Canada: pharmacy tobacco sales to mentally ill people
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* Charl Els

The mental health community is finally waking up to the reality of mentally ill people being disproportionately affected by the tobacco epidemic. In Canada, about one in five people are affected by mental illness, and an estimated 50% of them (and up to 90% of schizophrenics) are smokers. They are also less likely to quit than the general population. For this group, too, the high cost of smoking often means that regular meals, family responsibilities, stable housing and other necessities are relinquished, leading to an inevitable exacerbation of a downward drift in society, with more social ills further marginalising them. To retain smokers and recruit new ones the tobacco industry has conducted extensive research on factors impacting on the mentally ill, who may be seen as an easy target - industry documents describe them as “anxious”, “psychologically vulnerable”, “angry”, and “least likely to quit,” to name only a few.

There are virtually no cessation programmes designed to accommodate the special needs of severely mentally ill smokers and the barriers to their quitting are perceived by many as insurmountable. Despite a body of evidence that cessation treatment is effective, the majority of mentally ill people do not access effective, individualised treatment. Isolated, positive reform has occurred, with mental health groups deciding to refuse tobacco industry funding and a widespread trend towards smoke-free hospitals and healthcare facilities.

However, in some Canadian provinces "power walls" of cigarette packs in retail outlets remain a powerful marketing tool (see Canada: point of sale win – again. *Tobacco Control* 2005;14:78–79). Their impact on the mentally ill may well be amplified, due to cognitive deficits, impaired decision-making capabilities, diminished motivational and volitional assets, as well as other challenges inherent to mental illness. It has been widely demonstrated that the mentally ill use tobacco to self-medicate negative mood states, symptoms of schizophrenia, cognitive deficits, depression, as well as side-effects of medication. As a result of this vulnerability, mentally ill people face a real risk of a perpetuation of tobacco’s already devastating impact.

To add insult to injury, in some Canadian provinces pharmacies still sell tobacco. In these, power-wall tobacco marketing may be particularly problematic for the mentally ill as the pharmacy is the “place of health” most must frequent to collect their medication. The conflicts between the dual roles of such pharmacies - counselling on cessation and selling tobacco - has resulted in seven provinces and territories banning the sale of tobacco in pharmacies by law, with an additional ban, in Quebec, by the pharmacists’ own professional body in response to a complaint by a member of the public.

In 2005, I filed a formal complaint against every tobacco-selling pharmacist and pharmacy in Alberta. There seemed no reason why the Quebec ruling (and the ethical stance in the seven other provinces and territories) should not also apply to the remaining provinces with pharmacy tobacco sales, including Alberta. There was a general sentiment among pharmacists to help protect the public and not to support tobacco sales; and two large-scale surveys demonstrated overwhelming support for a ban in Alberta’s pharmacies. However, the complaint was rejected. It was followed by a second, similar complaint naming five specific pharmacies selling tobacco.

It took more than a year before a response was received. A legal opinion had been sought by the regulatory body and the listed pharmacists had a chance to provide rebuttals. These included: “tobacco sales are legal in Alberta”, “tobacco purchases are a matter of choice which the pharmacist should respect”, “decisions are made on corporate level, and not by the individual pharmacist” and “pharmacists do not profit from tobacco, and have no vested interest in the product”. However, the spirit of the overall response was not uniform: one pharmacist removed tobacco from his pharmacy. The complainant was notified that the issue was closed (no disciplinary action followed) and that it was wrong to use the disciplinary route as an indirect means to achieve a specific public policy goal.

The differing interpretation of a critical ethical issue among Canadian provinces remains perplexing, though the invitation of Alberta’s pharmacists to jointly seek solutions is welcome. The only remaining hope is for Alberta’s government to ban pharmacy tobacco sales, an initiative the premier supported in pre-election surveys. However, the legislative wheels turn slowly, and in the meantime, mentally ill people west of Ontario, like the general population, remain exposed to this most incongruous form of tobacco marketing.