Thursday, April 03, 2014

Op-Ed: Health Groups Fail to Exert Influence for Tobacco-Free Pharmacies

I had a little fun with this year’s April Fools’ Day post, but there is a serious debate about the pharmacy industry’s role in tobacco sales.

Below is an guest editorial from two of the physicians behind TobaccofreeRx, a group that advocates against the sale of tobacco products in pharmacies. The authors criticize such groups as the American Heart Association and the Department of Health and Human Services.

They conclude: “Corporations that choose to sell tobacco products should no longer be granted licenses to dispense medications or provide other health care services.”

What do you think?

Health groups fail to exert influence for tobacco-free pharmacies
by Vinayak Jha, MD, and Alan Blum, MD

Over the past fifty years, a growing public awareness of the harms of tobacco use, along with workplace smoke-free laws and increased federal and state taxes on cigarettes, has resulted in a decline in the US adult cigarette smoking rate from over 40% in the 1960’s to 18.1% today.1 Still, tobacco use remains the leading preventable cause of death in the United States, responsible for 480,000 deaths annually.2

Tobacco sales in pharmacies have long represented a conflict of interest acknowledged even by the retail pharmacy chains. Recognizing the conflict, almost all independent pharmacists ended their sales long ago. In 2010, we formed TobaccoFreeRx, a national, multidisciplinary organization that took as its mission the end of tobacco sales in pharmacies.

Since CVS’ announcement on February 5, 2014, twenty-eight attorneys-general and health groups such as TobaccoFreeRx have called on the remaining corporate pharmacies to cease tobacco sales.3 What has hardly been mentioned is that the only reason these sales are still happening is because institutions that should have known better have sat idly on the sidelines. These institutions, which include advocacy organizations, insurance companies, governmental agencies, pharmaceutical companies, and the vast majority of medical, pharmacy, and public health schools, have been guilty of inaction in addressing this conflict of interest.

The American Heart Association (AHA) has been one of the most egregious employers of selective vision. One might expect that America’s most prominent heart health advocate would have refused on principle to partner with any tobacco retailer. Not true. In a 2012 letter signed by our entire Board of Advisors at TobaccoFreeRx, we wrote the AHA asking them to stop partnering with Walgreens and other major sellers of tobacco products.4 Nancy Brown, CEO of the AHA, replied and trumpeted their work in tobacco control, but wrote that the AHA has “… an obligation to engage those who can help us reach consumers with lifesaving health information and resources.”5 It is a shame that the AHA cannot pursue that engagement without accepting more than five million dollars in donations from Walgreens in 2012-13.6

A similar paradox is present in the Million Hearts® campaign, an initiative of the Department of Health and Human Services that has as its mission to prevent a million heart attacks and strokes. In 2012 a senior official of the Million Hearts® campaign responded to our criticism of including Walgreens as a principal partner in their initiative, and wrote that “I agree that this is not ideal.”7 The Million Hearts® Campaign continues to include Walgreens as a private sector partner in this endeavor, despite Walgreens’ selling tobacco products in thousands of drugstores nationwide.8

Third-party payers, including private insurance companies and Medicare, have also been not-so-innocent bystanders. Though insurers could have adopted a payment structure that differentially reimburses tobacco-selling pharmacies and tobacco-free pharmacies, none has taken this step. Kaiser Permanente in 2011 declined to support local legislation in DC that would have prevented establishments that operate pharmacies from selling tobacco products. Interestingly, Kaiser Permanente, the nation’s largest health maintenance organization, held investments in big tobacco corporations such as Philip Morris as recently as 1997.9

The situation exists in America wherein tobacco retailers actually receive reimbursements from private health insurers, as well as Medicare and Medicaid. No formal analysis has been published, but one can estimate the amount of governmental funding paid to tobacco retailers in any given year. For example, Medicare and Medicaid in 2012 were the payment source for 34% of all US retail drug expenditures.10 Total prescription drug revenues in 2013 were $287.0 billion. Of that total revenue, $137.4 billion was generated by six leading pharmacy chains: CVS retail pharmacies, Walgreen, Wal-Mart Stores, Rite Aid, Kroger, and Safeway, all of which were tobacco retailers in 2013.12 Overall, we estimate that in 2013 the Medicare and Medicaid programs were the source of over $43 billion in payments to tobacco retailers.

Corporations that choose to sell tobacco products should no longer be granted licenses to dispense medications or provide other health care services.


Dr. Vinayak Jha is Assistant Professor of Medicine at the George Washington University School of Medicine, and founder of TobaccoFreeRx. Dr. Alan Blum is Professor of Family Medicine at the University of Alabama School of Medicine –Tuscaloosa, and chairs the Board of Advisors of TobaccoFreeRx. TobaccoFreeRx is a national interdisciplinary group of pharmacists, pharmacy school and medical school faculty, pharmacy students, nurses, physicians, attorneys, and health advocates that was organized in 2010 to end the sale of tobacco products in pharmacies.


1. Centers for Disease Control and Prevention. Current Cigarette Smoking Among Adults—United States, 2005–2012. Morbidity and Mortality Weekly Report 2014;63(02):29–34.

2. US Department of Health and Human Services. The Health Consequences of Smoking: 50 Years of Progress – A Report of the Surgeon General. Atlanta, GA: US Dept of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014.

3. TobaccoFreeRx calls on Walgreens and Rite Aid to join with CVS in ending tobacco sales in pharmacies. Press release, March 5, 2014.

4. Letter from TobaccoFreeRx to the American Heart Association, May 30, 2012.

5. Letter from the American Heart Association to TobaccoFreeRx, June 11, 2012.

6. American Heart Association Annual Report 2012-2013

7. Personal email communication, August 12, 2012.

8., accessed March 24, 2014.

9. Personal email communication. October 10, 2011.

10. Marquis, Julie. Kaiser Getting Rid of Tobacco Investments. Los Angeles Times. June 26, 1997.

11. "Medicare Up, Everyone Else Down: The Latest U.S. Drug Spending Data," Drug Channels, January 7, 2014.

12. Largest US Pharmacies Ranked by Total Prescription Revenues, 2013 [Table]. From 2013-14 Economic Report on Retail, Mail, and Specialty Pharmacies, Drug Channels Institute, January 2014.


  1. Adam,

    Thanks for giving this important issue some airtime, and thanks to Dr's Jha and Blum for their efforts. Unfortunately it is exactly this type of public shaming of public corporations that will be necessary to reduce the smoking rate below 18%. Selling cigarettes ensures that people continue to be sick and therefore increases profits directly for pharmacy chains who continue to sell them. The brands of Walgreens, Wal-Mart, Rite-Aid, Kroger, Safeway and the many other pharmacies who continue to sell cigarettes are tarnished as a result. Let's all recognize that, and act on it. CVS deserves our praise--and our business--for taking a real stand for health in America.


  2. This issue has major implications: How does the need for profit -- and Compound Annual Growth Rates (CAGR) for publicly traded firms mesh with professional and ethical responsibilities. Many years ago one of my kids got a summer job at a local chain drug store. Being bright and aggressive, she was soon assigned to the liquor department cash resister. This was also where the store sold lottery tickets and adult magazines such as Playboy.

    She quickly observed that she had been given responsibility for the store's sin venue. To be sure, unlike tobacco all of these can be seen as pastimes having some social value and are not intrinsically harmful.

    But a profound issue for Pharmacy is our responsibility, as health care professionals, for the environments in which we practice. I'm no great fan of CVS, but they deserve kudos for taking the lead on this and kick-starting this debate.

    But the recent publicity about the eye-popping costs for Gilead's Sovaldi is also on all fours with this debate about ethics and CAGR. Mindful of Pharma's abysmal general conduct resulting in many of these firms needing federal oversight to assure corporate integrity ( Check the OIG's web site:, I suggest that our entire industry needs a wake-up call about ethics.

  3. This is dangerous ground we're treading and a fruitless battle. So if I can't buy my tobacco at the drug store, let's see... I'll just drive to the nearest gas station, grocery store, big box, convenience store, or any number of other outlets that carry tobacco. Next, we can target alcohol sales. Then, we'll conquer that horrible substance called sugar and ban all candy sales. An while we're at it, let's go ahead and ban all products containing gluten. As a matter of fact, grocery stores sell many things that contribute to our poor health. Let's ban them too! If you like this sort of mentality, move to New York and let the Nanny State make all of your decisions for you. PATHETIC!!! Put your big-boy pants on and make responsible decisions for yourself and let others do the same.

  4. But those other places aren't "healthcare" providers

  5. My point is two-fold... 1) Discontinuing the sales of tobacco products at "healthcare" providers is not going to impact the # of smokers because the product is readily available in the market place. Actually, this could create a more significant problem of driving more smokers to purchase their tobacco products at gas stations, which in itself is a volatile mixture. 2) What will stop the next group of Nanny State activists to release a statement like "Corporations that choose to sell Twinkies, sugary snacks, sugary beverages (including apple juice), and potato chips should no longer be granted licenses to dispense medications or provide other health care services"? All of a sudden you have quite the conundrum. Now, all of those grocery stores and big boxes that have pharmacies in-house will either have to 1) leave the pharmacy business or 2) turn into Trader Joe equivalents. The reason Wal-Mart sells generics at $4 is because they can sell billions of dollars of high-margin Twinkies, sugary snacks, sugary beverages, and potato chips to all of those cost conscious shoppers who drive 30 miles and wait for hours for their $4 prescriptions. How much government funding do you think Wal-Mart receives not only on the pharmacy side but through the Supplemental Nutrition Assistance Program (aka, food stamps)? The battle being waged here is a righteous one indeed, but the battle plan proposed by these two individuals is simply foolish.

  6. Alcohol is next. It is a drug. Nicotine is a drug. So far society has not named sugar as a drug. By the way - a pharmacy's business is selling drugs. Ah, the conundrums that we must face.