Cigarette Promotions in U.S. Pharmacies - Brief Report
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Nicotine & Tobacco Research, 2022, 612–616
https://doi.org/10.1093/ntr/ntab204
Brief Report
Received April 29, 2021; Editorial Decision October 6, 2021; Accepted October 7, 2021
Brief Report
Cigarette Promotions in U.S. Pharmacies
Andrew B. Seidenberg PhD, MPH1,2, , Lisa Henriksen PhD3, ,
Kurt M. Ribisl PhD2,4,
Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute,
1
National Institutes of Health, Bethesda, MD, USA; 2Department of Health Behavior, Gillings School of Global Public
Downloaded from https://academic.oup.com/ntr/article/24/4/612/6384811 by guest on 08 June 2022
Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; 3Stanford Prevention Research Center,
Department of Medicine, Stanford University, Palo Alto, CA, USA; 4Lineberger Comprehensive Cancer Center,
University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
Corresponding Author: Andrew B. Seidenberg, PhD, MPH, Behavioral Research Program, Division of Cancer Control and
Population Sciences, National Cancer Institute, National Institutes of Health, 9609 Medical Center Drive, Room 2W-136
MSC 9712, Bethesda, MD 20892-9712, USA. Telephone: +1 240.276.5100; E-mail: andrew.seidenberg@nih.gov
Abstract
Introduction: The sale of tobacco products within American pharmacies has generated contro-
versy for several decades, leading two U.S. states and 45 municipalities to adopt tobacco-free
pharmacy policies. While previous research has reported cheaper cigarette prices in pharma-
cies, compared to other retailers, little is known about cigarette promotions in pharmacies,
which are associated with increased youth smoking and unplanned cigarette purchases among
adults.
Aims and Methods: Between May and August 2015, trained data collectors conducted store au-
dits at 2128 tobacco retailers located within 97 U.S. counties in 40 states. Observations were made
for three types of cigarette promotions: special price (e.g., $0.30 off/pack), multi-pack promotions
(e.g., buy one pack, get one free), and cross-product promotions (e.g., buy a pack of cigarettes and
a get free can of snus). We calculated weighted estimates of the proportion of pharmacies and
other retailer types with cigarette promotions and used weighted multivariable logistic regression
to compare cigarette promotions by tobacco retailer type, accounting for clustering at the county
level and controlling for county-level demographic characteristics.
Results: Cigarette promotions were observed in 94.0% of pharmacies, more than any other retailer
type (e.g., convenience stores: 82.0%, tobacco stores: 77.0%). All retailer types had lower odds of
promotions for Marlboro, Newport, Camel, menthol, or any interior cigarette promotion, com-
pared to pharmacies.
Conclusions: Nearly all pharmacies offered in-store cigarette promotions and pharmacies had
greater odds of offering cigarette promotions than all other retailer types. Whether voluntarily
or legislatively, tobacco-free pharmacies would eliminate a prevalent retail source of cigarette
promotions.
Implications: This is the first known national study to examine prevalence of cigarette promotions
in U.S. pharmacies compared to other retailer types. Nearly all pharmacies offered in-store cigar-
ette promotions and pharmacies had greater odds of offering cigarette promotions than all other
retailer types. These findings underscore the inherent contradiction of pharmacies serving both
as an important component of the health care system, but also as purveyors and promotors of
addictive and lethal tobacco products. Whether voluntarily or legislatively, tobacco-free pharmacy
policies would eliminate a prevalent retail source of cigarette promotions.
Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco 2021. 612
This work is written by (a) US Government employee(s) and is in the public domain in the US.Nicotine & Tobacco Research, 2022, Vol. 24, No. 4 613
Introduction a national sample of 2230 retailers. The Wave 3 sample was slightly
modified from the baseline sample by removing CVS Pharmacies
The sale of tobacco products in American pharmacies remains con-
(for stopping tobacco product sales in 2014)9 and adding dollar
troversial. More than 25 years ago, the Institute of Medicine (now
store chains, several of which began selling tobacco products after
National Academies of Sciences Engineering Medicine) recom-
the baseline sample was selected. Store audits were conducted by
mended prohibiting pharmacies from selling cigarettes in order to
professional data collectors who received 5 h of training with field
help reduce youth tobacco use.1 Additionally, surveys of pharma-
practice both inside and outside of tobacco retailers. Audits were
cists and pharmacy students reveal strong opposition to pharmacies
conducted between May and August of 2015. Working alone, data
selling tobacco products.2–5 Two-thirds of American adults also favor
collectors electronically recorded observations related to tobacco
tobacco-free pharmacies.6
product marketing (e.g., price promotions, advertisements), prices,
Outside the United States, there are few countries that allow
and product availability. Additional details about the study design
tobacco product sales in pharmacies.7 The Family Smoking
and protocol are published elsewhere.16
Prevention and Tobacco Control Act precludes the Food and Drug
Administration (FDA) from prohibiting face-to-face sales of tobacco
products by a specific category of retail outlets, including pharma- Measures
cies. However, as of April 2021, two states (Massachusetts and New Cigarette promotions recorded at each tobacco retailer included
York) and 45 municipalities (California and Minnesota) prohibit to- special prices on cigarettes (e.g., $0.30 off/pack), multi-pack promo-
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bacco sales in pharmacies.8 In addition, several pharmacy chains vol- tions (e.g., buy one pack, get one free), and cross-product promotions
untarily abandoned the sale of tobacco, including Medicine Shoppe, (e.g., buy a pack of cigarettes and a get free can of snus). Cigarette
Medicap Pharmacy, and CVS Health, the largest pharmacy chain in price promotions both outside and inside each retailer were recorded
the United States.9,10 separately for menthol and non-menthol versions of three leading
Despite facing increased scrutiny and attention, few studies cigarette brands (i.e., Marlboro, Newport, Camel) and for any other
have examined the sale and marketing of tobacco products within cigarette brands (combined). Due to the low prevalence of multibuy
pharmacies. One study found that cigarette sales in U.S. pharma- and cross-product promotions, we combined all three types of cig-
cies increased by 23% between 2005 and 2009 even though total arette promotions into a single category. Additionally, composite
U.S. cigarette sales declined by 17% during the same time period.11 cigarette price promotion variables were created for Marlboro (men-
A separate study found lower cigarette prices in independent sam- thol or non-menthol), Newport (menthol or non-menthol), Camel
ples of U.S. pharmacies and California pharmacies compared to (menthol or non-menthol), other brand (menthol or non-menthol),
other retailer types,12 which may have contributed to the increasing interior menthol (any brand), and any interior cigarette promotion
sales trend. (any brand/menthol status). Finally, because exterior cigarette price
In 2019, the four largest cigarette manufacturers spent over $6.6 promotions were less prevalent than interior promotions, all exterior
billion on discounts to reduce the price of cigarettes to consumers, cigarette promotions were combined (any brand/menthol status).
which accounted for 86.7% of their advertising and promotional ex- Data collectors also assigned a store type to each retailer using
penditures.13 Cigarette companies use a variety of point-of-sale pro- the following categories: convenience stores without gas, conveni-
motions to reduce the price of cigarettes, such as $0.30 off/pack or ence stores with gas (i.e., gas station), drug store/pharmacy, beer/
“buy one pack get one free” promotions. Point-of-sale marketing has wine/liquor store, grocery store, mass merchandiser (e.g., Walmart,
been shown to promote unplanned cigarette purchases, especially Costco), tobacco shop, dollar store (e.g., Family Dollar, Dollar
among smokers intending to quit.14 One study found that 76.5% of General), other. While some grocery stores and mass merchandisers
smokers making unplanned cigarette purchases reported that point- in the sample had pharmacies inside their stores, only standalone
of-sale tobacco advertising as the “precipitating factor.” 14 Moreover, pharmacies were coded as pharmacies. To reduce the number of re-
the use of cigarette price promotions is a significant predictor of tail categories for analyses, we combined similar store types (i.e.,
larger purchase quantities.15 However, little has been reported on mass merchandisers with dollar stores and convenience stores with/
cigarette promotions at pharmacies. Given that many smokers visit without gas).
pharmacies to purchase smoking cessation products (e.g., nicotine
replacement therapy), cigarette promotions may encourage cigarette Analyses
purchasing among smokers attempting to quit. The purpose of this All analyses were performed using Stata v16. Weighted popula-
study was to compare cigarette promotions in standalone pharma- tion estimates of cigarette promotions that are representative of all
cies to other retailer types using data from store audits conducted at U.S. cigarette retailers in the contiguous United States were calcu-
a representative sample of tobacco retailers in the contiguous United lated by applying sample population weights (inverse probability of
States. selection). Additionally, variance estimates were calculated by ac-
counting for weighting and clustering at the county level. We used
weighted multivariable logistic regression to examine how cigarette
Methods
promotions in pharmacies compared to other retailer types (refer-
Sample ence category = pharmacy). All models controlled for the following
Data for this study came from Wave 3 of the Advancing Science quartiled county-level demographic characteristics: % black (non-
& Practice in the Retail Environment, an observational study of Hispanic), % Asian/Pacific Islander (non-Hispanic), % Hispanic, %
U.S. tobacco retailers that sold cigarettes.16 A two-stage sampling youth (ages 5–17), and median household income. All county-level
design was used to obtain a representative sample of retailers (con- demographic data were obtained from the American Community
tiguous United States). In the first stage, 97 counties were chosen Survey 5-year estimates (2011–2015). Models also controlled for
using a probability proportionate to size method. Next, we ran- census region. Missingness was minimal at614 Nicotine & Tobacco Research, 2022, Vol. 24, No. 4
Results
Exterior promotions
19.7 (11.2, 32.4)
33.7 (14.5, 60.4)
25.7 (21.3, 30.5)
Any cigarette
5.8 (2.9, 11.3)
12.0 (7.3, 19.0)
Audits were completed at a total of 2128 retailers, of which 37 stores
2.1 (0.9, 5.2)
were excluded for no longer selling cigarettes. The analytic sample
(n = 2091) was comprised of 136 (6.5%) pharmacies, 1104 (52.8%)
gas/convenience stores, 198 (9.5%) liquor stores, 362 (17.3%) gro-
0
cery stores, 203 (9.7%) mass merchandise/dollar stores, 71 (3.4%)
tobacco stores, and 17 (0.8%) other store types.
Table 1 lists the weighted proportions of cigarette promotions
76.6 (62.8, 86.4)
51.1 (24.7, 76.8)
52.4 (44.3, 60.5)
51.7 (41.8, 61.5)
92.0 (77.0, 97.6)
79.9 (75.8, 83.5)
37.5 (29.5, 46.3)
found in pharmacies and all other store types. Nearly all pharma-
cies (94.0%, 95% CI = 82.6, 98.1) had any type of interior cigarette
Menthol
promotion. The proportion of pharmacies with any interior cigarette
promotions exceeded all other retailer types, including convenience
stores (82.0%, 95% CI = 77.9, 85.5) and tobacco stores (77.0%,
95% CI = 63.3, 86.7). Cigarette promotions for Marlboro, Camel,
and Newport were found in 87.1% (95% CI = 63.6, 96.3), 81.9%
(95% CI = 68.7, 90.3), and 72.2% (95% CI = 57.0, 83.5) of phar-
22.3 (15.2, 31.6)
63.5 (49.9, 75.3)
25.9 (17.1, 37.2)
38.1 (31.4, 45.3)
81.1 (65.0, 90.9)
64.4 (58.9, 69.5)
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26.5 (9.8, 54.3)
Other brand
macies respectively, which exceeded all other retailer types. Further,
promotions for menthol cigarettes were found in 92.0% (95%
CI = 77.0, 97.6) of pharmacies, more than all other retailer types.
Table 2 reports the odds of displaying interior cigarette promo-
tions for each retailer type, relative to pharmacies. All retailer types
had significantly lower odds of any interior cigarette promotions
than pharmacies, ranging from 74% lower odds in convenience
65.7 (52.6, 76.8)
30.0 (11.3, 59.0)
20.9 (13.5, 30.8)
27.7 (21.9, 34.2)
81.9 (68.7, 90.3)
68.7 (63.7, 73.2)
12.1 (7.4, 19.2)
stores to 96% lower odds in liquor stores. Additionally, all retailer
Camel
types had significantly lower odds of displaying Marlboro, Newport,
Camel, and other branded promotions. Moreover, with the excep-
Interior promotions
tion of tobacco shops, all retailer types had significantly lower odds
Table 1. Weighted Proportion (95% CI) of Retailers With Cigarette Price Promotions: United States, 2015
of displaying interior menthol cigarette promotions compared to
pharmacies, ranging from 69% lower odds in convenience stores to
95% lower odds in liquor stores.
19.0 (10.5, 31.9)
14.6 (10.4, 20.1)
16.4 (10.7, 24.3)
72.2 (57.0, 83.5)
29.4 (25.3, 34.0)
Although exterior cigarette promotions were much less common
16.3 (4.7, 43.4)
14.3 (9.3, 21.5)
Newport
than interior promotions across all retailer types, no pharmacies dis-
played any exterior promotions. Exterior promotions were highest
at other retailer types (33.7%), convenience stores (25.7%), and to-
bacco stores (19.7%).
Discussion 27.5 (11.0, 53.8)
56.9 (47.5, 65.9)
59.7 (44.2, 73.4)
20.9 (14.5, 29.2)
43.6 (35.4, 52.1)
87.1 (63.6, 96.3)
60.6 (54.4, 66.5)
Marlboro
To our knowledge, this is the first known study to examine the
Confidence intervals account for weighting and clustering at the county level.
prevalence of cigarette promotions in U.S. pharmacies compared to
other types of cigarette retailers. Cigarette price promotions were
omnipresent in pharmacies (94.0%), although none were advertised
on the store exterior. More pharmacies offered cigarette promo-
tions than traditional tobacco retailers, such as convenience stores
(82.0%) and tobacco shops (77.0%). After accounting for county-
77.0 (63.3, 86.7)
51.1 (24.7, 76.8)
56.7 (48.6, 64.5)
60.8 (51.4, 69.5)
94.0 (82.6, 98.1)
82.0 (77.9, 85.5)
42.5 (33.1, 52.5)
Any cigarette
level demographic characteristics, all retailer types had significantly
lower odds of offering cigarette promotions than pharmacies.
These findings underscore the inherent contradiction of phar-
macies serving both as an important component of the health care
system, but also as purveyors and promotors of addictive and lethal
tobacco products. Indeed, a study conducted in 2011–2012 found
that one in 20 customers with chronic illnesses purchased cigar-
Mass merchandise (n = 203)
ettes when they filled prescriptions for diseases that are exacerbated
Convenience (n = 1104)
Liquor stores (n = 198)
by smoking.17 The finding that a greater proportion of pharmacies
Pharmacy (n = 136)
offered cigarette promotions compared to all other retailer types
Grocery (n = 362)
Tobacco (n = 71)
is particularly concerning. For instance, many individuals seeking
Other (n = 17)
Retailer type
tobacco cessation assistance visit pharmacies to purchase nicotine
replacement therapy (often sold next to cigarettes), prescription ces-
sation medications, or for cessation counseling within pharmacy
clinics. Additionally, many states permit pharmacists to prescribeNicotine & Tobacco Research, 2022, Vol. 24, No. 4 615
medications for smoking cessation.18 Some retailers report con-616 Nicotine & Tobacco Research, 2022, Vol. 24, No. 4
Funding 11. Seidenberg AB, Behm I, Rees VW, Connolly GN. Cigarette sales in phar-
macies in the USA (2005-2009). Tob Control. 2012;21(5):509–510.
This study was supported by the National Cancer Institute of the National
12. Henriksen L, Schleicher NC, Barker DC, Liu Y, Chaloupka FJ. Prices for
Institutes of Health under Award numbers P01 CA225597 and U01 CA15428.
tobacco and nontobacco products in pharmacies versus other stores: re-
The funders had no involvement in the design, data collection, analysis, inter-
sults from retail marketing surveillance in California and in the United
pretation or decision to publish. The content is solely the responsibility of the
States. Am J Public Health. 2016;106(10):1858–1864.
authors and does not necessarily represent the official views of the National
13. Federal Trade Commission. Federal Trade Commission Cigarette Report
Institutes of Health.
for 2019. https://www.ftc.gov/system/files/documents/reports/federal-
trade-commission-cigarette-report-2019-smokeless-tobacco-report-2019/
cigarette_report_for_2019.pdf. Accessed August 20, 2021.
Declaration of Interests 14. Clattenburg EJ, Elf JL, Apelberg BJ. Unplanned cigarette purchases and
Dr. Henriksen has consulted for FDA’s Center for Tobacco Products and their tobacco point of sale advertising: a potential barrier to smoking cessation.
Centers for Tobacco Regulatory Science. Dr. Ribisl serves as an expert con- Tob Control. 2013;22(6):376–381.
sultant in litigation against tobacco companies and has a royalty interest in a 15. Doogan NJ, Cooper S, Quisenberry AJ, et al. The role of travel distance
store mapping and audit system owned by the University of North Carolina and price promotions in tobacco product purchase quantity. Health Place.
at Chapel Hill, but these systems were not used in this study. All other authors 2018;51:151–157.
declare no conflicts of interest. 16. Ribisl KM, D’Angelo H, Feld AL, et al. Disparities in tobacco marketing
and product availability at the point of sale: results of a national study.
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Prev Med. 2017;105:381–388.
Data and Code Availability 17. Krumme AA, Choudhry NK, Shrank WH, et al. Cigarette purchases at
pharmacies by patients at high risk of smoking-related illness. JAMA
The data and analytic code underlying this article will be shared on reasonable
Intern Med. 2014;174(12):2031–2032.
request to the corresponding author.
18. Adams AJ, Hudmon KS. Pharmacist prescriptive authority for smoking
cessation medications in the United States. J Am Pharm Assoc (2003).
2018;58(3):253–257.
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