In the wake of the 50th US Surgeon General’s report on smoking and health, published last week, and in the spirit of Lewis Carroll, whose birthday it was this week, I thought I’d tell you a tobacco tale so absurd and fantastical it can’t possibly be true. Except it is.
Before I lived there, I had always believed the US to be ultra progressive when it came to tobacco control. News snippets would periodically make their way over the Atlantic into my impressionable mind, covering such things as former New York Mayor Bloomberg’s anti tobacco policies: in 2002, Bloomberg banned smoking in New York City’s bars and restaurants. In 2011, he banned it in outdoor areas such as parks and beaches. And just in November, the sale of tobacco to anyone under 21 was made illegal. All this made the US seem like a model for anti tobacco policy. Little did I realise, however, that the big cities might be the exception, rather than the rule.
No other product, when used as intended, kills 50 per cent of its consumers. So when I moved to Massachusetts in 2012, I was shocked to discover that one particular group of retailers was still permitted, legally, to sell tobacco: pharmacies. Yes, pharmacies. In 2009, the city of Boston banned the sale of tobacco products in any retail location containing a pharmacy, but only 30% of Massachusetts’s municipalities followed suit. In those areas without a ban, you will see—as I did—certain pharmacies housing florid displays of cigarettes, cigars, flavoured and smokeless tobacco, all heavily marketed and frequently adjacent to nicotine gum and other smoking cessation products.
Curiously, then, Massachusetts finds itself in a situation where a healthcare organisation in its jurisdiction can sell the treatment and the cause of addiction and disease.
The public image of a pharmacy is inextricably linked with health, which distinguishes it from other retailers. Pharmacies are expanding their healthcare role to include the management of diseases caused or worsened by smoking, like COPD. Additionally, their customers include those who would be likely to suffer disproportionately from the effects of tobacco, like children and pregnant women. If, in this context, their selling tobacco is ethical, without a hint of hypocrisy, then perhaps hospitals and doctors’ offices, too, should do it?
In actual fact, several hospitals in MA have adopted very strict anti tobacco policies, such as not hiring smokers, in addition to having smoke free campuses. It all seems, to my (admittedly naïve) eyes, a curious, conflicting melting pot of positions, in which the sale of tobacco in pharmacies has been strikingly overlooked.
Pharmacy chains may argue that profits from tobacco sales allow them not only to keep afloat, but also to provide services that would otherwise be unaffordable. However, the evidence has not substantiated these concerns. In San Francisco, the first US city to introduce the ban, there has been “little or no impact” on pharmacy revenues.  Surveys suggest that pharmacists themselves are also overwhelmingly in favour of a ban. [2,3]
The economic arguments may be easier to counter than more deeply rooted, popular concerns about top down approaches, particularly those that appear to curtail individual freedoms. If you look at minutes of meetings, read the local press and legal cases, talk to local people, both pro- and anti-tobacco, it’s clear that, to many, “big government nanny state” is not welcome. And the constitution is inviolable. Or so it seems. For example, the right claimed by tobacco companies to advertise under the First Amendment (freedom of speech) means that public health campaigners trying to introduce and implement even state-wide—never mind federal—legislation face a Sisyphean task.
It’s certainly complex. But surely common sense, if nothing else, highlights the lunacy of allowing a substance known to cause death and disability to be sold in organisations that purport to promote good health? Boston and other cities have banned the sale of tobacco in pharmacies; it is time for the State of Massachusetts to follow suit.
Perhaps that ultimate victim of absurdity, Alice herself, would capture the sentiment better: “it would be so nice if something made sense for a change.”
1. Center for Public Health and Tobacco Policy. Ways & Means Common Concerns : Prohibiting the Sale of Tobacco Products at Pharmacies. Boston; 2013.
2. Hudmon KS, Fenlon CM, Corelli RL, Prokhorov A V, Schroeder SA. Tobacco sales in pharmacies: time to quit. Tobacco control. 2006;15(1):35–8.
3. Smith DM, Hyland AJ, Rivard C, Bednarczyk EM, Brody PM, Marshall JR. Tobacco sales in pharmacies: a survey of attitudes, knowledge and beliefs of pharmacists employed in student experiential and other worksites in Western New York. BMC research notes. 2012;5:413.
Suchita Shah is a family doctor in Oxford, UK, with a background in public health and international relations. She recently spent time living in Boston and was a student at the Harvard School of Public Health, Boston.