1. 2002 © Tobacco Control Resource Center, Inc. Tobacco-Free Pharmacies: Using Ethics, Economics, Education, and Law to Achieve an Attainable Public Health Goal NCTH Sarah Elisabeth Curi, JD, MPH Tobacco Control Resource Center Staff Attorney 11/18/02 4:00pm.

2. Legal Resources Tobacco Control Resource Center, Inc. Tobacco Control Resource Center, Inc., a non-profit organization based at Northeastern University School of Law, provides legal, technical, research and training support for regulatory and litigation-based initiatives to control the sale and use of tobacco as a public health strategy. TCRC serves as a national research clearinghouse, providing information to federal, state, and local officials throughout the United States. TCRC is a founding member of the new national Tobacco Control Legal Consortium which seeks to foster communication and cooperation among attorneys and tobacco control advocates on legal matters relating to tobacco control and to share legal resources. Contact TCRC at 617-373-2026 or www.tplp.com

3. A Call to Action!! The sale of tobacco in pharmacies: - is counter to good public health policy, - sends unhealthily mixed-messages, - not a clear economic necessity, and - undermines the credibility of pharmacists as health care providers.

4. Goal: To provide health care practitioners and tobacco control advocates an innovative strategy to tackle the leading threat to public health

5. Public Health Benefits of Tobacco-Free Pharmacies Sends a powerful message about the danger of tobacco productsSends a powerful message about the danger of tobacco products Changes social norms around tobacco useChanges social norms around tobacco use Reduces the number of retail outlets that sell tobacco products, allowing for more cost-effective compliance checks and fewer venues for advertisingReduces the number of retail outlets that sell tobacco products, allowing for more cost-effective compliance checks and fewer venues for advertising Massachusetts 1,000 Fewer Retail Outlets California 4,000 Fewer Retail Outlets

6. Health Care Providers “Every time a drugstore sells tobacco products, that store is implicitly legitimizing its uses. Hospitals stopped selling tobacco years ago because they understood that commercial centers of health should not be selling a product that kills.” Jack Lewin, MD Executive Director, California Medical Association

7. We should find health products and health services at health care facilities not health problems.

8. Ethical Conflicts In taking the Oath of a Pharmacist, pharmacists voluntarily agree to: maintain the highest principles of moral and ethical conduct, consider the welfare of humanity and the relief of human suffering as a primary concern, and embrace and advocate change in the profession of pharmacy to improve patient care. The Code of Ethics of the APhA: urges pharmacists to place concern for the well-being of the patient at the center of professional practice, and explicitly states “A pharmacist should never knowingly condone the dispensing, promoting, or distributing of drugs … that lack therapeutic value to the patient.”

9. Impact on Pharmacists who Sell Tobacco Products 47.6% reported that selling tobacco products differed from their personal values. 63.9% said that selling tobacco products differed from their professional values. lower levels of overall job satisfaction, higher levels of job-induced tension, and a higher propensity to leave their jobs than respondents working in pharmacies that did not sell tobacco products. Massachusetts Tobacco Free Pharmacy Survey, 1994

10. Pharmacists advocating for change Nationally, in 1970, the APhA stated - selling cigarettes in pharmacies is contradictory - pharmacies should be tobacco-free At the state level, in 1997, the Board of Pharmacy in Washington urged pharmacists to go tobacco- free to promote a healthy lifestyle to their patients.

11. The Washington Board of Pharmacy’s Policy Statement “ … given that the use of tobacco products is the most preventable cause of death and disability, and that pharmacies promote a healthy lifestyle to their patients, the board urges pharmacists to remove all tobacco products from their pharmacies and to actively support their patient’s efforts to quit using tobacco in any form.” Washington State Register, WSR 97-07-070, 1997

12. So … Why do Pharmacists sell Tobacco Products? Fear = loss of business BUTtheeconomics are not clear-cut

13. Economics Of Canadian pharmacists who discontinued tobacco sales, in 1987, 21% reported an increase in profits and only 2% reported a long-term decrease. The bleak predictions of 119 - 326 closures did not occur when Ontario pharmacies went tobacco-free in 1994. Instead, there was a net increase of 70 pharmacies.

14. Pharmacists as leaders in Tobacco Control By virtue of their accessibility to patients, pharmacists are in an ideal position to help people avoid initiating smoking or quit smoking.

15. Public Support 70% of California consumers favored tobacco-free pharmacies & 83% would continue to shop just as often at a tobacco-free pharmacy. By strategically marketing other products and services, pharmacies become less reliant on the revenue from tobacco products.

16. Business Strategies Tobacco-free pharmacies can replace any lost sales by promoting smoking cessation aids (nicotine patches, gum, etc.) and other consumer goods.

17. Voluntary Programs Only 60 out of approximately 1,250 pharmacies in Massachusetts are tobacco-free. All tobacco-free pharmacies in Massachusetts are independent pharmacies. Massachusetts Pharmacists Association, in cooperation with the Massachusetts Department of Public Health www.tobaccofreepharmacy.org In Massachusetts, 95% of pharmacies still sell tobacco products

18. Bans World-wide AustriaAustria BrazilBrazil Canada (in 5 provinces)Canada (in 5 provinces) DenmarkDenmark FranceFrance GermanyGermany GreeceGreece Ireland *Ireland * ItalyItaly Japan (most don’t sell – it is possible to request a special permit to sell ) Mexico * New Zealand Norway Spain Sweden Switzerland United Kingdom England, Scotland, Northern Ireland, Wales * * = still verifying

19. Law is a tool for public health In 1994, the sale of tobacco in pharmacies was banned in Ontario. New Brunswick, 1997. Quebec, 1998. Nova Scotia, 1999. Newfoundland, phase-out by 2005. In 2001, a bill to prohibit sale by pharmacists was re- introduced before the Massachusetts legislature. The bill died in committee. In 2001, an assemblyman in Marin County, CA agreed to introduce legislation in California to eliminate the sale of cigarettes in all healthcare facilities, including pharmacies. In Canada, there are laws pending in Newfoundland, British Columbia, and Prince Edwards Island.

20. Legislative Strategies The Massachusetts Model The proposed legislation prohibits the sale of tobacco by pharmacists, thereby creating a large loophole permitting, for example, supermarkets with pharmacies to sell tobacco products. 2001, H.B. 2695 The Ontario Model In contrast, the 1994 law is more comprehensive; it prohibits the sale if “a pharmacy … is located within the establishment, or customers of [that] pharmacy can pass into the establishment directly or by the use of a corridor or area used exclusively to connect the pharmacy with the establishment.” S.O. 1994, c. 10, s. 4

21. Comparing the Models The Massachusetts Model Focuses on the sale of of tobacco by pharmacists. (+) enforcement mechanism (-) creates a large loophole permitting stores containing pharmacies to sell (-) divides the pharmacy community between chains and independents 2/3 of the pharmacies in Massachusetts are chains. The Ontario Model Prohibits the sale based on location. (-) enforcement mechanism (+) makes all pharmacies and stores with on-site pharmacies tobacco-free (+) treats independent and chain pharmacies the same (+) covers all health care facilities such as hospitals, psychiatric facilities, and nursing homes

22. Power through Licensing Boards of registration may have the authority to act to prohibit the licensure of pharmacies on premises that sell tobacco.

23. What type of law? National Legislation National Legislation (-) power of the Tobacco Industry (+) one law covers every pharmacy in the US State Law State Law (-) power of the Tobacco Industry (+) one law covers every pharmacy in the state ALTERNATIVE regulation by licensing authority Local Action (-) incremental approach (+) Boards of Health (e.g., in MA have “plenary power to issue reasonable, general health regulations.”)

24. The Path Forward look for and call upon advocates in the United States and Canada form coalition of interested individuals and organizations to create synergy look for allies and leadership amongst consumers, pharmacists, colleges of pharmacy, boards of registration in pharmacy, and national associations of pharmacists

25. Means to an Achievable Goal... The process of educating pharmacists, consumers, and politicians, and of building coalitions will lead to greater awareness of the facts. The sale of tobacco products 1. presents an ethical conflict for pharmacists, 2. sends unhealthily mixed-messages, 3. is not a clear economic necessity, and 4. is counter to the public’s health.