Tobacco Control in NYC:The Perfect Storm?
Sarah B. Perl, MPH
Assistant Commissioner
Bureau of Tobacco ControlNew York City Department of Health and Mental Hygiene
May 2007
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)
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)
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
NYC’s Five-Point Plan forTobacco Control
• Taxation• Legal action• Cessation• Education• Evaluation
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)
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 won’t hurt business
Smoke-Free Air Act – 3 Years Later• Overwhelming compliance (>99%)• 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
Cessation
• Partnerships with NYC’s 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
Tobacco Cessation atNYC Public Hospitals
Patients Who Received Cessation Medications
875 85712221115
1628
2435
5723
7014
40194185
52514714
52514714
3765
5100
4225
0
1000
2000
3000
4000
5000
6000
7000
8000
Q103
Q203
Q303
Q403
Q104
Q204
Q304
Q404
Q105
Q205
Q305
Q405
Q106
Q206
Q306
Q406
Q107
# R
ec
eiv
ing
Ce
ss
ati
on
Me
dic
ati
on
s
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
2003 Nicotine Patch Giveaway Increased Quit
Rates 6-Fold• 34,000 six-week courses of
NRT patches given away to heavy smokers (10+ cpd)
• >11,000 (33%) quit after 6 months– More than double
expectations– 6x higher than quit rates
without NRT• If only half stay quit for life,
saves >1500 lives*
33%
5-7%
0
5
10
15
20
25
30
35
NoMedication
NRT
Quit Rates
Miller N, Frieden Tr, Liu SY et al. Effectiveness of large-scale distribution programme of free nicotine patches. Lancet 2005
Nicotine Patch ProgramsProgram Year
Length of program (days)
Partner NRT dosage and duration of treatment
NRT courses distributed (total)
Follow-up provided
2003 43 NYS Smoker’s 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
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
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 isn’t 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”
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
Public Education Targeted Ad Campaigns
Provider Education Campaigns
NYC’s Quitline Proxy: 311
• 311: NYC’s 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
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
“Artery” “Pam”
“Brain” “Ronaldo”
Calls to 311 Jan-June 2005 and 2006 by Week*
*Patch program calls (weeks 18-23) not included
0
500
1,000
1,500
2,000
2,500
3,000
3,500
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Week of Year (Mon-Sun)
Ca
lls t
o 3
11
*
2006 (Total=29,881)
2005 (Total=7,502)
2006 Media and Calls to 311Jan-June 2005 and 2006 by Week*
*Patch program calls (weeks 18-23) not included
0
500
1,000
1,500
2,000
2,500
3,000
3,500
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Week of Year (Mon-Sun)
Ca
lls t
o 3
11
*
0
100
200
300
400
500
600
700
20
06
GR
Ps
2006 GRPs
2006 (Total=29,881)
2005 (Total=7,502)
Pam Laffin Campaign
Mike Sams Campaign
SHS Campaign & Everybody
Loves a Quitter Campaign
Ronaldo Martinez
Campaign
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)
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
Teen Smoking in NYCDown 52% in the Past 8 Years…
And Less than Half the National Rate
11%15%
18%
24%23% 23%22%
29%
35%36%
0%
5%
10%
15%
20%
25%
30%
35%
40%
1997 1999 2001 2003 2005
NYC U.S.
YRBS, public high school students
% o
f H
.S.
Stu
dent
s
NYC Adult Smoking Prevalence1993-2005
Nearly 200,000 Fewer SmokersMore than 50,000 Premature Deaths Prevented
18.4%
21.6%
21.7%21.5%21.6%
19.2% 18.9%
0
5
10
15
20
25
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
% o
f ad
ult
s
City and Statetax increases
Smoke-free workplaces
Free patchprograms
3-yr average 3-yr average3-yr average
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)