This story from Philly.com/Health was posted on Monday by Terry Gerace, PhD, an anti-smoking activist and former research epidemiologist in Washington, DC who has been picketing CVS pharmacies for more than a year to protest their sale of tobacco products.
But this is beginning to feel like déjà vu all over again. Note both the title of the story and the public comments immediately under the story about activist pharmacist Daniel Hussar’s recent editorial calling for an end to tobacco sales in pharmacies. For all we know, these comments were planted by the drugstores or tobacco companies, but in any case public support for tobaccofree pharmacies is not a given.
If ending tobacco sales in pharmacies is the sole or primary goal of TobaccoFreeRx, then do we favor that this be accomplished by local legislation, state legislation, health department regulation, public referenda, voluntary cessation of the sale of tobacco products, or all of the above? Given that just two major cities have ended tobacco sales in pharmacies (both under court challenge), the chances of such measures gaining widespread traction are not great. (Most provinces in Canada, on the other hand, have banished tobacco from pharmacies.) Even if this were to happen, it would take a very long time to achieve throughout the US.
In California, just as the avant-garde state-funded program Prescription for Change (a forerunner of this TobaccoFreeRx) was gaining momentum a decade ago (http://www.scribd.com/blumarchive/d/46111677-Precription-for-Change-Final-Summative-Report), it was stopped by Governor Gray Davis from focusing on the chain drugstores (the only focus there really is) following a large campaign contribution from a drugstore chain. The program devolved into giving awards to independent pharmamcies that had long since stopped selling cigarettes. And that’s in our most progressive state.
This is typical of the history of anti-smoking endeavors. The timeline of tobacco control began in the 1970s with grassroots lobbying for the passage of restrictions on smoking in elevators and other confined spaces, gradually followed (over the ensuing 30 years) by public areas of government buildings, public transportation, movie theaters, sports arenas, restaurants, parks, beaches, and even bars. Hospitals did not go smokefree until their accrediting body prohibited smoking in health care facilities in the early 1990s. All US airlines, including those that fly internationally did not snuff out smoking until the mid-1990s Restrictions or bans on tobacco advertising, promotion, and sports and arts sponsorship in the US similarly were a very slow and gradual process that took upwards of 30-40 years for most such marketing to end or diminish.
Coalition-building in tobacco control began in the late-1980s with a conference hosted by the National Cancer Institute to mark its 50th anniversary. A leading proponent of coalitions was Mike Pertschuk, founder of the Advocacy Institute; former Federal Trade Commission chairman; leader of the effort to defeat the nomination of Robert Bork to the US Supreme Court; and aide to Senator Maurine Neuberger in the early-1960s in her pioneering battles against smoking and the tobacco companies. (She had succeeded her late husband, who died of lung cancer.)
Such coalitions became the governing councils for the 17 states that received $7 million anti-smoking grants under Project ASSIST. The problem was, Project ASSIST was not a success, and the much-vaunted coalitions (each including every conceivable organization related to public health) simply didn’t pull their weight. I realized early on that such a coalition is only as strong as its weakest members. There was and still exists fear of saying or doing anything that might involve a risk of offending anyone or any agency…or any funder. The anti-smoking battle is not one between those who smoke and those who do not. But it is most definitely a battle against those who continue to sell this poison–and that most definitely includes the chain drugstores as the worst offenders by virtue of their heavily marketed image as members of the health care team and their employment of health professionals.
If we are not willing to speak out forcefully and unwaveringly against Walgreens, CVS, and Rite-Aid (as opposed to a generic call for “tobacco-free pharmacies”), then we will only be prolonging and postponing the achievement of our stated goal. That’s because the legislative or regulatory routes will take forever, whereas finally putting these corporations permanently on the defensive by the constant repetition of their hypocrisy (which Prescription for Change was doing so well until it folded) will be bad for business and more likely lead to a change in policy. One of Prescription for Change’s brilliant paid newspaper advertisements aimed directly at Rite-Aid read, “To help a persistent cough, go to aisle 8. To get a persistent cough, go to aisle 14.”
Since I hadn’t received any feedback on my comments on January 29 (below), I wanted to reassure the group that I was not suggesting that anyone on the TobaccoFreeRx committee is any less committed than I am about ending tobacco product sales in pharmacies. (Nor was I suggesting that a better way to do this would be to throw in alcohol as long as we’re at it.) But surely there are varying opinions on exactly how to achieve this goal. And some individuals have perhaps never been involved in any advocacy organization and may be feeling uncomfortable. But in my view, any public health advocacy coalition or committee worth its salt must be as strong as its strongest advocates.
I am speaking from more than 35 years’ experience in tackling the smoking pandemic. I began my involvement in the issue Miami at a time when the chairman of my department of family medicine, where I was a resident in training, called me down to his office to ask me to stop talking to his secretaries about their smoking, because that was their personal lifestyle and freedom of choice; where the director of the Dade County Health Department rebuffed my entreaty to include anti-smoking in its mission; where the director of the large county hospital in which I served rejected my request to make the hospital smokefree by citing all the patients who were not mobile enough to go outside to smoke; where the chairman of obstetrics dismissed my suggestion to ban smoking in the prenatal clinic waiting room by saying “We have enough trouble just getting the babies delivered”; and where the beneficiary of the Virginia Slims Tennis Tournament of South Florida was the American Cancer Society. Pat Malone wrote about some of these events as the medical write for The Miami Herald.
Miami was actually one of the more progressive cities on smoking policy, having passed bans on smoking in elevators and some other public spaces. It became the first county in the US to hold a public referendum on a clean indoor air ordinance, which was defeated by just 800 votes out of nearly 200,000 cast, following a campaign in which the tobacco industry spent $10 million on mass media advertising, while proponents could barely raise $50,000 for bumper stickers and a few small newspaper ads. In 1977 I helped the local public television station in Miami conduct a tobacco sting (one of the first in the nation), whereby teenagers were employed to demonstrate the ease with which they could purchase cigarettes. Our chosen venues were…pharmacies.
But an awareness of the hypocrisy of selling a product so antithetical to health as cigarettes was not lost on many pharmacists even in that era. For example, the late Jim Myers, a beloved independent pharmacist in Tuscaloosa with several stores in the area, opened his first pharmacy in 1974 and within six months decided to end the sale of tobacco products because he could no longer live with himself for selling something that undermined the efficacy of the medications he was dispensing. In 1978, Dr. Stephen Schroeder published the earliest study of cigarette sales in pharmacies in the American Journal of Public Health. By the late-1980s, my telephone surveys of pharmacies in Houston showed that virtually all independent pharmacies had stopped selling cigarettes because of the contradiction of providing an irredeemably harmful product. I confirmed these results among Tuscaloosa area pharmacies several years ago. Indeed one could argue that by virtue of the chains having driven local independent pharmacies out of business, more pharmacies are selling cigarettes today than 25 years ago!
So the issue is not new. Nor is the goal of getting tobacco out of pharmacies. Granted every advance in the field from clean indoor air laws to restrictions on sports sponsorship seems to take off once a certain degree of support coalesces. And this may well be the time for tobacco-free pharmacies to be the next big thing. But I maintain that this is such a long-overdue policy that we also need to emphasize how seriously it cuts to the heart of the pharmacy profession and must no longer be tolerated. To do any less would be to eventually reward through praise and amnesia the chains that finally do stop selling cigarettes as well as to ignore the willful indifference to this issue on the part of schools of pharmacy for decades.
The question will be asked, as it already has for some years, how the pharmacy profession and its academic arm could have said or done so little on such a glaring contradiction. A few years ago the American Medical Association apologized for a century of having denied membership to African-American physicians. But it has yet to apologize for its decades of collaboration with the tobacco industry long after the facts about the lethality of cigarettes were known and its consequent long silence and inaction on smoking (see article below thes emails). Along these lines, I think it will be necessary for the pharmacy profession to apologize for having been part of the tobacco supply chain. And I think this is a good time for the increasing health promotion role of pharmacists to be matched by a stepped-up call by pharmacists for denial of licenses to sell medications (or administer urgi-care) to the owner of any retail outlet where cigarettes and alcohol are also sold.
In other words, one has to look beyond getting back to where pharmacies once were or should have been all along. To do that, one must emphasize that ridding the chain drugstores of tobacco is not an end-point but only a bare minimum standard by which the chains must now abide. And if they continue to ignore this basic healthcare obligation, then pharmacy professional societies and schools must turn from polite requests to do the right thing to condemnation of the chains—and must consider strategies aimed at economically punishing the corporations. If done right, TobaccoFreeRX could be the conscience and catalyst for giving permission to pharmacy schools to finally speak out.