Pharmacists and tobacco: Dollars before duty Brenda Gibson
Smnoking is the single most important cause of preventable disease, disability and death. It is a killer. The tobacco industry, those who sell tobacco to our children, are kissing cousins to those who push marijuana or hash or crack or heroin. It's time we treated them as such. Dr. Marcien Fournier, the CMA president, addressing the Medical Society of Nova Scotia Nov. 17, 1989 TNhe health hazards related to smoking are now beyond dispute, even if the sheer magnitude of tobacco's toll is not always appreciated. An estimated 35 000 Canadians die prematurely every year from smoking-related diseases. So do 390 000 Americans. And then there is the litany of diseases caused by smoking: 3 in 10 cases of cancer - 8 of 10 lung cancer cases - plus respiratory and heart
disease. All of which lead to some questions. Why are cigarettes so readily available? And why, in particular, are pharmacists still selling them? The Code of Ethics of the Ontario College of Pharmacists, Section 1, states: "A pharmacist should hold the health and safety of patients to be of first consideration; he should render to each patient the full measure of his ability as an essential health practitioner." Section 2 stipulates: "A* pharmacist should never knowingly condone the dispensBrenda Gibson is a freelance writer living near St. Catharines, Ont.
ing, promoting, or distributing of drugs .. . which lack therapeutic value for the patient." *Yet, most pharmacies continue to sell or even actively promote the sale of cigarettes despite attempts by pharmacists' leaders and the CMA to end the practice. In 1985 the Canadian Pharmaceutical Association (CPA) launched a "Stand Up and Be Counted" program that attempted to wean drugstores from tobacco sales in stages. It started by providing customers with information about the health hazards of smoking; next came the discontinuation of cigarette promotions, advertising and displays; the final step was ceasing to sell tobacco products of any kind. The result? Less than half participated in the first stage, and the prominence the information received from those that did take part is questionable. About 15% moved on to stage two, and a mere 12% agreed to go all the way. In 1987, the CPA tried again, declaring: "It is now time to take an even harder line against the leading cause of preventable death in the developed world ... pharmacists must face the fact that selling products which hinder good health is a serious conflict of interest which detracts from the image of pharmacists as professional health care providers." It launched a second program called PACT$ - Pharmacists Against Cigarette and Tobacco Sales. Accompanying the mass of posters, press releases and other promotional material was the assurance that discontinuing tobacco sales need not mean sacrificed profits because shelves emptied of cigarettes can be used for new and
profitable lines such as health foods, cosmetics and gifts. An improved public image was also stressed: "By removing tobacco products from your shelves, you will enjoy renewed respect and appreciation as an important health care consultant in your community." The campaign result? A September 1989 survey found that of a total of 6510 pharmacies, some 800 - 12% - no longer sell cigarettes. Most not only continue to sell them but actively promote their sale. How can one of health care's major professions explain such activities? Dale Toni, the CPA president, suggests that pharmacists are no different from the general public and their awareness needs to be awakened. "It's just going to take time", he says. He declines to be drawn into the ethical aspect of cigarette sales, but does admit that there is a conflict of interest when a health care establishment sells a product dangerous tohealth. Pharmacists are basically looking at "the bottom line" and fear change, says Toni, while the CPA is pointing to the reasons for change. He also cites the "conflict within a conflict" that exists because most pharmacies are owned by large corporations; only a small percentage are independent. Shoppers Drug Mart, for instance, is part of the Imasco conglomerate, which also owns Imperial Tobacco. The CPA has approached some of the major chains with the suggestion they go tobacco free, but has received no response. [The CMA past president, Dr. John O'Brien, had a well-publicized scrap with Shoppers Drug CAN MED ASSOC J 1990; 142 (6)
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621
Mart over this issue last year. He accused the chain of hypocrisy Ed.] In June 1989, the Ontario College of Pharmacists also adopted a policy against tobacco sales in drugstores. Like Toni, Jim Dunsdon, deputy registrar of the college, declines to commit himself on the ethical aspect of such sales. He says the college has no power to enforce its policy because tobacco is not legally defined as a drug and its sale has not been defined as unprofessional conduct. Dunsdon takes exception to action suggested by Physicians for a Smoke-Free Canada - that doctors direct patients to pharmacies that do not sell tobacco. He says it suggests there is a connection between selling tobacco and professional competence. However, he admits that the college has no alternative tactics in place to promote its policy. "Pharmacists are in a market economy", he says. Although the profit margin on tobacco is not high, it is seen as a "traffic builder" - it attracts customers who may buy something else when getting their cigarettes. David Sweanor, legal counsel for the Non-Smokers' Rights As-
sociation, maintains that it is both unethical and unprofessional for pharmacists to sell tobacco, "the only legal consumer product which kills when used exactly as intended". Pharmacies, he says, give tobacco an air of legitimacy, especially among young people. How can something sold by a health facility be that bad? Sweanor asserts that there is more to the profit aspect than meets the eye. Pharmacists, he claims, receive cash payments for the amount of shelf space devoted to cigarettes and for countertop displays. Thus, Sweanor argues that drugstores are putting profits ahead of ethical integrity. He would like to see pharmacists' governing bodies declare the sale of tobacco unprofessional conduct. Dr. James Walker, an Ottawa dermatologist active in Physicians for a Smoke-Free Canada - he was one of the first Canadian physicians to have a request printed on his prescription pads asking patients to take their prescriptions to drugstores that don't sell tobacco - regards the sale of tobacco by pharmacists as "totally inappropriate". He sees no ethical problem in directing patients to those who "have made the respon-
sible decision" not to sell tobacco. Indeed, he sees it as being in the interest of his patients. In his view, the sale of tobacco in a drugstore indicates a lack of professional judgement. He, too, would like to see pharmacists' governing bodies take a stronger line. The CMA has made its position clear. It wants to see pharmacists get out of the tobacco business and it is working with the CPA to achieve this. However, Doug Geekie, the CMA's director of communications and government relations, points to "the reality - cigarettes are a significant financial factor" in drugstore operations. He says the average pharmacy can turn the product around, from delivery to sale, in 10 days, but does not have to pay for it for 30 days. This means it is equivalent to an interest-free loan. As for the ethics of directing patients to pharmacies that don't sell tobacco, he sees no problem: "Damage to health far outweighs any such considerations." Toni says his association has chosen the route of "gentle, persistent and consistent pressure". It will be interesting to see how much effect this will have, and how soon.-
Seat-belt exemptions: "Just say No", experts tell MDs Patrick Sullivan says. Dr. Ronald Ailsby, who represents the Saskatchewan Medical Association (SMA) on the provincial safety council, says there is neither rhyme nor reason to the large number of exemptions being granted by many of his less-thancautious colieagues. "It is becoming fairly ridicuand fealous", he told a recent meeting of
octors must exercise more caution and common sense when asked to provide medical exemptions that free their patients from wearing seat belts, a Saskatchewan physician D
Patrick Sullivan is CMAJ news tures editor. 622
CAN MED ASSOC J 1990; 142 (6)
the SMA's Representative Assembly, pointing to one case in which a seat belt was not being worn because of a 6-year-old hip fracture. Ailsby acknowledged that temporary exemptions may be warranted in "rare" cases, but said frivolous ones must be stopped. "Some doctors give them
Smnoking is the single most important cause of preventable disease, disability and death. It is a killer. The tobacco industry, those who sell tobacco to our children, are kissing cousins to those who push marijuana or hash or crack or heroin. It's time we treated them as such. Dr. Marcien Fournier, the CMA president, addressing the Medical Society of Nova Scotia Nov. 17, 1989 TNhe health hazards related to smoking are now beyond dispute, even if the sheer magnitude of tobacco's toll is not always appreciated. An estimated 35 000 Canadians die prematurely every year from smoking-related diseases. So do 390 000 Americans. And then there is the litany of diseases caused by smoking: 3 in 10 cases of cancer - 8 of 10 lung cancer cases - plus respiratory and heart
disease. All of which lead to some questions. Why are cigarettes so readily available? And why, in particular, are pharmacists still selling them? The Code of Ethics of the Ontario College of Pharmacists, Section 1, states: "A pharmacist should hold the health and safety of patients to be of first consideration; he should render to each patient the full measure of his ability as an essential health practitioner." Section 2 stipulates: "A* pharmacist should never knowingly condone the dispensBrenda Gibson is a freelance writer living near St. Catharines, Ont.
ing, promoting, or distributing of drugs .. . which lack therapeutic value for the patient." *Yet, most pharmacies continue to sell or even actively promote the sale of cigarettes despite attempts by pharmacists' leaders and the CMA to end the practice. In 1985 the Canadian Pharmaceutical Association (CPA) launched a "Stand Up and Be Counted" program that attempted to wean drugstores from tobacco sales in stages. It started by providing customers with information about the health hazards of smoking; next came the discontinuation of cigarette promotions, advertising and displays; the final step was ceasing to sell tobacco products of any kind. The result? Less than half participated in the first stage, and the prominence the information received from those that did take part is questionable. About 15% moved on to stage two, and a mere 12% agreed to go all the way. In 1987, the CPA tried again, declaring: "It is now time to take an even harder line against the leading cause of preventable death in the developed world ... pharmacists must face the fact that selling products which hinder good health is a serious conflict of interest which detracts from the image of pharmacists as professional health care providers." It launched a second program called PACT$ - Pharmacists Against Cigarette and Tobacco Sales. Accompanying the mass of posters, press releases and other promotional material was the assurance that discontinuing tobacco sales need not mean sacrificed profits because shelves emptied of cigarettes can be used for new and
profitable lines such as health foods, cosmetics and gifts. An improved public image was also stressed: "By removing tobacco products from your shelves, you will enjoy renewed respect and appreciation as an important health care consultant in your community." The campaign result? A September 1989 survey found that of a total of 6510 pharmacies, some 800 - 12% - no longer sell cigarettes. Most not only continue to sell them but actively promote their sale. How can one of health care's major professions explain such activities? Dale Toni, the CPA president, suggests that pharmacists are no different from the general public and their awareness needs to be awakened. "It's just going to take time", he says. He declines to be drawn into the ethical aspect of cigarette sales, but does admit that there is a conflict of interest when a health care establishment sells a product dangerous tohealth. Pharmacists are basically looking at "the bottom line" and fear change, says Toni, while the CPA is pointing to the reasons for change. He also cites the "conflict within a conflict" that exists because most pharmacies are owned by large corporations; only a small percentage are independent. Shoppers Drug Mart, for instance, is part of the Imasco conglomerate, which also owns Imperial Tobacco. The CPA has approached some of the major chains with the suggestion they go tobacco free, but has received no response. [The CMA past president, Dr. John O'Brien, had a well-publicized scrap with Shoppers Drug CAN MED ASSOC J 1990; 142 (6)
-
621
Mart over this issue last year. He accused the chain of hypocrisy Ed.] In June 1989, the Ontario College of Pharmacists also adopted a policy against tobacco sales in drugstores. Like Toni, Jim Dunsdon, deputy registrar of the college, declines to commit himself on the ethical aspect of such sales. He says the college has no power to enforce its policy because tobacco is not legally defined as a drug and its sale has not been defined as unprofessional conduct. Dunsdon takes exception to action suggested by Physicians for a Smoke-Free Canada - that doctors direct patients to pharmacies that do not sell tobacco. He says it suggests there is a connection between selling tobacco and professional competence. However, he admits that the college has no alternative tactics in place to promote its policy. "Pharmacists are in a market economy", he says. Although the profit margin on tobacco is not high, it is seen as a "traffic builder" - it attracts customers who may buy something else when getting their cigarettes. David Sweanor, legal counsel for the Non-Smokers' Rights As-
sociation, maintains that it is both unethical and unprofessional for pharmacists to sell tobacco, "the only legal consumer product which kills when used exactly as intended". Pharmacies, he says, give tobacco an air of legitimacy, especially among young people. How can something sold by a health facility be that bad? Sweanor asserts that there is more to the profit aspect than meets the eye. Pharmacists, he claims, receive cash payments for the amount of shelf space devoted to cigarettes and for countertop displays. Thus, Sweanor argues that drugstores are putting profits ahead of ethical integrity. He would like to see pharmacists' governing bodies declare the sale of tobacco unprofessional conduct. Dr. James Walker, an Ottawa dermatologist active in Physicians for a Smoke-Free Canada - he was one of the first Canadian physicians to have a request printed on his prescription pads asking patients to take their prescriptions to drugstores that don't sell tobacco - regards the sale of tobacco by pharmacists as "totally inappropriate". He sees no ethical problem in directing patients to those who "have made the respon-
sible decision" not to sell tobacco. Indeed, he sees it as being in the interest of his patients. In his view, the sale of tobacco in a drugstore indicates a lack of professional judgement. He, too, would like to see pharmacists' governing bodies take a stronger line. The CMA has made its position clear. It wants to see pharmacists get out of the tobacco business and it is working with the CPA to achieve this. However, Doug Geekie, the CMA's director of communications and government relations, points to "the reality - cigarettes are a significant financial factor" in drugstore operations. He says the average pharmacy can turn the product around, from delivery to sale, in 10 days, but does not have to pay for it for 30 days. This means it is equivalent to an interest-free loan. As for the ethics of directing patients to pharmacies that don't sell tobacco, he sees no problem: "Damage to health far outweighs any such considerations." Toni says his association has chosen the route of "gentle, persistent and consistent pressure". It will be interesting to see how much effect this will have, and how soon.-
Seat-belt exemptions: "Just say No", experts tell MDs Patrick Sullivan says. Dr. Ronald Ailsby, who represents the Saskatchewan Medical Association (SMA) on the provincial safety council, says there is neither rhyme nor reason to the large number of exemptions being granted by many of his less-thancautious colieagues. "It is becoming fairly ridicuand fealous", he told a recent meeting of
octors must exercise more caution and common sense when asked to provide medical exemptions that free their patients from wearing seat belts, a Saskatchewan physician D
Patrick Sullivan is CMAJ news tures editor. 622
CAN MED ASSOC J 1990; 142 (6)
the SMA's Representative Assembly, pointing to one case in which a seat belt was not being worn because of a 6-year-old hip fracture. Ailsby acknowledged that temporary exemptions may be warranted in "rare" cases, but said frivolous ones must be stopped. "Some doctors give them
