Ending Tobacco Sales in Pharmacies: A Comprehensive Evaluation on Tobacco-free Pharmacy Laws

Background: California and Massachusetts are the only two states in the United States (US) with municipalities that have local laws prohibiting the sale of tobacco products by pharmacies. The process of adopting these tobacco-free pharmacy laws and the impacts of these laws remain understudied. The goal of this study was to comprehensively examine the tobacco-free pharmacy laws. The study consisted of a qualitative assessment of the process of adopting such laws and a quantitative assessment of the impacts of tobacco-free pharmacy laws on tobacco retailer density and smoking prevalence.Methods: Qualitative telephone interviews were performed with 23 key informants who were involved in the efforts to adopt tobacco-free pharmacy laws in California and Massachusetts. Key patterns and themes related to the process, barriers, and facilitators of adoption and implementation of the tobacco-free pharmacy laws were identified. The quantitative study examined changes in tobacco retailer density and smoking prevalence following the implementation of tobacco-free pharmacy laws. Data sources for the quantitative study included tobacco retailer license data in California and Massachusetts, Behavioral Risk Factor Surveillance Survey (BRFSS), Youth Risk Behavior Survey (YRBS) and California Healthy Kids Survey (CHKS). Mixed effects negative binomial models were performed primarily to examine longitudinal changes in outcomes. Results: The qualitative study results suggested that with the growing number of cities that have adopted such laws, and the recent efforts from CVS, banning tobacco sales in pharmacies is becoming less controversial and more normative to both pharmacy retailers and the general public. The results also highlight the needs to consistently regulate the sale of e-cigarettes as a part of tobacco-free pharmacy laws.The quantitative results indicated that tobacco-free pharmacy laws were associated with significant reductions in tobacco retailer density in both California and Massachusetts, after adjusting for demographic and economic characteristics, and for the presence of other local tobacco control policies at the city level. Our results suggest that since the first implementation of such laws, the decrease in retailer density among cities with such laws was 1.44 (95% CI [1.37, 1.51]) to 3.18 (95% CI [1.11, 5.25]) times as great as the decrease among cities without such a law. With regard to smoking prevalence, tobacco-free pharmacy laws were associated with a slight non-significant reduction in smoking prevalence. In Massachusetts, there was an 8.6% relative reduction in adult smoking prevalence after the implementation of such laws, and the effect was not significant after adjusting for other factors. Decreases in smoking prevalence were directionally similar in California and among adolescents in Massachusetts.Discussion: This study comprehensively evaluated tobacco-free pharmacy laws with regard to the adoption process and real-world impacts. Our findings provide useful information and supportive evidence for decision-makers of cities or states that are considering such laws. Future studies that focus on the impacts of tobacco-free pharmacy laws with a prolonged time span and additional comparison group (e.g. neighboring states) are needed.