Tobacco use is the single largest preventable cause of early death in the U.S. today [1
]. Perceptions concerning cigarettes and tobacco use have changed since the 1950’s when tobacco companies used physicians and invoked science in their advertising campaigns [2
]. Yet as attitudes towards tobacco have changed, so has the role of the pharmacist. That role once consisted solely of dispensing medications; it now includes counseling patients. This change in role in counseling among pharmacists is now increasingly important with providing smoking cessation counseling, given the change in Nicotine Replacement Therapy (NRT) from being previously being available by prescription, and now being available over-the-counter [3
]. This places pharmacists in a unique position to provide tobacco cessation counseling at point-of-sale. Training programs for smoking cessation counseling are increasingly prevalent in schools of pharmacy across the U.S., and more graduates of these schools are being taught the necessary skills to counsel patients on quitting smoking [4
]. However, even though they possess knowledge on tobacco cessation counseling, few pharmacists actually engage patients, citing several potential barriers [4
]. Other research has shown that the majority of pharmacists do not discuss tobacco use with new patients [5
In other countries, tobacco cessation counseling training for pharmacists have progressed more rapidly, as many nations have a more focused preventative medicine framework within their health care systems. For example, in Finland, the Finnish Current Care Guideline (which outlines smoking cessation responsibilities for all health care professionals) states that pharmacy owners should arrange for tobacco cessation training for their pharmacy staff [8
]. Additionally, a 1998 study conducted by researchers in Scotland found that pharmacy staff who underwent training for smoking cessation based on the “stages-of-change” model were more readily able to identify and assist in patients efforts to quit using tobacco than pharmacy staff who did not undergo such formal training [9
]. Observed levels of engaging patients for tobacco cessation counseling also appear to be higher in countries outside of the U.S., a likely reflection on smoking cessation training efforts [5
]. For example, a Canadian study found that within their sample of pharmacists, fewer than 50% of pharmacists in the provinces studied intervened with more than half of their smoking patients [10
]. This same group found that nearly 44% of current smokers surveyed would be very or somewhat likely to ask a pharmacist for advice on quitting smoking, making pharmacists a somewhat trusted source for solicitation of quit advice in some areas [11
]. A 2011 systematic review of public health practices in community pharmacies conducted by a research group in the United Kingdom indicates that sets of public health services, including providing smoking cessation counseling, are now required by community pharmacists in some areas of the U.K. due to the establishment of a new pharmacy contract [12
]. This suggests that the role of pharmacists in population-health objectives are more widely acknowledged and advanced in these nations, and training in public health practice in community pharmacies are more heavily emphasized.
The sale of tobacco products in pharmacies in any locality may send conflicting messages to consumers who come to pharmacies in search of medication or health promotion products. Most U.S. pharmacists oppose the sale of tobacco products in pharmacies [13
]. Nonetheless, many pharmacies in the United States still sell tobacco products, and polls of pharmacists and pharmacy students show that these groups feel that selling tobacco products in pharmacies violates their personal and professional values [14
Research has found that chain pharmacies are more likely than others to sell tobacco [18
]. Pharmacists who work in chain pharmacies also have the least influence on tobacco product sales [18
]. A study conducted in 2003, a repeat of a study conducted in the same county in 1976 [19
], found that, although the overall percentage of pharmacies selling tobacco products decreased, this change was due mainly to sales decreases in independently owned pharmacies and pharmacies in medical clinics. Chain pharmacies increased in numbers, though there was no change in the percentage of them selling tobacco products [19
In 1971, the American Pharmacists Association (APhA) House of Delegates released a statement, declaring: “APhA recommends that tobacco products not be sold in pharmacies.” [20
]. This statement has been periodically renewed to keep smoking cessation a priority [21
]. The APhA also recommends that pharmacists “provide services, education, and information on public health issues”, which supports the pharmacist role in providing tobacco cessation services to patients [20
]. The American Society of Health-System Pharmacists (ASHP) advocates that pharmacists should become involved in smoking cessation counseling and include patients’ tobacco usage in patient profiles [22
]. Although a large percentage of pharmacists are opposed to the sale of tobacco products in pharmacies, and pharmacy organizations have spoken out against this practice, studies still show that, in some areas, more than half of pharmacies sell tobacco products [13
]. As students are taught about smoking cessation counseling and the importance of this practice in pharmacies, the contradiction of tobacco sales in pharmacies is becoming more apparent. The American Association of Colleges of Pharmacy (AACP) passed a resolution in 2003 recommending that schools of pharmacy only choose experiential sites for students that do not sell tobacco products [17
]. However, student experiential sites are selling tobacco products, and whether these sites are effectively counseling patients on smoking cessation remains important, because pharmacists could play a more decisive role than they do. Additionally, sites that guide students through a university affiliate may provide a differential level of experiential education, as these preceptors are subject to standards and guidelines to which other, non-university affiliated sites may not be subject.
The continued availability of tobacco products within pharmacies in the U.S., including student experiential sites, is due to a host of different factors. These include, but are not limited to: the voluntary nature of businesses in the U.S. adopting recommendations by professional organizations such as the APhA; pharmacies located in “big box” stores like Wal-Mart not having the freedom to choose what products are sold in their workplaces due to corporate business interests [23
]; and added incentive for pharmacies to stock tobacco products due to additional revenue provided from displaying tobacco product marketing displays and advertisements [24
Recently, the United States passed the Family Smoking Prevention & Tobacco Control Act (FSPTCA) of 2009, [25
] which gave the FDA and state and local jurisdictions the power to regulate aspects of the sale and marketing of tobacco products. For example, communities can prohibit the sale of tobacco products in pharmacies; this has taken place in Boston and San Francisco [26
]. While other countries have managed to implement voluntary tobacco sales bans within pharmacies in some areas [10
], this is relatively new legislation that gives similar authority to establish such bans within the United States. This legislation could have important implications regarding tobacco sales in pharmacies in the U.S., and aligning the pharmacy as a health promotion resource per APhA recommendations.
The purpose of this study was to establish preliminary data for the Western New York (WNY) area, which included addressing the following research objectives: 1) How do pharmacists feel about the sale of tobacco products in pharmacies?; 2) How do pharmacists view their role regarding patient smoking cessation?; 3) Do thoughts on these issues differ based on the type of work setting in which the pharmacist is employed?; And 4) Do non-university affiliated sites provide on the job training to pharmacy students in outlets where tobacco is sold and where smoking cessation counseling is practiced?