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The availability of tobacco and alcohol products in community pharmacies contradicts the pharmacists’ Code of Ethics and presents challenges for a profession that is overwhelmingly not in favor of the sale of these products in its practice settings. The primary aim of this study was to estimate the proportion of pharmacies that sell tobacco products and/or alcoholic beverages and to characterize promotion of these products. The proportion of pharmacies that sell non-prescription nicotine replacement therapy (NRT) products as aids to smoking cessation also was estimated. Among 250 randomly-selected community pharmacies in Los Angeles, 32.8% sold cigarettes, and 26.0% sold alcohol products. Cigarettes were more likely to be available in traditional chain pharmacies and grocery stores than in independently-owned pharmacies (100% versus 10.8%; P < 0.001), and traditional chain drug stores and grocery stores were more likely to sell alcoholic beverages than were independently-owned pharmacies (87.5% vs. 5.4%; P < 0.001). Thirty-four (41.5%) of the 82 pharmacies that sold cigarettes and 47 (72.3%) of the 65 pharmacies that sold alcohol also displayed promotional materials for these products. NRT products were merchandised by 58% of pharmacies. Results of this study suggest that when given a choice, pharmacists choose not to sell tobacco or alcohol products.
Cigarette smoking and alcohol abuse are two leading preventable causes of morbidity and mortality [1, 2]. In the US, an estimated 443,595 deaths each year are attributable to smoking or exposure to second-hand smoke . Although the documented effects of moderate alcohol consumption range from protective [4–7] to harmful , it is clear that heavy alcohol use poses a serious public health problem , with excessive alcohol use being listed as the third leading lifestyle-related cause of death in the US . Each year, an estimated 1.7 million hospital admissions  and 7.6 million emergency department visits  are associated with alcohol use. Given that community pharmacies are locations where health-care services are rendered, availability of these products sends a mixed message to consumers and is a direct violation of the pharmacist’s Code of Ethics [12, 13].
Over the past 40 years, the pharmacy profession has repeatedly expressed opposition to the sale of tobacco products in pharmacies [12, 14, 15]. While professional pharmacy organizations have been advocating for tobacco-free policies, these recommendations have been largely ignored by retail chain pharmacy corporations. In 1976, Schroeder and Showstack determined that 93% of non-clinically affiliated pharmacies in San Francisco sold cigarettes . This study was replicated in 2003 by Eule and colleagues, who found a significant change among independently-owned pharmacies (a reduction from 90.6 to 24.1%), but little change among retail chain pharmacies (100 to 93.8%) . Furthermore, surveys of pharmacists conducted more than a decade ago in the Midwest (Indiana and Kentucky) found that a substantial proportion of pharmacies sold cigarettes [18–21] and alcohol [20–22], despite the fact that most pharmacists were opposed to this practice. Over time, these survey studies have collectively revealed a shift in pharmacists’ opinions toward reduced acceptance of tobacco and alcohol sales in pharmacies.
Because California historically has been a leader in tobacco control activities, and because California was the first state to ensure that all of its pharmacy graduates receive comprehensive training for tobacco cessation (a minimum of 7 hours) , the availability of these products and their presentation in pharmacies within Los Angeles, the largest and most densely populated city in California,  is of interest. This study builds upon prior research [16, 17] in assessing the availability of tobacco and alcohol products in pharmacies through direct observation (as opposed to survey-based reports from pharmacists). The primary aims of this study were to: (a) to estimate the proportion of community pharmacies in Los Angeles that sell cigarettes and/or alcoholic beverages, and (b) characterize the promotion of tobacco products and alcoholic beverages. To date, no studies have simultaneously characterized sales of these products in pharmacies through direct observation (i.e., on-site data collection).
Study methods were similar to those used by Eule and colleagues in a 2003 study conducted in San Francisco . A list of licensed community pharmacies (n = 390) within the city of Los Angeles was obtained from the California State Board of Pharmacy. Clinics that listed more than one active pharmacy license on the same street address (n = 8) were represented only once in the pharmacy population from which a random sample of 250 pharmacies was selected. Researchers visited each pharmacy between September 2005 and January 2006, and data were collected based on observation. Pharmacies determined to be closed to the public or permanently closed upon visit were replaced by random selection.
Pharmacies were categorized as follows: traditional chain, independently-owned, clinically-affiliated, part of a grocery store, or part of a mass merchant store. Similar to previous studies, [16, 17] “traditional chain pharmacy” was defined as one clearly identified with other stores or pharmacies of the same name, an “independently-owned pharmacy” was defined as one not identified with any other pharmacies or clinics, and a “clinically-affiliated pharmacy” was defined as one that was located on the grounds of a medical building, office, or clinic. “Part of a grocery store” indicated that the pharmacy was located within a market that primarily was a venue for the sale of groceries, and “part of a mass merchant” indicated that the pharmacy was located within a much larger retail establishment that primarily was a venue for the sale of wholesale merchandise. These identifications were based on appearance and did not represent legal ownership.
For each pharmacy, cigarette availability and location of the cigarettes (behind the front cash register counter, behind the pharmacy counter, and/or at a separate counter in the store), whether the products were stocked in the same half of the store as the pharmacy dispensing area, and whether the cigarettes were visible to consumers was assessed . If cigarettes were not visible, store personnel were queried regarding cigarette availability. If cigarettes were within sight of a pharmacist, the cigarettes were considered to be located in the same half of the store as the pharmacy dispensing area. Whether the pharmacy merchandised other forms of tobacco (e.g., cigars, smokeless tobacco, pipe tobacco) also was assessed. Pharmacies were classified as having tobacco advertising (e.g., signage such as display stands, shelf ticklers, shopping cart signs) or not, and the location of the advertisements was described as one or more of the following: immediately adjacent to the cigarettes (e.g., part of a cigarette display), elsewhere within the store, or visible from the outside of the store. Presence of resources for smoking cessation support (e.g., brochures, advertisements for smoking cessation services, and availability of non-prescription NRT products) also was documented.
For each pharmacy, availability of alcoholic beverages (i.e., beer, wine, or distilled spirits) was assessed, along with location of the alcohol relative to the pharmacy dispensing area (e.g., alcohol was stocked in the same half of the store as the pharmacy dispensing area) and whether the alcohol was visible to consumers. If alcoholic beverages were not visible, store personnel were queried regarding its availability. If alcoholic beverages were within sight of a pharmacist, the alcohol was considered to be located in the same half of the store as the pharmacy dispensing area. The presence of alcoholic beverage advertising (e.g., signage, shelf ticklers, shopping cart signs) and the location of any advertisements (inside store, part of an alcohol display, elsewhere within the store, and/or visible from the outside of the store) was documented. Presence of resources for alcohol cessation support (e.g., brochures, advertisements for alcohol abstinence counseling services) at each pharmacy also was documented.
Descriptive statistics were used to characterize the measured variables, and chi-squared analyses were used to test for group differences among categorical variables. Analyses were conducted using SPSS Version 17.0.
A total of 264 pharmacies were visited by the study team; of these, 14 were excluded because they were either closed to the public or permanently closed, yielding a final sample of 250 pharmacies. Just over one-fifth (22.4%) were traditional chain drug stores, 66.8% were independently-owned, 3.2% were grocery stores, 0.4% were mass merchants, and 7.2% were clinically-affiliated pharmacies.
Approximately one-third of pharmacies (n = 82, 32.8%) sold cigarettes (Table 1); of these, cigarettes were visible to the public in 95.1% (n = 78). Most stores stocked cigarettes behind the front cash register (79.3%; 65 of 82 pharmacies that sold cigarettes), and two (2.4%) displayed cigarettes on the pharmacy counter. The remaining (n = 15, 18.3%) stocked cigarettes elsewhere in the store. In 17 of the 82 pharmacies that sell cigarettes (20.7%), the products were located in the same half of the store as the pharmacy dispensing area. In addition to cigarettes, 60 (73.2%) also sold other forms of tobacco. Cigarettes were more likely to be available in traditional chain pharmacies and grocery stores than in independently-owned pharmacies (100% vs. 10.8%; P < 0.001), and none of the clinically-affiliated or mass merchant pharmacies sold cigarettes. Thirty-four (41.5%) of the 82 pharmacies that sold cigarettes also displayed promotional materials for these products. Tobacco advertisements were positioned as part of the cigarette display in 28 stores (82.4%); five (14.7%) had advertisements in areas within the store that were not part of the cigarette display, and one (2.9%) displayed an advertisement that was visible from outside of the store.
Fourteen pharmacies (5.6%) had resources posted for tobacco cessation support (n = 11; 13.4% of pharmacies that sell cigarettes), and more than half of the pharmacies (n = 145; 58.0% of all pharmacies and 89% of those that sold cigarettes) stocked non-prescription NRT products (100% of traditional chain, grocery store, and mass merchant pharmacies; 45.5% of independent pharmacies; 22.2% of clinically-affiliated pharmacies). Of 82 pharmacies that sold NRT products and cigarettes, 7 pharmacies (8.5%) stocked the NRT products immediately adjacent to the cigarettes.
Twenty-six percent (n = 65) of pharmacies sold alcoholic beverages (Table 1); of these, alcohol was visible to the public in 64 (98.5%). Fewer than half of the pharmacies (n = 27; 41.5%) stocked alcoholic beverages in the same half of the store as the prescription dispensing area. Traditional chain drug stores and grocery stores were more likely to sell alcoholic beverages than were independently-owned pharmacies (87.5% vs. 5.4%; P < 0.001), and none of the clinically-affiliated pharmacies sold alcohol. Forty-seven (72.3%) of the 65 pharmacies that sold alcohol also displayed promotional materials for these products. The advertisements were positioned as part of the alcohol display in 39 stores (83.0%); 5 (10.6%) had advertisements in areas within the store that were not part of the alcohol display, and 7 (14.9%) displayed advertisements that were visible from outside of the store (categories not mutually exclusive). Three pharmacies (1.2%) had resources posted for alcohol cessation support (n = 2; 3.1% of pharmacies that sell alcoholic beverages).
This is the first study to apply direct observational methods to investigate the availability of tobacco and alcohol products in community pharmacies. The study results demonstrate that in the city of Los Angeles, California, cigarettes and alcoholic beverages are sold in 32.8 and 26.0% of community pharmacies, respectively. In addition, we found that a substantial proportion of pharmacies that sold alcohol and cigarettes displayed promotional materials for these products that were clearly visible to the public.
Previous studies have shown a significant association between exposure to alcohol and tobacco promotion at the point-of-sale and initiation/susceptibility to alcohol consumption and cigarette smoking [26, 27]. It is estimated that one quarter of adult smokers purchase cigarettes impulsively, and one third of recent quitters have urges to smoke after seeing tobacco products displayed . Because the pharmacy profession is responsible for the welfare of patients and, according to their Code of Ethics, should avoid actions that compromise dedication to the best interests of their patients, many community pharmacists practice in an environment that is in direct conflict with this code. Furthermore, the sale of tobacco and alcohol products in pharmacies sends a mixed message to consumers that is inconsistent with the pharmacy’s mission of promoting health. Indeed, it has been suggested that it is an inherent conflict of interest for pharmacies to sell tobacco products and simultaneously profit from the sale of medications used in the treatment of tobacco-related disease .
Our data and the results of several previous studies suggest that when given a choice, pharmacists choose not to sell tobacco or alcohol products. Independently-owned pharmacies are far less likely to sell tobacco [16, 17, 19–21, 30] and alcohol [20–22] than are chain-, grocery store-, or mass-merchant-affiliated pharmacies, for which decisions to merchandise products (or not) are made at the corporate level, often by non-pharmacists, and these decisions are subject to the influence of shareholders of for-profit corporations. Prior studies have shown that fewer than 2% of licensed pharmacists and pharmacy students are in favor of tobacco sales in pharmacies, and a greater proportion of these individuals were smokers themselves [14, 31]. Given the rapid expansion of the types of pharmacy outlets that choose to sell tobacco and alcohol products (e.g., chain-, grocery-, and mass merchant stores) , voluntary efforts to fully eliminate the sale of alcohol and tobacco in pharmacies are unlikely to occur.
Because pharmacies affiliated with chains, grocery stores, and mass merchants are unwilling to discontinue the sale of alcohol and tobacco products, stronger measures—including but not limited to relevant legislation—should be adopted as a public health measure. Notably, in San Francisco, legislative action led by the Director of Public Health (a physician) resulted in a county-wide ban on the sale of tobacco products in pharmacies . The cities of Boston and Needham in Massachusetts soon followed, and similar measures have been passed or are being pursued at the city, county, and state-wide level throughout the US . These initiatives, however, are being challenged. For example, separate lawsuits by a tobacco manufacturer and a retail chain pharmacy, at the federal and state levels respectively, have challenged the constitutionality of the San Francisco ordinance. Decisions by the courts have sustained the ban of tobacco sales in pharmacies with the provision that the law does not treat similar stores containing pharmacies differently from one another [34, 35]. A national grocery store chain also has recently filed a lawsuit in federal court contending that the amended San Francisco ordinance that effectively repealed the exemption for grocery stores and “big box” retailers violates equal protection laws and would result in financial harm . It is likely that these types of lawsuits will continue until social norms are changed, and the sale of tobacco products in pharmacies is deemed no longer acceptable by the broader medical community and/or the general public.
In 2004, Federation Internationale Pharmaceutique (FIP), which represents pharmacists around the globe, recommended that pharmacy organizations should pursue policies to ban tobacco sales in pharmacies [12, 37], but little progress has been made. Further studies are needed to determine consumer perceptions regarding the ban of tobacco sales in pharmacies and associated impact on the tobacco initiation and cessation rates in areas affected by the bans. Similarly, the economic effect of removal of tobacco products in pharmacies should be examined.
Our study is subject to limitations such as lack of generalizability of the findings to other municipalities throughout the US. It should be noted that Los Angeles exhibits a high proportion of independently-owned pharmacies compared to other locations in California and elsewhere in the US. Strengths of this study include a high sampling rate (64%) of licensed community pharmacies in Los Angeles and a study design that included direct observation by study investigators rather than surveys of pharmacists, as has been used in several prior studies [18–22].
In concept, the sale of tobacco or alcohol products in a community pharmacy is no different than the sale of these same products in a gift shop within a hospital, given that both are licensed health facilities where health-care services are rendered. Despite the fact that pharmacists do not support the sale of tobacco and alcohol products in community pharmacies, for decades the profession has been ineffective in advancing policies to eliminate their sales in this practice settings. As such, we believe it is necessary for the broader health-care establishment to collectively engage and address this ongoing ethical dilemma that directly compromises patient health through relevant policy and regulatory changes.
The authors would like to thank Drs. Jasmin Chen, Kim H. Ha, Mary S. Lam, Athena Y. Lau, Shirley C. Young for data collection and contributions to earlier versions of this manuscript. Marcus Ferrone, PharmD, JD, provided consultation and invaluable assistance regarding the recent legal actions regarding tobacco sales in pharmacies. Funded in part by the National Cancer Institute grants R25 CA 90720 and R01 CA 129312 to K Hudmon.
Robin L. Corelli, Department of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco, 521 Parnassus Avenue [C-152], BOX 0622, San Francisco, CA 94143-0622, USA.
Briseis Aschebrook-Kilfoy, Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, CT, USA.
Gilwan Kim, Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN, USA.
Peter J. Ambrose, Department of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco, 521 Parnassus Avenue [C-152], BOX 0622, San Francisco, CA 94143-0622, USA.
Karen Suchanek Hudmon, Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN, USA.