMA. 1990;263:2784-7. 3. Fischer PM, Schwartz MP, Richards JW, et al. Brand logo recognition by children aged 3 to 6 years, Mickey Mouse and Old Joe the Camel. JAMA. 1991;266:3145-8. 4. DiFranza JR, Richards JW, Paulman PM, et al. RJR Nabisco's cartoon camel promotes camel cigarettes to children. JAMA. 1991;266:3149-53. 5. Jason LA, Ji PY, Anes MD, et al. Active enforcement of cigarette control laws in the prevention of cigarette sales to minors. JAMA. 1991;266:3159-61. 6. Kandel DB, Logan JA. Patterns of drug use from adolescence to young adulthood: I. Periods of risk for initiation, continued use and discontinuation. Am J Pub Health. 1984;74:660-6. 7. Aitken PP, Leathar DS, O'Hagan FJ. Children's awareness of cigarette advertisements and brand imagery. Brit J Addict. 1987;82:615-22. 8. Charlton A. Children's advertisement-awareness related to their views on smoking. Health Educ J. 1986;45(2):75-8. 9. Aitken PP, Leathar DS, Squair SI. Children's awareness of cigarette brand sponsorship of sports and games in the UK. Health Educ Res. 1986;1 (3):203-11. 10. Goldstein AO, Fischer PM, Richards JW, et al. Relationship between high school student smoking and recognition of cigarette advertisements. J Pediatr. 1987;110:488-91. 11. Chapman S, Fitzgerald B. Brand preference and advertising recall in adolescent smokers: some implications for health promotion. Am J Pub Health. 1982;72(5):491-4. 12. Klein JD, Forehand B, Oliveri J, et al. Candy cigarettes: do they encourage children's smoking? Pediatrics. 1992:89(1 ):27-31. 13. Health or tobacco. An end to tobacco advertising and promotion. Toxic Substances Board, New Zealand, 1989. 14. Media advertising for tobacco products. American Medical Association Board of Trustees Report. JAMA. 1986;255(8):1033. 15. Blasi V, Monaghan HP. The first amendment and cigarette advertising. JAMA. 1986;256:502-9. 16. DiFranza JR, Norwood BD, Garner DW, et al. Legislative efforts to protect children from tobacco. JAMA. 1987;257:3387-9. 17. Massachusetts General Laws, chapter 270, sections 6 and 7. 18. American Pharmaceutical Association, Code of Ethics, July 1981, Washington, DC. 19. Committee Reports. JAm Pharm Assoc. 1970;NS10(6):357. 20. Committee Reports. JAm Pharm Assoc. 1971;NS11(5):270. 21. Forster JL, Klepp K-I, Jeffrey RW. Sources of cigarettes for 10th graders in two Minnesota cities. Health Educ Res. 1989;4:45-50. 22. Skretney MT, Cummings M, Sciandra R, et al. An intervention to reduce the sale of cigarettes to minors. NY State J Med. 1990;90:54-5. 23. Hoppock KC, Houston TP. Availability of tobacco products to minors. J Fam Pract. 1990;30: 174-6. 24. Forster JL, Hourigan M, Weigum J. The movement to restrict children's access to tobacco in Minnesota. Presented at the Surgeon General's Interagency Committee on Smoking and Health, May 31, 1990. 25. Altman DG, Foster V, Rasemick-Douss L, et al. Reducing the illegal sale of cigarettes to minors. JAMA. 1989;261 :80-3. 26. Students and tobacco, the 1990 Nova Scotia Council on Smoking and Health Survey, final report. Nova Scotia Council on Smoking and Health, March 1991, p. 20. 27. Blum A. When "more doctors smoked Camels," cigarette advertising in the journal. NY State J Med. 1983;83(13):1347-52. 28. RJR ordered by FTC to show cause in MR FIT case. Mealey's Litigation Reports: Tobacco. Mealey Publications, April 1989;4(4):7-8.
Advertising Woos Children to Smoking Surgeon General Antonia Novello, MD, has joined the American Medical Association (AMA) in calling on R.J. Reynolds and other tobacco companies to stop using advertising that appeals to children. AMA recently held a press conference publicizing a study showing that Reynolds' "Old Joe Camel," a cartoon character used in advertising Carn.,els cigarettes since 1988, was correctly identified by 300/0 of three-year-olds and 91% of six-year-olds. The study, by Paul Fischer, MD, et al. showed that children ~ecognized Old Joe Camel from exposure to billboards, movies, tee shirts, toys, and candy. "The tobacco and advertising industries are attempting to take hostage the most vulnerable in our population--our nation's youth," Novello said. "While cigarette companies claim that they do not intend to market to children, the reality is that this argument becomes irrelevant if advertising affects what children know," Novello said. "Did you ever imagine that six-year-alds are as familiar with Old Joe as with Mickey Mouse?" Surveys before 1988 indicated little preference for Camels among young people, Novello said. Recent surveys show that in some communities, 25% or more of young smokers are now buying Camels; since 1986, its market share has increaseQ,230% among the youngest group of smokers. Also actively battling the health consequences of smoking is the National Cancer Institute (NCl). In 1990, NCI spent $47 million to fight smoking, according to NCI's director Samuel Broder, MD, but the tobacco companies spent 80 times that amount promoting smoking, and about 3,000 teenagers take up smoking each day .. In 1989, a Reynolds' ad that appeared in Rolling Stone magazine offered dating advice to young men. The back page of the ad suggested that to get a free pack of cigarettes "even if you don't like to redeem coupons," they should ask a friend or "a kind looking stranger" to redeem the coupon for them. As Broder asked, who "would feel compelled to ask a 'kind looking stranger' to redeem a coupon for free merchandise-unless, of course, they were underage?"
29. Warner KE. Selling Smoke: Cigarette Advertising and Public Health. Washington DC: American Public Health Association, 1986. 30. Imperial Tobacco Ltd. Continual Market Assessment Study, quoted by Dr. Jeffrey Harris in Exhibit AG-196, p. 43, RJR-MacDonald and Imperial Tobacco Ltd. v. Attorney General of Canada. Quebec Superior Court, 1989.
33. Quebec to limit sale of tobacco. Wall Street Journal, February 21, 1991:A10.
31. Cunningham G. You can do without discounting, tobacco. Drug Merchandizing. February 1988;72-3.
34. Hall C. Pharmacists want to ban tobacco sales in drug stores. Ottawa Citizen, October 18, 1990:A1.
Report, April 1987, TR# 72428.
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