Transcript Document
Tobacco Control in NYC:
The Perfect Storm?
Sarah B. Perl, MPH
Assistant Commissioner
Bureau of Tobacco Control
New 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 for
Tobacco 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 at
NYC Public Hospitals
# Receiving Cessation Medications
Patients Who Received Cessation Medications
8000
7014
7000
5723
6000
5251
5251
5100
4714
4714
4225
40194185
3765
5000
4000
3000
2435
2000
1000
875 857
1628
12221115
0
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1
03 03 03 03 04 04 04 04 05 05 05 05 06 06 06 06 07
Public Health Detailing
• Uses pharmaceutical
sales approach
• “Sells” public health
interventions
• Provides brief, one-onone 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*
Miller N, Frieden Tr, Liu SY et al. Effectiveness of large-scale
distribution programme of free nicotine patches. Lancet 2005
Quit Rates
33%
35
30
25
20
15
10
5-7%
5
0
No
Medication
NRT
Nicotine Patch Programs
Program
Year
Length of
program
(days)
Partner
NRT dosage and
duration of
treatment
NRT
Follow-up
courses
provided
distributed
(total)
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 3weeks to
smokers of
10-20 cpd
2006
34
NYC 311
4 wks 21mg;
option for 2
additional wks 14
mg
35,000
Calls at 3weeks 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 866NY-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”
“Brain”
“Pam”
“Ronaldo”
Calls to 311
Jan-June 2005 and 2006 by Week*
3,500
2006 (Total=29,881)
2005 (Total=7,502)
3,000
Calls to 311*
2,500
2,000
1,500
1,000
500
0
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)
*Patch program calls (weeks 18-23) not included
2006 Media and Calls to 311
Jan-June 2005 and 2006 by Week*
3,500
3,000
Pam Laffin
Campaign
SHS Campaign
& Everybody
Loves a Quitter
Campaign
Ronaldo
Martinez
Campaign
Mike Sams
Campaign
700
600
500
2,000
400
1,500
300
1,000
200
500
100
0
0
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)
*Patch program calls (weeks 18-23) not included
2006 GRPs
Calls to 311*
2,500
2006 GRPs
2006 (Total=29,881)
2005 (Total=7,502)
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 NYC
Down 52% in the Past 8 Years…
And Less than Half the National Rate
40%
36%
35%
% of H.S. Students
35%
29%
30%
25%
24%
23%
22%
23%
18%
20%
15%
15%
11%
10%
NYC
5%
U.S.
0%
1997
YRBS, public high school students
1999
2001
2003
2005
NYC Adult Smoking Prevalence
1993-2005
Nearly 200,000 Fewer Smokers
More than 50,000 Premature Deaths Prevented
25
3-yr average
21.6%
% of adults
20
15
3-yr average
21.5%
3-yr average
21.7%
City and State
tax increases
Smoke-free
workplaces
Free patch
programs
21.6%
19.2%
18.9%
18.4%
10
5
0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
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)