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Don’t let the “tobacco stain” on pharmacies that sell cigarettes be a barrier to advanced pharmacy practice (Report to Surgeon General calls for recognition and compensation of pharmacists)
January 26, 2012

Pharmacists, especially those in the ambulatory care setting, are on the brink of an extraordinary opportunity that promises to bring about a paradigm shift regarding how healthcare is delivered, while addressing many current challenges related to access to care, patient safety, quality of health outcomes, and healthcare costs. A December 2011 Report to the US Surgeon General, Improving Patient and Health System Outcomes through Advanced Pharmacy Practice, provides a compelling and evidence-based discussion in support of healthcare reform that recognizes and advances the role that pharmacists play in delivering patient care services that add value and improve health outcomes.(1) The report calls for recognition of pharmacists as health-care providers via statute, legislation, and policy, which would remove barriers to compensating pharmacists for clinical services they provide. Beyond payment for a drug product or device, the report notes that pharmacists should be compensated for activities that promote health and prevent adverse drug events, such as conducting patient assessments; interpreting lab tests to monitor drug therapy; developing therapeutic plans of care; recommending drug therapy changes; education and follow-up with patients who have a complex drug regimen; coordination of care for disease prevention; and other monitoring activities. 

As a longtime advocate of the issues brought forth in the report, the Institute for Safe Medication Practices (ISMP) will continue to provide our unwavering support for advancing the professional role of pharmacists and compensating pharmacists commensurate with the level of services provided by other practitioners providing comparable services. In light of this remarkable opportunity to improve health outcomes through advanced pharmacy practice, we feel compelled to speak frankly about an elephant in the room that has long loomed large and cast a shadow on the pharmacy profession: the selling of tobacco products in many community pharmacies.(2)  According to the Centers for Disease Control and Prevention (CDC), tobacco is the leading preventable cause of death in the US—more than 433,000 deaths annually, and more than all deaths from human immunodeficiency virus (HIV), illegal drug use, alcohol use, motor vehicle injuries, suicides, and murders combined.(3)

"Pharmacies should be places where people go to get better, not where people go to get cancer."  Mayor of San Francisco(11)

While most small, independent pharmacies do not sell tobacco products, many chain pharmacies do, often placing these products at the cash register where they can be seen by customers.(2) Prominently displaying tobacco products alongside healthcare products normalizes their use, reduces the stigma associated with smoking, makes children and young adults believe it is acceptable, and furthers the smoking epidemic.(4) It places pharmacists in a compromised environment: at one end of the pharmacy, cigarettes that destroy health are being sold; at the other end of the pharmacy, prescriptions are being filled to promote health and, sometimes, to treat the devastating health consequences of smoking.(5) 

Pharmacies are supposed to be dedicated to protecting and promoting health. They sell products and medications designed to prevent and treat illness; they offer health screenings and immunizations; some even provide health clinics.(6) Although many sell a variety of products not related to health, pharmacies are considered among the most trusted sources of health information for the public.(6,7) Pharmacies that promote and sell tobacco products still portray themselves as an important part of our healthcare system, but they also appear to be dead serious about maximizing tobacco sales.(7) We would be horrified if we found a cigarette vending machine in a physician’s waiting room; we should be just as horrified that cigarettes are promoted and sold in many of our chain pharmacies.

In 2009, the American Medical Association (AMA) approved a resolution calling for the stoppage of the promotion and sale of tobacco products in pharmacies.(5,8) In 2010, the American Pharmacists Association (APhA) called for a stoppage of tobacco product sales in pharmacies (and facilities that include pharmacies).(9) APhA policies urge the federal and state governments, state boards of pharmacy, colleges of pharmacy, and the Accreditation Council for Pharmacy Education (ACPE) to only allow pharmacies that do not sell tobacco products to participate in government-funded prescription programs, receive and renew pharmacy licenses, or serve as experiential sites for pharmacy students. Given that the sale of tobacco contradicts the pharmacist’s code of ethics, the American Society of Health-System Pharmacists (ASHP) also strongly opposes the sale or distribution of tobacco products in all establishments where healthcare services are rendered.(10) In June 2009, President Obama signed a new law that gives the FDA authority to regulate the manufacture, sale, distribution, and marketing of tobacco products.(8) Some cities, including Boston and San Francisco, have enacted laws prohibiting tobacco sales at pharmacies, but not without legal challenges by a large chain pharmacy.(11_ There are also a small number of pharmacists working within organizations that have taken on a mission to stop the sale of tobacco products in pharmacies.(2,4,6,11-13)

These efforts have yet to make a significant dent on a national level, nor have they erased the blemish on the pharmacy profession. Pharmacies that continue to profit from the sale of tobacco products make a mockery of pharmacists, who, surveys suggest, are largely disinclined participants.(12) Executives of chain pharmacies that sell tobacco products should be challenged, and the thousands of independent pharmacies and some chains, such as Target and Wegmans, that do not sell cigarettes, should be commended.(12)

Today, a new opportunity exists for health leadership and policy makers to support and implement evidence-based models of cost-effective pharmacist-delivered patient care, as detailed in the recent report to the Surgeon General.(1) If there has ever been an optimal time to promote a professional image of pharmacists as providers who improve health outcomes, it is now! We need to maximize the scope of pharmacy practice and eliminate any barriers to the provision of advanced pharmacy care. Don’t let tobacco sales in pharmacies remain as one of those barriers. Take a stand by sending a letter to the executives of chain pharmacies who allow tobacco sales, and sign a national petition against tobacco sales in pharmacies at: http://rxforchange.ucsf.edu/petition.php

References
1)
Giberson S, Yoder S, Lee MP. Improving patient and health system outcomes through advanced pharmacy practice. A report to the U.S. Surgeon General. Office of the Chief Pharmacist. U.S. Public Health Service. Dec. 2011. www.usphs.gov/corpslinks/pharmacy/comms/pdf/2011AdvancedPharmacyPracticeReporttotheUSSG.pdf
2) Hussar DA. Merchants of death. Chain pharmacy CEOs must stop the sale of cigarettes! The Pharmacist Activist. 2011;6(11):1-2. www.pharmacistactivist.com/2011/PDFs/November_2011.pdf
3) Centers for Disease Control and Prevention. Tobacco-related mortality. March 21, 2011. www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/tobacco_related_mortality/ 
4) Daynard RA, Gerace TA Jr, Gerace TA Sr. Letter to Troyen A Brennen, CVS Caremark Corporation. Breaking news. Toxic-Tobacco Law. Oct. 8, 2009. www.toxic-tobaccolaw.org/13news.shtml#CVSNR  
5) Elliott VS. AMA meeting: More to do on tobacco control. Amednews.com. June 29, 2009. www.ama-assn.org/amednews/2009/06/29/prse0629.htm 
6) Cadman B. Activists target tobacco in pharmacies with ‘CVS sells poison’ campaign. Change.org. Feb. 17, 2011. http://news.change.org/stories/activists-target-tobacco-in-pharmacies-with-cvs-sells-poison-campaign
7) Americans for Nonsmoker’s Rights. Why cigarettes and pharmacies don’t mix: prescription for change. Oct. 3, 2008. PRNewswire-USNewswire. http://www2.prnewswire.com/cgi-bin/stories.pl?ACCT=104&STORY=/www/story/10-03-2008/0004897726&EDATE  
8) Wilson CB. Health system reform: what does the future hold? Aug. 5, 2009. American Medical Association. www.ama-assn.org/ama/pub/news/speeches/wilson-florida-hospital-hsr.page
9) American Pharmacists Association. APhA announces new policies adopted by House of Delegates. May 18, 2010. www.pharmacist.com/AM/Template.cfm?Section=News_Releases2&Template=/CM/ContentDisplay.cfm&ContentID=23367 
10) American Society of Health-System Pharmacists. ASHP policy position 0713: tobacco and tobacco products. www.ashp.org/s_ashp/docs/files/BP07/HR_Positions.pdf   
11) Madanick R. Tell pharmacies to stop selling tobacco products. Change.org. Dec. 2011. www.change.org/petitions/tell-pharmacies-to-stop-selling-tobacco-products 
12) Hussar DA. Pharmacy cigarette sales must end. Drug Topics. May 1, 2009. http://drugtopics.modernmedicine.com/drugtopics/Modern+Medicine+Now/Pharmacy-cigarette-sales-must-end/ArticleStandard/Article/detail/585685   
13) 100 reasons why CVS should stop selling cigarettes. WhyQuit News. May 20, 2011. http://whyquit.com/pr/052011.html 
14) Prescription for change. New York pharmacy facts. TobaccofreeNYS.org. Adapted from CA Department of Public Health, CA Tobacco Control Program. 2010. www.smokefreecapital.org/pdf/PharmacyRXChange.pdf 

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