During the last decade, local, state and federal governments have sought to make smoking inconvenient by restricting where and when people can light up. They have made it more expensive by increasing taxes — to the point that a pack of cigarettes costs at least $10.50 in New York City. They have tried to make it scary by requiring ever larger and blunter warnings about the health risks of smoking on cigarette packaging. And they have worked to make it un-cool, most recently with a new advertising and social media campaign this week aimed at teens.
But even as the efforts to convince people not to smoke have gotten more aggressive, the smoking rate has remained about the same. According to the Centers for Disease Control and Prevention, about 19 percent of the adult population smoked in 2011, the most recent year for which data are available. That's less than half the rate from 1965, when the CDC first started keeping track. But the numbers also suggest that the decline has largely leveled off; the big drops in smoking petered out in the last two decades. From 2001-2011, the decline was just 3.8 percentage points, and smoking remains the nation's leading cause of preventable deaths.
That's why today's announcement that CVS/Caremark, one of the nation's largest drugstore chains, has decided to stop selling tobacco products by this October is so encouraging. It's not that taking tobacco out of CVS will make it so much more difficult for smokers to buy cigarettes — company officials readily admit that smokers will just go elsewhere. It's that a decision by a major, publicly traded corporation to get out of the tobacco business signals a future in which smoking is increasingly marginalized.
CVS' decision was based on strategic considerations, not altruistic ones. It estimates it will lose about $2 billion in sales out of $123 billion total as a result of dropping tobacco, but it is essentially dropping what is likely to be a stagnant or (ideally) declining revenue stream in favor of one that offers great opportunity for growth. The chain is seeking to position its stores as health centers, and indeed, it is the leader in a new niche in the health care market of limited service clinics located inside retail outlets. Eight hundred CVS stores have clinics inside, and the company hopes to nearly double that number within the next few years. They are staffed by nurse practitioners or physician assistants and offer basic screening, vaccinations and treatments. If it's not an outright conflict of interest, it's at least a conflict of perception for consumers to see products that will kill you sold in a store marketed as a place to keep you well.
It may wind up being good for CVS' bottom line, but it is also part of what Dr. Troyen A. Brennan, CVS' chief medical officer, and Dr. Steven A. Schroeder, head of the University of California, San Francisco's Smoking Cessation Center, describe as the "denormalizing" of smoking. In an article published today on the Journal of the American Medical Association's website, Drs. Brennan and Schroeder note recent developments like the ban on outdoor smoking in New York and the increasing reluctance of companies to hire smokers as part of a trend toward marginalizing smokers and stigmatizing the practice. The effort to ban smoking in parks in Baltimore County follows along the same lines. Selling cigarettes in pharmacies, Drs. Brennan and Schroeder argue, "renormalizes" smoking "by sending the subtle message that it cannot be all that unhealthy if it is available for purchase where medicines are sold."
So far, none of CVS' major competitors have rushed to follow its lead, but there is no question that its decision changes the political dynamics of regulations about where tobacco is sold. San Francisco and Boston, along with some smaller cities, have already made it illegal to sell tobacco in any store that also has a pharmacy, a type of law that applies not only to drug stores but also many grocery stores and discounters like Walmart and Costco. Having the largest drug store chain voluntarily take the same step makes it much more likely that other local and state governments will enact similar restrictions.
Nearly one out of every five deaths in the United States is caused by smoking, and treating smoking-related illnesses costs $96 billion a year, according to the CDC. By itself, CVS' decision isn't going to change that. But it is an important step in the effort to send a unified message that smoking is not and should not be accepted as the norm.
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