CVS Leads: Will Other Pharmacies Follow?

CVS Caremark stunned the business community on February 5, 2014 when it announced that as of October 1, 2014 it would no longer sell tobacco products in its 7600 pharmacies. In explaining its decision to forgo up to $2 billion in annual revenue, CVS highlighted the growing incompatibility between its emerging role as a site for health care delivery--with more than 600 “minute clinics” providing medical care plus dispensing a host of other health care products--and its health-worsening role as seller of cigarettes. After all, smoking remains the number one cause of death and disability in the United States, resulting in nearly 500,000 deaths annually and 16 million people with tobacco-related disabilities such as emphysema and heart disease. Over the long run, CVS reasoned, the lost tobacco sale revenues could be replaced by other products. Moreover, the good will generated by the ban might attract new customers, and by eliminating the sale of tobacco products in the same setting where diseases are diagnosed and treated, the company might reinforce a culture of improving health.

As a physician who has worked for decades at the intersection of clinical medicine and public health, I was elated by the CVS decision. (In fact, I co-authored an article in the Journal of the American Medical Association along with CVS Chief Medical Officer Troyen Brennan, MD, about the CVS decision, published first online Feb 5, 2014 and later in print.) Although the harm from smoking cigarettes is certainly well known, tobacco remains insinuated into many aspects of our culture, including drug stores. The pharmacists I know are embarrassed at having their profession sullied by association with tobacco sales. We share the hope that the CVS move is the first step in uncoupling cigarettes from pharmacies, rather than representing a lonely symbolic effort.

One way to assess the soundness of CVS’ business decision to forego revenue from tobacco sales is by tracking stock performance. On February 4, 2014, CVS stock closed at $66.11; at the end of August its stock price was $79.45, a 20 % increase. During that same period, the stock price for Walgreens rose from $55.95 to $60.52, an 8 % increase, and for Rite Aid it went from $5.34 to $6.22, a 16 % rise. Thus, at least in the short run, CVS does not seem to have suffered financially from its decision. One could even argue that it was helped.

Multiple organizations had already called for all pharmacies to ban tobacco sales, including the American Pharmacists Association, American Medical Association, American Heart Association, American Cancer Society, American Lung Association, and municipalities such as San Francisco and Boston. In the wake of the CVS decision those voices were amplified. Twenty-six state and territorial attorneys general and some members of Congress also called for similar bans in Walgreens and Rite Aid, as well as the national grocery chains Safeway and Krogers that feature pharmacies in many of their retail outlets.

Does it make any difference whether pharmacies sell cigarettes? After all, avid smokers can certainly purchase them in grocery stores, liquor stores, or Walmart--the largest seller of cigarettes nationwide. Recent studies have shown that 5% of patients with three conditions worsened by smoking--chronic obstructive pulmonary disease, hypertension, and usage of oral contraceptives by women over age 35 (who have a much higher risk of stroke if they smoke)--purchased cigarettes at the same time they refilled their medications. But perhaps they would not have done so if cigarettes were not readily available. Furthermore, a review of tobacco sales in San Francisco and Boston showed that cigarette purchases in those municipalities decreased after the tobacco sale ban in pharmacies. So, at least for some smokers, such bans may encourage them to either quit or cut back on smoking.

In the rapidly evolving world of health care delivery, pharmacies are emerging as important clinical sites. Almost 2000 retail health clinics are now operated by Walgreens, CVS Caremark, Rite Aid, Target, and many grocery stores, highlighting the conflict between improving health and selling tobacco products. To date, most independent pharmacies, which are a dwindling breed, do not sell tobacco products. Neither do the Wegman’s grocery chain or Target. And in virtually every other country, pharmacies sell a more limited set of products, and do not stock cigarettes.

To date, the two other large national pharmacy chains, Walgreens and Rite Aid, have resisted pleas to follow the example of CVS Caremark. CVS, on the other hand, has accelerated its date of going tobacco-free from October 1 to September 3. Furthermore, on that same date it will announce a corporate name change, from CVS Caremark to CVS Health, a change partly enabled by its decision to forgo tobacco sales. Will Walgreens and Rite Aid follow suit? Will large grocery chains with pharmacies and medical clinics persist in selling tobacco products? As we continue to learn more about the health ravages of using combustible tobacco, as rates of smoking decline, and as smoking becomes more and more a marginalized behavior, it will become increasingly difficult for those who purport to be in the health business to simultaneously sell one of the most deadly products. For me and my colleagues who are working to reduce the ravages of tobacco use, that time cannot come soon enough.