tobacco control in nyc: the perfect storm? sarah b. perl, mph assistant commissioner bureau of...
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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
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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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NYC’s 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 won’t hurt business
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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
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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
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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
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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)
• >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
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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
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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 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”
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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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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
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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”
“Brain” “Ronaldo”
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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)
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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
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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 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
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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
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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)