In the latest edition of Journal Watch, Dr Melissa Stoneham reviews a recent study from Aotearoa/New Zealand that investigates a potential role for pharmacies in selling tobacco (as currently happens in the United States).
Dr Melissa Stoneham writes:
It’s 10 pm and my daughter staggers out of her bedroom complaining of nausea, the shakes and a headache.
Running through the options for healthcare, I think about calling an after-hours GP – but a quick Google search reveals the closest one is over 30km away.
I could head to the Emergency Department at the hospital, but I wonder if these symptoms are in fact an emergency and if I would be using valuable resources that may be needed elsewhere.
My next thought is to head to the pharmacy down the road.
There my daughter receives some helpful advice, and we are both pleased with the outcome – just like so many other people, who report generally high levels of satisfaction with community pharmacies.
In 2018, there were 5,723 community pharmacies; the industry is good at promoting the value of pharmacists as sources of health and wellbeing information.
Study in the spotlight
With so many families visiting and trusting pharmacies as a setting to receive health advice, I have concerns about a recently published journal article that suggests pharmacies should sell tobacco.
Published in the Australian and New Zealand Journal of Public Health, the New Zealand researchers stated in the discussion that “there would be an important reduction in overall availability of tobacco if it were only sold through liquor stores or petrol stations, which are subsets of current retailers who sell tobacco, or through pharmacies, compared with the status quo.”
The article, authored by Louise Marsh and colleagues, aimed to examine what would happen if tobacco was available only from pharmacies in NZ, or only from liquor stores or only from petrol stations.
One of the reasons for this study was to assess whether selling tobacco from these locations would reduce availability near schools. The study did not recommend one policy option over another, but explored the geo-spatial aspects of the impact of policy options for reducing tobacco availability in New Zealand, and contributing to Smokefree Aotearoa 2025.
Descriptive analyses were undertaken to determine the number and type of retailers, density by population and current smokers, and their location in terms of community deprivation, rural access, and proximity to secondary schools.
The study found there were 5, 243 tobacco retail outlets, with 46 percent being convenience stores, 20 percent being petrol stations, 17 percent being liquor stores and 13 percent being supermarkets. The total number of adults aged over 15 years in NZ was 602,000.
This equated to approximately one tobacco outlet per 115 smokers. There were 1,035 pharmacies identified, which equated to one pharmacy per 4,099 adults and one per 582 current smokers.
The majority of tobacco retailers, liquor stores and pharmacies were located in urban areas, with about one-quarter in semi-urban areas. There were fewer pharmacies in rural areas compared with tobacco retailers.
The researchers then mapped tobacco retailers and pharmacies in relation to walking distances from secondary schools. Fifty-four percent of secondary schools had at least one tobacco retail outlet within a 500 metre walk, and 83 percent of secondary schools had at least one outlet within a one kilometre walk. Fewer secondary schools had at least one pharmacy located within 500 metres (22%) and one kilometre (55%) compared with tobacco retailers overall.
Evidence suggests that if tobacco retailers are around a school, it is more likely that students will engage in experimental smoking and be susceptible to future smoking. Based on this evidence and findings from this study, the authors stated that changing the tobacco retail landscape to include pharmacies would result in an overall reduction in the availability of tobacco.
In addition, they stated that the positive aspects of tobacco only being available through pharmacies was the potential for reduced opportunity for the sale of tobacco to minors, reduced operating hours, and that pharmacists were already trained to provide brief smoking cessation interventions.
So, is selling tobacco at pharmacies a good idea?
The retail and policy context is quite different between America and New Zealand, with very few restrictions on advertising and promotion of tobacco in America.
Yet in 2015, a major US pharmacy brand (CVS) stopped selling tobacco. As of January 2016, 134 municipalities in California and Massachusetts had enacted tobacco-free pharmacy laws. In 2018, New York City implemented a tobacco-free pharmacy law as part of a comprehensive policy approach to curb tobacco use.
These policy changes may be in response to a 2016 CDC study, that found that two-thirds of US adults — including nearly half of smokers — favoured a pharmacy tobacco ban.
It seems even the pharmacists agree, with the American Pharmacists Association urging pharmacies and facilities that include pharmacies to discontinue the sale of tobacco products.
Emerging evidence suggests that the removal of tobacco from pharmacies could have a positive impact on health, so I am mystified as to why a research project would consider the sale of tobacco at a pharmacy as a viable option, especially in a country that has a goal to be smokefree by 2025.
The World Health Organization (WHO) states that the role of a pharmacy is among other things, to dispense prescription and non-prescription drugs, provide drug information to health professionals, patients and the general public, and participation in health-promotion programs.
The sale of cigarettes is incompatible with what pharmacies are supposed to do. The sale of tobacco in a health promoting environment such as a pharmacy goes against the important and growing role pharmacies play in our wellbeing.
When I contacted the Pharmacy Guild of Australia about this issue, they said they “don’t support selling tobacco at any outlet”.
Yet, it is not simply the sale of tobacco I am concerned about. It is also the advertising that would inevitably accompany the sale of tobacco products. Many children visit pharmacies and would be exposed to this advertising.
With organisations such as Quit Victoria promoting ways pharmacists could help someone quit smoking, it would create a paradox if any policies or regulations changed to enable pharmacies to sell tobacco.
Tobacco is the leading preventable cause of death and disease. There is no doubt that smoking kills.
It is important to prevent young people from being exposed to tobacco retailers around schools. But selling tobacco at pharmacies is not the answer. Keeping our pharmacies tobacco free for the sake of families and young people throughout Australia is paramount.
Note from Croakey
Dr Melissa Stoneham approached the authors of the study for a response to this article. Their reply follows.
“This blog has raised some points that we would like to respond to.
Citing US evidence for a NZ policy is possibly misleading. The retail and policy context is quite different between these two countries.
First, NZ operates in a ‘dark market’ where the marketing and sale of tobacco is subject to heavy restrictions, including an advertising and point-of sale display ban.
Second, NZ has a goal to be smokefree by 2025. Our research looks at various tobacco retail options for how we might achieve this goal, and where tobacco may be sold following 2025. The policy options described in our paper are focused on ONLY selling tobacco from one type of retail outlet, for example, liquor stores, petrol stations and pharmacies.
This includes examining whether the people working in the retail outlet have the opportunity to intervene and offer consumers cessation advice, whether sales to children and young people would diminish, that outlets that are not located on every street corner or visited daily (by most people) and therefore far less likely to trigger relapse purchases, and equitable access.
In contrast, the US does not have a national goal to be smokefree. There are very few restrictions on advertising and promotion of tobacco in the US, and no state in the US has yet enacted tobacco retail display bans, creating a very different marketing and point-of-sale retail environment for tobacco.
Pharmacies in the US are one of a large number of retailers selling tobacco, and are generally large supermarket style businesses which sell a vast array of products.
With regards to the role that pharmacies play, if the sale of tobacco would be accompanied with smoking cessation advice, it would be a health promotion program and in line with other health programs run by pharmacies in New Zealand such as supplying methadone.
Tobacco could possibly even be made prescription only (as was proposed in Iceland) and given over the counter in disclosed bags (like all other prescription medications). In addition, a New Zealand study to gauge support among pharmacists for selling tobacco, if it was not available elsewhere, found that 26 percent of pharmacists interviewed thought it was ‘very likely’ to ‘extremely likely’ that their pharmacy would sell tobacco.
This increased to 37 percent if it was shown that this strategy was successful elsewhere.
Our study did not recommend one policy option over another, but explored the geo-spatial aspects of the impact of these three policy options for reducing tobacco availability in NZ, and contributing to Smokefree Aotearoa 2025.”
How would the tobacco retail landscape change if tobacco was only sold through liquor stores, petrol stations or pharmacies? Authored by Louise Marsh, Crile Doscher, Claire Cameron, Lindsay Robertson and Frederieke Sanne Petrović‐van der Deen. Published in the ANZJPH early view on 8 January 2020.
About Journal Watch
The Public Health Advocacy Institute WA (PHAIWA) JournalWatch service reviews 11 key public health journals on a monthly basis, providing a précis of articles that highlight key public health and advocacy related findings, with an emphasis on findings that can be readily translated into policy or practice.
The Journals reviewed include:
- Australian & New Zealand Journal of Public Health (ANZJPH)
- Journal of Public Health Policy (JPHP)
- Health Promotion Journal of Australia (HPJA)
- Medical Journal of Australia (MJA)
- The Lancet
- Environmental Health Perspectives (EHP)
- Tobacco Control (TC)
- American Journal of Public Health (AMJPH)
- Health Promotion International (HPI)
- American Journal of Preventive Medicine (AJPM)
- Injury Prevention BMJ
These reviews are then emailed to all JournalWatch subscribers and are placed on the PHAIWA website. To subscribe to Journal Watch, click here.