By selling tobacco products, pharmacies convey tacit approval to their purchase and use; this, in turn, sends a mixed message to consumers, who typically patronise pharmacies to receive health care services. Although the studies described here were conducted in the USA, other countries (for example, Canada17
) have similarly encountered this issue. In the USA, several grass roots efforts in recent years have attempted to encourage pharmacies to quit selling tobacco, such as the California Medical Association Foundation's Prescription for Change project, which successfully enlisted more than 900 tobacco‐free pharmacies throughout California and provided an online index to aid consumers and health professionals in identifying tobacco‐free pharmacies in their community. Despite this project's success in engaging segments of the profession and in raising awareness for this issue through edgy, broad scale media campaigns, its efforts to influence the decision makers within chain drugstore management were unsuccessful. While pharmacies that sell tobacco often state that they carry tobacco products as a convenience to customers, our results suggest that most consumers are not in favour of tobacco sales in pharmacies, the majority of tobacco users do not routinely purchase their cigarettes at pharmacies, and if tobacco sales were to cease, the impact on profits is likely to be small. Indeed, a report from the Physicians for a Smoke‐Free Canada concluded that despite initial predictions, banning cigarette sales in pharmacies did not result in pharmacy closures in the province of Ontario.17
In addition to lack of support by consumers, our data also indicate that only a small minority (fewer than 2%) of the pharmacy profession in California is in support of tobacco sales in pharmacies. Even among tobacco users, few (7.5% of pharmacists and 5.3% of students) were in favour of tobacco sales in pharmacies. Clearly, there is a logical and ethical disconnect between the sales of tobacco in pharmacies and the pharmacist's code of ethics.12
As the majority of US schools of pharmacy integrate comprehensive tobacco cessation training through implementation of the Rx for Change: Clinician‐Assisted Tobacco Cessation
we anticipate that social norms within the profession will change, and pharmacists of the future will be more vocal against tobacco sales in their practice environments. Indeed, exposure to the Rx for Change
programme has been demonstrated to strengthen (p < 0.001) California pharmacy students' opposition toward tobacco sales in pharmacies.16
The prevalence of current tobacco use among California pharmacists is low (3.5%), and this value is similar to that observed (4.5% current smokers) in a recent, national survey of 403 pharmacists.19
Individual smoking behaviour has been shown to be associated with health professionals' tobacco cessation counselling practices,20
and our results demonstrate that tobacco users are less likely to believe that the profession should be more active in promoting cessation. As such, it is worrisome that the 7.7% prevalence of tobacco use among pharmacy students is more than double that of the licensed pharmacists in our study. Currently, tobacco cessation programmes are being developed specifically for health professionals through collaborations with the Robert Wood Johnson Foundation and the Smoking Cessation Leadership Center at the University of California San Francisco (http://smokingcessationleadership.ucsf.edu/
Our study results should be generalised with caution, given that all three studies were conducted in California, where the prevalence of tobacco use is lower than the national median.21
Additionally, the response rate for the survey of licensed pharmacists (54%) is subject to response bias, although the pharmacists' perceptions were notably similar to the student pharmacists' perceptions. Generalisability of the pharmacy student data is supported by evidence that 3.5% of 3064 pharmacy students surveyed throughout the USA are in favour of tobacco sales in pharmacies,22
a proportion that is similar to that obtained from our sample of pharmacy students in California.
The reasons that pharmacies cite for selling tobacco have been described as “weak and unconvincing”.23
Given the current national shortage of pharmacists, the window of opportunity is wide open for licensed and future pharmacists to make public their opinions and negotiate with employers for tobacco‐free practice settings, thereby continuing to raise awareness of this issue and ultimately leading to the removal of the single most important cause of preventable death in our country from pharmacy shelves. Physicians and other health care providers can support this effort by referring their patients to community pharmacies that do not sell tobacco.
What this paper adds
Despite the fact that tobacco sales in US pharmacies contradict the pharmacist's code of ethics, many community pharmacies in the USA sell tobacco products. Grass roots efforts in recent years have attempted to encourage pharmacies to cease selling tobacco; however, these efforts have been largely unsuccessful. Efforts to convince pharmacy management to remove tobacco products from pharmacy shelves are in need of convincing, published data.
This report presents data from a series of three studies conducted in California: (1) A survey of 1168 licensed pharmacists; (2) a survey of 1518 pharmacy students; and (3) telephone interviews with 988 adult consumers. In sum, there is little‐to‐no support for tobacco sales in pharmacies among currently licensed pharmacists (1.6% in favour) and future pharmacists (2.0% in favour). Most smokers do not purchase tobacco products from pharmacies, and only 3.2% would shop at their pharmacy less often if it stopped selling tobacco, compared to 14.2% who would shop there more. In conclusion, there is little professional or public support for tobacco sales in pharmacies.