The CVS tobacco decision is no small thing — Keep the chips and soda please

Yesterday, CVS Caremark announced that its 7600 stores will stop selling tobacco products. Company leadership said that selling tobacco is not consistent with being a health company. This decision, which takes effect in October 2014, will result in 2 billion less revenue.

I am no business person, (though, as an observer of humans, I follow business news), but giving up 2 billion dollars in revenue seems like a bold and courageous move. Forbes journalist Matt Herper explains the business aspects. He teaches us that CVS’ model is changing. Not only are pharmacies like CVS turning into health care delivery portals, with Minute-clinics staffed by physician extenders, but also, the company plans greater partnerships with hospitals and health systems in the future.

You can see why selling tobacco doesn’t fit in a health model. Praise was near unanimous. President Obama, Michal Bloomberg, the AMA, the American Cancer Society and many other health organizations offered high fives. My Twitter feed buzzed with kudos.

My thoughts on the decision are similar. I think it’s a pretty amazing call, especially if it nudges other pharmacies and grocery chains to follow suit.

Cigarettes and other tobacco products are special. In the category of damage done to humanity, they reside in a class by themselves. Everyone knows that smoking kills. Smoking causes irritable endothelium, sticky platelets and promotes plaque buildup in the arteries to all organs. Promoting diffuse blood vessel disease causes dementia (from strokes), heart attacks and heart failure (from coronary artery disease), kidney disease, bowel rotting, and loss of limbs, to name just a few. Smokers who get emphysema and COPD often suffer a slow and breathless death. But there is more; vascular and lung disease are not the worst outcomes of smoking. The worst are the cancers. Smoking is causally linked to many of the most gruesome cancers, like head and neck cancer. (And remember–it’s not just the disease that’s so bad, it’s our treatments too.)

So for me, smoking is horrible not so much because it kills but because it causes suffering. Terrible suffering. There is fear, loss of dignity and independence and pain. And this too: In the US, dealing with human suffering is an especially acute problem. We are good at life-prolonging care, but not so good at relief of suffering. Few patients get the benefit of compassionate skilled palliative care. In my city of one million, here in tobacco central, there are hundreds of cardiology, oncology and other life-prolonging specialists, but only a handful of palliative care doctors. The human suffering wrought by smoking is immense.

Keep the chips and soda:

A final note about health companies selling unhealthy products. My friend and social media mentor, Dr Bryan Vartebedian, wrote that CVS did not go far enough. He called for the health company to stop selling soda and chips. He points to another scourge of health: obesity from over-consumption of junk food. “You can’t make money peddling savory snacks while at once setting the pace for a healthy lifestyle.  And condemning one vice works for the press release, but not as a brand offering health solutions, ” he wrote yesterday.

Of course it is right and just to emphasize the coming public health crisis of obesity, especially in children. We are in big trouble as a nation if things don’t change.

But I respectfully disagree that chips and soda can be grouped with cigarettes on the banned list. My argument centers on the notion of dose. There are no healthy doses of cigarettes. But chips and soda can be consumed in a manner that does not destroy our bodies. Make no mistake, I’m not advocating for junk food, I’m just saying that it’s unrealistic to expect Americans to transform themselves to plant-eating acolytes of Dr Esselstyn. If chips and soda are that bad, it would follow that we should ban McDonalds and Burger King and dare I say, Chick-Filet. And where is that line? Are baked chips ok? What about granola bars?

I tell patients this all the time:

Pizza isn’t the problem; eating the entire pie is. Beer isn’t the problem, drinking the entire six-pack is. Same with cookies, birthday cake and M & Ms.

Deep in the hills of Southern Indiana, about 80k into a 120k ride, sits a CVS store. It’s a hot summer day; your body and mind drained of fluid and glycogen. Your brain can think of only one thing–it comes in a red can and is carbonated and sugary. No it is not healthy, surely not healthy, but it is no cigarette.

JMM

Comments

  1. says

    My post had little to do with potato chips…or corn nuts, pork rinds, or candy bars. The point was to illustrate the tension that exists when one sells things and delivers health. Stopping the sale of cigarettes is obviously a big step. But when you go into the business of health care delivery, all of that needs to be realigned.

    The argument that there are no bad foods, only bad diets is a tired way to deal with the fact that America has a huge problem with its patterns of consumption. And it doesn’t address the fact that the ‘food’ options at CVS are disgracefully misaligned with an organization now trying to position itself for health delivery.

    But I guess we see the world through our own lens. You worry about what kills this generation of adults. I worry about what will destroy the next.

    Good post and thanks for chiming in.

    • says

      Thanks Bryan. It’s a thought-provoking topic–what aligns with or against health, that is.

      The other “health” items one sees walking the aisles of CVS are NSAIDs and decongestants (now behind the counter). These “health products” are frequent contributors to major health problems. Hardly a week goes by that I don’t see an adult who became ill as a result of a health product. I won’t even mention the C-diff problem that arises from antibiotics prescribed from Minute clinics. Again, I’m not suggesting sugary drinks align with health promotion, just that it’s a very fuzzy line these days.

      Thank you for commenting and promoting this important conversation.

      • Joe says

        While we’re busy deciding which 100% legal products free adults should be allowed to buy from a merchant of their choice, I’ll also note that a lot of the health harm done via the pharmacy gets its start in the Doctors office. Heaven help you if you work at a pharmacy in the same county as a rural pain clinic. The black market demand for opioids is staggering and it is always someone with a DEA number who starts the supply chain. Something about glass houses….

        To get philosophical for a moment – health seems to me a worthy goal, but we all fail in the end. Is there any room in our system for someone who might not share that goal? Is there any room for Ed Abbey style patient autonomy?

        “A venturesome minority will always be eager to set off on their own, and no obstacles should be placed in their path; let them take risks, for godsake, let them get lost, sunburnt, stranded, drowned, eaten by bears, buried alive under avalanches – that is the right and privilege of any free American.” Ed Abbey

        I’ve never smoked a puff, and have lost grandparents to lung cancer (the two are related). I also value self determination for those who are willing to finance the consequences. Finance the consequences – that’s a whole ‘nother ball of wax….

        FWIW – My personal guess is that this decision had more to do with corporate image and branding than a desire to reduce smoking. It’s great that the two go together in this case, but I would also guess it has something to do with the CVS PBM business and marketing that service to insurers. Just as hospital systems are lining up to win favor with insurers who control large blocks of profitable patients , pharmacies are galloping down the same path.

        Imagine walking into that sales meeting and pointing out that your company allows patients to pick up their prescriptions, and their smoking cessation products, but offers no opportunity to buy smokes.

        Call me a cynic, but I guess that’s my lens.

        • says

          Thanks Joe. I appreciate your emphasis of autonomy and freedom. (Plus you do it so skillfully.) The exception here is smoking. It’s just that bad. I might see 15-20 patients in a day; seeing a single smoker is enough change my mood, not always, but often. I’m like…are you serious? You want me to medicate and burn and do all this and all that and you smoke! Little that an electrophysiologist has in his or her toolbox can help a persistent smoker. I don’t know how the vascular guys do it. And, heart disease is one of the better outcomes for a smoker.

          Then there’s the issue of financial responsibility…Never mind. We can play catch with that hot potato later.

  2. Steven Horvitz, D.O. says

    Agree with a statement by Joe.

    CVS is corporate.
    They are moving into trying to become a healthcare company as it appears that only large corporations will survive in the coming Obamacare rules/reg onslaught.

    Not selling tobacco is simply a PR room for their image. Nothing more. The PR from not selling tobacco will increase their bottom line, which is all that matters to CVS and other large corporations.

    So don’t for one second think it is a benevolent choice.

  3. says

    Excellent post JOHN! – and CVS IS worthy of receiving praise for this in my strong opinion. That said – I fully agree with Steven Horvitz that the most likely reason for this CVS decision is not a benevolent one, but rather a matter of dollars & cents. That said – I consider this a HUGE VICTORY for better health – so I don’t mind praising CVS since end result is a good one (even if the reason for this CVS decision had little to do with truly wanting to improve general health). While it would be ideal for the next step to limit food display to uniquely healthy items – that is unrealistic to expect, and as per John, far down on the potential-for-harm scale compared to the huge negatives of smoking.

    • says

      Sometimes, not always, a single decision can benefit both parties. Here it seems incidental, but nonetheless, limiting access to cigs is a good thing. A win-win.

  4. Dr. Wilcox says

    As for chips and sodas– these highly refined ‘foods’ will prove, ultimately, just as dangerous as smoking to the population, at large, given the current American addiction to fat and sugar. One would not contemplate banning chips/sodas, but a hefty tax might go some way to limiting consumption. As a competitive cyclist I tend to avoid sodas and chips given the relatively high sugar/fat concentrations. For many years, I used to drink only water and eat only ‘real food’ while cycling, but in a 2013 study (David Nieman, et al.) eating Bananas was compared to ingesting an Energy Drink (6% carbohydrate) and resulted in ‘similar performances’ for a 75 kilometer cycling time trial in terms of blood glucose, inflammation, oxidative stress and innate immune levels… the only difference was that banana consumption resulted in higher Dopamin levels (nice!). But I do not think that Coke really qualifies as an ‘Energy Drink’.

    • says

      Thx DR W,

      No doubt, sugary drinks and junk food are a problem. It’s especially significant when it starts in children. So you may be right on a cumulative basis. My views on nudges get me in trouble with my friends from the right. But I see no downside for taxing junk food, and gas and gas-guzzlers. Pay to play. A visitor who followed me for a week, would soon become a nudge convert.

  5. says

    I love this post, Dr. John. Especially your spirited defense of that little red can . . . ;-)

    I tend to agree with those who cynically paint the CVS no-cigs announcement as a thinly-veiled PR strategy. As a person who’s spent 30+ years in the public relations field, this is precisely the advice I’d be offering my pharmacy clients, too. The initial revenue loss (and you’re absolutely correct – no more tobacco sales would mean a huge hit to the CVS bottom line) is a smart and calculated risk.

    But in marketing, it’s good to be first, and this massive public “deposit in the bank of goodwill” – as we used to call this type of corporate strategy – will no doubt bring financial rewards that will offset and even surpass any initial losses. I don’t see this cynically however. It’s a good news story no matter how we might try to spin it.

    My own very first reaction to the CVS news was: “Wow. I would start shopping at CVS – if only we had these stores here in Canada!”