UCSF pharmacy faculty advocate for legislation banning tobacco sales in pharmacies

by Lisa Bero, from San Francisco Business Times, Friday, July 25, 2008

The San Francisco Board of Supervisors is expected to vote next week on an ordinance that will ban the sale of tobacco in our city's pharmacies.

There's been a lot of attention on the negative economic impact to chain pharmacies of such a bold move, yet we haven't seen the figures.

Let's put the spotlight where it belongs—on the health of San Franciscans and the role of pharmacies and pharmacists in promoting health, not enabling disease.

We all know that cigarette smoking is the leading cause of preventable disease and death in this country. Tobacco products are sold in pharmacies, with the knowledge that they cause harm. What if you could buy a pack of influenza virus or a carton of HIV at your local pharmacy? Tobacco is not that different. It, too, is an agent of disease. That's why it's a conflict of interest for pharmacies, which provide health care, to profit from the sale of tobacco products, which put health at risk. Furthermore, the sale of tobacco products alongside medications used to treat tobacco dependence is an ethical contradiction.

Add to this the fact that the sale of tobacco also contradicts the pharmacist's code of ethics to avoid "actions that compromise dedication to the best interests of patients," and it's no wonder that pharmacists say no to tobacco in pharmacies. Research shows that only 2 percent of pharmacists favor tobacco sales in pharmacies. Studies in San Francisco and Los Angeles show that 76 percent to 89 percent of independent pharmacies choose not to sell tobacco products. In contrast, only 7 percent of corporately-owned pharmacies are tobacco-free.

What's more, the public also says no to tobacco sales in pharmacies. A survey of California consumers found that almost three fourths were not in favor of pharmacies selling tobacco. When asked "If your drugstore stopped selling tobacco products, would you shop there more, less or the same?"—83 percent said they would shop there as often, 14 percent said more often, and only 3 percent said they'd shop there less.

One of the issues voiced by those opposing the ordinance is that warehouse stores and grocery stores are not included in the legislation. We also think this is an issue; we believe there is no place for the sale or promotion of tobacco in any pharmacy, wherever that pharmacy is located.

The current ordinance is a bold first step, and we support it fully.

Lisa Bero is UCSF professor of clinical pharmacy and health policy. Mary Anne Koda-Kimble, dean of the UCSF School of Pharmacy, and UCSF professors Robin Corelli, Karen S. Hudmon and Lisa Kroon co-wrote this opinion.

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Position Paper on the Ban of Tobacco Sales in San Francisco Pharmacies

July 14, 2008

Position on:

City and County of San Francisco, Ordinance amending the San Francisco Health Code by amending Section 1009.53 and adding Section 1009.60 and Article 19J, to prohibit pharmacies from selling tobacco products.

Prepared by:

• Lisa Bero, PhD, Professor, UCSF School of Pharmacy
• Robin Corelli, PharmD, Professor of Clinical Pharmacy, UCSF School of Pharmacy
• Karen Hudmon, DrPH, RPh, Assistant Clinical Professor, UCSF School of Pharmacy
• Lisa Kroon, PharmD, Professor of Clinical Pharmacy, UCSF School of Pharmacy

This document declares our full support of the City and County of San Francisco ordinance amending the San Francisco Health Code by amending Section 1009.53 and adding Section 1009.60 and Article 19J, to prohibit pharmacies from selling tobacco products. Our position is from the perspective of 74 cumulative years as healthcare providers, patient advocates, health policy researchers, and faculty members at the UCSF School of Pharmacy, the number one-ranked Doctor of Pharmacy degree program in the nation.[1]

One of our most important responsibilities as faculty members at UCSF, the only UC campus dedicated solely to the health sciences, is to speak out on policies that affect the health of the public we serve. We believe that this ordinance is not only a bold government action to safeguard the public's health but also an affirmation of our commitment to disease prevention and health promotion, both of which are core elements of the patient-centered care provided by pharmacists.

Our position is supported by the following facts:

1. Tobacco product sales in pharmacies raise ethical questions.

The sale of tobacco products, which cause death and disease, side-by-side with the sale of medications used to treat addiction to tobacco, conveys a disturbing message.

• Cigarette smoking is the leading preventable cause of disease and death in the United States. Approximately 438,000 deaths annually in the United States are attributable to smoking. The majority of conditions causing these deaths are cardiovascular diseases (e.g., high blood pressure, heart disease, and stroke), lung cancer, and respiratory diseases (e.g., pneumonia, emphysema, and bronchitis).[2]
• Tobacco is the only consumable product that, when used as intended, will kill at least one-half of its users. On average, cigarette smokers die 10 years younger than do nonsmokers.[3]
• It is a conflict of interest for pharmacies, providers of health care, to also profit from the sale of harmful products known to cause cancer, heart and pulmonary diseases.
• Community pharmacists are one of the most trusted health care professionals and are an important part of the health care team. Pharmacists are also the most accessible of all health care providers and are "the first line of health care."[4]
• Tobacco sales in pharmacies directly contradict the pharmacist's code of ethics, which states that "pharmacists must be committed to the welfare of their patients and must act with honesty and integrity in professional relationships, avoid actions that compromise dedication to the best interests of their patients."[5] Pharmacies that sell tobacco, regardless of whether the financial transactions are rendered by a pharmacist, technician, clerk, or other store personnel, violate the code of ethics.
• The tobacco industry has actively recruited pharmacies to sell tobacco products, oppose tobacco control legislation, and emphasize profit motives over health concerns.[6-10]

2. Pharmacists say no to tobacco product sales in pharmacies.

• Schools of pharmacy, pharmacists, and Doctor of Pharmacy students are opposed to the sale of tobacco products in pharmacies.
• Data from a large survey of pharmacists in Northern California reveal that fewer than 2 percent of licensed pharmacists are in favor of tobacco sales in pharmacies.[11]
• Only 2 percent of pharmacy students in California11 and 3.5 percent of pharmacy students nationally[12] are in favor of tobacco sales in pharmacies.
• Direct observational studies in San Francisco and Los Angeles have found that the majority (76-89 percent) of independently owned community pharmacies in California do not sell tobacco products.[13,14] In contrast, tobacco products are sold by more than 93 percent of pharmacies owned by large corporations (e.g., chain- and grocery-store pharmacies).[13,14]

3. The public says no to tobacco product sales in pharmacies.

• 72.3 percent of California consumers (n=988) surveyed by telephone disagreed with the statement, "I am in favor of tobacco products being sold in drugstores."[11]
• When asked, "If your drugstore stopped selling tobacco products, would you shop there more, less or the same?" 83 percent stated they would shop there just as often, 14 percent would shop there more often, and only 3 percent would shop there less often.[11]

4. A ban on tobacco sales supports healthy lifestyles and the prevention of disease.

The prevention of addiction and tobacco-related diseases is preferable and much less expensive to society than treatment of these conditions.

• The costs to society associated with smoking are enormous. It is estimated that the per pack cost of smoking to society is approximately $7.18 per pack of cigarettes.[15]
• It is inconsistent for a pharmacy to sell prescription and nonprescription medications that will help treat diseases and also sell tobacco products that cause disease.
• Pharmacies that do not sell tobacco products promote health and wellness to consumers

We respectfully submit our evidence-based position that it is in the best interest of the health of the people of the City and County of San Francisco that pharmacies be prohibited from selling tobacco products. It is a matter of patient health and professional ethics.

References:

1. America’s Best Graduate Schools. U.S. News & World Report, 2009 Edition. Pharmacy school ranking [link defunct] [Accessed 06/10/2008]
2. Centers for Disease Control and Prevention (CDC). Annual smoking-attributable mortality, years of potential life lost, and productivity losses—United States, 1997–2001. Morbidity & Mortality Weekly Report 2005;54:625–628.
3. Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years’ observations on male British doctors. British Medical Journal 2004;328:1519-1527.
4. National Association of Chain Drug Stores. Community Pharmacists One of Most Trusted Health Care Professionals. [link defunct as of October 18, 2012] [Accessed 06/10/2008]
5. American Pharmacists Association. Code of Ethics for Pharmacists. [Accessed 06/10/2008]
6. Le, A. and Bero, L. Tobacco Free Pharmacies: What the Tobacco Industry Documents Tell Us. National Conference on Tobacco or Health, San Francisco (November 19, 2002).
7. Le, A and Bero, L. Tobacco Free Pharmacies: Using Ethics, Economics, Education and Law to Achieve an Attainable Public Health Goal. American Public Health Association meeting, Philadelphia (November 11, 2002).
8. “Drug Stores” Philip Morris. Bates no: 1004885394/5397. 4 pages. [Accessed 06/10/2008]
9. No title (update of drug store pamphlet). Philip Morris. Bates no: 2070049450/9452. 3 pages. [Accessed 06/10/2008]
10. 1992 Retail Fact Book. RJ Reynolds. Bates no: 524187123/7267. 145 pages. [Accessed 06/10/2008]
11. Hudmon KS, Fenlon CM, Corelli RL, Prokhorov AV, Schroeder SA. Tobacco sales in pharmacies: Time to quit. Tobacco Control 2006;15(1):35-38.
12. Hudmon KS, Hussar DA, Fenlon CM, Corelli RL. Pharmacy student perceptions of tobacco sales in pharmacies and suggested strategies for promoting tobacco-free experiential sites. American Journal of Pharmaceutical Education 2006;70:75.
13. Eule B, Sullivan MK, Schroeder S, Hudmon KS. Merchandising cigarettes in San Francisco pharmacies: 27 years later. Tobacco Control 2004;13(4):429-432.
14. Corelli RL, Chen J, Ha KH, Lam MS, Lau AY, Young SC, Ambrose PJ, Hudmon KS. Tobacco and alcohol sales in Los Angeles community pharmacies. Advances in Tobacco Control Symposium. UCSF Center for Tobacco Control Research & Education: February 26, 2008.
15. Centers for Disease Control and Prevention (CDC). Annual smoking-attributable mortality, years of potential life lost, and economic costs—United States, 1995–1999. Morbidity & Mortality Weekly Report 2002;51:300–303.