Tobacco sales in pharmacies: a survey of attitudes, knowledge and beliefs of pharmacists employed in student experiential and other worksites in Western New York

Tobacco use is the single largest preventable cause of early death in the U.S. today [1]. Perceptions concerning cigarettes and tobacco use have changed since the 1950’s when tobacco companies used physicians and invoked science in their advertising campaigns [2]. Yet as attitudes towards tobacco have changed, so has the role of the pharmacist. That role once consisted solely of dispensing medications; it now includes counseling patients. This change in role in counseling among pharmacists is now increasingly important with providing smoking cessation counseling, given the change in Nicotine Replacement Therapy (NRT) from being previously being available by prescription, and now being available over-the-counter [3]. This places pharmacists in a unique position to provide tobacco cessation counseling at point-of-sale. Training programs for smoking cessation counseling are increasingly prevalent in schools of pharmacy across the U.S., and more graduates of these schools are being taught the necessary skills to counsel patients on quitting smoking [4]. However, even though they possess knowledge on tobacco cessation counseling, few pharmacists actually engage patients, citing several potential barriers [4–7]. Other research has shown that the majority of pharmacists do not discuss tobacco use with new patients [5].

In other countries, tobacco cessation counseling training for pharmacists have progressed more rapidly, as many nations have a more focused preventative medicine framework within their health care systems. For example, in Finland, the Finnish Current Care Guideline (which outlines smoking cessation responsibilities for all health care professionals) states that pharmacy owners should arrange for tobacco cessation training for their pharmacy staff [8]. Additionally, a 1998 study conducted by researchers in Scotland found that pharmacy staff who underwent training for smoking cessation based on the “stages-of-change” model were more readily able to identify and assist in patients efforts to quit using tobacco than pharmacy staff who did not undergo such formal training [9]. Observed levels of engaging patients for tobacco cessation counseling also appear to be higher in countries outside of the U.S., a likely reflection on smoking cessation training efforts [5–7, 10]. For example, a Canadian study found that within their sample of pharmacists, fewer than 50% of pharmacists in the provinces studied intervened with more than half of their smoking patients [10]. This same group found that nearly 44% of current smokers surveyed would be very or somewhat likely to ask a pharmacist for advice on quitting smoking, making pharmacists a somewhat trusted source for solicitation of quit advice in some areas [11]. A 2011 systematic review of public health practices in community pharmacies conducted by a research group in the United Kingdom indicates that sets of public health services, including providing smoking cessation counseling, are now required by community pharmacists in some areas of the U.K. due to the establishment of a new pharmacy contract [12]. This suggests that the role of pharmacists in population-health objectives are more widely acknowledged and advanced in these nations, and training in public health practice in community pharmacies are more heavily emphasized.

The sale of tobacco products in pharmacies in any locality may send conflicting messages to consumers who come to pharmacies in search of medication or health promotion products. Most U.S. pharmacists oppose the sale of tobacco products in pharmacies [13–16]. Nonetheless, many pharmacies in the United States still sell tobacco products, and polls of pharmacists and pharmacy students show that these groups feel that selling tobacco products in pharmacies violates their personal and professional values [14, 17].

Research has found that chain pharmacies are more likely than others to sell tobacco [18]. Pharmacists who work in chain pharmacies also have the least influence on tobacco product sales [18]. A study conducted in 2003, a repeat of a study conducted in the same county in 1976 [19], found that, although the overall percentage of pharmacies selling tobacco products decreased, this change was due mainly to sales decreases in independently owned pharmacies and pharmacies in medical clinics. Chain pharmacies increased in numbers, though there was no change in the percentage of them selling tobacco products [19].

In 1971, the American Pharmacists Association (APhA) House of Delegates released a statement, declaring: “APhA recommends that tobacco products not be sold in pharmacies.” [20, 21]. This statement has been periodically renewed to keep smoking cessation a priority [21]. The APhA also recommends that pharmacists “provide services, education, and information on public health issues”, which supports the pharmacist role in providing tobacco cessation services to patients [20]. The American Society of Health-System Pharmacists (ASHP) advocates that pharmacists should become involved in smoking cessation counseling and include patients’ tobacco usage in patient profiles [22]. Although a large percentage of pharmacists are opposed to the sale of tobacco products in pharmacies, and pharmacy organizations have spoken out against this practice, studies still show that, in some areas, more than half of pharmacies sell tobacco products [13, 14, 16–18]. As students are taught about smoking cessation counseling and the importance of this practice in pharmacies, the contradiction of tobacco sales in pharmacies is becoming more apparent. The American Association of Colleges of Pharmacy (AACP) passed a resolution in 2003 recommending that schools of pharmacy only choose experiential sites for students that do not sell tobacco products [17]. However, student experiential sites are selling tobacco products, and whether these sites are effectively counseling patients on smoking cessation remains important, because pharmacists could play a more decisive role than they do. Additionally, sites that guide students through a university affiliate may provide a differential level of experiential education, as these preceptors are subject to standards and guidelines to which other, non-university affiliated sites may not be subject.

The continued availability of tobacco products within pharmacies in the U.S., including student experiential sites, is due to a host of different factors. These include, but are not limited to: the voluntary nature of businesses in the U.S. adopting recommendations by professional organizations such as the APhA; pharmacies located in “big box” stores like Wal-Mart not having the freedom to choose what products are sold in their workplaces due to corporate business interests [23]; and added incentive for pharmacies to stock tobacco products due to additional revenue provided from displaying tobacco product marketing displays and advertisements [24].

Recently, the United States passed the Family Smoking Prevention & Tobacco Control Act (FSPTCA) of 2009, [25] which gave the FDA and state and local jurisdictions the power to regulate aspects of the sale and marketing of tobacco products. For example, communities can prohibit the sale of tobacco products in pharmacies; this has taken place in Boston and San Francisco [26, 27]. While other countries have managed to implement voluntary tobacco sales bans within pharmacies in some areas [10], this is relatively new legislation that gives similar authority to establish such bans within the United States. This legislation could have important implications regarding tobacco sales in pharmacies in the U.S., and aligning the pharmacy as a health promotion resource per APhA recommendations.

The Survey Research and Data Acquisition Resource (SRDAR), within the Department of Health Behavior in the Cancer Prevention Research Program at Roswell Park Cancer Institute, administered two similar surveys to local area pharmacists from October 2010 to December 2010 to address these questions. Sample members were identified through 2 lists provided by the University at Buffalo (UB) School of Pharmacy and Pharmaceutical Sciences. The preceptor sample consisted of a list of contact information for 530 eligible preceptors affiliated with the school. (“Preceptors” are volunteer providers of experiential education within their own worksite that have gained approval from the university, and are subject to adhering to particular guidelines and standards for their worksite and practices as governed by the school.) This web-based survey was sent to all pharmacist preceptor sample members. (Additional file 1) Participants received a survey invitation via e-mail, which included a direct link to the survey online. Reminder e-mails were issued 5 days and 12 days after the initial e-mail was sent; a total of 148 preceptors participated in the survey. The response rate for the web-based preceptor survey was 28%. The supervising pharmacist sample was list-based, and included 345 local area pharmacies for which contact information was available for the supervising pharmacist. This was a mail-based survey sent to all supervising pharmacist sample members in the Western New York Area. (Additional file 2) Potential participants were mailed a survey package via the United States Postal Service containing an advance letter, survey instructions, and the survey instrument. Two weeks after the initial mailing was sent, a reminder letter was sent out to sample members who had not yet responded; a total of 120 pharmacists responded to this survey. The response rate for the mail-based supervising pharmacist survey was 35%. Passive consent was obtained upon receipt of the completed survey, and no compensation was provided. Approval for this research was obtained from Institutional Review Boards at both Roswell Park Cancer Institute and the University at Buffalo.

This report describes the attitudes of a potentially important leader in the struggle against what is likely the most devastating public health threat of the 20^th and now the 21^st century: cigarette smoking. We sampled from two important sectors of the pharmacy practice community of Western New York: preceptors of the University at Buffalo School of Pharmacy, and supervising pharmacists at Western New York pharmacies.

The results indicated that preceptors, as members of a recognized and highly respected academic community, tended to have more education, were more likely to have completed a residency, and were more likely to engage in tobacco cessation counseling activities than supervising pharmacists. The pharmacies where preceptors and supervising pharmacists work are about equally likely to sell tobacco products and nicotine replacement treatments. In retail settings, preceptors were more likely than supervising pharmacists to have received formal tobacco cessation counseling, although the difference between these two groups is slight. These are differences that may influence the quality of experiential education that pharmacy students receive, particularly with respect to applied training for the provision of smoking cessation counseling to patients.

A striking component of these findings is that preceptors are more likely than supervising pharmacists to be familiar with patient tobacco use, and to take rudimentary steps to advise regarding tobacco use. Even with the presence of confounding with respect to work setting and preceptor designation, measures of association still point toward preceptors more actively engaging in smoking cessation activities than pharmacists not enrolled in the preceptor program. Preceptors are more likely than supervising pharmacists to ask prescription patients about tobacco use and to refer tobacco-using patients to the New York State Quit line. Therefore, students receiving training by those in the university-affiliated preceptor group employed in retail settings are likely being exposed to tobacco cessation counseling practices through their mentors at a slightly higher level than those who are not receiving training with university affiliates. Nonetheless, the percentages of even preceptors who report that they always or usually take such actions are very low: below one fourth. Half to three fourths of even preceptors report that they rarely or never record tobacco use, ask about tobacco use, or refer patients to the New York State Smoker Quit line. Other studies have shown similar results [3–6, 10]. Ninety percent of the pharmacies of preceptors, even at this internationally recognized school of pharmacy, are not required to document tobacco use.

These data offer no easy answers as to why pharmacists do not take a more active role in addressing patient tobacco use. Among retail preceptors and supervising pharmacists, few are likely to report that lack of time, inadequate staffing, lack of upper management support, discomfort over initiating a conversation about tobacco use or lack of training is definitively or often a barrier to providing tobacco cessation counseling. About a third of pharmacists report concern over patient time, and over the possibility that patients might feel like pharmacist advice regarding tobacco use might be intrusive. In fact, one interesting finding from this study was that over 50% of supervising pharmacists reported that lack of reimbursement for smoking cessation counseling was not a barrier to providing such services, which is consistent with what other studies have shown in the U.S. and in other nations [12]. Our discomforting finding is that local area pharmacists do not take advantage of the opportunity to educate and counsel patients regarding tobacco use. We need to better understand why such action is not undertaken. Would more cessation training help? Should such training be mandatory? Although our current data do not address such questions, these are questions that warrant further research. For example, in other areas, research has suggested that economic incentives for pharmacists to provide such counseling may provide additional motivation for the provision of such services to patients, as would the provision of an appropriate, private setting in which counseling sessions could be conducted [12]. Responses from participants in our study are also consistent with that of other studies with regard to barriers to providing cessation counseling involving patient-pharmacist interaction. Other research studies have mentioned that of those patients who have received public health services (such as tobacco cessation counseling) in community pharmacy settings, the response to such services by patients has been largely positive [12]. Eades et al. mention that additional training for pharmacists to engage in such public health practices in their work sites may boost confidence in the provision of such services, and this confidence may yield higher levels of counseling practices. Additionally, this team mentions that these training sessions may include a review of research indicating the positive consumer experiences of those who have been recipients of public health services may be helpful in motivating pharmacists to provide such services such as smoking cessation counseling [12].

In spite of their relative inaction, both preceptor and supervising pharmacists regard tobacco sales in pharmacies as inappropriate. Pharmacists as health professionals are fully aware of the myriad pathogenic effects of tobacco, and they recognize the conflict between their roles as health professionals and as merchants dispensing what is clearly a major preventable pathogen. Their position is in this vein consistent with the position of the American Pharmaceutical Association, that pharmacies should not be selling tobacco products. Despite this point, our data show that 80% of preceptors and 85% of supervising pharmacists that work in chain retail pharmacies indicated that tobacco products were sold in their worksites. As mentioned, other studies have shown that pharmacists employed in chain retail outlets have little influence on the products that are sold within their work sites [18]. However, nearly all pharmacists employed in chain retail and independently-owned pharmacies included in our study reported that their site sold non-prescription NRT. As mentioned by other research conducted outside of the United States [10, 11], this can serve as an important tool for pharmacists to encourage their own involvement in patient smoking cessation counseling.

Data collected in New York indicate that tobacco sales are a decreasing source of pharmacy income [28]. It may be the modesty of income, but is more likely the inconsistency of the pharmacist’s ethical code regarding tobacco merchandising that overwhelming majorities of both preceptor and supervising pharmacists voice agreement with the establishment of laws banning pharmacy tobacco sales. Other studies have shown this [13–16].

The New York State Assembly and Senate have considered bills banning tobacco sales in pharmacies, although those bills have not progressed very far. Coupling this information with the enactment of the FSPTCA of 2009 [25], which gives state and local communities the authority to regulate aspects of the sale and marketing of tobacco products, the data in this paper may help inform such policy debates regarding the sale of tobacco products in pharmacies in the WNY area, and other parts of the U.S. In other areas outside of the United States, bans on the sale of tobacco products in pharmacies have already been implemented [10]. Surveys conducted amongst pharmacists in these locations show that pharmacists generally yield more positive attitudes toward smoking cessation counseling practices compared with areas that do not have sales bans [10]. If bans were to be implemented in other areas in the U.S, these may have an impact on smoking cessation counseling practices. While this Canadian study noted that sales bans appeared to have had little effect on intervention levels among pharmacists [10], circumstances faced by pharmacists practicing in the U.S. may yield other results. Regardless of the impact on practice, tobacco sales in pharmacies continue to be inconsistent with the role of the pharmacist as a health care provider, and these data could go on to inform policy that will help align their role within public health practice.

The information presented in this report may also serve as a basis for those in other institutions to examine the environmental characteristics and behaviors by pharmacists that take on student trainees to determine what student trainees are exposed to in these sites. Other organizations may also wish to examine pharmacists’ opinions about the sale of tobacco in their workplaces in their own communities, which may give data to inform community policy debates in other geographic areas.