A zombie-led protest in front of a Walgreens store in Washington, D.C., in January.
Recently, I called Osborn Drugs, a local pharmacy in Miami, Oklahoma, and asked how much it charged for Marlboros. “We don’t sell cigarettes,” the clerk replied. “We’re a pharmacy.”
Call most of the 10,000 pharmacies operated by Walgreens in the United States, however, and you’ll get the price of a pack. The nation’s largest pharmacy chain “at the corner of happy and healthy,” as its former tagline proclaimed, sells hundreds of millions of dollars’ worth of cigarettes, cigars, chewing tobacco, and electronic cigarettes each year.
That’s a lot of unhealthy. Smoking, while on the decline, is the nation’s top cause of preventable death, according to the Centers for Disease Control and Prevention (CDC). Since the Surgeon General declared smoking a health hazard in 1964, twenty million Americans have died prematurely of lung cancer, heart disease, chronic obstructive pulmonary disease, and other smoking-related diseases for which Walgreens fills prescriptions. The death toll is roughly 500,000 people each year, or 1,300 each day, including victims of second-hand smoke.
Walgreens is officially against smoking.
“Quitting smoking is one of the best things you can do for your health,” the company states on its website. Walgreens on Tumblr lists the chemicals in cigarettes and known health effects under the headline, “Here’s why you should quit today.”
Walgreens (officially Walgreens Boots Alliance following its 2014 merger with a European pharmacy chain) sells nicotine patches and gum, and directs smokers to its pharmacists and 400 or so in-store clinics for additional help. That’s laudable. Yet the sight of cigarettes next to nicotine patches behind the checkout counter vexes public health experts. For a smoker, just looking at packs of Marlboros can trigger impulse purchases, thwarting the anti-smoking advice from a pharmacist.
‘Cigarettes are the only products that will kill you if used as directed.’
Walgreens “finds itself in a hypocritical place,” says Douglas Luke, a professor at Washington University in St. Louis who studies tobacco control. “Cigarettes are the only products that will kill you if used as directed.”
True enough, the candy, soda, potato chips, and other junk food on Walgreens’ shelves pose their own health risks. “The difference is, there’s no safe level of tobacco use,” says Dr. Shannon Udovic-Constant, vice chair of the California Medical Association, which has campaigned for tobacco-free pharmacies since the 1990s.
Everyone from the American Medical Association to the CDC wants Walgreens to kick the habit. CVS Health, Walgreens’ biggest competitor among pharmacy chains, pulled tobacco from its 8,100 stores in 2014. Two-thirds of American adults, including almost half of current smokers, agree that cigarettes don’t belong in drugstores, according to a 2016 survey published in the American Journal of Preventive Medicine. A growing number of cities require pharmacies to be tobacco-free.
An intransigent Walgreens continues to defend tobacco sales with arguments that provoke chuckles from anti-smoking advocates and researchers who spoke to me for this article. Sample argument: We respect the choices of our smoking customers. Expert rebuttal: It’s not about smokers choosing to indulge—they’re addicted to the nicotine in cigarettes. Seventy percent of the thirty-eight million Americans who smoke want to quit.
Claiming to respect smokers’ freedom of choice is “an old tobacco industry tactic,” says Lisa Henriksen, a tobacco regulation expert at Stanford University.
Walgreens executives say they regularly review the tobacco issue. They’ve even removed the deadly products from the shelves of seventeen stores in Gainesville, Florida, as a pilot project “to gauge customer reaction,” company spokesperson Michael Polzin told me in an email. (Walgreens declined a face-to-face or telephone interview.) The pilot stores, which offer more health care services such as lab tests as well as more beauty products, are part of a larger strategy to reposition the company in a tough, Internet-roiled retail marketplace. Polzin says no decision has been made on what will happen long-term with regard to the seventeen pilot stores.
In other words, the company is keeping its options open. It’s not quitting today.
T
he United States is one of only a handful of major countries that allow pharmacies to sell cigarettes, according to a survey of the International Pharmaceutical Federation published last year in the journal Tobacco Control. Throughout most of Europe, Asia, and South America, such sales are illegal.
Tobacco and American pharmacies have been so intertwined that the Rite Aid chain, which sold some of its stores to Walgreens last year, once had its own in-house brand of cigarettes. In 2012, pharmacies accounted for 7 percent of U.S. tobacco sales, according to an analysis of U.S. Economic Census data performed for this article by Joseph Lee, a public health professor at East Carolina University. That percentage may have shrunk since CVS dropped tobacco.
Stand-alone pharmacies depend on prescription drugs for most of their revenue, but the share from cigarettes isn’t negligible. CVS said annual tobacco sales amounted to $2 billion when it announced in 2014 that it was going tobacco-free. That’s about 3 percent of store sales.
Cigarettes produce “steady, predictable cash flows” for pharmacies, according to a 1990 market analysis by Philip Morris, unearthed by the 1998 court settlement in which Big Tobacco agreed to pay forty-six states and Washington, D.C., tens of billions of dollars as compensation for what they spent, and will spend, on sick and dying smokers. However, the Philip Morris study suggested that drugstores nursed a guilty conscience about tobacco sales.
“The retailer perceives the cigarette category as one that conflicts with its health care image, and consequently, the trade class is reluctant to accept any [in-store marketing] visibility other than the most low profile version,” the Philip Morris study said. “Scenic Marlboro advertising is preferable to a bold ‘red roof’ and/or lit signage.”
Predictable revenue from tobacco isn’t indispensable revenue, though, as CVS discovered when it cleared its conscience in 2014. Retail sales apart from prescription drugs took a temporary hit, but company-wide revenue and earnings still rose in 2014 and thereafter.
“In the grand scheme of things, the tobacco decision wasn’t that meaningful in terms of impacting profitability,” says Brian Tanquilut, who analyzes health care companies at the investment banking firm Jefferies Group.
CVS claims far-reaching public health benefits from dropping tobacco.
In states where CVS controlled 15 percent or more of the retail pharmacy market, smokers bought ninety-five million fewer packs of cigarettes across all retail outlets, not just CVS stores, in the first eight months after the chain went tobacco-free, according to a company-authored study published in the American Journal of Public Health.
Dr. Troyen Brennan, the chief medical officer and executive vice president of CVS, calls the company’s discontinuation of tobacco sales a “great source of pride.”
“If we wanted CVS to be credibly viewed as a setting where health care is delivered, then the sale of tobacco had no place in our business model,” Dr. Brennan says in an email.
‘If we wanted CVS to be credibly viewed as a setting where health care is delivered, then the sale of tobacco had no place in our business model.’
Osborn Drugs of Miami, Oklahoma, has never wrestled with a guilty conscience because it has sold nary a cancer stick since its founding in 1971, says pharmacist Bill Osborn. The outlet, like most independents, is owned by a pharmacist working the back counter. Of the 22,000 pharmacies represented in the National Community Pharmacists Association, of which Osborn is president-elect, only 3.7 percent sell tobacco products, according to association spokesperson Scott Brunner.
“How can you justify selling tobacco?” Osborn asks in an interview. “Nothing about it makes your patients better.”
Mercedes Farhat, a former Walgreens pharmacist in Denver, Colorado, says working for a company that sells cigarettes was an uncomfortable experience. She would sometimes think about her grandfather, who died from a smoking-related respiratory disease when she was in third grade. “For them to make money on cigarettes is sickening,” says Farhat, who now works at an independent, tobacco-free drugstore.
The anti-tobacco sentiments of Osborn and Farhat reflect a long-standing position taken by their profession. The American Pharmacists Association recommended in 1971 that pharmacies not sell tobacco products, a stance that has only grown stronger since then, with the word “urges” replacing “recommends.”
In January, the American Medical Association, the American Cancer Society, the American Lung Association, the Association of State and Territorial Health Officials, the Campaign for Tobacco-Free Kids, and eleven other groups wrote a letter to Walgreens urging it to snuff out its smokes.
Some municipal leaders, alarmed by the heavy health care costs of smoking, have lost patience with trying to persuade pharmacies to stop selling cigarettes. In 2008, San Francisco became the first city to ban tobacco sales in pharmacies. It extended the ban to any retailer with a pharmacy counter after Walgreens challenged the law in court as discriminatory.
In its lawsuit, Walgreens denied that its customers received a “mixed message” of “tacit approval” of tobacco because a pharmacy sold it. White-coated pharmacists didn’t ring up cigarettes in the back of the store, the company contended. Clerks sold them at the front counter. No mixed message.
“They really seem to be splitting hairs,” says Vince Willmore, vice president for communications at the Campaign for Tobacco-Free Kids, about the Walgreens argument. “I don’t think most consumers distinguish between the front of the store and the back.”
In Massachusetts, more than 160 municipalities have banned tobacco sales in pharmacies along with a handful of other municipalities in New York, California, and Minnesota, according to CounterTobacco.org. Douglas Luke at Washington University says such bans help “denormalize” smoking: “We don’t want people to feel comfortable with tobacco.”
But Luke notes that there are no statewide bans and the idea has not spread beyond these four states. Might Congress pass a nationwide ban on tobacco sales in pharmacies? Luke is pessimistic. “There’s no appetite for that right now in D.C.,” he says.
With political will in short supply, public health advocates are left with only a few other tactics, like nagging and shaming, to turn Walgreens around. In January, some fifty young members of the anti-tobacco group Truth Initiative dressed up as rotting, bleeding zombies and walked through a Walgreens store in Washington, D.C. They carried signs that read “Not Healthy, Not Happy: Tobacco and Pharmacies Don’t Mix.”
“The idea was zombies coming back from the dead to warn people about smoking,” says Dan Fitzgerald, a zombie walker and network coordinator of the Tobacco-Free Rhode Island project of the American Lung Association.
A week later, Fitzgerald wore a coat and tie when he confronted Walgreens executives at their shareholders’ meeting in Scottsdale, Arizona. “Why do you believe in selling a product that we know [is] killing your customers?” he asked.
In response, James Skinner, the executive chairman of Walgreens, and Alex Gourlay, its co-chief operating officer, laid out the company’s standard response to Fitzgerald’s question. They explained that cigarette sales were “down considerably” because the company allots less space for tobacco. They said the company has trained its 23,000 pharmacists to counsel customers who are trying to quit smoking. They said that, with regard to smoking, “We still respect the choice of our consumers to make that decision.” And they boasted that 19 percent of all nicotine patches, nicotine gum, and other smoking cessation products are sold in Walgreens stores.
“We’ve got to believe that helping people to stop smoking is the most effective way of attacking this health care issue,” Gourlay said.
Luke, the tobacco control expert, notes that nobody wants Walgreens to stop selling nicotine patches. “But cessation is never as effective as prevention,” he says. “It’s one thing to help people quit. It’s better to keep them from starting.”
Cigarette displays also undermine cessation attempts. A 2015 study published in Tobacco Control showed that a smoker’s craving to smoke was stoked not only by the sight of cigarette packs, but also by accompanying advertisements and price promotions. Tobacco makers spent more than $9 billion in 2016 on marketing, mostly in retail settings like Walgreens.
Interestingly, the Walgreens board of directors includes two individuals who might have special insight to share on this issue. Nancy Schlichting is a former chief executive officer of the not-for-profit Henry Ford Health System in Michigan who was once honored by the American Lung Association for making her system smoke-free and helping employees quit. Dr. David Brailer chairs Health Evolution Partners, which seeks to improve health care by convening industry leaders to share ideas.
Schlichting and Brailer referred questions about tobacco sales to Walgreens management.
It’s possible Walgreens has plans to go tobacco-free, but if that’s true, it’s a well kept secret. No one interviewed for this article said they’ve gotten wind of any planned “smokexit.”
The chain’s pilot program to suspend tobacco sales in seventeen Florida stores has won guarded applause. “It sounds like a positive step,” says Vince Willmore of the Campaign for Tobacco-Free Kids. “We hope they don’t stop there.” Stanford’s Lisa Henriksen offers a snarkier appraisal: “You don’t need pilot stores to figure out that giving up tobacco is the right thing to do.”
According to spokesperson Michael Polzin, Walgreens will base its next tobacco decision on the customer feedback it collects over the next twelve to eighteen months. Amy Taylor, a senior vice president at Truth Initiative, wants Walgreens to move faster, because more than 3,200 kids under age eighteen smoke their first cigarette each day. “Any day Walgreens waits is a day too long,” she says.
Walgreens, which earned $4.1 billion in its 2017 fiscal year on $118 billion in sales, can afford to forgo tobacco revenue, says stock analyst Tanquilut. “They have the financial flexibility to make the move if they want to.”
Meanwhile, some health care industry players that partner with Walgreens seem to turn a blind eye to its tobacco sales. For example, although smoking raises the risk of various blood cancers, the website for the Leukemia and Lymphoma Society nevertheless lists Walgreens as a corporate sponsor that has contributed more than $1 million. The society trains Walgreens pharmacists on blood cancer under a collaborative relationship.
Linda Heaney, a spokesperson for the society, skirted the question of tobacco sales, explaining in an email that the collaboration “is based on the value and support Walgreens allows us to provide for patients.”
Even the National Institutes of Health, as anti-smoking as anybody, subcontracts with Walgreens to help enroll participants in the federal government’s Precision Medicine Initiative, which seeks to develop customized therapies for cancer and other diseases. “We need to reach people regardless of where they live, especially those who are not close to a traditional academic medical center,” NIH spokesperson Jilliene Drayton said in an email that didn’t address a question about cigarette sales. “Our partnership with Walgreens and others allows people to participate in research who otherwise wouldn’t be able to.”
So it’s business as usual for a company that sells the leading cause of preventable death. Other than scoldings from academics, zombie walks, and opposition from physicians and pharmacists, Walgreens doesn’t seem to suffer any ill consequences from its smoking habit. Cigarette dollars flow in, partnerships are struck. And ex-smokers with lung cancer cough far into the night.
Sidebar: Walgreens at a Glance
Number of U.S. stores: 10,000*
Revenue in fiscal 2017: $118 billion
Profit in fiscal 2017: $4.1 billion
Prescriptions filled in 2017: 764 million
Tobacco products sold: Cigarettes, cigars, chewing tobacco, electronic cigarettes
Current tagline: “Trusted Since 1901”
*Includes Duane Reade and Rite Aid stores operated by Walgreens. Walgreens recently acquired 1,900 stores in the Rite Aid chain, but is closing roughly a third.
Sources: Walgreens website, company filings with the U.S. Securities and Exchange Commission, Jefferies Group