This retrospective qualitative review describes the marketing of antipsychotics by pharmaceutical companies to prisons and jails to increase prescribing. This review relied on internal pharmaceutical industry documents released in litigation and stored in the Drug Industry Documents archive at the UCSF Industry Documents Library. At least two pharmaceutical companies directly marketed antipsychotics to correctional facilities to increase sales, using targeted promotions and indirect "educational" advertising and by seeking control of state advisory boards that made formulary decisions. Further research on how medications are marketed is needed, along with stronger conflict-of-interest policies to reduce industry involvement on advisory boards that approve medications. National regulations that restrict pharmaceutical manufacturers from involvement in formulary decisions and prescribing guidelines would likely improve the provision of health care to people who are incarcerated.

Many pharmacists have expressed a desire to become more involved in patient care, in part by being compensated for patient counseling, as well as by providing services traditionally offered by physicians and nurse practitioners. Recent efforts to develop collaborative care models, as well as major restructurings of US health insurance coverage, provide a unique opportunity for pharmacists to become recognized as independent health care providers and be reimbursed as primary care providers. Achieving that goal would require addressing advocacy challenges familiar to other health care professionals who have achieved provider status under existing reimbursement rules. Historically, political advocacy has not been a major part of pharmacy practice, or even viewed as necessary. However, pharmacists would be more politically effective with a single organization to speak for them as a profession, and with further education in advocacy.

Objectives

Although tobacco is the leading preventable cause of death in the USA, it is routinely sold in pharmacies. In 2008, San Francisco became the first city in the USA to pass a tobacco-free pharmacy ordinance. Over the next decade, 171 municipalities enacted similar policies, and in 2018, Massachusetts banned tobacco sales in pharmacies. Our objective was to assess the perceived effects of tobacco-free pharmacy policies on displays, sales, customer visits and counselling.

Design

Observational study and survey.

Setting

In 2017, we visited Walgreens and CVS stores in San Francisco and nearby San Jose, which allows tobacco sales, to assess placement of tobacco and over-the-counter tobacco cessation products (nicotine replacement therapy or NRT). We surveyed an employee at each site regarding the impact that tobacco-free pharmacy policies had had on customer traffic and sales of NRT.

Participants

We obtained display data from 72 pharmacies and collected surveys from 55 employees (76% response rate).

Results

A majority of respondents at tobacco-free pharmacies (55%) reported that the policy had not affected customer visits. In comparison, 70% of respondents at tobacco-selling pharmacies believed that eliminating tobacco sales would reduce the number of customers visiting their stores. Pharmacies that were tobacco free and those that sold tobacco reported comparable displays, sales and counselling for NRT.

Conclusions

Pharmacies operating under tobacco-free policies did not report reduced customer visits. Greater awareness of this outcome could help pharmacies implement public health recommendations to eliminate tobacco sales.

Background

Increasing tobacco taxes, and through them, prices, is an effective public health strategy to decrease tobacco use. The tobacco industry has developed multiple promotional strategies to undercut these effects; this study assessed promotions directed to wholesalers and retailers and manufacturer price changes that blunt the effects of tax and price increases.

Methods

We reviewed tobacco industry documents and contemporaneous research literature dated 1987 to 2016 to identify the nature, extent, and effectiveness of tobacco industry promotions and price changes used after state-level tobacco tax increases.

Results

Tobacco companies have created promotions to reduce the effectiveness of tobacco tax increases by encouraging established users to purchase tobacco in lower-tax jurisdictions and sometimes lowering manufacturer pricing to "undershift" smaller tax increases, so that tobacco prices increased by less than the amount of the tax.

Conclusions

Policymakers should address industry efforts to undercut an effective public health intervention through regulating minimum prices, limiting tobacco industry promotions, and by enacting tax increases that are large, immediate, and result in price increases.

Implications

Tobacco companies view excise tax increases on tobacco products as a critical business threat. To keep users from quitting or reducing tobacco use in response to tax increases, they have shifted manufacturer pricing and developed specific promotions that encourage customers to shop for lower-taxed products. Health authorities should address tobacco industry efforts to undercut the effects of taxes by regulating prices and promotions and passing large and immediate tax increases.

Background

Multiple efforts to generate evidence-informed policy have attempted to teach policymakers how to understand and apply scientific research findings in their decision-making. These efforts have had limited success, because policymakers generally do not understand scientific methods.

Objective

We piloted efforts to teach policy intermediaries - specifically consumer advocacy groups - how to understand and apply health research, anticipating that they might offer such evidence to policymakers in more accessible forms.

Design

Four workshops focusing on research design and methods were conducted with consumer advocacy groups in 2010. We coded and analyzed participant responses regarding their confidence in interpreting research findings and assessments of research credibility, and the extent to which their knowledge about research findings changed after completing the workshops.

Results

Our findings suggest that although participants expressed strong interest in understanding scientific research, their ability to develop confidence about scientific research methods was limited. However, like policymakers, consumer advocacy group members intuited that financial conflicts of interest could compromise scientific findings, although they initially underestimated their effects on research results. After training, consumer advocates also saw the value of using systematic reviews rather than individual studies.

Discussion and conclusions

Our findings suggest that although advocates may not feel confident in their understanding of scientific research, they found it easier to understand the value of systematic reviews and the risks of conflicts of interest than other statistical concepts and terminology. Focusing on making these types of information available may offer a useful way for policymakers and consumer advocates to interpret the validity of policy-relevant scientific research.

Introduction

Researchers advocating for evidence-informed policy have attempted to encourage policymakers to develop a greater understanding of research and researchers to develop a better understanding of the policymaking process. Our aim was to apply findings drawn from studies of the policymaking process, specifically the theory of policy windows, to identify strategies used to integrate evidence into policymaking and points in the policymaking process where evidence was more or less relevant.

Methods

Our observational study relied on interviews conducted with 24 policymakers from the USA who had been trained to interpret scientific research in multiple iterations of an evidence-based workshop. Participants were asked to describe cases where they had been involved in making health policy and to provide examples in which research was used, either successfully or unsuccessfully. Interviews were transcribed, independently coded by multiple members of the study team and analysed for content using key words, concepts identified by participants and concepts arising from review of the texts.

Results

Our results suggest that policymakers who focused on health issues used multiple strategies to encourage evidence-informed policymaking. The respondents used a strict definition of what constituted evidence, and relied on their experience with research to discourage the use of less rigorous research. Their experience suggested that evidence was less useful in identifying problems, encouraging political action or ensuring feasibility and more useful in developing policy alternatives.

Conclusions

Past research has suggested multiple strategies to increase the use of evidence in policymaking, including the development of rapid-response research and policy-oriented summaries of data. Our findings suggest that these strategies may be most relevant to the policymaking stream, which develops policy alternatives. In addition, we identify several strategies that policymakers and researchers can apply to encourage evidence-informed policymaking.

Background

The cannabis industry has an interest in creating a regulatory environment which maximizes profits at the cost of public health, similar to the tobacco, alcohol, and food industries. This study sought to describe the cannabis industry's lobbying activities in the Colorado State Legislature over time.

Methods

This retrospective observational study analyzed publicly available lobbying expenditures data from fiscal years (FY) 2010-2021. Measures included inflation-adjusted monthly lobbying expenditures by funder and lobbyist, origin of funding, and lobbyist descriptions of cannabis industry clients. This dataset was supplemented with business license documentation, legislative histories, and public testimony.

Results

The cannabis industry spent over $7 million (inflation adjusted) from FY 2010-2021 to lobby the Colorado legislature on 367 bills. Over $800,000 (11% of total cannabis spending) was from out-of-state clients. In 48% of lobbyist reports lobbyists did not disclose their funder's cannabis affiliation, and cannabis organizations used strategies that may have obscured the true amount and source of funding. Lobbyists and agencies concurrently represented the alcohol, tobacco, and cannabis industries, possibly facilitating inter-industry alliances when interests align.

Conclusion

The cannabis industry dedicated significant resources towards lobbying the Colorado State Legislature on behalf of policies intended to increase cannabis use. Creating transparency about the relationships between the cannabis industry, related industries, and policymakers is essential to ensure appropriate regulation of cannabis products.

Background

Increasing the price of tobacco products has the potential to reduce tobacco consumption. As other forms of promotion have been increasingly restricted over time, tobacco manufacturers have relied more on trade discounts. Minimum price laws that prevented the use of manufacturer promotions were once common; however in most US jurisdictions these discounts are now legally protected.

Methods

We collected tobacco industry documents, state legislation and court cases between 1987 and 2016 to review tobacco manufacturer strategies to change minimum price laws in the USA.

Results

Beginning in 2000, tobacco manufacturers lobbied to amend minimum price legislation after state regulators indicated that manufacturer promotions were illegal under existing laws. Companies viewed changing these laws as critical to maintaining tobacco sales, and after the initiation of an industry lobbying campaign, at least 20 states changed the way they calculated tobacco prices.

Conclusions

Modifying existing minimum price laws so that manufacturer discounts are no longer protected, and implementing new minimum price policies with comparable scope, would likely increase prices and reduce tobacco use.

In the United States, state laws establish a minimum age of legal access (MLA) for most tobacco products at 18 years. We reviewed the history of these laws with internal tobacco industry documents and newspaper archives from 1860 to 2014. The laws appeared in the 1880s; by 1920, half of states had set MLAs of at least 21 years. After 1920, tobacco industry lobbying eroded them to between 16 and 18 years. By the 1980s, the tobacco industry viewed restoration of higher MLAs as a critical business threat. The industry's political advocacy reflects its assessment that recruiting youth smokers is critical to its survival. The increasing evidence on tobacco addiction suggests that restoring MLAs to 21 years would reduce smoking initiation and prevalence, particularly among those younger than 18 years.