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Table.  
Store Purchase Characteristics of All Patients and Those Who Purchased Cigarettes
Store Purchase Characteristics of All Patients and Those Who Purchased Cigarettes
1.
Chaudhuri  R, Livingston  E, McMahon  AD, Thomson  L, Borland  W, Thomson  NC.  Cigarette smoking impairs the therapeutic response to oral corticosteroids in chronic asthma. Am J Respir Crit Care Med. 2003;168(11):1308-1311.
PubMedArticle
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How does smoking affect the heart and blood vessels? National Institutes of Health website. http://www.nhlbi.nih.gov/health/health-topics/topics/smo/. Accessed May 12, 2014.
3.
Pomp  ER, Rosendaal  FR, Doggen  CJ.  Smoking increases the risk of venous thrombosis and acts synergistically with oral contraceptive use. Am J Hematol. 2008;83(2):97-102.
PubMedArticle
4.
Tanis  BC.  Oral contraceptives and the risk of myocardial infarction. Eur Heart J. 2003;24(5):377-380.
PubMedArticle
5.
Food and Drug Administration. Guidance for industry labeling for combined oral contraceptives.http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/ucm075075.pdf. Published March 2004. Accessed May 12, 2014.
6.
Open letter to America’s retailers, especially those with pharmacies, from leading public health and medical organizations. Americans for Nonsmoker’s Rights website. http://www.no-smoke.org/pdf/pharmacies-letter.pdf. Accessed May 12, 2014.
Research Letter
December 2014

Cigarette Purchases at Pharmacies by Patients at High Risk of Smoking-Related Illness

Author Affiliations
  • 1Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
  • 2CVS Health, Woonsocket, Rhode Island
JAMA Intern Med. 2014;174(12):2031-2032. doi:10.1001/jamainternmed.2014.5307

Cigarette smoking can make managing chronic diseases more difficult. For instance, in patients with certain respiratory conditions, smoking increases the risk of acute exacerbation, can worsen disease control, and may limit the effectiveness of inhaled corticosteroids.1 Similarly, by raising blood pressure, smoking can make it challenging to effectively control hypertension and may increase the risk of atherosclerosis and coronary heart disease.2 Smoking can also increase the risk of serious adverse drug events. Oral contraceptive (OC) users older than 35 years who smoke have a 9-fold higher risk of myocardial infarction and venous thromboembolism compared with nonsmokers.3,4

A visit to the pharmacy to fill a prescription is, paradoxically, often an opportunity to purchase cigarettes. Using a deidentified database of linked retail pharmacy purchases and prescription data, we estimated the incidence and frequency of cigarette purchases made in retail pharmacies by individuals filling prescriptions for asthma or chronic obstructive pulmonary disease (COPD), hypertension, and OC medications.

Methods

The study population was drawn from a previously defined cohort of 361 114 patients who received pharmacy benefits through Caremark and filled a statin prescription between January 1, 2011, and June 30, 2012. This cohort included linked data from all purchases at CVS retail locations made with a CVS loyalty card that patients receive as a Caremark benefit and all prescription fills in the year before the patient’s first statin prescription.

Within this cohort, we identified individuals who filled a prescription for an antihypertensive, asthma or COPD, or OC medication during the 365-day observation period and set the date of the patient’s first prescription fill for a drug of interest as the index date. We identified cigarette purchases after a patient’s index date and defined a co-purchase as a day on which an individual purchased cigarettes and had medication available, using a 7-day grace period to allow for modest nonadherence. Oral contraceptive users were restricted to women aged at least 35 years, consistent with US Food and Drug Administration label warnings.5 The institutional review board of Brigham and Women’s Hospital approved this study.

Results

Of 38 939 patients taking a medication in a class of interest, 6.0% of asthma or COPD medication users, 5.1% of antihypertensive medication users, and 4.8% of OC medication users had at least 1 cigarette co-purchase (Table). Across all medication classes, patients with a cigarette co-purchase made an average of twice as many monthly store visits (1.9 vs 0.9 in all patients). Among patients who purchased cigarettes, the median number of store visits with a cigarette purchase was 2; 25% of asthma and COPD medication users had 4 to 53 visits, OC users had 4 to 94 visits, and antihypertensive medication users had 4 to 135 visits. Approximately 10% of patients with cigarette purchases were taking medications in 2 or 3 of the classes.

Discussion

Using a novel data source that links retail pharmacy purchase data to prescription dispensing data, we found that 1 in 20 patients who were taking medications in 3 classes purchased cigarettes at the pharmacy. On average, these patients made a cigarette purchase at the pharmacy every other month.

Our analysis is limited by potentially incomplete purchasing information because individuals may not use their loyalty cards for every purchase, and these data do not capture cigarette purchases made at other locations. Some of the cigarette purchases may have been made for or by another household member with whom the patient shares their loyalty card.

Nevertheless, our results highlight an opportunity to improve outcomes for patients receiving widely used treatments. The decision of some pharmacies, including CVS, to stop selling cigarettes has been met with widespread support from public health and medical organizations.6 Similar actions by other pharmacies may help prevent cigarette purchasing by individuals at greatest risk.

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Article Information

Corresponding Author: Joshua J. Gagne, PharmD, ScD, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, 1620 Tremont St, Ste 3030, Boston, MA 02120 (jgagne1@partners.org).

Published Online: October 20, 2014. doi:10.1001/jamainternmed.2014.5307.

Author Contributions: Ms Krumme and Dr Gagne had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Krumme, Choudhry, Brennan, Gagne.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Krumme, Gagne.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Krumme, Brill.

Obtained Funding: Choudhry, Matlin.

Administrative, technical, or material support: Shrank, Brennan, Matlin, Gagne.

Supervision: Choudhry, Shrank, Gagne.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported by an unrestricted grant from CVS Health to Brigham and Women’s Hospital.

Role of the Funder/Sponsor: Other than the contributions of the coauthors noted above, CVS Health had no role in the design and conduct of the study; collection, management, analysis, and interpretation of data; or preparation, review, decision to submit for publication, or approval of the manuscript.

References
1.
Chaudhuri  R, Livingston  E, McMahon  AD, Thomson  L, Borland  W, Thomson  NC.  Cigarette smoking impairs the therapeutic response to oral corticosteroids in chronic asthma. Am J Respir Crit Care Med. 2003;168(11):1308-1311.
PubMedArticle
2.
How does smoking affect the heart and blood vessels? National Institutes of Health website. http://www.nhlbi.nih.gov/health/health-topics/topics/smo/. Accessed May 12, 2014.
3.
Pomp  ER, Rosendaal  FR, Doggen  CJ.  Smoking increases the risk of venous thrombosis and acts synergistically with oral contraceptive use. Am J Hematol. 2008;83(2):97-102.
PubMedArticle
4.
Tanis  BC.  Oral contraceptives and the risk of myocardial infarction. Eur Heart J. 2003;24(5):377-380.
PubMedArticle
5.
Food and Drug Administration. Guidance for industry labeling for combined oral contraceptives.http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/ucm075075.pdf. Published March 2004. Accessed May 12, 2014.
6.
Open letter to America’s retailers, especially those with pharmacies, from leading public health and medical organizations. Americans for Nonsmoker’s Rights website. http://www.no-smoke.org/pdf/pharmacies-letter.pdf. Accessed May 12, 2014.
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