Tobacco Control in NYC: The Perfect Storm?

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Tobacco Control in NYCThe Perfect Storm?

• Sarah B. Perl, MPH
• Assistant Commissioner
• Bureau of Tobacco Control
• New York City Department of Health and Mental
  Hygiene
• May 2007

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Overview of New York City

• Prevalence 21.6 for a decade (1993-2002)
• Commissioner Thomas R. Frieden made tobacco
  control No. 1 priority (2002)
• Implemented CTC program (as per 1999 CDC Best
  Practices)
• Prevalence decreased 13 (2002 to 2005)
• Current Status
• Adult prevalence 18.9 (2005 CHS)
• 1.2 million adult smokers
• 30,000 public high school smokers
• Teen prevalence 11 (2005 YRBS)

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Making it Harder to Smoke

• Increased the price of cigarettes in NYC to about
  7 per pack
• 1.50 NYS excise tax (increased 39 cents,
  effective April 2, 2002)
• 1.50 NYC excise tax (increased 1.42, effective
  July 2, 2002)
• Implemented comprehensive indoor air laws,
  prohibiting smoking in almost all workplaces,
  including restaurant and bars
• NYC Smoke-Free Air Act of 2002 (effective March
  30, 2003)
• NYS Clean Indoor Air Act (effective July 24, 2003)

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Making it Easier to Quit

• Increased access to cessation treatment, services
  and medications
• Giving away NRT directly to the public (Nicotine
  Patch Program 2003, 2005-2007)
• Increasing enrollment and use of medications at
  cessation programs at public hospitals (Health
  and Hospitals Corporation)
• Promoting systematic screening for tobacco use
  and delivery of cessation services by providers
  through Public Health Detailing
• Providing medication, technical assistance and
  support to clinic- and community-based
  organizations to provide cessation services
• Normalizing use of medications and aided quits

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NYCs Five-Point Plan forTobacco Control

• Taxation
• Legal action
• Cessation
• Education
• Evaluation

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Taxation

• The most effective strategy to decrease tobacco
  use
• Influences current smokers and future initiators
• 2002 NYC and NYS tax increases of 3 brought
  price in NYC to about 7 per pack -- highest
  combined city/state cigarette tax then, 6th
  highest now, behind four Illinois counties and
  Anchorage, Alaska
• Proportion of sales not taxed doubled after 2002
  tax increases (31) and continues to be a major
  challenge (23)
• NYC seeking 50 cent increase to excise tax
  (inflation eroded tax)

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Legal Action

• Passed comprehensive law, prohibiting smoking in
  almost all workplaces, including restaurant and
  bars
• Conducted public-opinion polls, environmental
  testing and extensive education campaign with
  legislators, business and the public
• Framed issue around worker health and safety --
  all workers deserve equal protection
• Message SFAA will save lives and wont hurt
  business

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Smoke-Free Air Act 3 Years Later

• Overwhelming compliance (gt99)
• Business in restaurants/bars increased 8.7
• Number of liquor licenses increased 5.1 (500 new
  licensees) restaurant/bar employment increased
  8.4 (13,600 new jobs)
• Air quality in bars improved average 6-fold
• Levels of cotinine decreased 65 in non-smoking
  restaurant/bar workers (NYS data)
• 150,000 fewer NYers exposed to SHS on the job
• 90 of NYers including 70 of smokers have
  made their homes smoke-free
• 125,000 fewer NYers exposed to SHS at home

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Cessation

• Partnerships with NYCs public hospital system
  and with community- and clinic-based sites to
  promote and support aided quits
• Public Health Detailing to maximize the clinical
  encounter and promote systems change at clinics
• Nicotine Patch giveaways to distribute
  barrier-free nicotine replacement to NYC smokers

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Tobacco Cessation atNYC Public
HospitalsPatients Who Received Cessation
Medications
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Public Health Detailing

• Uses pharmaceutical sales approach
• Sells public health interventions
• Provides brief, one-on-one interactions with
  health care providers
• Promotes use of clinical systems to ensure that
  opportunities for care are not missed

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2003 Nicotine Patch Giveaway Increased Quit Rates
6-Fold

• 34,000 six-week courses of NRT patches given
  away to heavy smokers (10 cpd)
• gt11,000 (33) quit after 6 months
• More than double expectations
• 6x higher than quit rates without NRT
• If only half stay quit for life, saves gt1500
  lives

Quit Rates
Miller N, Frieden Tr, Liu SY et al. Effectiveness
of large-scale distribution programme of free
nicotine patches. Lancet 2005
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Nicotine Patch Programs
Program Year Length of program (days) Partner NRT dosage and duration of treatment NRT courses distributed (total) Follow-up provided
2003 43 NYS Smokers Quitline 2 wks 21mg 2 wks 14 mg 2 wks 7 mg 35,000 Calls at 3- and 14-weeks to all enrollees
2005 36 NYC 311 6 wks 15mg 45,000 Calls at 3-weeks to smokers of 10-20 cpd
2006 34 NYC 311 4 wks 21mg option for 2 additional wks 14 mg 35,000 Calls at 3-weeks to smokers of 10-20 cpd
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Costs of NRT Giveaways

• Medication how many weeks, how many recipients,
  donations
• Outreach earned, paid (novelty of first time)
  and value-added
• Fulfillment packing and shipping (fixed costs)
• Counseling and follow-up provision, frequency,
  evaluation
• Staffing call center, surge capacity, program
  management

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Maximizing Cessation

• 9 out of 10 smokers want to quit
• Two-thirds of smokers try to quit each year, but
  .
• Smokers need to be motivated to
• Move along the readiness/stage of change
  continuum
• Make a quit attempt (or another quit attempt --
  it takes most smokers multiple attempts)
• Try medication
• Offering free meds/services isnt enough
• Meds/services needs to be driven using media
• Because most smokers quit without the aid of
  medication, the primary message is Quit the
  secondary message is Call

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Education

• Shift social norms
• Prompt aided and unaided quits
• Promote the benefits of quitting and the
  availability of cessation services
• Increase awareness of the dangers of smoking and
  exposure to second-hand smoke
• Use hard-hitting counter-advertising campaigns
• Develop print materials and resources for lay and
  provider audiences

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Public Education
Targeted Ad Campaigns
Provider Education
Campaigns
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NYCs Quitline Proxy 311

• 311 NYCs non-emergency government info line
• Highly normalized one-stop number for all NYC
  government services
• Quit Smoking Assistance services
• Referral to local HHC clinics (2)
• Send self-help materials (2)
• Transfer to NYS Smokers Quitline (96)
• NYS Smokers Quitline services
• Counseling, self-help materials, 2-week starter
  kits of NRT, referrals to local programs,
  automated quit tips, web-based cessation,
  pro-active call backs
• All NYC and NYS TV media co-tagged 311 and
  866-NY-QUITS as of Sept. 2006

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2006 Media Campaign

• Launched largest NYC campaign ever in Jan. 2006
• Every Cigarette is Doing Damage (AU)
• Testimonials of sick and dying smokers
• Mike Sams (AL)
• Pam Laffin (MA)
• Ronaldo Martinez (MA)
• Calls to 311 for quit smoking assistance
  quadrupled to 30,000 (Jan-June 2006) from 7,500
  (Jan-June 2005)
• Generated significant earned media

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Artery
Pam
Ronaldo
Brain
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Calls to 311 Jan-June 2005 and 2006 by Week
Patch program calls (weeks 18-23) not included
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2006 Media and Calls to 311Jan-June 2005 and
2006 by Week
Patch program calls (weeks 18-23) not included
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Maximizing Media

• Media needs to provide consistent, persuasive
  salient messages to smokers
• Air media of sufficient intensity, frequency and
  duration (4 flights, 4 weeks, 1200 GRP per
  flight)
• Show hard-hitting ads that provoke a negative
  emotional response
• Ideally spending warrants value-added and
  generates earned media
• May be a threshold of effectiveness below which
  media may not the best investment
• Adult-focused ads may be effective with kids (the
  reverse may not hold)

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Evaluation

• Collect, analyze and disseminate ongoing
  community-specific tobacco-related behaviors
• Use registries and other data to inform program
  implementation
• Track effectiveness of different interventions
  and adjust approaches
• Use qualitative data to enhance understanding of
  findings and inform decision-making
• Use data to educate smokers and prompt quits

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Teen Smoking in NYCDown 52 in the Past 8
YearsAnd Less than Half the National Rate
of H.S. Students
YRBS, public high school students
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NYC Adult Smoking Prevalence1993-2005Nearly
200,000 Fewer SmokersMore than 50,000 Premature
Deaths Prevented
City and State tax increases
Smoke-free workplaces
3-yr average
3-yr average
3-yr average
Free patch programs
of adults
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Maximizing CTC Creating the Perfect Storm

• Ensure sufficient political support and funding
• Implement effective interventions
• 1) Tax increase the price of cigarettes,
  consider of price
• 2) Smoke-Free include restaurants, bar, casinos
  resist carve-outs, reject enclosures
• 3) Media prompt smokers to make aided and
  unaided quits with hard-hitting campaigns
• 4) Cessation increase availability and access
• Evaluate overall synergistic effect (relative
  contribution of individual components may not be
  quantifiable)