Tobacco-Free Pharmacies:
Using Ethics, Economics,
Education, and Law
to Achieve an
Attainable
NCTH
Public Health
Sarah Elisabeth Curi, JD, MPH
Goal
Tobacco Control Resource Center
Staff Attorney
11/18/02
4:00pm
2002 © Tobacco Control Resource Center, Inc.
Legal Resources
Tobacco Control Resource Center, Inc., a
non-profit organization based at
Northeastern University School of Law,
provides legal, technical, research and
training support for regulatory and
litigation-based initiatives to control
the sale and use of tobacco as a public health strategy.
TCRC serves as a national research clearinghouse, providing
information to federal, state, and local officials throughout
the United States.
TCRC is a founding member of the new national
Tobacco Control Legal Consortium which seeks to foster
communication and cooperation among attorneys and
tobacco control advocates on legal matters relating to
tobacco control and to share legal resources.
Contact TCRC at 617-373-2026 or www.tplp.com
A Call to Action!!
The sale of tobacco in pharmacies:
- is counter to good public health policy,
- sends unhealthily mixed-messages,
- not a clear economic necessity, and
- undermines the credibility of
pharmacists as health care providers.
Goal:
To provide health care
practitioners and tobacco
control advocates an
innovative strategy to
tackle the leading threat
to public health
Public Health Benefits of
Tobacco-Free Pharmacies
• Sends a powerful message about the danger of
tobacco products
• Changes social norms around tobacco use
• Reduces the number of retail
outlets that sell tobacco
products, allowing for
more cost-effective
compliance checks and
fewer venues for advertising
Massachusetts
1,000 Fewer Retail Outlets
California
4,000 Fewer Retail Outlets
Health Care Providers
“Every time a drugstore sells tobacco
products, that store is implicitly
legitimizing its uses. Hospitals
stopped selling tobacco years ago
because they understood that
commercial centers of health should
not be selling a product that kills.”
Jack Lewin, MD
Executive Director, California Medical Association
We should find
health products and
health services at
health care facilities
not health problems.
Ethical Conflicts
In taking the Oath of a Pharmacist, pharmacists voluntarily agree to:
• maintain the highest principles of moral and ethical conduct,
• consider the welfare of humanity and the relief of human
suffering as a primary concern, and
• embrace and advocate change in the profession of pharmacy to
improve patient care.
The Code of Ethics of the APhA:
• urges pharmacists to place concern for the well-being of the
patient at the center of professional practice, and
• explicitly states “A pharmacist should never knowingly condone
the dispensing, promoting, or distributing of drugs … that lack
therapeutic value to the patient.”
Impact on Pharmacists who Sell
Tobacco Products
• 47.6% reported that selling tobacco
products differed from their personal values.
• 63.9% said that selling tobacco products
differed from their professional values.
• lower levels of overall job satisfaction,
higher levels of job-induced tension, and a
higher propensity to leave their jobs than
respondents working in pharmacies that did
not sell tobacco products.
Massachusetts Tobacco Free Pharmacy Survey, 1994
Pharmacists advocating for change
Nationally, in 1970, the APhA stated
- selling cigarettes in pharmacies is contradictory
- pharmacies should be tobacco-free
At the state level, in 1997, the Board of Pharmacy
in Washington urged pharmacists to go tobaccofree to promote a healthy lifestyle to their
patients.
The Washington Board of
Pharmacy’s Policy Statement
“ … given that the use of tobacco products
is the most preventable cause of death and
disability, and that pharmacies promote a
healthy lifestyle to their patients, the board
urges pharmacists to remove all tobacco
products from their pharmacies and to
actively support their patient’s efforts to
quit using tobacco in any form.”
Washington State Register, WSR 97-07-070, 1997
So … Why do Pharmacists
sell Tobacco Products?
Fear =
loss of
business
BUT
the
economics
are not
clear-cut
Economics
Of Canadian pharmacists who
discontinued tobacco sales, in 1987,
21% reported an increase in profits and
only 2% reported a long-term decrease.
The bleak predictions of 119 - 326
closures did not occur when Ontario
pharmacies went tobacco-free in 1994.
Instead, there was a net increase of 70
pharmacies.
Pharmacists as leaders in
Tobacco Control
By virtue of their accessibility
to patients, pharmacists are
in an ideal position to help
people avoid initiating
smoking or quit smoking.
Public Support
• 70% of California consumers favored
tobacco-free pharmacies &
83% would continue to shop just as
often at a tobacco-free pharmacy.
• By strategically marketing other
products and services, pharmacies
become less reliant on the revenue
from tobacco products.
Business Strategies
Tobacco-free pharmacies can
replace any lost sales by
promoting smoking cessation aids
(nicotine patches, gum, etc.) and
other consumer goods.
Voluntary Programs
Only 60 out of
approximately 1,250
pharmacies in
Massachusetts are
tobacco-free.
All tobacco-free
pharmacies in
Massachusetts are
independent
pharmacies.
Massachusetts Pharmacists Association, in cooperation with the
Massachusetts Department of Public Health
www.tobaccofreepharmacy.org
In Massachusetts,
95% of pharmacies still sell
tobacco products
Bans World-wide
• Austria
• Japan
• Brazil
• Mexico *
• Canada
(most don’t sell –
it is possible to request a special permit to sell)
(in 5 provinces)
• New Zealand
• Denmark
• Norway
• France
• Spain
• Germany
• Sweden
• Greece
• Switzerland
• Ireland *
• United Kingdom
• Italy
England, Scotland, Northern Ireland, Wales
Law is a tool for public health
In 1994, the sale of tobacco in
pharmacies was banned in Ontario.
New Brunswick, 1997. Quebec, 1998.
Nova Scotia, 1999. Newfoundland,
phase-out by 2005.
In 2001, a bill to prohibit sale by pharmacists was reintroduced before the Massachusetts legislature. The bill died
in committee.
In 2001, an assemblyman in Marin County, CA agreed to
introduce legislation in California to eliminate the sale of
cigarettes in all healthcare facilities, including pharmacies.
In Canada, there are laws pending in Newfoundland, British
Columbia, and Prince Edwards Island.
Legislative Strategies
The Massachusetts Model
The Ontario Model
The proposed legislation
prohibits the sale of tobacco
by pharmacists, thereby
creating a large loophole
permitting, for example,
supermarkets with
pharmacies to sell tobacco
products.
In contrast, the 1994 law is
more comprehensive; it
prohibits the sale if
“a pharmacy … is located
within the establishment, or
customers of [that]
pharmacy can pass into the
establishment directly or by
the use of a corridor or area
used exclusively to connect
the pharmacy with the
establishment.”
2001, H.B. 2695
S.O. 1994, c. 10, s. 4
Comparing the Models
The Massachusetts Model
The Ontario Model
Focuses on the sale of of
tobacco by pharmacists.
Prohibits the sale based on
location.
(+) enforcement mechanism
(-) enforcement mechanism
(-) creates a large loophole
permitting stores containing
pharmacies to sell
(+) makes all pharmacies
and stores with on-site
pharmacies tobacco-free
(-) divides the pharmacy
community between chains
and independents
(+) treats independent and
chain pharmacies the same
2/3 of the pharmacies in
Massachusetts are chains.
(+) covers all health care
facilities such as hospitals,
psychiatric facilities, and
nursing homes
Power through Licensing
Boards of registration may
have the authority to act to
prohibit the licensure of
pharmacies on premises
that sell tobacco.
What type of law?
National Legislation
(-) power of the Tobacco Industry
(+) one law covers every pharmacy in the US
State Law
(-) power of the Tobacco Industry
(+) one law covers every pharmacy in the state
ALTERNATIVE regulation by licensing authority
Local Action
(-) incremental approach
(+) Boards of Health (e.g., in MA have “plenary power to
issue reasonable, general health regulations.”)
The Path Forward
• look for and call upon advocates in the
United States and Canada
• form coalition of
interested individuals and
organizations to create synergy
• look for allies and leadership amongst
consumers, pharmacists, colleges of pharmacy,
boards of registration in pharmacy, and national
associations of pharmacists
Means to an Achievable Goal ...
The process of educating pharmacists, consumers,
and politicians, and of building coalitions will lead
to greater awareness of the facts.
The sale of tobacco products
1.
presents an ethical conflict for pharmacists,
2.
sends unhealthily mixed-messages,
3.
is not a clear economic necessity, and
4.
is counter to the public’s health.