Evolving Past Tobacco

Earlier this month, CVS Caremark, the nation’s largest pharmacy chain, announced that it would stop selling cigarettes and other tobacco products in its 7,000 retail stores by October 2014. The news drew praise from all corners. President Obama said the decision “will have a profoundly positive impact on the health of our country."

Helping steer the company toward this decision was Troyen Brennan, MD, MPH, Chief Medical Officer at CVS Caremark, who serves on the Board of Overseers at the Mailman School. We spoke to Dr. Brennan about how the tobacco decision came about, the evolving role of pharmacies, and the responsibilities of private companies in creating public health.

A Q&A with CVS Caremark Chief Medical Officer, Troyen Brennan

How was the decision to ban sales of tobacco made?

I am trained in medicine and public health, but it doesn’t take that training to know that cigarettes are not good for people. In fact, they are probably the most harmful consumer product available. Since I started here at CVS, I have been a strong advocate for stopping the sale of tobacco products in the stores. It has been the subject of debate in the company over at least the last four or five years. What made the decision for us is that we increasingly see ourselves as a healthcare company. We realize that it was antithetical to us to continue to sell cigarettes.

How does this shift to being a healthcare company factor into the tobacco decision?

We are increasingly in the business of asking our pharmacists to provide advice to people to be proactive in terms of their illnesses. We’re opening retail clinics called MinuteClinics in many of our stores. We grew that from about 400 three years ago to 1,600 in two years. As we become more integrated into healthcare, convenience store notions of a retail pharmacy have to fade a bit, and certainly the provision of tobacco products is part of that.

The tobacco decision is right out of the public health playbook. Is it part of a broader shift from treating people when they are sick to helping them maintain or improve their health?

Absolutely. Most of the medications we provide are medications for chronic disease, which are relatively inexpensive, generic medications. Most people who take those medications are going to stay healthy, and overall that’s going to reduce healthcare costs.  If we’re able to council them and identify places where they have gaps in care, we can make their care that much better. It’s one of few places in healthcare where higher quality really does lead to lower costs, clearly. This move just takes advantage of that.

You are doing research with Harvard looking at medication adherence. Is research something new for a pharmacy chain?

I was a professor at the law school and medical school at Harvard for 15 years, and when I went to Aetna to be the Chief Medical Officer, I adopted a research mentality and began to support research, and have done the same thing at CVS. If we have interventions that we think are going to be successful, we should we should be subjecting them to serious scientific scrutiny. We should write up our results and have them peer reviewed. That makes what we do resonate that much more with our clients and makes them feel like they can trust us.   

What are you finding about CVS’s role increasing adherence?

For most chronic medications, about half of people aren’t taking them by six months. They tell their doctors they’re taking medication, but they’re really not. There are a lot of interventions we have that are proving to be efficacious. We have to surround people with a lot of different interventions because it’s such a tricky area to reinforce healthy behaviors. There’s not any one thing that’s enough. Better labeling, script synchronizations so people get all of their medications at the same time, better packaging, smart devices in homes, electronic reminders, social media, calls from our pharmacy, counseling from our pharmacists and pharmacy techs. We’re employing all those things.

It was reported that CVS will lose $2 billion annually brought in by selling tobacco. Was that a tough pill to swallow?

That’s a pill we’ve been looking at for at least the five years I’ve been here. Yes, we’re going to forego $2 billion. On the other hand, there is plenty of growth opportunity in healthcare. And if you’re going to be a healthcare company, you can’t be selling tobacco.

CVS Store, Brooklyn, NY

Dean Linda Fried suggested in the Huffington Post that CVS has raised the stakes for other pharmacy chains. Do you think they will follow suit?

There’s a financial hurdle on the one hand, and there’s corporate integrity on the other. Most of the rest of the pharmacy chains are trying to move front and center into healthcare, so it’s hard to believe that they are going to maintain sales of cigarettes as such. They have people in same position as me in their companies and I’m sure those people, like me, have been advocating around this issue for years. The hard thing was to go first. We went first and didn’t suffer a financial cataclysm. Our stock price is actually up since we announced. I think others will eventually make the same decisions that we did. They are really good people there and really thoughtful people and people really committed to healthcare.

If they don’t, should states or the federal government step in?

There’s a public health case here. From our point of view, we made our decision and we’re making it clear to consumers what we’re about. But the public health issue is only going to be significant if we can get the other retailers to stop. There are rules and regulations at the state and local level and some rules at the federal level that could make it less attractive for people to stay in cigarette sales. There are municipalities—Boston and San Francisco, being the leading ones—that have banned the sale of tobacco products in places that have pharmacies. A similar approach could be taken in states and municipalizes, or at the federal level. Some editorials have been calling for the federal government to not use pharmacies that sell cigarettes for people whose medication is paid for under Medicare Part D. I do think there is a public heath aspect to it, and there will probably be efforts to initiate regulation. This is why I think that more and more retail pharmacies will make their own decisions rather than face regulation.

What do you see as the role of the private sector in public health? In many cases, of course, the two have been at odds. Tobacco regulation, for one.  

The private sector has an important role to play. There are lot of private sector companies that for their own somewhat narrow interests are addressing tobacco cessation, but also with the realization that helping employees to quit smoking is better for health and productivity. The private sector is very effective when the motives correlate with a public health initiative.

Some have said that CVS should take the next step and banish soda, potato chips, and the like. Do you agree?

I don’t think I agree with it wholeheartedly. We’re completely aware of the importance of nutrition to an overall healthy public, but if someone is drinking a soda next to me, there is no harm to me. If someone is smoking there is harm to me from passive smoke inhalation. You can use soda and candy, sweets in moderation, not gain weight, and still remain very healthy. It’s impossible to do that with cigarettes. Cigarettes are in a category by themselves in terms of being wholly unhealthy.