PRESCRIPTION FOR A HEALTHY ITY - NYC Smoke …nycsmokefree.org/sites/default/files/wysiwyg/docs/Citywide/aafe_rx... · Prescription for a Healthy City: Making NYC Pharmacies Tobacco

PRESCRIPTION FOR A HEALTHY CITY MAKING NEW YORK CITY PHARMACIES TOBACCO FREE

Published by Asian Americans for Equality, Inc. in partnership with the NYC Coalition for a Smoke-Free City

TABLE OF CONTENTS

I. Executive Summary 1

II. Tobacco and Health Equity in the Asian American Community 3 III. Tobacco Control Efforts in New York City 4

IV. A Focus on the Point of Sale in Pharmacies 6

V. Methodology 7

VI. Neighborhood Backgrounds 9

VII. Findings 11 VIII. Recommendations 16 IX. Conclusion 17

Appendices: Appendix A: Survey Instrument 18 Appendix B: Identified Pharmacies and Tobacco Retailers 21 ACKNOWLEDGEMENTS This report was authored by Michael Schmeltz, Matthew Ryder, and Douglas Nam Le. We would like to thank the following individuals for their time and support on research conducted for this report: Devlin Chen, Abigail Deatley, Jian Hui Huang, Tiffany Kan, Sammi Lin, Min Chao Liu, Theo Oshiro, Cindy Wen, Ling Juan Wu, Julia Yu, Jian Qiang Zeng, Liu Zhen, and Susan Zhao. We also thank Shannon Farley, Sheelah Feinberg, Dan Ferris and the members of the NYC Coalition for a Smoke-Free City for their leadership and contributions to this important issue.

This publication was made possible in part by funding from the U.S. Department of Health and Human Services and the New York State Department of Health. For more information about this and other Asian Americans for Equality publications, please contact Douglas Nam Le at [email protected]. Photography Credit: Matthew Ryder © Asian Americans for Equality, 2012

Prescription for a Healthy City: Making NYC Pharmacies Tobacco Free 1

I. Executive Summary Over the past decade, New York City has made significant strides in reducing smoking rates through price increases on tobacco products, public health policy including the 2002 Smoke- Free Air Act, hard hitting educational media, and increased access to smoking cessation services and products. However, progress is impeded by the $1 million spent every day in New York State by tobacco companies marketing their deadly products.1 With recent federal and legal restrictions on how cigarettes are promoted, tobacco companies now spend the vast majority of their marketing budget on advertising, promotions, and product placement at the point-of-sale. The marketplace for tobacco is also changing. While the number of cigarettes sold nationwide has declined 17.43% between 2005 and 2009, national cigarette sales in pharmacies have actually increased by 22.72% during the same time period.2 In the summer of 2011, Asian Americans for Equality conducted an observational study of the prevalence of cigarettes and tobacco advertising in pharmacies, both chain and independent, in three neighborhoods: Chinatown in Manhattan (10002, 10012, 10013), Flushing in Queens (11354, 11355), and Sunset Park in Brooklyn (11220). The areas sampled within this study serve as socially and economically significant hubs for the Asian American community across New York City. These neighborhoods also represent a rich mix of residential and commercial uses that provided for a concentration of tobacco retailers to be sampled. Key Findings

1) Many independent pharmacies are choosing to stop selling tobacco. Of the 45 pharmacies licensed to sell tobacco that were surveyed, 19 no longer sold

tobacco products 64% of all independent pharmacies licensed to sell tobacco products no longer do,

compared to 94% of all chain pharmacies that continue to sell tobacco products. These findings may indicate that discontinuing the sale of tobacco products does not

affect the financial viability of these businesses

2) Strategic placement of tobacco products perpetuates tobacco use 71% of pharmacies surveyed placed their tobacco products close to candy, gum, and

other items that kids usually purchase 42% of pharmacies surveyed placed tobacco products near smoking cessation items

3) Interior advertising and promotions for tobacco products remains a problem

92% of all pharmacies that sold tobacco had some type of interior advertising Tobacco promotions such as coupons, mail-in-rebates and multi-carton discounts

were seen in 69% of chain pharmacies compared to 37% in independent pharmacies

1 Campaign for Tobacco Free Kids. “Estimated Tobacco Industry Marketing in NYS.” 2 Seidenberg AB, Behm I, Rees VW, et al. “Cigarette Sales in Pharmacies in the USA (2005 – 2009). Tobacco Control, 2011


4) The “Power Wall” is a pervasive marketing tool for tobacco products sold in pharmacies. Power walls are large displays of cigarettes found behind cash registers at

convenience stores, pharmacies and other tobacco retailers A power wall was present in 79% of all pharmacies that were surveyed 88% of chain pharmacies had the presence of a power wall 17% of all pharmacies had overhead shelving for tobacco products, a marketing

tactic that positions tobacco products and advertising at eye-level for all purchases Since 1970, The American Pharmaceutical Association has held the position that the display of cigarettes in pharmacies is in direct opposition to the role of a pharmacy as a health care facility. More recently, San Francisco and Boston have passed ordinances making their pharmacies tobacco-free. A 2009 report from the American Heart Association highlights that, based on empirical evidence, reducing tobacco product access and visibility may reduce the rate at which non-smokers experiment and become addicted to smoking.3 New York has always been at the forefront of tobacco control efforts. Supporting tobacco-free pharmacies in New York is critical to denormalizing smoking, reducing access to tobacco products and improving the health of all New Yorkers. Recommendation I: Make New York Pharmacies Tobacco-Free Generally, pharmacies are places that help individuals become healthier and promote wellness. Many independent pharmacies, often owned by practicing pharmacists, are choosing not to sell tobacco products. However, the largest chain pharmacies have not followed suit. Therefore, a universal tobacco-free pharmacy policy is necessary to improve community health in New York. Recommendation II: Prevent Aggressive Tobacco Industry Marketing Tactics A major incentive for retailers to sell tobacco products is the promotional funding provided by tobacco companies and not the sale of tobacco products themselves. There is a need for community education with the small business community about preventing aggressive tobacco marketing tactics, particularly when it encourages smoking among youth.

3 American Heart Association. “Eliminating the Sale of Tobacco Products in Pharmacies.” June 4, 2009. Available at: http://www.heart.org/idc/groups /heart-public/@wcm/@adv/documents/downloadable/ Ucm_304805.pdf


II. Tobacco and Health Equity in the Asian American Community Since its founding in 1974, Asian Americans for Equality (AAFE) has pursued its mission of advancing the rights of Asian Americans and all those in need through advocacy, community service, asset-building, and neighborhood development. AAFE has led campaigns to promote a broad array of issues that impact Asian American communities, immigrants, communities of color, and low and moderate-income families in New York City: equal employment; affordable housing; fair housing; transportation equity; local economic development; community lending; civic participation; healthcare access; immigrant rights; and educational access. AAFE recognizes that tobacco use contributes to significant health disparities in Asian American communities, leading to premature mortality from lung and bronchial cancers, cardiovascular disease and diabetes. It affects not only the health of individuals who use tobacco but impacts the health and economics of their family and community members as well. Tobacco control is also a major social justice issue for our communities. The global tobacco industry has a complex history of aggressive marketing in Asia, as well as within the Asian Diasporas in the United States. This marketing to promote the use of and addiction to tobacco has especially impacted urban, low-income communities in the United States, Asian Americans and other communities of color, and youth. Disaggregated data on the rate of Asian American adult smokers is sparse, however some studies have reported a rate of 13.8% in California4 and 11% in New York.5 Rates of smoking among different Asian ethnic groups also vary widely. An analysis of state-wide data of adult smokers in California disaggregated by ethnic group found smoking rates as high as 20.8% for Koreans and 16.8% for Filipinos; and as low as 8.8% for South Asians and 9.7% for Chinese. 6 In health needs assessments of Asian American communities in New York City conducted using community-driven sampling, adult smoking rates varied from 32% for Koreans and 23% for Cambodians, to as low as 13% for South Asians.7 Since 2006, AAFE has been a member of the NYC Coalition for a Smoke-Free City, a health advocacy group that works to increase public and policy maker awareness of tobacco control issues. The Coalition partners with community groups, elected officials, and health advocates to support neighborhood-based efforts for effective and long term change throughout NYC. As a partner of the Coalition, AAFE has provided culturally competent and linguistically accessible smoking prevention education and smoking cessation to Asian American communities and has led grassroots advocacy campaigns to build support for key initiatives such as smoke-free outdoor air and smoke-free housing.

4 Tang H., Shimizu R., Chen M. English Language Proficiency and Smoking Prevalence among California's Asian Americans. Cancer. 2005 December 15; 104 (12 Suppl): 2982–2988. 5 NYC Department of Health and Mental Hygiene. 2009 Community Health Survey. 6 Tang H., Shimizu R., Chen M. English Language Proficiency and Smoking Prevalence among California's Asian Americans. Cancer. 2005 December 15; 104 (12 Suppl): 2982–2988. 7 New York University Center for the Study of Asian American Health. Community Health Needs and Resources Assessments: Exploratory Studies of Asian Americans in New York City. 2007.


III. Tobacco Control Efforts in New York City Recent efforts to reduce and prevent tobacco use in New York began in the early 1990’s when the National Cancer Institute (NCI) initiated the American Stop Smoking Intervention Study (ASSIST).8 Throughout the 1990’s, the rate of current smokers in New York City remained steady near 21.5% of adults. From 2002 – 2012, however, New York City and New York State have made significant strides in reducing smoking rates through tax policy, air quality legislation, aggressive health communications and public information, limiting the sale of tobacco products, and facilitating access to smoking cessation products. New York State increased taxes on cigarettes in 2002, 2008 and 2010. Additionally, tax increases were implemented by New York City in 2002 and the federal government in 2009. New York City has led the tobacco control effort on several fronts, including the passage of legislation making all workplaces including bars and restaurants smoke-free in 2002, as well as parks, beaches and pedestrian plazas in 2010. The New York City Department of Health and Mental Hygiene (NYC DOHMH) has also provided access to no-cost smoking cessation products since 2004, and began “hard-hitting” media campaigns that encourage smokers to quit and prevent new smokers from ever starting. According to the NYC DOHMH, by 2010 the citywide adult smoking rate had fallen to 14.0%.9

Source: NYC Department of Health and Mental Hygiene, Community Health Survey 8 New York State Department of Health. First Annual Independent Evaluation of New York’s Tobacco Control Program. RTI International, 2004. Available at: http://www.health.ny.gov/nysdoh/tobacco/reports/docs/nytcp_eval_report_final_11-19-04.pdf 9 New York City Department of Health and Mental Hygiene. “New York City Community Health Survey 2010.”

0%

5%

10%

15%

20%

25%

30%

2002 2003 2004 2005 2006 2007 2008 2009 2010

Rate of Current Smokers, 2002-2010

All New Yorkers

Asian New Yorkers


The rate of smoking varies significantly across neighborhoods of New York City, and among New Yorkers. The most reliable measure of smoking trends is the NYC DOHMH annual Community Health Survey. Generally, the rate of smoking has been found to be lower among Asian New Yorkers and foreign-born New Yorkers when compared to the city-wide average. However when rates of smoking have been studied and disaggregated by specific race and ethnic groups, numerous studies have found variance in Asian adult smoking rates.

Source: NYC Department of Health and Mental Hygiene, Community Health Survey

0%

5%

10%

15%

20%

25%

30%

2002 2003 2004 2005 2006 2007 2008 2009 2010

Rate of Current Smokers by Borough, 2002-2010

Bronx

Brooklyn

Manhattan

Queens

Staten Island


IV. A Focus on the Point of Sale in Pharmacies The tobacco control strategies that have made a significant impact on smoking have focused on financial disincentives through taxation, consumer behavior, limiting opportunities to smoke through air quality legislation, and public information. However, tobacco companies spend $1 million every day in New York State marketing their deadly products. Since there are some restrictions on how cigarettes are promoted, the vast majority of this is spent on advertising, promotions, and product placement at the point-of-sale at or behind the cash register. The marketplace for cigarettes is also changing. While the number of cigarettes sold nationwide has continued to decline 17.43% between 2005 and 2009, cigarette sales in pharmacies have increased by 22.72%. Additionally, it is projected that 15% of all cigarette purchases will occur in licensed pharmacies by 2020.10 A contributing factor to this trend may be the increased number of national chain pharmacies and the decreased number of individually owned and operated independent pharmacies. However current market research suggests that revenue generated from tobacco products still account for less than 1% of pharmacy retailers’ total sales.11 Since 1970, The American Pharmaceutical Association has held the position that the display of cigarettes in pharmacies is in direct opposition to the role of a pharmacy as a health care facility. More recently, San Francisco and Boston have made their pharmacies tobacco-free. A 2009 report from the American Heart Association indicates that empirical research confirms that reducing the access and visibility of smoking may reduce the rate at which non-smokers experiment and become addicted to smoking.12 After Ontario made its pharmacies tobacco-free long before Boston or San Francisco, a 1994 study showed no detrimental financial effects on businesses. In fact, there was actually an increase in the number of pharmacies opening from the previous year, suggesting that the loss of revenue from tobacco products did not impact financial investments.13 New York has long been at the forefront of tobacco control efforts. Supporting tobacco-free pharmacies is a key component of denormalizing the use of a deadly product, reducing access to cigarettes and youth exposure to tobacco advertising, and improving the health of New Yorkers.

10 Seidenberg AB, Behm I, Rees VW, et al. Cigarette Sales in Pharmacies in the USA (2005-2009). Tobacco Control, 2011. 11 McDonald M, Cuesta L, Loebsack, Sans G. Removing Tobacco from the Product-Mix: Evaluating Opportunities for Pharmacy Retailers, 2011. 12 American Heart Association. Eliminating the Sale of Tobacco Products in Pharmacies, June 4, 2009. Available at: http://www.heart.org/idc/groups/heart-public/@wcm/@adv/documents/downloadable/ucm_304805.pdf 13 Taylor MC. Banning Cigarette Sales in Pharmacies Does Not Result in Pharmacy Closure. Physicians for a Smoke-Free Canada,1997. Available at: http://www.smoke-free.ca/pdf_1/pharmacy.pdf


V. Methodology

Selection of neighborhoods and stores Asian Americans for Equality (AAFE) has strong ties to the Asian community in New York City, and decided to focus this study on neighborhoods with significant Asian populations: Chinatown (Manhattan), Sunset Park (Brooklyn) and Flushing (Queens). The neighborhoods were further identified by zip code (10002, 10012, 10013, 11220, 11354, 11355). Geocoded locations of tobacco retailers were obtained from the NYC Coalition for a Smoke-Free City and geocoded pharmacy retailers were obtained from the New York State Department of Education, Division of Professional Licensing. There were approximately 180 pharmacies and over 500 tobacco retailers located in these neighborhoods. Using ArcGIS, pharmacy locations that were also tobacco retailers were identified and mapped. A total of 57 pharmacies that are licensed to sell tobacco were identified for all neighborhoods combined (Appendix A). Of the stores identified, only 88% of identified retailers were sampled. These stores were clustered in major commercial corridors while those that were outside these commercial areas were excluded. This brought the total to 45 locations surveyed. Development of survey instrument A data collection instrument was developed to capture detailed information on the type and placement of tobacco advertisements and products as well as placement of cessation products and warning signs. The data collection instrument included items pertaining to exterior and interior tobacco advertisements, power walls, countertop displays, and information on promotions as well as presence of ‘age of sale’ and ‘we card’ signage (Appendix B). Retailers were either identified as a chain pharmacy (e.g. Duane Reade) or an independent pharmacy. The National Community Pharmacist Association and other nationally recognized organizations define a chain pharmacy as any pharmacy that is publically traded and an independent pharmacy as a pharmacy that is privately owned. Additional information was collected concerning the placement of tobacco products within eye level of children and within sight of confectionary products. In developing the survey instrument, previous research and existing data collection instruments were consulted (NYS retail advertising tobacco study). Data Collection and Analysis Data collectors received two days of training during which they learned about the history of tobacco advertising and tobacco legislation. Data collectors also familiarized themselves with the survey instrument, reviewed the checklists, and practiced filling out the survey before heading out into the field. During three days in August 2011 data collectors were divided into groups of two or more including a supervisor (AAFE staff member) and traveled to selected retail locations (Appendix C). Upon reaching a retail location, data collectors scanned the exterior of the store for any identifiable tobacco advertisements. They then entered the store and continued to scan the environment for items on the survey instrument. Data collectors did not identify themselves and, as not to disrupt normal store operations, surveys were completed outside of each location. If needed, data collectors re-entered stores to collect additional information. Ethics approval was obtained by the CUNY Graduate Center. All data analyses were conducted in SPSS version 20. Statistical analysis included frequency distribution and crosstabs.


Limitations & Notes It should be noted that the study only included licensed tobacco retailers, so the total number of independent pharmacies that do not sell tobacco products is much higher. The small sample size, as well as being an observational study, may limit a broader interpretation of these results. Also, while the study did not include pharmacies in other ethnic communities, the findings were consistent with other research and statistics that show most tobacco sales by licensed pharmacies occur at retail chain locations. Further research can be focused on more qualitative analyses of why smaller independent pharmacies are no longer selling tobacco products. A more detailed analysis, including interviews with store managers and a review of contractual obligations of how tobacco products are displayed and advertised in chain pharmacies will provide more insight how tobacco advertisement works in chain pharmacies.


VI. Neighborhood Backgrounds Asian Americans for Equality selected Chinatown in Manhattan (10002, 10012, 10013), Flushing in Queens (11354, 11355), and Sunset Park in Brooklyn (11220) for the purposes of this study because of our long history working in these neighborhoods and local expertise. The areas sampled within this study serve as socially and economically significant hubs for the Asian American community across New York City. These neighborhoods also represent a rich mix of residential and commercial uses that provided for a concentration of tobacco retailers to be sampled. The figures that follow identify these neighborhoods, and their demographic and economic characteristics.


Chinatown, Manhattan Zip Codes 10002, 10012, 10013 Total Population 113,200 Race Groups White 44.4% Black or African American 6.4% Asian 39.0% American Indian or Alaska Native 0.3% Native Hawaiian or Pacific Islander 0.0% Some Other Race 6.8% Two or More Races 3.2% Latino or Hispanic Ethnicity 18.0% Number of Housing Units 62,634 Number of Business Establishments 10,672 Sunset Park, Brooklyn Zip Codes 11220 Total Population 99,598 Race Groups White 30.6% Black or African American 3.0% Asian 41.0% American Indian or Alaska Native 1.0% Native Hawaiian or Pacific Islander 0.0% Some Other Race 20.2% Two or More Races 3.6% Latino or Hispanic Ethnicity 40.8% Number of Housing Units 31,045 Number of Business Establishments 2,073 Flushing, Queens Zip Codes 11354, 11355 Total Population 140,749 Race Groups White 21.0% Black or African American 3.5% Asian 66.0% American Indian or Alaska Native 0.3% Native Hawaiian or Pacific Islander 0.1% Some Other Race 6.0% Two or More Races 3.0% Latino or Hispanic Ethnicity 15.5% Number of Housing Units 52,882 Number of Business Establishments 4,428

Sources: U.S. Census Bureau, 2010 Census and 2009 County Business Patterns Survey.


VII. Findings Of the 45 pharmacies licensed to sell tobacco products that were visited, 19 no longer sold tobacco products and two were permanently or temporarily closed. Twenty-four complete observations included 16 chain pharmacies and eight independent pharmacies. Sixty-four percent of all independent pharmacies visited no longer sold tobacco products even though they are licensed, compared to 94% of all chain pharmacies visited which continue to sell tobacco products (Table 1). This may be indicative of a trend to phase out selling tobacco products in smaller independent pharmacies from either personal preferences of the pharmacist/owner or because there may be a lack of financial incentive.


Table 1: Number of Pharmacies Licensed as Tobacco Retailers

Sales Discontinued Sales Closed Total

Chain Pharmacies 16 (94%) 1 (6%) - 17 Independent Pharmacies 8 (29%) 18 (64%) 2 (7%) 28 All Pharmacies 24 (53%) 19 (42%) 2 (5%) 45

Exterior store advertising was limited for all locations. Only three stores (one chain and two independent pharmacies) had exterior tobacco advertising, in the form of a small poster/sticker facing the outside of the store. There were no other displays such as illuminated signs or large window posters. 67% percent of all pharmacies did have a ‘We Card’ sign on their outside door and one store had an ‘age of sale’ sign displayed outside (Table 2).

Table 2: Exterior Advertising

Small Display

Large Display

Illuminated Sign

We Card Sign

Age of Sale Sign

Chain Pharmacies (n=16) 1 (6%) - - 12 (75%) 1 (6%) Independent Pharmacies (n=8) 2 (25%) - - 4 (50%) - All Pharmacies (n=24) 3 (13%) - - 16 (67%) 1 (4%)

The interior of the pharmacies were where most of the tobacco advertisements were placed though most of this was concentrated at or behind the cashier. Only three locations (one chain and two independent pharmacies) had advertising in other parts of the store. In addition, only one store had an illuminated display while most advertisements were small to medium sized


displays at or behind the register. Power walls, large displays of cigarettes found behind cash registers at convenience stores, pharmacies and other tobacco retailers, are important cigarette promotional vehicles. In pharmacies that were surveyed, a power wall was present in 79% of stores while 17% had overhead shelving for tobacco products and one other had tobacco products displayed or stored by different methods (Table 3).


Table 3: Interior Advertising and Tobacco Product Point-of-Sale

Small Display

Large Display

Illuminated Sign Powerwall Overhead

Shelving Chain Pharmacies (n=16) 15 (94%) - 1 (6%) 14 (88%) 2 (13%) Independent Pharmacies (n=8) 7 (87%) - - 5 (62%) 2 (25%) All Pharmacies (n=24) 22 (92%) - 1 (4%) 19 (79%) 4 (17%)

Eighty-eight percent of chain pharmacies had a power wall displayed. This set-up of a power wall and concentrated advertisements behind the cashier was apparent in the majority of chain pharmacies. The displays are set up similarly in each chain pharmacy so that no matter what the purchase is, tobacco products will be viewed by each patron. In addition, most chain pharmacies have confectionary items displayed within sight of tobacco products as well as cessation products right next to tobacco products. Along with advertisement, the use of tobacco promotions, such as coupons, prizes, mail-in-rebates and multi-carton discounts was seen in 69% of chain pharmacies compared to 37% in independent pharmacies (Table 4). A majority of both chain and independent pharmacies did have postings of anti-tobacco warning and age of sale signs (Table 5).

Table 4: Tobacco Product Placement

Tobacco Products near Confectionary

Tobacco Products near Cessation

Products Tobacco

Promotions Present

Chain Pharmacies (n=16) 12 (75%) 7 (44%) 11 (69%) Independent Pharmacies (n=8) 5 (62%) 3 (37%) 3 (37%) All Pharmacies (n=24) 17 (71%) 10 (42%) 14 (58%)


Table 5: Required Signage and Health Messages

DOHMH Health Warning Poster

We Card Sign

Age of Sale Sign

Chain Pharmacies (n=16) 3 (19%) 13 (81%) 8 (50%) Independent Pharmacies (n=8) 3 (37%) 6 (75%) 8 (100%) All Pharmacies (n=24) 6 (25%) 19 (79%) 16 (67%)

Though advertising is limited, the tobacco product advertisement placement is increasingly strategic in chain pharmacies. Being located near confectionary items and cessation products and usually right behind the cashier allows for tobacco product advertisements to be viewed by adults and children alike. Studies show that smokers and youth are much more likely to notice and recall tobacco advertising than non-smoking adults. Action is needed as studies have found that 90% of adult smokers begin smoking before the age of 18.14

14 US Department of Health and Human Services. “Youth and Tobacco: Preventing Tobacco Use among Young People” A Report of the Surgeon General.” 1995.


VIII. Recommendations Recommendation 1: Make New York Pharmacies Tobacco-Free Generally, pharmacies are perceived as places that promote wellness and help individuals become healthier. The fact that pharmacies sell tobacco, the number one cause of preventable death and disease responsible for over 400,000 deaths each year in the United States, conveys an inconsistent message about health. Independent pharmacies, often owned by practicing pharmacists, are choosing not to sell tobacco products even if they are licensed to do so. However, the largest chain pharmacies have not followed suit. Since chain pharmacies operate under a corporate structure, the focus may be more on business and not health, and franchise owners have less choice in which products to sell. Successful policies in major cities such as San Francisco and Boston have made pharmacies tobacco-free and have withstood legal challenges from the tobacco industry. Economically, tobacco products account for less than 1% of total sales and much of the financial incentive from the sale of tobacco products comes from the promotional funding from tobacco manufacturers that contribute to youth smoking initiation and an ongoing epidemic of tobacco-related death and disease. Tobacco-free pharmacies will also remove the ethical dilemma faced by pharmacists as health care professionals and solidify the image of pharmacies as promoting good health.

Recommendation 2: Prevent Aggressive Tobacco Industry Marketing Tactics A major enticement for retailers to sell tobacco products may not come from actual sales but the promotional funding provided by tobacco manufacturers for in-store point-of-sale advertising. Tobacco advertising at pharmacies and other retailers where youth often shop contributes to increased youth smoking rates, and controlling how and where tobacco advertisements are placed on the exterior and interior of retail locations can have a significant impact on the introduction of tobacco products for non-smokers. Furthermore, a 2006 study found that reductions in tobacco retail density may reduce youth smoking rates.15 This research indicates that not only a reduction in tobacco retail density, but also a reduction of tobacco advertisements and promotions are needed. There is also a need for greater outreach and education with the small business community to prevent aggressive tobacco marketing tactics as it encourages smoking among young people.

15 Novak SP, Reardon SF, Raudenbush SW, Buka SL. Retail Tobacco Outlet Density and Youth Cigarette Smoking: A Propensity-Modeling Approach. American Journal of Public Health 2006:96;670-676.


IX. Conclusion In summary, it was observed that most independent pharmacies that were licensed as tobacco retailers no longer sell tobacco products. The reasoning for this was not explicitly known. Based on these observations we can assume that independent pharmacies discontinued sales of tobacco products in order to avoid the ethical conflict of selling products that are harmful to health while serving as a health care resource for the community. The widespread practice of discontinued sales among the independent pharmacies sampled in this study may indicate that discontinuing sales of tobacco products was not detrimental to the financial viability of these businesses. Additional research, including interviews with business owners is needed to better understand why some independent pharmacies are no longer selling tobacco products and why chain pharmacies continue to sell products that account for the primary known risk factor for death in the United States. Also, other harmful products are already regulated. Decades of aggressive tobacco marketing and the normalization of smoking makes the average adult non-smoker less surprised to see cigarettes behind the cash register at a pharmacy as opposed to liquor. But smoking, not alcohol, is the number one cause of death and disease in the United States.

Flushing, Queens


Appendix A: Survey Instrument

ASIAN AMERICANS FOR EQUALITY OBSERVATIONAL SURVEY OF PHARMACIES LICENSED TO SELL TOBACCO

1) Surveyors Initials: ___________________________________________ 2) Store Identification: i. Store Location (List of stores in commercial district from geocoding – surveyor will circle one)

ii. Type of Store

⧠ Chain pharmacy ⧠ Independent pharmacy ⧠ Wellness store

3) Store Comments: ⧠ Disallowed from conducting survey ⧠ Permanently/temporarily closed ⧠ Does not sell tobacco products ⧠ Other _____________________________________ Store Exterior 1) Presence of “age of sale” sign – “Sale of cigarettes, cigars,

chewing tobacco, powdered tobacco, or other tobacco products, herbal cigarettes, rolling papers, or pipes to persons under 18 years of age is prohibited by law”.

⧠ Yes ⧠ No

2) Presence of “We Card” sign ⧠ Yes ⧠ No

3) Does the store have exterior tobacco advertising? ⧠ Yes ⧠ No (If no, skip to Store Interior section) 4) Presence of posters or similar displays with cigarette logo or branding ⧠ Yes ⧠ No 5) Presence of illuminated signs with cigarette logo or branding ⧠ Yes ⧠ No


6) Presence of small displays (smaller then posters or similar displays – may just be a listing of tobacco brand names) with cigarette logo or branding

⧠ Yes ⧠ No 7) Exterior tobacco advertisements in non-English language ⧠ Yes (Please specify language: ______________) ⧠ No Store Interior 1) Presence of “age of sale” sign – “Sale of cigarettes, cigars,

chewing tobacco, powdered tobacco, or other tobacco products, herbal cigarettes, rolling papers, or pipes to persons under 18 years of age is prohibited by law”.

⧠ Yes ⧠ No 2) Presence of NYC DOHMH tobacco use warning posters ⧠ Yes ⧠ No

3) Presence of “We Card” sign ⧠ Yes ⧠ No

4) Does the store have interior tobacco advertising? ⧠ Yes ⧠ No (If no, please note in Store Comments section and end survey) 5) Presence of posters or similar displays with cigarette logo or branding ⧠ Yes ⧠ No 6) Presence of illuminated signs with cigarette logo or branding ⧠ Yes ⧠ No


7) Presence of tobacco advertisements throughout store (not just behind cash register) ⧠ Yes ⧠ No 8) Presence of power wall behind cash register ⧠ Yes ⧠ No

9) Presence of overhead shelving for tobacco ⧠ Yes ⧠ No 10) Presence of shelf display – pricing of tobacco ⧠ Yes ⧠ No 11) Presence of countertop cigarette displays ⧠ Yes ⧠ No 12) Tobacco products at or below child’s eye level (within 3’ of floor) ⧠ Yes ⧠ No 13) Tobacco products within 1 foot of candy, gum or toys or within line of these items ⧠ Yes ⧠ No 14) Tobacco products adjacent to smoking cessation products ⧠ Yes ⧠ No 15) Tobacco branded functional items (i.e. shopping basket, shopping cart, cashier counter) ⧠ Yes ⧠ No 16) Tobacco promotions (i.e. coupons, prizes, mail-in rebate, multi-carton discount) ⧠ Yes ⧠ No 17) Interior tobacco advertisements in non-English language ⧠ Yes (Please specify language: ______________) ⧠ No


Appendix B – Identified Pharmacies-Tobacco Retailers



ABOUT ASIAN AMERICANS FOR EQUALITY, INC. Asian Americans for Equality is a non-profit organization established in 1974 with a mission of advancing the rights of Asian Americans and all those in need through advocacy and access in civil rights, immigrant assistance, social services, youth development, affordable housing, and economic development; to empower our communities through research and publishing that embody our issues and concerns; and to foster understanding and unity among diverse communities through building coalitions and forming collaborations. During the past 37-years, AAFE has evolved into a nationally recognized affordable housing developer and an experienced social service provider. With offices in Chinatown, Lower East Side, Flushing and Sunset Park, AAFE is the only citywide community development corporation serving New York City's one million Asian American residents. Services include community development and housing preservation, housing legal services, community education, citizenship preparation, and social services. AAFE affiliate organizations the AAFE Community Development Fund and Renaissance Economic Development Corporation provide homeownership counseling and small business training, respectively.

ABOUT THE NYC COALITION FOR A SMOKE-FREE CITY The NYC Coalition for a Smoke-Free City is committed to reducing the harmful impact of tobacco use and secondhand smoke to benefit the health of all New Yorkers. Partnering with community groups, elected officials, and health advocates, we support neighborhood-based efforts for effective and long-term change through the five boroughs. The Coalition’s main areas of focus are reducing access to tobacco products, limiting industry marketing to youth, increasing the number of smoke-free outdoor spaces, providing assistance to apartment buildings that are interested in going smoke-free, and engaging community partners to build support for policy campaigns. The Coalition is funded by the New York State Department of Health and the Department of Health and Human Services. © Asian Americans for Equality, 2012

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PRESCRIPTION FOR A HEALTHY ITY - NYC Smoke …nycsmokefree.org/sites/default/files/wysiwyg/docs/Citywide/aafe_rx... · Prescription for a Healthy City: Making NYC Pharmacies Tobacco