Introduction

The sale of cigarettes and other tobacco products in pharmacies has been criticised by public health advocates for decades.1 2 Indeed, marketing an addictive and deadly substance contradicts the claim that pharmacies promote health and wellness in communities. Moreover, some consumers may misperceive the health risks of tobacco when the products are advertised and prominently displayed in retailers that also provide health services and sell medications.2 Recognising this paradox, many public health agencies have urged pharmacies to stop selling tobacco and have publicly supported legislative bans on the practice. Consumer support for this tobacco control strategy is also high. A population-based survey in California found that nearly three-quarters of respondents disagreed that tobacco should be sold in pharmacies; 97% would shop at their usual drug store just as often or more frequently if tobacco products were no longer sold.3 In 2012, nearly 60% of New York City (NYC) residents reported that they would support a policy prohibiting pharmacies from selling tobacco.4 Even the American Pharmacists Association, the largest association of pharmacists in the USA, calls for the discontinuation of tobacco sales in their policy manual.5 With the exception of CVS, which voluntarily stopped selling tobacco in 2014,6 most chain pharmacies and some independent drug stores have ignored these appeals and continue to sell tobacco products, which generate enormous sales revenue. CVS is estimated to have lost nearly US$2 billion in annual sales after discontinuing tobacco sales.7

Emerging evidence suggests that the removal of tobacco from pharmacies could have a positive impact on health. A state-level analysis using point-of-sale purchase data indicated that after CVS discontinued tobacco sales, households in states with CVS pharmacies were significantly more likely to stop purchasing tobacco compared with control households in states with no CVS locations.8 In Massachusetts, the first state with municipalities that banned tobacco sales in pharmacies, there was a statistically significant decrease in smoking prevalence among cities with tobacco-free pharmacy laws compared with those without such laws.9 One of the most beneficial effects of this policy is that it would reduce the density of tobacco retailers in communities, a strong correlate of youth and adult smoking behaviours.10–12 In California and Massachusetts, Jin et al documented a significantly larger reduction in tobacco retailer density over time in cities that implemented a tobacco-free pharmacy law versus cities without such a law.13 Computational modelling confirms that removing tobacco from pharmacies would reduce tobacco retailer density, thereby decreasing accessibility of tobacco products by driving up search and purchase costs.14 15

It is well documented that tobacco retailer density and exposure to tobacco marketing are significantly greater in neighbourhoods with lower income levels and a higher percentage of African American and Hispanic/Latino residents.16 17 Policies that reduce tobacco retailer density, such as tobacco-free pharmacy laws, could conceivably minimise tobacco use disparities if they positively impact communities that have historically been targeted by the tobacco industry. To date, however, only one known study evaluated whether banning tobacco sales in pharmacies has an equitable impact on retailer density across diverse neighbourhoods. Tucker-Seeley et al investigated the association between neighbourhood sociodemographic characteristics and tobacco retailer density in Rhode Island before and after removing pharmacies from the sample.18 Consistent with other studies on the tobacco retail environment,16 17 census tracts with high poverty levels and a greater proportion of African American and Hispanic/Latino residents had higher tobacco retailer density. When pharmacies were excluded as tobacco retailers, however, there were no observed changes in these associations. The authors concluded that a tobacco ban in pharmacies may not address disparities in tobacco retail.18

In August 2017, NYC passed one of the most progressive tobacco control laws in the nation, supplementing its already strong policy measures. In addition to raising minimum prices on cigarettes and little cigars, setting a minimum price for all other tobacco products, increasing retailer licensing fees, creating a retail licence for electronic cigarettes and expanding a ban on smoking in common areas of multiunit buildings, the new legislation aims to drastically reduce the number of tobacco retailers in each of the city’s 59 community districts.19 To achieve this goal, the bill caps the tobacco retail licences in each district at 50% of the current number of licences. No new licences will be issued until the total falls below that cap through retailer attrition. The effects of this particular policy, however, may not materialise for several years since no current tobacco retail dealers will lose their licence as a result of the proposal. Existing retailers may continue to apply for licence renewals, as can new businesses opening in locations where the previous owner held a tobacco licence.19 Indeed, city officials suggest that a 40% reduction in tobacco retailers as a result of this policy is expected to occur approximately 10 years after implementation.19 In contrast, one of the bill’s most notable and celebrated components, a city-wide ban on tobacco sales in pharmacies, will have a more immediate effect. Pharmacies without a current tobacco licence are prohibited from applying for one and, by the end of 2018, all of the city’s pharmacies—both chain and independent—must cease selling tobacco products altogether.19 The goal of this study is to model the reduction in tobacco retailer density across NYC neighbourhoods following the ban on tobacco sales in pharmacies. Additionally, we will examine demographic and socioeconomic correlates of changes in retailer density to examine the equity of the tobacco-free pharmacy law and identify communities that may be more likely to benefit.

Methods

Results

Table 1 displays descriptive statistics for neighbourhood demographic characteristics and tobacco retailer density. Although NYC is a racially, ethnically and socioeconomically diverse city, the wide range of values for the demographic variables in each NTA indicates that some neighbourhoods are considerably homogenous. For example, one NTA had 0.12% non-Hispanic black residents (Great Kills, Staten Island), compared with 90.2% in another NTA (Rugby-Remson Village, Brooklyn). Similarly, median annual household income ranged from approximately US$21 000 (East Tremont, Bronx) to over US$170 000 (Upper East Side, Manhattan). Before the tobacco-free pharmacy law, the average number of tobacco retailers in each NTA was 43.1 (SD: 31.0, range: 3–272). Adjusting for population size, the average retailer density per 1000 residents was 0.97 (SD: 0.76, range: 0.11–9.68). After removing all pharmacies from the sample (n=510), average retailer density reduced to 0.91 (SD: 0.68, range: 0.11–8.47). On average, the per cent reduction in tobacco retail density postban across all NTAs was 6.8% (SD: 6.3), but ranged from 0% to 50%. Seventeen NTAs experienced density reductions over 15%.

The impact of the tobacco ban in pharmacies on retailer density was not equal across neighbourhoods. Table 2 displays unadjusted regression coefficients (B) between neighbourhood demographic characteristics (in 10 unit increments) and the per cent and absolute reduction in tobacco retailer density following the ban. Figure 1 presents scatter plots of neighbourhood demographic variables and the per cent reduction in tobacco retailer density with their Pearson correlation coefficients (r) to graphically illustrate the direction and strength of the linear relationships. Racial and ethnic neighbourhood composition was significantly associated with policy impact. Impact was greater in neighbourhoods with a higher percentage of non-Hispanic white residents (r: 0.35, B: 0.79, p<0.0001) and non-Hispanic Asian residents (r: 0.18, B: 0.78, p=0.015). An increasing proportion of non-Hispanic black and Hispanic residents was correlated with lower policy impact (r: −0.18, B: −0.46, P=0.012 and r: −0.36, B: −1.07, p<0.0001, respectively). Socioeconomic indicators produced even larger effect sizes for reductions in retailer density. For example, increases in median household income corresponded with a significantly greater reduction in retailer density postban (r: 0.41, B: 1.00, p<0.0001). On average, for every US$10 000 increase in median household income, tobacco retailer density decreased by 1%. Neighbourhoods with a higher percentage of uninsured residents (r: −0.33, B: −3.75, p<0.0001) and a higher percentage of adults with less than a high school education (r: −0.44, B: −2.60, p<0.0001) benefited less from the policy, as did neighbourhoods with a higher percentage of youth residents (r: −0.42, B: −4.48, p<0.0001). For every 10% decrease in the proportion of youth residents, retailer density decreased by approximately 4.5%. To account for potential biases from the non-normal data distribution and any outliers in the dataset, we replicated the correlation analyses using Spearman’s correlation coefficients; though there were slight differences in the coefficient values, neither the statistical significance nor the magnitude of our findings changed.

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Figure 1

Scatter plots of the relationship between neighbourhood demographics and per cent change in tobacco retailer density following the ban on tobacco sales in pharmacies (n=188), New York City, 2017. NH, non-Hispanic.

Higher median household income was moderately associated with greater retailer density at baseline, perhaps influenced by wealthier residents living in NYC’s dense business districts (eg, Midtown, Soho). Conversely, a greater proportion of youth residents was associated with lower retailer density at baseline. No other demographic or socioeconomic characteristics were associated with baseline retailer density, suggesting that a confounding relationship does not explain the major findings.

When the per cent and absolute changes in retailer density are mapped using geographic information system (GIS) software, geographical patterns emerge (figure 2). High-income neighbourhoods in Manhattan and the more suburban outskirts of other boroughs are more likely to benefit from the new policy. For example, among the seven NTAs experiencing a density reduction greater than 20% include: Brooklyn Heights, Brooklyn (73% non-Hispanic white, median household income: US$104 500, Density₁: 0.89); West Brighton, Brooklyn (96% non-Hispanic white, median household income: US$38 100, Density₁: 0.20); Yorkville, Manhattan (77% non-Hispanic white, median household income: US$101 700, Density₁: 0.67); and Rossville-Woodrow, Staten Island (85% non-Hispanic white, median household income: US$85 000, Density₁: 0.33). More disadvantaged neighbourhoods in the city frequently experienced no change in retailer density. Among the NTAs with a 0% change in retailer density following the pharmacy ban include: Crotona Park East, Bronx (30% non-Hispanic black, 67% Hispanic, median household income: US$24 900, Density₁: 1.21); Morrisania-Melrose, Bronx (34% non-Hispanic black, 63% Hispanic, median household income: US$27 400, Density₁: 1.18); East New York, Brooklyn (71% non-Hispanic black, 25% Hispanic, median household income: US$32 100, Density₁: 1.01) and South Jamaica, Queens (66% non-Hispanic Black, 18% Hispanic, median household income: US$53 500, Density₁: 0.84). Absolute changes in retailer density followed similar patterns, with the greatest reductions occurring in Midtown Manhattan and the city’s more suburban outskirts (figure 2).

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Figure 2

Per cent and absolute change in tobacco retailer density per 1000 population after the ban on tobacco sales in pharmacies, 2017.

Discussion

NYC’s newest legislative efforts to reduce tobacco retailer density, including a ban on tobacco sales in pharmacies, have received deserved praise. It is important, however, to evaluate whether policies applied equally across the city will have an equitable impact on neighbourhoods and populations. Strong evidence exists that tobacco tax increases have a proequity effect on the socioeconomic status gradient in smoking,27 but research evaluating the equity impact of other tobacco control measures, including reductions in retailer density, is lacking.28 This study demonstrated that the overall effect of the pharmacy ban on tobacco retailer density is substantial. On average, retailer density decreased by nearly 7% across neighbourhoods, with some NTAs experiencing reductions as high as 50% after policy implementation.

Neighbourhoods that benefit most from this new policy, however, generally have higher income levels, greater educational attainment and a higher proportion of non-Hispanic white residents—demographic groups with a relatively low burden of tobacco use in NYC. In contrast, neighbourhoods in the South Bronx, East and Central Harlem, and North and Central Brooklyn—areas identified as ‘high risk’ for tobacco retail by the American Cancer Society29—experience little to no change in density after implementation of this policy. An underlying reason for this effect is that pharmacies that sell tobacco make up a greater proportion of tobacco retailers in higher income neighbourhoods in NYC, consistent with studies in other cities.30 In lower income areas, where non-chain convenience stores (eg, ‘bodegas’, corner stores) are historically more prevalent and popular for ‘convenience’ needs,31 including tobacco purchases, pharmacy bans are less likely to have a strong impact. Although NYC’s new tobacco control laws include another policy that aims to reduce tobacco retailer density by half in each community district, this is expected to occur over time through retailer attrition.19 It is critical to assess which neighbourhoods might be the first to benefit from comprehensive policies with both immediate and gradual impacts.

Several study limitations are noted. First, NTAs were used to designate city neighbourhoods, but these administrative boundaries may not accurately represent community members’ own conceptualisations of their neighbourhoods. Indeed, different definitions of ‘neighbourhood’ can strongly impact findings in studies examining tobacco retail and access.32 Similarly, the activity spaces of city residents are not confined to the neighbourhoods in which they live; districts where people work and spend free time are also important when examining the intersection between ‘place’ and health. Second, it is possible that not every pharmacy selling tobacco was identified on the licensing list. For example, some of the store names may not have contained our search terms or may have instead listed the name of the owner or parent company. We believe, however, that the sample had high validity due to statements released by the City of New York in which they estimated that approximately 550 pharmacies would be affected by the new policy.19 This number is close to the number of pharmacies we identified in the licensing dataset (n=510). Further, we do not believe that the omission of any unidentified pharmacies would change the consistent linear trends observed. Third, some neighbourhoods that did not benefit directly from the pharmacy tobacco ban may still experience decreases in retailer density through the aforementioned second retailer density policy or other circumstances (eg, store closings). Finally, this study identifies the differential effects of a policy on the tobacco retail environment in communities, but the impact of the policy on residents’ tobacco use behaviours is not yet known. Future studies should monitor the prevalence of tobacco use across neighbourhoods in the years following the city’s new policies to assess their effectiveness and equitable distribution.

Conclusions

A ban on tobacco sales in pharmacies, retailers that often claim to be centres of health and wellness, is a sensible public health strategy to curb tobacco use. Strong evidence exists that tobacco-free pharmacy laws have positive public health effects, including reductions in both smoking prevalence8 9 and tobacco retailer density.13–15 In NYC, the recent ban on tobacco sales in pharmacies decreases tobacco retailer density overall, but the impact of this policy is not evenly distributed across neighbourhoods. Neighbourhoods that historically have had higher exposure to tobacco promotions and the greatest burden of tobacco use are significantly less likely to benefit. NYC has supplemented this policy with a ‘retail agnostic’ plan to reduce all tobacco retail licences by half in each community district, but this is likely to occur gradually over time, and disparities may still persist if some neighbourhoods benefit earlier from the immediate ban on tobacco sales in pharmacies. Although most municipal policies are applied equally across neighbourhoods, their effects may not achieve health equity. In order to minimise health disparities related to the tobacco retail environment, local governments should consider targeted policy approaches that attempt to balance retailer density evenly across neighbourhoods.