Should stores selling tobacco be allowed to provide publicly funded health services?


Dr Andrew Furber

Follow Dr Furber on Twitter at @FurberA

Imagine a patient with a health problem accessing a publicly-funded health service where the substance causing the problem was on sale within the same premises. You would probably think this was completely unethical. But this is exactly what happens in hundreds of supermarkets in the United Kingdom every day.

The provision of accessible health services, including where people shop, is a good thing. However as National Health Service (NHS) England has recently made clear in their Five Year Forward View, health services must be as focused on the prevention of illness as they are on its cure.

Tobacco remains the leading cause of preventable mortality and morbidity and causes 80,000 deaths in England every year. Although smoking prevalence is declining in the United Kingdom, recently falling below 20% for adults in England, tobacco will kill half of its regular users. Around one in ten of the current UK population will die from smoking. Smoking is strongly correlated with socioeconomic deprivation and is the main behavioural determinant of health inequalities.

So why is such a toxic substance to be sold from supermarkets which provide NHS services when it has such a devastating effect on the health of individuals, families and the nation?

Recently the CVS chain of pharmacies in the United States decided to stop selling tobacco . The company felt these sales were incompatible with its aim of being recognised for its role in healthcare.

So why do UK supermarkets continue to sell tobacco? The answer is probably to act as a lead product which brings customers in, who then purchase other items. Tobacco sales are likely to have a small margin for the retailer. Most of the cost of a packet of cigarettes goes on tax or to the tobacco company. The risk for any supermarket that unilaterally decided to stop selling tobacco would be the possibility of losing nearly one in five of its customers to its competitors. However if none of the major supermarkets sold tobacco it is unlikely that any of them will lose custom. People will still shop at supermarkets as they do now.

Supermarkets might argue that this is a slippery slope. If tobacco sales are not permitted what would be next? Alcohol? Foods with high fat, sugar or salt content? Well, no. Tobacco is uniquely dangerous. There is no safe level of tobacco consumption, whereas alcohol, fat, sugar and salt can all be consumed in moderation without any harm to health.

Is there a plan B if supermarkets indicate they would rather sell tobacco than provide NHS services? Possibly: a compromise could be to require supermarkets providing NHS services to provide information and advice at the point of tobacco sale on smoking cessation services. They could also supply tobacco sales data (which should apply to all tobacco retailers through a system of licensing) to assist authoroities with local tobacco control efforts.

Another alternative is a supplementary charge on business rates paid by large stores selling tobacco. This has been tried in Scotland in the Government Health Levy, and applies to outlets with a rateable value of more than £300,000 selling alcohol or tobacco.

If health services are to get serious about the prevention of ill health then they can have no association with its main behavioural cause – tobacco. It’s time for NHS contracts to reflect this.

Dr Furber is the Director of Public Health for Wakefield Council, UK. The opinions expressed in this article are the author’s personal views and do not necessarily represent the views of his employer or other associated institutions.

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