Tobacco Documents Online

Pharmacists VWho Choose Not 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 Ithough they are still in the minority nationwide, inaeasing numbers of independent phar- macists 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 phannacists' mission to promote positive drug therapy. I just finally decided I had to do il" For Thomas the timing couldn't have been better. In the past few months ttiree pharmaceutiral 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; induding nicotine patches, gum, and other drugs. He also plan..s to replace his tobacco section wi&pamphlets and educational materials on smoking. "All the smoking .cessation products out now heighten awareness and may help people who w•ant to quit get started,` Thomas says (see side- hi+r, p. 51). Althou0h the kns in revenue was "never Ob AAIF.RIC1ti PflARdtACS' voL NS32. nb:,5 nt.Y 1992/425 ®

I amacist CBarles C Iborxas, wbo decided to stop seAtng 2cco, plans to pr'omote s-okiieg cessation pr+odurts far from my mind," says Thomas, the positive publicity he's had from local media has helped him overcome potentially . negative reactions fnom 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 Evidence on what phartnacists are doing nationwide about aobaceo sales •is sketchy and, at times, contradictory. An informal 1991 survey found that 25% of the indepen dents in lansing, Mich. do not sell tobacco. t The legal age for purchasing cigarettes in Michigan is 18, but younger teenagers do nor have any problem buying agarettes in the t' independent pharmacies that sell them" In Georgia, an unpublished study conducted several years ago found that 35 of 95 independent pharmacies were tobacco-free,2 and in California virtually all independents in San Luis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 phamiacies, a 1989 survey showed that more than 50% of phamracies were GObaCCO-fPCe.4 However, a survey of 100 pharmacies in Massachusetts last year found that only ftve, all independents, had a policy of not selling tobacco.5 Pros and Cons Smoking is the leading preventable cause of death every year, it kills 2.5 million people worldwide6; 434,000 men and women in the United States alone. Mounting evidence has also implicated cigarette smoke in the cancer deaths of many nonsmokers, induding the children of smokers.7 Nicotine addiction, as measured' by relapse rates$ and craving, equaLs-or exceeds--that of alcohol, and even heroin.9 Today, vircually 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 soci- eties 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 phannades that don't sell tobacco. ~Tttdependent pharmacists viho- iiave'stopped selling tobat:- co most often are personally against smoking and are con- cerned! about their patients' health. On [he other hand, pharmacies cvho seff tobacco say that they have a simple obligation to sell what their patrons want. >fay 1992/42G'. voL N532.X0. 5 ,lMfJiIGN PHARMAGY ~ ` ~

Tobacco Sales and Pharmacy Profits Tobacco is a convenience item frequendy used to build store traffic for retailers. Selling tobacco products can also he extremely 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 pharmacists who have made -the decision to remove tobacco say they have gained goodwill and lost lit- de, if any, revenue. "While it may be true that some phar- macies have lost some revenues, most of those who have contacted us indicate that they have not suffenDd financial- ly; reports Robert Gadoua, corporate affairs director of the Canadian Pharmaceutical Association.4 Most Canadian pharmacists have substituted "photo- graphic equiptnent," or some "high-ticket items you would not want shoplifted. Many have added health food lines, and new vitamin products," says Ernest Stefanson of Viking Pharmacy in Gimli, Manitoba. One Pharmacy's Experience The Mar-Main Pharmacy, a 1,?00-square-foot facility in South Bend; Ind., serves neighborhood dientele and hos- pices in northern Indiana and southem 'Michigan. The phar- maey%s partners Charles N. Spiher and Janice Bopp enjoy a strong prescription business, including 15 to Z0 compound- ed 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, sa~,s Spiher, pretty much like a mini K-Mart. carrying the usual front-end items. His tobacco sales in 1990 were around S100.000, with a"bottom-line„ black inl:- profit of about S15,000, gained from an 8% margin on cartons, 20% on packs, and direct payments from the manufacturers. 'he cigarette companies are really grasping by their finger- nails," says Spiher. 'They bribe you to sell cigarettes. They don't call them bribes--~, have their own euphemistic names, like 'off-shelf payments' and 'promotional allowances." Spiher and Bopp debated a good while about whether they ought to. drop their cigarettes, liquor. ma~s; tzines, and grocery items, so they could expand the square footage devoted to compounding, 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 whaE: -to'his mind, was a terrible irony: oncologists and relatives of hospice patients had to walk past his extensive cigarette display to consult wich himat the phamnacy counter. The partners did eliminate their line of tobacco prodtrcts (and the associated $100,000 in potential gross :ales) in Jan- 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. 0 Set a'quit date.` Put it on your cralendar.  Condition yourself for. the change. Stan a modest exercise regimen, increase .fluids, get plenty of rest. Keep a diary to help set strategies when the time comes to stop. 7 Try cutting down and then stopping for one day at a time.  Make an appointment with your dentist to have your teeth deaned on quit day. On Quit Day  Throw away all cigarettes and; matches. Eliminate all reminders, such as ashtrays and lightets.  Have your teeth deaned  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 smoking.  To satisfy the need to put something in your mouth, try hand; sugarless candy.  Eliminate the *odor of 'smoke wherever possible, e.g., get your dothes cleaned and shampoo your car Sea ts.  Reward youtself regularly with new things to do.  Remember, changes.do not occur easily..Do not get discouraged- with •f;tilure. Just get started again, and sooner or later you will succeed if you reallti• want to. 290Y 236- 68753 VoL voL NS32~, No. 5. Atnv~1992/4~_^7. AA1F.K1(:A1 111IAhN 1C1 ®

uary 1991. Janice and I feel much, much bet,ter,.' says Spi- her. -lt is like the loss of a real burden not to have to sell cigarettes. You just feel better alxout yourself and your lot3.-and :evervdling.° : . In recognition of its decision, Mar-Main Pharmacy received' front-page newspaper coverage in the htdianapo- !is 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 the decision to discontinue tobacco say they have gained goodwiA' and lost little revenue. Spiher anticipated lowered gross sales from lost tobacco revenue the first year, but says he is not concemed "I feel so good about having done what I know to be the right thing, and with all the Eavotable, 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 Universitys Center for Ethics and Humanities, says pharmacists in various prac- tice settings-health cue-0riented pharmacies, large chain pharmacies, and employees--may have different individual 'ethical contracts' with the custonler. .`One approach would be to' make::an 'ahalogy. between the role of the phamlacist andthat of the physician." Tom- linson says. If the physician haci! a cigarette vending machine in his c.-aiting roomL 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~ .a 1IFRIGIN'PHAR1tACY, 0 "is not necessarily entering into the same kind of relation- ship" with the pharmacist, he says. Consequently, it is not as morally inconsistent for a p1lanYtacy---especially a large chain--to sell toliacco products. But, Tomlinson adds, as health professionals, pharmacists assume a general obligation to promote public health. He concedes that many phartnacists,, especially chain employ- ees, have no control over whether or not to sell tobacco. This is a business decision made by business managers, often non-pharmaasrs. If these employees feel ethically or professionally compromised, their only options are to per- suade their employers to stop selling tobacco or change jobs, he says. In contrast, pharmacy owners and employee pllarmaciscs who share business profits are in a position to change poli- cy. "These pharmacists are not only responsible, they are morally culpable for their tobacco sales," Tomlinson believes. An Individual Decision In the end, for independent pharmacy 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 emotional issue with some people," admits Thomas. "You wony about customers taking their_ business el5ewhere. 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 baspital pharntacrst a part-time relief pbannacis4 and a fieelance turiter in Larrsing, Mrcb. References 1. Taylor HG. Telephone survey of pharmacies listed in the Lansing, Michigan tekphone directory. Unpublished data, May 1991. 2. Fscher P. Unpublished study. Department of Family Medicine. Medical College of Georgia. Augusta. Ga. 3. Martin A Owner of Economy Drug, San Luis Obispo. Califl Personal communication. 4. Gadoua R. 1989 survey by the Canadian ~ Pharmaceutical Association. Personal communication. : - 5. Brown W. DiFranza JR: The pharmacyls role in the promotion of tobacco use among children in Massachusetts. Am Phartn. 1992iVS31(5):45-8. 6. Centers for Disease Control: World no•tobacco day. Morbid Mortal INeeldy Rep.1990:39,:218. . 7. John EM. Savia DA: Sandier DP. Prenatal exposure to parents' smoking and childhood cancer. Am J EpidemioL 1991:133:123-32. 8. Henningfield JE. Nicotine: An O/d-Fashioned Addiction: New York: Chelsea House Publishers. 1985:87-9. 9. Kozlowski LTS Wilkinson DA. Skinner W; et al. Comparing tobacco cigarette dependence with other drug dependencies. JAMA. 1989j261:898-941: Nav t993/42H vol' N532..No. 5