Making It Harder to Smoke and Easier to Quit: The Effect of 10 Years of Tobacco Control in New York City

Abstract

In 2002, New York City implemented a comprehensive tobacco control plan that discouraged smoking through excise taxes and smoke-free air laws and facilitated quitting through population-wide cessation services and hard-hitting media campaigns.

Following the implementation of these activities through a well-funded and politically supported program, the adult smoking rate declined by 28% from 2002 to 2012, and the youth smoking rate declined by 52% from 2001 to 2011.

These improvements indicate that local jurisdictions can have a significant positive effect on tobacco control.

An estimated one third of smokers will die of a smoking-related illness, losing, on average, 14 years of life.¹ In New York City, New York, in 2006, it was estimated that more than 7000 adults died from smoking-related illnesses, with these deaths accounting for approximately 14% of all adult deaths—or one in seven.²

In 2002, tobacco control became a major priority of the New York City Health Department. At that time, a pack of cigarettes cost about $5.20, and smoking in bars, restaurants with fewer than 35 seats, and separate areas of workplaces was permitted. The adult smoking prevalence averaged 22% and showed no sign of change over the 10 preceding years.³

To address tobacco use, the health department implemented a “Five Point Plan” in 2002, making it harder to smoke and easier to quit. This population-based tobacco control strategy consisted of

1. an increase in the price of cigarettes,

2. comprehensive smoke-free air legislation,

3. access to cessation medications,

4. mass media messages on the health consequences of smoking and secondhand smoke exposure, and

5. evaluation of key interventions.

MAKING IT HARDER TO SMOKE

In 2002, two interventions were launched simultaneously: an increase in the city’s cigarette excise tax and the passage of a comprehensive smoke-free air law. The New York City cigarette excise tax increased from $0.08 to $1.50. At the same time, the New York State excise tax increased from $1.11 to $1.50, resulting in a combined city and state tax of $3. Increasing the price of cigarettes has been shown to reduce smoking, especially among youths who are more sensitive to price than are adults.⁴ Further state tax increases in 2008 and 2010, of $1.25 and $1.60, respectively, as well as a 2009 federal increase of $1.01, brought the total tax per pack in New York City to $6.86 and the retail pack price to the highest in the nation at the time, at approximately $11.

In 2003 when the comprehensive smoke-free air legislation was implemented,⁵ California was one of the few other jurisdictions to have such legislation. New York City’s law was built on a law established in 1995 and prohibited smoking in virtually all city workplaces, including more than 20 000 restaurants and bars. The effect of the Smoke-Free Air Act on workers was made poignant by testimonials from bar and restaurant workers who had experienced the health effects of secondhand smoke prior to the law’s passage. Although initially the proposal was met with warnings that the law would adversely affect business, a report issued one year after implementation showed 95% compliance among restaurants and bars, with no negative effect on sales or employment, and air-monitoring tests showed that pollution in bars decreased after the law took effect.⁶

Since 2002, the area covered under New York City’s Smoke-Free Air Act has grown. In 2009, the Smoke-Free Air Act was expanded to prohibit smoking within 15 feet of entrances, exits, and grounds of New York City’s hospitals, diagnostic and treatment centers, and residential health care facilities. In 2011, a further expansion of the law prohibited smoking in all of the city’s 1700 public parks, 14 miles of beaches, and pedestrian plazas, including the plazas in Times Square. Although this law is not the first of its kind in the United States, the city engaged in extensive education on the effect of outdoor secondhand smoke exposure and on the environmental effect of smoking-related litter. Evaluation of the rule one year later showed nearly a two-thirds decrease in smoking in parks and smoking-related litter in parks and on beaches.⁷

MAKING IT EASIER TO QUIT

Prior to 2006, the New York City Health Department’s public education strategy for tobacco control relied primarily on print educational information. The 2005 “Everybody Loves a Quitter” campaign featured images of happy quitters, surrounded by family and friends. Focus groups with smokers showed that these kinds of positive messages were generally well received but suggested that they had little effect on cessation attempts.

On the basis of a review of promising evidence from Australia and Massachusetts on the efficacy of campaigns that aggressively show the health effects of smoking,^8,9 the health department began producing and airing hard-hitting, antismoking media campaigns. To date, nine television campaigns have been produced by the health department, and many other similarly focused campaigns produced elsewhere also have been aired. These emotionally provocative campaigns feature graphic images of the health effects of smoking and stories of real people and families devastated by smoking-related illness and death. One such New York City campaign, “Cigarettes Are Eating You Alive,” juxtaposed images of cigarette smoke entering the body with images of smoking-related damage in adults and children. It has been adopted for use in 14 countries and continues to be evaluated as a highly effective antismoking campaign.¹⁰ New York City’s other advertising campaigns—“Marie,” “Reverse the Damage,” “Secondhand Smoke Kids,” “Suffering Every Minute,” “One Cigarette,” and “Pain”—continue to pair graphic health consequences with emotionally provocative narratives to prompt smokers to quit. Early advertisements such as “Marie” and “Reverse the Damage” showed the health consequences for the smoker. “Marie,” a woman with Buerger’s disease and amputations as a result of smoking, told about her difficulty doing everyday activities. Later advertisements, such as “Suffering Every Minute” and “Pain,” showed not only the consequences of smoking but also the effect on family members—a theme that was particularly powerful. Although all of these advertisements spoke to smoking-related death, they also depicted the suffering and debilitation that smoking-related illnesses can cause. New York State anti-tobacco campaigns also aired in New York City, as did national campaigns, such as those by the American Legacy Foundation.

Advertisements typically air on television four to five periods per year at an average gross rating point level (gross rating points measure reach of the media times the frequency of exposure; one gross rating point means that 1% of the audience had one exposure) of 1100 over a three- to four-week period and also may have included supporting placement in subway cars, on the sides of city buses, in daily newspapers, and online. The campaigns ended with the call to action to “Quit Smoking Today” and to call 3-1-1, New York City’s information line, for help. Through 3-1-1, eligible smokers are referred to the New York State Smokers’ Quitline and provided with free nicotine replacement therapy, which has been shown to double the chances of quitting successfully.¹¹

The New York City Health Department also began an annual, population-based nicotine patch and gum distribution program to complement the routine services provided through the New York State Smokers’ Quitline.¹² This program was designed as a time-limited effort occurring a few weeks per year and has been driven, since 2006, by hard-hitting media campaigns with a call to action directing smokers to call 3-1-1 for help quitting. By instilling a sense of urgency with a time-limited program, the giveaways greatly increased call volume and in 2010 resulted in more than 40 000 enrollees in just 16 days, the most successful campaign to date.

EVALUATION OF EFFECT

Beginning in 2002, the New York City Health Department launched the annual New York City Community Health Survey.¹³ Modeled after the national Behavioral Risk Factor Surveillance System (BRFSS), this telephone survey of 8000 to 10 000 adults uses a stratified random design and is weighted to represent the New York City adult population while maintaining comparability with the BRFSS. It contains the same items used in the national BRFSS to assess current smoking, cigarettes smoked per day, and quit attempts. The health department also conducts a biannual (administered in odd-numbered years) Youth Risk Behavior Survey¹⁴ to assess smoking behavior in about 10 000 New York City public high school students.

Since New York City implemented the five-point plan in 2002, the adult smoking prevalence decreased 28%, from 21.5% in 2002 to 15.5% in 2012 (P < .001; Figure 1).¹³ Smoking among public high school students significantly decreased 52%, from 17.6% in 2001 to 8.5% in 2011 (P < .001; Figure 2).¹⁴ The rate of decline in New York City (b = −0.83; SE = 0.07) was significantly greater than the decline in the rest of the United States estimated from BRFSS between 2002 and 2010 (b = −0.65; SE = 0.02) when comparable data were available (z = 2.47; P = .007). Comparing the trends suggests that 22% of the decline is unique to New York City. The trend for the rest of New York State (b = −0.72; SE = 0.13) was not significantly different from New York City (P = .214), which is not surprising given that interventions on taxes, smoke-free air, and media also occurred at the state level. Compared with the rest of New York State, about 13% of the decline is unique to New York City.

FIGURE 1—

Adult smoking prevalence in New York City and the United States: 2002–2012.

FIGURE 2—

Prevalence of current smoking among public high school students in New York City and the United States: 2001–2011.

In addition, those still smoking are smoking fewer cigarettes per day. Between 2002 and 2012, the average number of cigarettes smoked by daily smokers in New York City decreased from 14.6 to 11.8 per day (P < .001).¹³ With this decrease, the proportion of current smokers who were heavy smokers (> 10 cigarettes per day) decreased significantly in this 10-year period, from 52% to 38% (P < .001), indicating a shift in behavior to lower consumption patterns.^13,15 Conversely, the proportion of nondaily current smokers increased significantly between 2002 and 2012, from 32% to 39% (P = .009).^13,16

Yearly calls to 3-1-1 for quit smoking assistance increased from 43 008 in 2005 to 104 602 in 2011 and peaked in 2008 at 163 988, the year when hard-hitting campaigns were funded at the highest level. Since implementing the hard-hitting media strategy in 2006, New York City smokers made 837 552 calls through 2011. The New York City Nicotine Patch and Gum Program, specifically, has prompted more than 350 000 people to call for help in quitting smoking, resulting in an estimated 115 000 people who have quit smoking from this program. Neither of these estimates includes those who may have been motivated to quit without calling for assistance. Estimates now indicate that more former smokers (1 180 000) than current smokers (981 000) reside in New York City.¹³

Hospitalization rates for smoking-related illnesses in New York City declined 21% from 2000 to 2010,¹⁷ and declines in cancers related to smoking are also starting to be seen.¹⁸ By the year 2052, nearly 50 000 adult New Yorkers who quit smoking as a result of tobacco control efforts from 2002 to 2010 are predicted to avoid smoking-related death before age 75 years.¹⁹

Since 2006, an average of about $10 million has been spent annually on tobacco control by New York City—a little more than $1 per capita, a small sum compared with the estimated $3 billion annually in medical costs and productivity losses for the city’s nearly one million smokers.²⁰ Furthermore, the revenue generated from tobacco taxes in New York City since 2003—more than $1 billion²¹—although not earmarked specifically for tobacco control, has generated many times the funding needed to implement the program. Although political commitment has helped move policy changes, work by local coalitions to raise awareness and need for tobacco control has been integral to achieving these results, and adequate funding for tobacco control was also crucial for mass media and nicotine replacement therapy giveaways.

CONTINUED INNOVATION AND FUTURE DIRECTIONS

Although much progress has been made, New York City was still home to nearly one million smokers in 2012.¹ To further reduce smoking, New York City continues innovative efforts. New York City was the first jurisdiction requiring tobacco retailers to post graphic signs depicting the adverse health effects of tobacco use at the point of purchase. Although this 2009 Board of Health rule was overturned by a lawsuit brought by the tobacco industry, it was an innovative strategy to educate the public about the dangers of tobacco use and increased consideration of quitting.²²

In 2009, New York City also banned the sale of flavored noncigarette tobacco products, including cigars, blunts, cigarillos, chewing tobacco, and new spitless products, such as snus. This law, the first of its kind in the nation, eliminated the sale of certain tobacco products that are attractive to youths. The legislation complements the federal ban on flavored cigarettes under the Family Smoking Prevention and Tobacco Control Act.

In 2013, New York City became the first large US city to raise the minimum sales age for tobacco products, including e-cigarettes, from 18 to 21 years. Also, given the increase in use of cigars, including little cigars, among youths, New York City passed a law requiring inexpensive cigars to be sold in bundles of at least four and little cigars to be sold in packs of 20 with a minimum price of $10.50, similar to the price of cigarettes.

New York City also has engaged in efforts to protect the high price of cigarettes. Studies of littered cigarette packs in New York City show that a significant proportion of packs originate from low- or no-tax jurisdictions, and more than 70% of retailers in New York City have price promotions for cigarettes.^23–25 To combat tax evasion, the city has sued retailers supplying untaxed cigarettes through Internet sales and illegal smuggling, and in 2011, New York State closed a legal loophole, preventing American Indian reservations from selling untaxed cigarettes. Also, legislation passed in 2013 prohibited price discounts on tobacco products and strengthened laws to deter tax evasion. In addition, New York City, along with other partners, has urged the US Food and Drug Administration to implement a track and trace system for tobacco products, which would aid in law enforcement efforts to reduce tax evasion.

As smokers consume fewer cigarettes per day, New York City has been developing techniques and messages that speak to light and nondaily smokers. New York City’s first light smokers’ mass media campaign succeeded in reaching a greater proportion of light smokers than typically enroll during the annual Nicotine Patch and Gum Program and distributed almost 1500 courses of nicotine replacement therapy to those who smoke five to nine cigarettes per day.

In 2010, life expectancy at birth for New York City residents reached a record high of 80.9 years, three years higher than in 2001,²⁶ substantially outpacing the gains nationally; decreases in smoking may have contributed to these gains. New York City was fortunate to have strong leadership from elected officials on public health issues, particularly tobacco control. The successes of the city’s efforts indicate that local jurisdictions can make significant progress in tobacco control. Furthermore, they suggest that reductions in smoking can lead to improvements in health outcomes in the relatively short term. New York City’s approach to tobacco control may serve as a model for other cities and local jurisdictions seeking health gains.