Thomas R. Frieden, MD, MPH
New York City Department of Health and Mental Hygiene
Sarah B. Perl, MPH
Assistant Commissioner for the Bureau of Tobacco Control
New York City Department of Health and Mental Hygiene
New York, New York
In 2003, there was a sharp decline in smoking prevalence in New York City after a decade during which the proportion of adult smokers remained steady at about 22%. In 2004, smoking prevalence decreased again (Figure 1). This decline corresponded to implementation of a five-point tobacco control strategy, launched in 2002, that consists of taxation, legal action, cessation, public education, and evaluation.
Increased taxation is the single most effective intervention to reduce tobacco use. In 2002, both New York State and New York City increased excise taxes on cigarettes, each levying $1.50 per pack tax. The $3.00 total taxes resulted in New York City having the highest purchase price of cigarettes in the nation, at about $7.00 per pack.
Smoke-free legislation passed in 1995 limited smoking in many, but not all, New York City workplaces. The New York City Department of Health and Mental Hygiene (DOHMH) undertook a legal strategy to extend regulation of smoking in the workplace, arguing that no worker should be exposed to second-hand smoke in order to earn a living. Passage of the Smoke-Free Air Act of 2002 (SFAA), which became effective on March 30, 2003, made virtually all workplaces smoke-free, including restaurants and bars.
To garner support for this proposed legislation, DOHMH educated elected officials and the public that second-hand smoke causes illness and death, and provided evidence demonstrating that stronger smoke-free legislation would not be detrimental to business. Prior to enactment of the SFAA, exposure to second-hand smoke killed an estimated 1,000 New York City residents annually and caused 40,000 illnesses every year, including 14,000 asthma exacerbations, 5,000 respiratory infections, and 24,000 ear infections in children.
Initial concern that the SFAA would have a negative economic effect on the City’s restaurants and bars proved unfounded. A joint report by several City agencies (Health and Mental Hygiene, Finance, Small Business Services, and Economic Development), issued on the one-year anniversary of the SFAA’s implementation found that tax receipts in restaurants and bars had risen 8.7%, employment in restaurants and bars had increased 7%, and all but a handful of restaurants and bars were in full compliance with the law.
The primary strategy to promote smoking cessation has been to increase access to and use of nicotine replacement therapy (NRT) and counseling to improve quit rates. An estimated 70% of smokers want to quit, and 66% of New York City smokers made a quit attempt in 2004. Smokers who attempt to quit with the help of NRT are up to twice as likely to succeed as smokers who do not use medication.
Since 2003, DOHMH and its partners have distributed more than 100,000 free courses of nicotine replacement therapy (NRT) to City residents, mainly through telephone call-in. Follow-up of a representative sample of patch recipients in 2003 showed that about 34% of respondents reported that they were smoke-free after 6 months. In 2005, DOHMH partnered with 311, NYC’s government services and information phone line, to provide patches and counseling to the public. This effort – which distributed 45,000 free 6-week courses of nicotine patches that were donated by Pfizer Inc. – is one of the largest such giveaway programs ever.
Educational efforts have focused primarily on raising awareness about the negative health effects of smoking and the positive effects of quitting, and on changing tobacco-related social norms. Efforts included mass media campaigns, such as “Bob Quits” in 2004 and “Everybody Loves a Quitter” in 2005 and also focused on assisting healthcare providers in promoting cessation among their patients. Strategies to educate this group include public health detailing, which uses the approach pioneered by the pharmaceutical industry to market ideas and products, and publications such as City Health Information (“Treating Nicotine Addiction”) distributed to all physicians in New York City as well as other health care providers. Information is also made available to the public through ￼ the agency Web site, publications such as the Health Bulletin series (“You Can Quit Smoking” ) designed for lower-literacy audiences, and the City’s health policy ￼ “Take Care New York (TCNY).” TCNY identifies 10 actions New Yorkers can take to improve their health – including “Be Tobacco-Free.”
Underlying and informing all these efforts – taxation, legal action, cessation, and education – is data collection, analysis, and evaluation. Between 2002 and 2003, New York City’s adult smoking prevalence declined 11%, from 21.6% to 19.2%. This decline was seen in all age groups, races, and ethnic groups, and in all five boroughs, and is one of the largest single-year declines in smoking rates ever recorded nationally. Smoking prevalence declined further between 2003 and 2004, to 18.4%; this two-year 15% decrease represents nearly 200,000 fewer adult smokers and more than 60,000 premature deaths prevented.
DOHMH’s tobacco control accomplishments since 2002 are considerable, yet much more can be done. More than 1 million adults in New York City still smoke; one third of them will die an average of 14 years prematurely of a smoking-related illness. About 30% of smokers avoid New York City taxes by buying cigarettes in neighboring states, through Native American reservations, on the Internet, or through other informal sources. The adolescent smoking rate, while declining, is still too high at 14.8% for 2003 (the latest year for which data are available). Considerable challenges remain as “Big Tobacco” continues to pour billions of dollars each year into marketing, promotion, and new product development, including candy-flavored cigarettes designed to appeal to you and purported “reduced-harm” tobacco products. And while some issues will be addressed locally, the next level of significant gain is likely to require national action.