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

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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

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)