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Pharmacists who dispense cigarettesWith reference to drug storechains and pharmaceutical companies

JOHN W. RICHARDS, JR, MD, ALAN BLUM, MD

In recent years pharmacists in the United States have at-tempted to move beyond the role of dispenser of medica-tions and toward that of "gatekeeper of the communityshealth." 1 In many instances the pharmacy has become asite for screening of high blood pressure, reading of He-moccult tests, and diabetic monitoring. The president ofthe California Public Health Association, a pharmacist,has predicted that pharmacists will be reimbursed bythird-party payers for providing health care information.Organizations of retail pharmacies sponsor mu ltiphasichealth screening and health fairs, through which abnor-mal results of blood pressure measurements and laborato-ry blood and urine profiles stimulate increased utilizationof health care servicesncluding pharmacies. Aided bypharmaceutical manufacturers, pharmacies participate inpublicity campaigns to curtail such problems as sexuallytransmitted diseases and accidental poisonings. McNeilLaboratories (makers of Ty lenol with codeine) is sponsor-ing the program "Pharmacists Against Drug Abuse" (Fig1), and Schering Laboratories has attempted to enhancethe image of the pharmacist as a health educator and con-sumer advocate through pamphlets and mass media ad-vertising that encourage the public to "Ask Your Pharma-cist."Such image-making coincides with increased advertis-ing for numerous analgesics, antacids, vitamins, "dietpills," cough syrups, and "cold remedies," many of whichhave been cited by the Food and Drug Administration asineffective and unnecessary. Pharmacy trade journals arereplete with advertisements for these preparations re-minding pharmacists who display and recommend thedrugs to patients that substantial profits are assured.

INNOCENCE BY AssocIATIoNAs questionable as such promotions may be, they palein comparison to advertisements in pharmacy publica-tions aimed at increasing the sale of tobacco products.These advertisements do not even carry the health warn-ing of the Surgeon General (Fig 2). In pharmacy publica-tions, the role of the pharmacist as tobacconist is seldom ifever questioned, as is illustrated in the following state-ments from Drug Store News, the largest circulation pub-lication of the pharmacy business:

Considering the increased health warnings about smoking, high-er federal, state and local taxes and price hikes on several leadingbrands, chain drug stores continue to rack up strong cigarettesales.Drug store retailers also say theyll promote [tobacco] harderand improve in-store displays to counter the decreased consump-

From DOC (Doctors Ought to Care).Address correspondence to or Richards, Assistant Professor, Department ofFamily Medicine, Medical College of Georgia, Augusta, GA 30912.

T H E ; K IN D SI~V

C F 4 D R U G SKIDS$ARE:G E T T I I G1 N:RightnbWOver:one-thirdof all kicl in-America e eilleg-al drugsIn fact;onout of every 18 highsthoolseniors is using marijuanaevery

FIGURE 1. Pharmacists Against Drug Abuse: Pharmaceutical company-sponsored organization warns about widespread use of Illicit drugs byteenagers.

tion due to increased health conc&rns. Attractive retail displayallowances result in "very lucrative" agreements between [to-bacco] vendors and retailers. 3Twenty-five percent of cigarette purchases are made inpharmacies. Eight percent of chain drugstore profits (and6.2% of all drug store purchases) are derived from the saleof cigarettes, which ranks fourth among all products sold

in pharmacies. 35 Moreover, at a time when overall tobac-co sales increases have slowed, chain drug store sales of tobaccoproducts increased 9% in 1984 to nearly $2 billion. 5 Ac-cording to the United States Tobacco and Candy Journal,the major trade newspaper of tobacco distributors, ciga-rettes have become a "staple and stable" product categoryfor the chain drug stores. Cigarettes represent more of an"automatic sale," "volume-builder," and "traffic-build-er" than any other single product sold in drug stores. Al-though cigarette sales are not rising in the United States,cigarettes and drug store chains retain a "top-of-mind"association among consumers: in other words, one of themajor reasons for going to the drug store is to buy ciga-

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\egot)oupeedFIGURE 2.xamples of pro-amok-ing advertisements In Drug StoreNews. Top: Ads, minus the SurgeonGenerals warning. for. Marlboro( P h i l i p M o r r i s ) , K e n t I I I (Loews). andStride (Grand Metropolitan) suggestgreater profits for pharmacistso

31yjd r i mi , .: --7 sell these cigarettes. A generic olga-rette manufacturer pushes value andvisibility. Bottom: "it youre hookedon profits" slogan promotes rollingpapers. RJ Reynolds touts its salesai1

rettes. The most recent survey by the Point-of-PurchaseAdvertising Institute and Dupont Laboratories found that70% of cigarette purchases in drug stores were spe-cifically planned. 5Marketing s trategies of tobacco compan ies for pharma-cy sales are me ticulously plann ed and implemen ted. Ciga-rette salesmen pay premiums of $120-$140 per year topharmac is ts to place c igarette displays at the cash regis teror check-out counter .4 Maximum visibility is reinforcedby applying stickers ("PUSH Winston," "Its KOOL In-side," "PULL Marlboro," for example) at child-eye levelon doors and shopping carts. Such "pointof.purchase"*messages, changed frequently, encourage customers tobelieve there are new and improved (and hence possiblymore healthful) attributes of one brand or another. What-ever th e brand, the poin t is to buy c igarettes . A major pur-pose of such cigarette advertisements in pharmacies is toIn October 1984 Ri Reynolds (maker of Camel. Winston, Salem, Marc, Now,

Sterling. Bright, and Vantage cigarettes) received the first Chief Award of thePo int.of-Purchaae Advertising Institute for its "outstanding and innovative" point-of-purchase program. Pierre Salinger, chief foreign correspondent for ABC News,presented the award to Gerald Long, president and chief executive officer of RiReynolds, at a banquet attended by 1,000 busines., leade rs. Long told the gather-ing. "Ifs company desires to be a premier consumer products firm, then it must bea leader in point of purchase." (Sources: Advertising Age. November 5,1984, p 28;United Slates Tobacco and Candy Journal. November 29-December 19, 1984, p40.)

introduce those who do not smoke or who have not yetstarted to smoke to the acceptability of selling tobacco ---products in an ostensible health care setting. Who candoubt that patients who smoke rationalize their adverse.health behavior by pointing to the sale of cigarettes at theplace where they are directed by physicians to obtainmedications?COMMON OBJECTIVESMany pharmacists doubtless have misgivings aboutaiding the perpetuation of tobacco use. But in one surveyof 100 retai l pharmacies in San Fran cisco, only 11 did notsell cigarettes. 6 And sales of c igarettes in ph armacies ap-pear likely to rise as the trend toward concentration ofownership of pharmacies by large conglomerates in-crease s. In 1983, tobacco sales rose 6% to $2.56 billion, 3 Incontrast to their staunch support of various public healthmeasures, no retail pharmacy chain has led a campaign tocurtail smoking and its promotion. (Similarly, many retailpharmacy chains have become major discount liquor out-lets.) Thus, the definition of drug abuse that many of thepharmacy chains and pharmaceutical manufacturers aresupporting refers only to abuse of illicit drugs. Publicitysurrounding the widespread abuse of a legal drugmeth-aqualone or dextroamphetamine, for examplehas led to

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voluntary if belated withdrawal of various products. Butthe fact remains that the connections between the tobaccoand pharmaceutical industries run deep and remainstrong. One has only to consider the role of BAT Indus-tries (formerly British American Tobacco), the Britishparent corporation of Brown and Williamson TobaccoCompany (USA), manufacturer of such brands as Kool,Raleigh, and Barclay. In Canada, BAT owns 45% ofImasco (formerly Imperial Tobacco Company), the coun-trys largest cigarette manufacturer. In 1983, Imasco purchased Shoppers Drug Mart, the largest retail pharmacychain in Canada, with more than 450 stores. In 1984,Imasco added Peoples Drug Stores, which operates morethan 750 outlets in the United States under such names asSay-A-Lot, Lane, Reed, Lee, Haag, Rae and Derrick,Mill, Health Mart, and Peoples. The company is expectedto become the largest retail pharmacy chain in NorthAmerica.

In developing nations, certain pharmaceutical compan-ies are launching major advertising campaigns for drugsnot named on the World Health Organizations list of es-sential drugs; yet these companies have done nothing todiscourage cigarette smoking, which has shown a rapidincrease due to major advertising campaigns and freesampling by tobacco companies. Certain advertisingagencies develop campaigns for both cigarettes and phar-maceutical products, a clear conflict of interest where hu-man health is concerned. A cynical viewpoint would holdthat the tobacco companies are paving the way for greateruse of medications through the anticipated increase incigarette-related disease. Cynicism aside, there is evi-dence of direct ties between the two industries. At leasttwo pharmaceutical companies (Sterling; Johnson &Johnson) advertise products (Bayer aspirin; Tylenol) intobacco trade journals. The chairman and chief executiveofficer of CIBA-Geigy (makers of Transderm-nitroglyc-

erin, Esidri, and Serpasil) serves on the InternationalAdvisory Bdard of RJ Reynolds, one of the worlds ciga-rette manufacturing giants. Merrell Dow (makers of Ni-corette) is a major supplier of pesticides for tobacco grow-ing as well as chemical additives used in cigarette manu-facture. Pfizer (makers of Minipress, Procardia, andVibramycin) owns a cigarette flavorings factory. Hoechst(makers of Lasix) manufactures cellophane for cigarettepackaging. More than half the revenue of the billboardsubsidiary of Minnesota Mining and Manufacturing (3-M), makers of Theolair, surgical masks and the Littmanstethoscope, is derived from tobacco company advertising(Fig 3).

In spite of the clear conflict of interest in aiding the saleof the leading preventable risk factor for cancer and a ma-jor factor for heart disease, duodenal ulcers, bronchitis,and a host of other ailments, only a handful of Americanretail pharmacies have refused to sell cigarettes. Indeed,pharmacy journals have only once addressed the ethics ofdispensing tobacco products. 7

PROGIESS IN CANADAThere are hopeful signs, however. In 1984, the Canadi-an Pharmaceutical Association, the leading pharmacistssociety in Canada, launched a health campaign, "Stand

Up and Be Counted," aimed at ending tobacco sales in thecountrys 5,400 drugstores, as well as distributing educa-tional materials on smoking prepared by the CanadianHealth Department. Jean-Guy Cyr, editor of the Canadian Pharmaceutical Journal, condemned the "harmfuland irresponsible act" of selling tobacco products andpointed to the mockery it makes of the health role of thepharmacist. 8 Doubtless aware of the failure of its ownpolicy that pharmacists should not dispense cigarettes, theAmerican Pharmaceutical Association (APA) in 1984proposed a "guilt-free" solution for pharmacists, whereby

Alifcthcofemouons wrapupin one w6ff:-"w_Hoechst -

FIGURE 3.xamples of pharmaceutical company links to the tobacco Industry: Hoechst, manufacturer of Lasix and a leader in cigarette packaging; Pfizerowns a tobacco flavoring products company, advertises in tobacco trade publications, and publishes an editorial-style advertisement in major dailynewspapers to allay public anxiety about cancer ("Too much fear can be dangerous . . . Hope is the key to the future"). The advertisement Implies thatsubstantial control and cure of cancers will be achieved by the year 2000.cientists in universities, pharmaceutical organizations and governmentalhealth agencies are coordinating activities that are supported by huge budgets and by an Immense technology. No mention of smoking is madeor thenumber of deaths from cancer that could be prevented simply by not smoking.

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Sausalito pharmacist Fred Mayer decided five yearsago that ethics outbalanced economics, and opted to,droptobacco and tobacco-related products from his inventory."I realized that as a health professional, I was beinghypocritical by selling tobacco products," said Mayer."So I dumped the whole linepipes, rolling papers, pipecleaners, the entire thing."

That decision would have cost Mayer $50,000 a year ingross income, had he not hit on a remedy: remerchandis-ing. Mayer redesigned his smoking products section, sub-stituting a line of cameras and films. He had his sales-clerks trained in the subject, and what might have been a

profits from the sale of tobacco products could be donatedto the American Cancer Society. Apart from the fact thatheart disease and chronic obstructive pulmonary diseaseaccount for an even greater overall smoking-related mor-tality and morbidity than cancer, the APA is shirking re-sponsibility in lieu of playing an active role to curtailsmoking and its promotion.Whereas hospital-based pharmacists have earned a role

as respected members of the health care team, retail phar-macists who continue to sell cigarettes do not have a credi-ble claim to the role of health educator or consumer advo-cate. Unlike their American counterparts (with few ex-ceptions), many Canadian pharmacists have recognizedtheir proper role and are foregoing tobacco sales. Regret-tably, efforts by both American and Canadian pharma-cists are being undermined by executives of both the to-bacco and retail pharmacy industries.Physicians should support those pharmacists who makea commitment to health promotion and should aid phar-macists in effecting a policy change in their stores. A reg-ister of pharmacies that refuse to sell tobacco productsshould be set up by local medical societies and publicized

deficit based on sound principle is instead a better profitmargin based on sound economics."I dont think Ive lost money or customers, and I no-ticed that when we announced we were throwing tobaccoproducts out, people began to perceive us differently. If acustomer comes in and doesnt see the cigarettes and roil-ing papers, and he or she knows youve gotten rid of thembecause you felt its your obligation as a health profession-al, then the customer begins to perceive you as more of ahealth professional."

MICHAEL DOLANAmerican Pharmacy 1978; 18(9):29

among their membership. A national registry is beingcompiled by Paul Fischer, MD, Director of Research, De-partment of Family Medicine, Medical College of Geor-gia, Augusta, GA 30912. Physicians should submit reso-lutions to their local and state medical societies condemn-ing the sale of cigarettes in pharmacies and praisingpharmacists (perhaps by giving a plaque or certificate todisplay) who refuse to sell cigarettes. Pharmacies are thelast place in which cigarettes should be sold.

REFERENCESI. The pharmacist: gatekeeper of the communitys health. Drug Topics, May

16, 1983:38.2. Tobacco sales still strong despite warnings, pricing. Drug Store News, Sep-tember Il, 1984:13.3. Drug Store News, March 19, 1984.4. "Automatic" cigarette sales a boon to drug chain. US Tobacco and CandyJournal, Feb. Il -Mar. 6, 1985:13.S. 1985 annual report of the chain drug industry: cigarettes garner high sales

per sq. ft. Drug Store News April 29, 1985:124, 159.6. Schroeder SA, Showsiack JA: Merchandising cigarettes in pharmacies; aSan Francisco survey. Am J Pub Health 1978; 68:494-495.7. Dolan M: Caught between ethics and economics: pharmacists and tobacco.American Pharmacy, September 1978:28-29.S. Smith D: Canadian groups target drugstores and print ads in new anti-

smoking campaigns. Advertising Age. July 9, 1984:38.

I - Jo in the AM Aand Newsweek G ood M edicinefor Hea lth C areS) j for an historic hou se rjercall on 22 m illion1Amer i cansI .a s I *-,-.---_-.,_ _ f l s _ _ ._.1...3.- ----. bES* I*., ,-,,-,--,s,. .,,.ta" ---"----- . ,,.".4o._._._ee I Newsweek

Newsweek (ovined by the Washington Post Co) has advertised Itself In The US Tobacco and CandyJournal and other tobacco trade publications as a leadingvehicle for lighting up worldwide sales of cigarettes (left). At the same time, the magazine has attempted to portray itself as a reliable source of Informationon health. In Special Issues in 1983 and 1984, Newsweek used the prestige of the American Medical Association to lend credibility to advertisers. BothIssues contained numerous cigarette advertisements. There was scant mention of smoking In otherwise detailed advice on personal health care.

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