On 2016 Dec 17, Matthew Romo commented:

In their article, Kelling and colleagues identified clinical preventive services recommended by the US Preventive Services Task Force (USPSTF) that can be offered by community pharmacists, including folic acid supplementation, smoking cessation, and screening for osteoporosis and HIV (1). Clinical services are typically thought of in the context of individual patient-provider interaction, but adapting a population-level approach is particularly important for pharmacy-based preventive care services. Specifically, pharmacies located in high poverty areas have a tremendous opportunity to not only meet their communities’ public health needs, but to also reduce health disparities.

New York City exemplifies the need for this type of population-level thinking because health differs greatly by neighborhoods, which often have both poverty and racial/ethnic distinctions. For example, there are major disparities in HIV incidence, with a median annual HIV diagnosis rate of 75.6 per 100,000 population in the highest poverty neighborhoods vs. 13.7 per 100,000 population in the lowest poverty neighborhoods (2). Pharmacy-based HIV testing is indeed feasible in the city (3) and could be a service targeted to residents of high-risk neighborhoods. Nonprescription syringe sales by pharmacies to injection drug users present a propitious opportunity to promote screening for HIV.

Smoking prevalence in the highest poverty neighborhoods of New York City is more than double that of the lowest poverty neighborhoods (29.7% vs. 14.3%) (4). Availability of tobacco in pharmacies is germane if community pharmacies are to be regarded by the public as health promoting institutions. Tobacco bans in pharmacies are, of course, strongly advisable but do not appear to have a real impact on tobacco availability in poorer neighborhoods where smoking prevalence is highest. In an analysis of 240 census tracts in Rhode Island (5), tobacco retail outlet density was positively associated with neighborhood poverty and when excluding pharmacies as tobacco retailers, this association did not change. Of course, the availability of nicotine replacement therapy on pharmacy shelves allows pharmacists to counsel patients on their use. However, as mentioned by Kelling and colleagues, simple frameworks like “Ask, Advise, Refer” can help pharmacists connect patients to a telephone quitline, which can provide counseling and linkage to programs offering free or low cost nicotine replacement therapy and medication. Linkage to quitlines could be coupled with existing services, such as administering seasonal influenza vaccines or screening for drug-tobacco interactions (which are numerous). These opportunities could give a non-intrusive opportunity to “ask” and “advise.”

Pharmacy services, like other healthcare services, can differ by neighborhood. In New York City, higher poverty neighborhoods are characterized as having significantly more independent (vs. chain) pharmacies and pharmacies that are more likely to have medications out of stock (6). Nevertheless, it appears that community pharmacists support providing clinical preventive services, regardless of the neighborhood poverty level where their pharmacy is located. This was suggested by a study assessing New York City pharmacists’ attitudes about providing vaccinations to their patients when state legislation was passed allowing them to do so (7).

As highlighted by Kelling and colleagues, community pharmacists are highly accessible (and often underutilized) healthcare professionals who are clearly capable of implementing USPSTF recommendations, among others. Pharmacies are also attractive conduits for improving public health, as demonstrated by successes in immunization uptake and most recently with expansion of non-prescription naloxone access. Because of their focus on population health, local health departments should partner with community pharmacists and pharmacy owners, if they are not doing so already, to better meet the public health needs of their communities. Community pharmacists not only have the potential to positively impact public health, but because of where they work in the community, they are ideally positioned to reduce health disparities.

Matthew L. Romo, PharmD, MPH

Department of Epidemiology and Biostatistics, CUNY Graduate School of Public Health and Health Policy; CUNY Institute for Implementation Science in Population Health; matthew.romo@sph.cuny.edu

REFERENCES 1. Kelling SE, Rondon-Begazo A, DiPietro Mager NA, Murphy BL, Bright DR. Provision of clinical preventive services by community pharmacists. Prev Chronic Dis 2016;13:160232. DOI: http://dx.doi.org/10.5888/pcd13.160232. 2. Wiewel EW, Bocour A, Kersanske LS, Bodach SD, Xia Q, Braunstein SL. The association between neighborhood poverty and HIV diagnoses among males and females in New York City, 2010-2011. Public Health Rep. 2016;131(2):290-302. 3. Amesty S, Crawford ND, Nandi V, Perez-Figueroa R, Rivera A, Sutton M, et al. Evaluation of pharmacy-based HIV testing in a high-risk New York City community. AIDS Patient Care STDS. 2015;29(8):437-44. 4. Perlman SE, Chernov C, Farley SM, Greene CM, Aldous KM, Freeman A, et al. Exposure to secondhand smoke among nonsmokers in New York City in the context of recent tobacco control policies: Current status, changes over the past decade, and national comparisons. Nicotine Tob Res. 2016;18(11):2065-74. 5. Tucker-Seeley RD, Bezold CP, James P, Miller M, Wallington SF. Retail pharmacy policy to end the sale of tobacco products: What is the impact on disparity in neighborhood density of tobacco outlets? Cancer Epidemiol Biomarkers Prev. 2016;25(9):1305-10. 6. Amstislavski P, Matthews A, Sheffield S, Maroko AR, Weedon J. Medication deserts: survey of neighborhood disparities in availability of prescription medications. Int J Health Geogr. 2012;11:48. 7. Crawford ND, Blaney S, Amesty S, Rivera AV, Turner AK, Ompad DC, et al. Individual- and neighborhood-level characteristics associated with support of in-pharmacy vaccination among ESAP-registered pharmacies: pharmacists' role in reducing racial/ethnic disparities in influenza vaccinations in New York City. J Urban Health. 2011;88(1):176-85.

On 2016 Dec 17, Matthew Romo commented:

In their article, Kelling and colleagues identified clinical preventive services recommended by the US Preventive Services Task Force (USPSTF) that can be offered by community pharmacists, including folic acid supplementation, smoking cessation, and screening for osteoporosis and HIV (1). Clinical services are typically thought of in the context of individual patient-provider interaction, but adapting a population-level approach is particularly important for pharmacy-based preventive care services. Specifically, pharmacies located in high poverty areas have a tremendous opportunity to not only meet their communities’ public health needs, but to also reduce health disparities.

New York City exemplifies the need for this type of population-level thinking because health differs greatly by neighborhoods, which often have both poverty and racial/ethnic distinctions. For example, there are major disparities in HIV incidence, with a median annual HIV diagnosis rate of 75.6 per 100,000 population in the highest poverty neighborhoods vs. 13.7 per 100,000 population in the lowest poverty neighborhoods (2). Pharmacy-based HIV testing is indeed feasible in the city (3) and could be a service targeted to residents of high-risk neighborhoods. Nonprescription syringe sales by pharmacies to injection drug users present a propitious opportunity to promote screening for HIV.

Smoking prevalence in the highest poverty neighborhoods of New York City is more than double that of the lowest poverty neighborhoods (29.7% vs. 14.3%) (4). Availability of tobacco in pharmacies is germane if community pharmacies are to be regarded by the public as health promoting institutions. Tobacco bans in pharmacies are, of course, strongly advisable but do not appear to have a real impact on tobacco availability in poorer neighborhoods where smoking prevalence is highest. In an analysis of 240 census tracts in Rhode Island (5), tobacco retail outlet density was positively associated with neighborhood poverty and when excluding pharmacies as tobacco retailers, this association did not change. Of course, the availability of nicotine replacement therapy on pharmacy shelves allows pharmacists to counsel patients on their use. However, as mentioned by Kelling and colleagues, simple frameworks like “Ask, Advise, Refer” can help pharmacists connect patients to a telephone quitline, which can provide counseling and linkage to programs offering free or low cost nicotine replacement therapy and medication. Linkage to quitlines could be coupled with existing services, such as administering seasonal influenza vaccines or screening for drug-tobacco interactions (which are numerous). These opportunities could give a non-intrusive opportunity to “ask” and “advise.”

Pharmacy services, like other healthcare services, can differ by neighborhood. In New York City, higher poverty neighborhoods are characterized as having significantly more independent (vs. chain) pharmacies and pharmacies that are more likely to have medications out of stock (6). Nevertheless, it appears that community pharmacists support providing clinical preventive services, regardless of the neighborhood poverty level where their pharmacy is located. This was suggested by a study assessing New York City pharmacists’ attitudes about providing vaccinations to their patients when state legislation was passed allowing them to do so (7).

As highlighted by Kelling and colleagues, community pharmacists are highly accessible (and often underutilized) healthcare professionals who are clearly capable of implementing USPSTF recommendations, among others. Pharmacies are also attractive conduits for improving public health, as demonstrated by successes in immunization uptake and most recently with expansion of non-prescription naloxone access. Because of their focus on population health, local health departments should partner with community pharmacists and pharmacy owners, if they are not doing so already, to better meet the public health needs of their communities. Community pharmacists not only have the potential to positively impact public health, but because of where they work in the community, they are ideally positioned to reduce health disparities.

Matthew L. Romo, PharmD, MPH

Department of Epidemiology and Biostatistics, CUNY Graduate School of Public Health and Health Policy; CUNY Institute for Implementation Science in Population Health; matthew.romo@sph.cuny.edu

REFERENCES 1. Kelling SE, Rondon-Begazo A, DiPietro Mager NA, Murphy BL, Bright DR. Provision of clinical preventive services by community pharmacists. Prev Chronic Dis 2016;13:160232. DOI: http://dx.doi.org/10.5888/pcd13.160232. 2. Wiewel EW, Bocour A, Kersanske LS, Bodach SD, Xia Q, Braunstein SL. The association between neighborhood poverty and HIV diagnoses among males and females in New York City, 2010-2011. Public Health Rep. 2016;131(2):290-302. 3. Amesty S, Crawford ND, Nandi V, Perez-Figueroa R, Rivera A, Sutton M, et al. Evaluation of pharmacy-based HIV testing in a high-risk New York City community. AIDS Patient Care STDS. 2015;29(8):437-44. 4. Perlman SE, Chernov C, Farley SM, Greene CM, Aldous KM, Freeman A, et al. Exposure to secondhand smoke among nonsmokers in New York City in the context of recent tobacco control policies: Current status, changes over the past decade, and national comparisons. Nicotine Tob Res. 2016;18(11):2065-74. 5. Tucker-Seeley RD, Bezold CP, James P, Miller M, Wallington SF. Retail pharmacy policy to end the sale of tobacco products: What is the impact on disparity in neighborhood density of tobacco outlets? Cancer Epidemiol Biomarkers Prev. 2016;25(9):1305-10. 6. Amstislavski P, Matthews A, Sheffield S, Maroko AR, Weedon J. Medication deserts: survey of neighborhood disparities in availability of prescription medications. Int J Health Geogr. 2012;11:48. 7. Crawford ND, Blaney S, Amesty S, Rivera AV, Turner AK, Ompad DC, et al. Individual- and neighborhood-level characteristics associated with support of in-pharmacy vaccination among ESAP-registered pharmacies: pharmacists' role in reducing racial/ethnic disparities in influenza vaccinations in New York City. J Urban Health. 2011;88(1):176-85.