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Pharmacists Who Choose Not to Sell Tobacco
Phar",aclats Who ChooaeNot to Sell Tobacco Some pharmacists) believing that selling tobacco is at odds with their ethics and health professional responsibilities) have chosen to take tobacco products off their shelves. by H. Gordon Taylor
A
lthough they are still in the minority nationwide, increasing numbers of independent pharmacists are taking tobacco products off their shelves. For many the decision was a long time in coming. "I just decided in good conscience that I couldn't sell cigarettes and promote health at the same time," says Charles Thomas, owner of Thomas Discount Drugs in Huntsville, Ala. "I've been thinking about this for some time, especially since our state has started talking about the pharmacists' mission to promote positive drug therapy. I just finally decided I had to do it." For Thomas the timing couldn't have been better. In the past few months three pharmaceutical companies have come out with smoking cessation patches that are expected to have a major impact on people who are trying to stop smoking. In fact, Thomas hopes to recover the income he expects to lose from tobacco sales by promoting smoking cessation aids, including nicotine patches, gum, and other drugs. He also plans to replace his tobacco section with pamphlets and educational materials on smoking. "All the smoking cessation products out now heighten awareness and may help people who want to quit get started," Thomas says (see sidebar, p. 51). Although the loss in revenue was "never
Vol. NS32, No. 5 May 1992/ 425
AMERICAN PHARMACY
far from my mind," says Thomas, the positive publicity he's had from local media has helped him overcome potentially negative reactions from some customers. "In fact, I haven't had one negative comment so far," he says, "and lots of people come in and shake my hand. Even smokers thank me."
No Clear Picture
Pharmacist Charles C Thomas, who decided to stop seUing tobacco, plans to promote smoking cessation products.
Evidence on what pharmacists are doing nationwide about tobacco sales is sketchy and, at times, contradictory. An informal 1991 survey found that 250/0 of the independents in Lansing, Mich. do not sell tobacco. 1 The legal age for purchasing cigarettes in Michigan is 18, but younger teenagers do not have any problem buying cigarettes in the independent pharmacies that sell them. 1 In Georgia, an unpublished study conducted several years ago found that 35 of 95 independent pharmacies were tobacco-free, 2 and in California virtually all independents in San Luis Obispo County have eliminated tobacco products from their shelves3 (although chains continue to sell them). In Canada, where many people have been calling for legal prohibition of tobacco-product sales in all pharmacies, a 1989 survey showed that more than 500/0 of pharmacies were tobacco-free. 4 However, a survey of 100 pharmacies in Massachusetts last year found that only five, all independents, had a policy of not selling tobacco. S
Pros and Cons
APhA Opposes Tobacco Sales The American Pharmaceutical Association (APhA) Code of Ethics says, '(A pharmacist should never knowingly condone the dispensing, promoting, or distributing of drugs ... that lack therapeutic value for the. patient." In 1970, APhA declared that "mass display of cigarettes in pharmacies is in direct contradiction to the role of the pbarmacy as a public health facility." One year later APHA recommended that tobacco products not be sold in pharmacies.
AMERICAN PHARMACY
Smoking is the leading preventable cause of death: every year, it kills 2.5 million people worldwide 6; 434,000 men and women in the United States alone. Mounting evidence has also implicated cigarette smoke in the cancer deaths of many nonsmokers, including the children of smokers. 7 Nicotine addiction, as measured by relapse rates 8 and craving, equals-or exceeds-that of alcohol, and even heroin. 9 Today, virtually every medical journal regularly describes some aspect of nicotine addiction. The American Pharmaceutical Association (see box, at left), the American Public Health Association, the American Medical Association, and several other professional societies have adopted resolutions asking pharmacists to stop selling tobacco products. In Canada, some physicians use prescription pads that bear a preprinted message asking their patients to make purchases only in pharmacies that don't sell tobacco. Independent pharmacists who have stopped selling tobacco most often are personally against smoking and are concerned about their patients' health. On the other hand, pharmacies who sell tobacco say that they have a simple obligation to sell what their patrons want.
May 1992/426 Vol. NS32, No.5
Tobacco Sales and Pharmacy Profits Tobacco is a convenience item frequently used to build store traffic for retailers. Selling tobacco products can also be extren1ely profitable. The companies that make cigarettes pay incentives , based on a store 's sales volume and whether or not the store features eye-level displays of tobacco products in high-traffic areas. Many phanuacists who have n1ade the decision to ren10ve tobacco say they have gained goodwill and lost little, if any, revenue. "While it luay be true that some pharmacies have lost son1e revenues, most of those who have contacted us indicate that they have not suffered financially, " repol1s Robel1 Gadoua, corporate affairs director of the Canadian Pharmaceutical Association. 4 Most Canadian pharmacists have substituted "photographic equipment," or son1e "high-ticket items you would not want shoplifted. Many have added health food lines, and new vitamin products," says Ernest Stefanson of Viking Phanuacy in Gituli, Manitoba.
• Make an appointment with your dentist to have your teeth cleaned on quit day.
One Pharmacy's Experience
On Quit Day
The Mar-Main Pharmacy, a 1,200-square-foot facility in South Bend, Ind. , serves neighborhood clientele and hospices in northern Indiana and southern Michigan. The pharmacy's partners Charles N. Spiher and Janice Bopp enjoy a strong prescription business, including 15 to 20 cOlupounded prescriptions per day. They prepare 30,000 suppositories and 50,000 to 75 ,000 capsules every year. The two pharmacists found they were cramped within a 200-square-foot section. But the rest of the pharmacy was, says Spiher, pretty much like a luini K-Mart, carrying the usual front-end items . His tobacco sales in 1990 were around $100,000, with a "bottom-line, black ink" profit of about $15,000, gained from an 8% margin on cartons, 200/0 on packs , and direct payments from the luanufacturers. "The cigarette companies are really grasping by their fingernails, " says Spiher. "They bribe you to sell cigarettes. They don't call them bribes-they have their own euphemistic names , like 'off-shelf payments ' and 'proluotional allowances. '" Spiher and Bopp debated a good while about whether they ought to drop their cigarettes, liquor, magazines, and grocery items , so they could expand the square footage devoted to cOlupounding, and also add more eye care, foot care, cough and cold remedies, vitamins, and other health care nonprescription drugs. In short, they wanted a better image as health care providers. Spiher was particularly troubled by what, to his mind, was a terrible irony: oncologists and relatives of hospice patients had to w alk past his extensive cigarette display to consult with him at the pharmacy counter. The partners did eliminate their line of tobacco products (and the associated $100,000 in potential gross sales) in JanVol. NS32, No.5 May 1992/ 427
Strategies to Quit Smoking Preparing to Quit • Make a list of the reasons you want to quit. • Make the decision that you want to quit. • Set a "quit date." Put it on your calendar. • Condition yourself for the change. Start a modest exercise regimen, increase fluids, get plenty of rest. Keep a diary to help set strategies w hen the time comes to stop. • Try cutting down and then stopping for one day at a time.
• Throwaway all cigarettes and matches. Eliminate all reminders, such as ashtrays and lighters. • Have your teeth cleaned. • Make a list of things you would like to buy with the money you will save by not smoking. • Keep busy. Avoid places where you find you really want to smoke; substitute another activity.
Sticking to It • At first, spend as much time as possible in places where smoking is prohibited. • Force yourself to drink fluids, such as water and fruit juices, but not alcohol, coffee, or other beverages you associate with sluoking. • To satisfy the need to put something in your mouth, try hard, sugarless candy. • Eliminate the odor of smoke wherever possible, e.g., get your clothes cleaned and shampoo your car seats. • Reward yourself regularly with new things to do. • Remember, changes do not occur easily. Do not get discouraged with failure. Just get started again, and sooner or later you will succeed if you really want to.
AMERICAN PHARMACY
uary 1991. "Janice and I feel much, much better," says Spiher. "It is like the loss of a real burden not to have to sell cigarettes. You just feel better about yourself and your job-and everything." In recognition of its decision, Mar-Main Pharmacy received front-page newspaper coverage in the Indianapolis Star and other local newspapers. Explaining that he didn't want "an award from the American Lung Association or the American Heart Association, or something like that," Spiher says that, instead, his reward is knowing that he has done "the right thing."
Many pharmacists who have made
"is not necessarily entering into the same kind of relationship" with the pharmacist, he says. Consequently, it is not as morally inconsistent for a pharmacy--especially a large chain-to sell tobacco products. But, Tomlinson adds, as health professionals, pharmacists assume a general obligation to promote public health. He concedes that many pharmacists, especially chain employees, have no control over whether or not to sell tobacco. This is a business decision made by business managers, often non-pharmacists. If these employees feel ethically or professionally compromised, their only options are to persuade their employers to stop selling tobacco or change jobs, he says. In contrast, pharmacy owners and employee pharmacists who share business profits are in a position to change policy. "These pharmacists are not only responsible, they are morally culpable for their tobacco sales, " Tomlinson believes.
the decision to discontinue tobacco say they have gained goodwiU and lost little revenue.
Spiher anticipated lowered gross sales from lost tobacco revenue the first year, but says he is not concerned. "I feel so good about having done what I know to be the right thing, and with all the favorable, but unsought publicity, we may even come out ahead."
A Moral Question? For some the question comes down to this: Should a pharmacist, who is a health professional, sell cigarettes? Tom Tomlinson, PhD, of Michigan State University's Center for Ethics and Humanities, says pharmacists in various practice settings-health care-oriented pharmacies, large chain pharmacies, and employees-may have different individual "ethical contracts" with the customer. "One approach would be to make an analogy between the role of the pharmacist and that of the physician," Tomlinson says. If the physician had a cigarette vending machine in his waiting room , its mere presence would clearly be at odds with the physician's obligation to protect and promote the health of his patients. A pharmacy patron AMERICAN PHARMACY
An Individual Decision In the end, for independent phannacy owners-who have the freedom to decide whether or not they want to sell tobacco-it is an individual decision. Employees, unless they decide to quit their job, rarely have anything to say about the decision to sell tobacco. "Smoking is an elnotional issue with some people, " admits Thomas. "You worry about custolners taking their business elsewhere. But some chain pharmacists have called and congratulated me, wishing they could do the same. I would urge all pharmacists to think about this and assess their responsibilities to their patients." H. Gordon Taylor is a hospital pharmaCist, a part-time relief pharmaCist, and a freelance writer in Lansing, Mich.
References 1. Taylor HG. Telephone survey of pharmacies listed in the Lansing, Michigan telephone directory. Unpublished data, May 1991. 2. Fischer P. Unpublished study. Department of Family Medicine, Medical College of Georgia, Augusta, Ga. 3. Martin A. Owner of Economy Drug, San Luis Obispo, Calif. Personal communication. 4. Gadoua R. 1989 survey by the Canadian Pharmaceutical Association. Personal communication. 5. Brown LJ, DiFranza JR. The pharmacy's role in the promotion of tobacco use among children in Massachusetts. Am Pharm. 1992;NS31 (5):45-8. 6. Centers for Disease Control. World no-tobacco day. Morbid Mortal Weekly Rep. 1990;39:218. 7. John EM, Savitz DA, Sandler DP. Prenatal exposure to parents' smoking and childhood cancer. Am J Epidemiol. 1991;133:123-32. 8. Henningfield JE. Nicotine: An Old-Fashioned Addiction. New York: Chelsea House Publishers, 1985:87-9. 9. Kozlowski LT, Wilkinson DA, Skinner W, et al. Comparing tobacco cigarette dependence with other drug dependencies. JAMA. 1989;261 :898-901.
May 1992/428 Vol. NS32, No.5
A
lthough they are still in the minority nationwide, increasing numbers of independent pharmacists are taking tobacco products off their shelves. For many the decision was a long time in coming. "I just decided in good conscience that I couldn't sell cigarettes and promote health at the same time," says Charles Thomas, owner of Thomas Discount Drugs in Huntsville, Ala. "I've been thinking about this for some time, especially since our state has started talking about the pharmacists' mission to promote positive drug therapy. I just finally decided I had to do it." For Thomas the timing couldn't have been better. In the past few months three pharmaceutical companies have come out with smoking cessation patches that are expected to have a major impact on people who are trying to stop smoking. In fact, Thomas hopes to recover the income he expects to lose from tobacco sales by promoting smoking cessation aids, including nicotine patches, gum, and other drugs. He also plans to replace his tobacco section with pamphlets and educational materials on smoking. "All the smoking cessation products out now heighten awareness and may help people who want to quit get started," Thomas says (see sidebar, p. 51). Although the loss in revenue was "never
Vol. NS32, No. 5 May 1992/ 425
AMERICAN PHARMACY
far from my mind," says Thomas, the positive publicity he's had from local media has helped him overcome potentially negative reactions from some customers. "In fact, I haven't had one negative comment so far," he says, "and lots of people come in and shake my hand. Even smokers thank me."
No Clear Picture
Pharmacist Charles C Thomas, who decided to stop seUing tobacco, plans to promote smoking cessation products.
Evidence on what pharmacists are doing nationwide about tobacco sales is sketchy and, at times, contradictory. An informal 1991 survey found that 250/0 of the independents in Lansing, Mich. do not sell tobacco. 1 The legal age for purchasing cigarettes in Michigan is 18, but younger teenagers do not have any problem buying cigarettes in the independent pharmacies that sell them. 1 In Georgia, an unpublished study conducted several years ago found that 35 of 95 independent pharmacies were tobacco-free, 2 and in California virtually all independents in San Luis Obispo County have eliminated tobacco products from their shelves3 (although chains continue to sell them). In Canada, where many people have been calling for legal prohibition of tobacco-product sales in all pharmacies, a 1989 survey showed that more than 500/0 of pharmacies were tobacco-free. 4 However, a survey of 100 pharmacies in Massachusetts last year found that only five, all independents, had a policy of not selling tobacco. S
Pros and Cons
APhA Opposes Tobacco Sales The American Pharmaceutical Association (APhA) Code of Ethics says, '(A pharmacist should never knowingly condone the dispensing, promoting, or distributing of drugs ... that lack therapeutic value for the. patient." In 1970, APhA declared that "mass display of cigarettes in pharmacies is in direct contradiction to the role of the pbarmacy as a public health facility." One year later APHA recommended that tobacco products not be sold in pharmacies.
AMERICAN PHARMACY
Smoking is the leading preventable cause of death: every year, it kills 2.5 million people worldwide 6; 434,000 men and women in the United States alone. Mounting evidence has also implicated cigarette smoke in the cancer deaths of many nonsmokers, including the children of smokers. 7 Nicotine addiction, as measured by relapse rates 8 and craving, equals-or exceeds-that of alcohol, and even heroin. 9 Today, virtually every medical journal regularly describes some aspect of nicotine addiction. The American Pharmaceutical Association (see box, at left), the American Public Health Association, the American Medical Association, and several other professional societies have adopted resolutions asking pharmacists to stop selling tobacco products. In Canada, some physicians use prescription pads that bear a preprinted message asking their patients to make purchases only in pharmacies that don't sell tobacco. Independent pharmacists who have stopped selling tobacco most often are personally against smoking and are concerned about their patients' health. On the other hand, pharmacies who sell tobacco say that they have a simple obligation to sell what their patrons want.
May 1992/426 Vol. NS32, No.5
Tobacco Sales and Pharmacy Profits Tobacco is a convenience item frequently used to build store traffic for retailers. Selling tobacco products can also be extren1ely profitable. The companies that make cigarettes pay incentives , based on a store 's sales volume and whether or not the store features eye-level displays of tobacco products in high-traffic areas. Many phanuacists who have n1ade the decision to ren10ve tobacco say they have gained goodwill and lost little, if any, revenue. "While it luay be true that some pharmacies have lost son1e revenues, most of those who have contacted us indicate that they have not suffered financially, " repol1s Robel1 Gadoua, corporate affairs director of the Canadian Pharmaceutical Association. 4 Most Canadian pharmacists have substituted "photographic equipment," or son1e "high-ticket items you would not want shoplifted. Many have added health food lines, and new vitamin products," says Ernest Stefanson of Viking Phanuacy in Gituli, Manitoba.
• Make an appointment with your dentist to have your teeth cleaned on quit day.
One Pharmacy's Experience
On Quit Day
The Mar-Main Pharmacy, a 1,200-square-foot facility in South Bend, Ind. , serves neighborhood clientele and hospices in northern Indiana and southern Michigan. The pharmacy's partners Charles N. Spiher and Janice Bopp enjoy a strong prescription business, including 15 to 20 cOlupounded prescriptions per day. They prepare 30,000 suppositories and 50,000 to 75 ,000 capsules every year. The two pharmacists found they were cramped within a 200-square-foot section. But the rest of the pharmacy was, says Spiher, pretty much like a luini K-Mart, carrying the usual front-end items . His tobacco sales in 1990 were around $100,000, with a "bottom-line, black ink" profit of about $15,000, gained from an 8% margin on cartons, 200/0 on packs , and direct payments from the luanufacturers. "The cigarette companies are really grasping by their fingernails, " says Spiher. "They bribe you to sell cigarettes. They don't call them bribes-they have their own euphemistic names , like 'off-shelf payments ' and 'proluotional allowances. '" Spiher and Bopp debated a good while about whether they ought to drop their cigarettes, liquor, magazines, and grocery items , so they could expand the square footage devoted to cOlupounding, and also add more eye care, foot care, cough and cold remedies, vitamins, and other health care nonprescription drugs. In short, they wanted a better image as health care providers. Spiher was particularly troubled by what, to his mind, was a terrible irony: oncologists and relatives of hospice patients had to w alk past his extensive cigarette display to consult with him at the pharmacy counter. The partners did eliminate their line of tobacco products (and the associated $100,000 in potential gross sales) in JanVol. NS32, No.5 May 1992/ 427
Strategies to Quit Smoking Preparing to Quit • Make a list of the reasons you want to quit. • Make the decision that you want to quit. • Set a "quit date." Put it on your calendar. • Condition yourself for the change. Start a modest exercise regimen, increase fluids, get plenty of rest. Keep a diary to help set strategies w hen the time comes to stop. • Try cutting down and then stopping for one day at a time.
• Throwaway all cigarettes and matches. Eliminate all reminders, such as ashtrays and lighters. • Have your teeth cleaned. • Make a list of things you would like to buy with the money you will save by not smoking. • Keep busy. Avoid places where you find you really want to smoke; substitute another activity.
Sticking to It • At first, spend as much time as possible in places where smoking is prohibited. • Force yourself to drink fluids, such as water and fruit juices, but not alcohol, coffee, or other beverages you associate with sluoking. • To satisfy the need to put something in your mouth, try hard, sugarless candy. • Eliminate the odor of smoke wherever possible, e.g., get your clothes cleaned and shampoo your car seats. • Reward yourself regularly with new things to do. • Remember, changes do not occur easily. Do not get discouraged with failure. Just get started again, and sooner or later you will succeed if you really want to.
AMERICAN PHARMACY
uary 1991. "Janice and I feel much, much better," says Spiher. "It is like the loss of a real burden not to have to sell cigarettes. You just feel better about yourself and your job-and everything." In recognition of its decision, Mar-Main Pharmacy received front-page newspaper coverage in the Indianapolis Star and other local newspapers. Explaining that he didn't want "an award from the American Lung Association or the American Heart Association, or something like that," Spiher says that, instead, his reward is knowing that he has done "the right thing."
Many pharmacists who have made
"is not necessarily entering into the same kind of relationship" with the pharmacist, he says. Consequently, it is not as morally inconsistent for a pharmacy--especially a large chain-to sell tobacco products. But, Tomlinson adds, as health professionals, pharmacists assume a general obligation to promote public health. He concedes that many pharmacists, especially chain employees, have no control over whether or not to sell tobacco. This is a business decision made by business managers, often non-pharmacists. If these employees feel ethically or professionally compromised, their only options are to persuade their employers to stop selling tobacco or change jobs, he says. In contrast, pharmacy owners and employee pharmacists who share business profits are in a position to change policy. "These pharmacists are not only responsible, they are morally culpable for their tobacco sales, " Tomlinson believes.
the decision to discontinue tobacco say they have gained goodwiU and lost little revenue.
Spiher anticipated lowered gross sales from lost tobacco revenue the first year, but says he is not concerned. "I feel so good about having done what I know to be the right thing, and with all the favorable, but unsought publicity, we may even come out ahead."
A Moral Question? For some the question comes down to this: Should a pharmacist, who is a health professional, sell cigarettes? Tom Tomlinson, PhD, of Michigan State University's Center for Ethics and Humanities, says pharmacists in various practice settings-health care-oriented pharmacies, large chain pharmacies, and employees-may have different individual "ethical contracts" with the customer. "One approach would be to make an analogy between the role of the pharmacist and that of the physician," Tomlinson says. If the physician had a cigarette vending machine in his waiting room , its mere presence would clearly be at odds with the physician's obligation to protect and promote the health of his patients. A pharmacy patron AMERICAN PHARMACY
An Individual Decision In the end, for independent phannacy owners-who have the freedom to decide whether or not they want to sell tobacco-it is an individual decision. Employees, unless they decide to quit their job, rarely have anything to say about the decision to sell tobacco. "Smoking is an elnotional issue with some people, " admits Thomas. "You worry about custolners taking their business elsewhere. But some chain pharmacists have called and congratulated me, wishing they could do the same. I would urge all pharmacists to think about this and assess their responsibilities to their patients." H. Gordon Taylor is a hospital pharmaCist, a part-time relief pharmaCist, and a freelance writer in Lansing, Mich.
References 1. Taylor HG. Telephone survey of pharmacies listed in the Lansing, Michigan telephone directory. Unpublished data, May 1991. 2. Fischer P. Unpublished study. Department of Family Medicine, Medical College of Georgia, Augusta, Ga. 3. Martin A. Owner of Economy Drug, San Luis Obispo, Calif. Personal communication. 4. Gadoua R. 1989 survey by the Canadian Pharmaceutical Association. Personal communication. 5. Brown LJ, DiFranza JR. The pharmacy's role in the promotion of tobacco use among children in Massachusetts. Am Pharm. 1992;NS31 (5):45-8. 6. Centers for Disease Control. World no-tobacco day. Morbid Mortal Weekly Rep. 1990;39:218. 7. John EM, Savitz DA, Sandler DP. Prenatal exposure to parents' smoking and childhood cancer. Am J Epidemiol. 1991;133:123-32. 8. Henningfield JE. Nicotine: An Old-Fashioned Addiction. New York: Chelsea House Publishers, 1985:87-9. 9. Kozlowski LT, Wilkinson DA, Skinner W, et al. Comparing tobacco cigarette dependence with other drug dependencies. JAMA. 1989;261 :898-901.
May 1992/428 Vol. NS32, No.5