Shannon M. Farley

Public opinions on tax and retail-based tobacco control strategies

Background While tobacco taxes and smoke-free air regulations have significantly decreased tobacco use, tobacco-related illness accounts for hundreds of thousands of annual deaths. Experts are considering additional strategies to further reduce tobacco consumption. Methods We investigated smokers’ (n=2118) and non-smokers’ (n=2210) opinions on existing and theoretical strategies, including tax and retailer-based strategies in New York City, across three cross-sectional surveys. Results Compared with smokers, non-smokers were significantly more likely (p<0.05) to favour all tobacco control strategies. Overall, 25% of smokers surveyed favoured increasing taxes on cigarettes, climbing to 60% if taxes were used to fund healthcare programmes. Among non-smokers, 72% favoured raising taxes, increasing to 83% if taxes were used to fund healthcare programmes. 54% of non-smoking New Yorkers favoured limiting the number of tobacco retail licences, as did 30% of smokers. The most popular retail-based strategies were raising the minimum age to purchase cigarettes from 18 to 21, with 60% of smokers and 69% of non-smokers in favour, and prohibiting retailers near schools from selling tobacco, with 51% of smokers and 69% of non-smokers in favour. Keeping tobacco products out of customers’ view, prohibiting tobacco companies from paying retailers to display or advertise tobacco products and prohibiting price promotions were favoured by more than half of non-smokers surveyed, and almost half of smokers. Conclusions While the support level varied between smokers and non-smokers, price and retail-based tobacco control strategies were consistently supported by the public, providing useful information for jurisdictions examining emerging tobacco control strategies.

Awareness and impact of New York City's graphic point-of-sale tobacco health warning signs

Background To increase knowledge of smoking-related health risks and provide smoking cessation information at the point of sale, in 2009, New York City required the posting of graphic point-of-sale tobacco health warnings in tobacco retailers. This study is the first to evaluate the impact of such a policy in the USA. Methods Cross-sectional street-intercept surveys conducted among adult current smokers and recent quitters before and after signage implementation assessed the awareness and impact of the signs. Approximately 10 street-intercept surveys were conducted at each of 50 tobacco retailers in New York City before and after policy implementation. A total of 1007 adults who were either current smokers or recent quitters were surveyed about the awareness and impact of tobacco health warning signs. Multivariate risk ratios (RR) were calculated to estimate awareness and impact of the signs. Results Most participants (86%) were current smokers, and the sample was 28% African–American, 32% Hispanic/Latino and 27% non-Hispanic white. Awareness of tobacco health warning signs more than doubled after the policy implementation (adjusted RR =2.01, 95% CI 1.74 to 2.33). Signage posting was associated with an 11% increase in the extent to which signs made respondents think about quitting smoking (adjusted RR =1.11, 95% CI 1.01 to 1.22). Conclusions A policy requiring tobacco retailers to display graphic health warning signs increased awareness of health risks of smoking and stimulated thoughts about quitting smoking. Additional research aimed at evaluating the effect of tobacco control measures in the retail environment is necessary to provide further rationale for implementing these changes.

Evaluating New York City’s Smoke-Free Parks and Beaches Law: A Critical Multiplist Approach to Assessing Behavioral Impact

This article describes the evaluation of the law banning smoking in New York City’s parks and beaches that went into effect in 2011. We discuss the practical and methodological challenges that emerged in evaluating this law, and describe how we applied the principles of critical multiplism to address these issues. The evaluation uses data from three complementary studies, each with a unique set of strengths and weaknesses that can provide converging evidence for the effectiveness of the law. Results from a litter audit and an observational study suggest the ban reduced smoking in parks and beaches. The purpose, methodology and baseline results from an ongoing survey that measures how frequently adults in NYC and across New York State notice people smoking in parks and on beaches are presented and discussed. Limitations are considered and suggestions are offered for future evaluations of similar policies.

Teen Use of Flavored Tobacco Products in New York City

INTRODUCTION Teen use of flavored tobacco products is a concern. Menthol cigarettes have been found to influence teen smoking; however, less is known about the association between teen use of other flavored tobacco products, such as cigars and dip, and cigarette smoking. METHODS The New York City 2010 Special Communities Putting Prevention to Work Youth Risk Behavior Survey data (N = 1,800 aged 13-17 years) were analyzed to examine the association between ever trying flavored tobacco products and current smoking, after we adjusted for demographics and ever-use of menthol cigarettes. RESULTS Twenty percent of teens reported ever trying flavored tobacco products; youth who were current smokers (58%) were more likely to have tried flavored tobacco products than youth who were not current smokers (16%). Controlling for menthol cigarette use, teens who had ever tried flavored tobacco products were nearly 3 times more likely to be current smokers than those who had never tried flavored tobacco products (odds ratio = 2.70, 95% confidence interval = 1.47-4.98). CONCLUSIONS Ever trying flavored tobacco products was strongly associated with current smoking among teens. The findings from this study suggest that regulations prohibiting sales of flavored tobacco products could decrease youth smoking.

New York City flavoured tobacco product sales ban evaluation

Introduction The availability of flavoured tobacco products is associated with increased initiation and youth smoking. New York City prohibited all sales of flavoured cigars, cigarillos, little cigars, chew, snuff, snus, tobacco, pipe tobacco, roll-your-own tobacco, and dissolvables, excluding menthol, in October 2009; enforcement began in November 2010. This paper describes the sales ban evaluation. Methods Data on retail tobacco sales of cigars, smokeless and other tobacco products such as pipe tobacco and roll-your-own, were analysed using interrupted time series methods, estimating changes in flavoured and non-flavoured tobacco product inflation-adjusted dollar sales overall, and by product type. Changes in ever use of flavoured tobacco products, any tobacco product use, and smoking prevalence among adolescents were estimated using multivariable logistic regression. Results Sales of flavoured tobacco products declined overall (87%; p<0.001), and for flavoured cigars (86%; p<0.001) and flavoured pipe and roll-your-own (91%; p<0.001) following ban enforcement, while non-flavoured sales increased for cigars (5%; p=0.003) and pipe and roll-your-own (4%, p=0.030). In adjusted models, teens in 2013 had 37% lower odds of ever trying flavoured tobacco products (p<0.001), 28% lower odds of using any type of tobacco product (p=0.025), and a non-significant change in current smoking prevalence (p=0.114) compared with teens in 2010. Conclusions Flavoured tobacco product sales and odds of ever using flavoured tobacco products or using any tobacco products among teens declined significantly after ban enforcement began. Collectively these findings demonstrate significant evidence that the flavoured tobacco products sales ban was successful in New York City, and could succeed elsewhere.

Exposure to Secondhand Smoke Among Nonsmokers in New York City in the Context of Recent Tobacco Control Policies: Current Status, Changes Over the Past Decade, and National Comparisons

INTRODUCTION Exposure to secondhand smoke is hazardous and can cause cancer, coronary heart disease, and birth defects. New York City (NYC) and other jurisdictions have established smoke-free air laws in the past 10-15 years. METHODS NYC Health and Nutrition Examination Survey (HANES) 2013-2014 was a population-based survey of NYC residents, aged 20 years and older, in which biospecimens were collected and cotinine levels were measured. Secondhand smoke exposure was assessed by demographics and risk factors and compared with that from NYC HANES 2004 and national HANES. RESULTS More than a third (37.1%, 95% confidence interval [CI] = 33.3%-41.2%) of nonsmoking adult New Yorkers were exposed to secondhand smoke, defined as a cotinine level of 0.05-10ng/mL. This was significantly lower than in 2004 NYC HANES, when 56.7% (95% CI = 53.6%-59.7%) of nonsmokers were exposed to secondhand smoke, but was greater than the proportion of adults exposed nationwide, as measured by national HANES (24.4%, 95% CI = 22.0%-26.9% in 2011-2012). Men, non-Hispanic blacks, adults aged 20-39, those with less education, and those living in high-poverty neighborhoods were more likely to be exposed. CONCLUSIONS There has been a large decrease in secondhand smoke exposure in NYC, although disparities persist. The decrease may be the result of successful policies to limit exposure to secondhand smoke in public places and of smokers smoking fewer cigarettes per day. Yet NYC residents still experience more secondhand smoke exposure than US residents overall. Possible explanations include multiunit housing, greater population density, and pedestrian exposure. IMPLICATIONS Measuring exposure to secondhand smoke can be difficult, and few studies have monitored changes over time. This study uses serum cotinine, a nicotine metabolite, from a local population-based examination survey, the NYC HANES 2013-2014, to examine exposure to secondhand smoke in an urban area that has implemented stringent antismoking laws. Comparison with NYC HANES conducted 10 years ago allows for an assessment of changes in the last decade in the context of municipal tobacco control policies. Results may be helpful to jurisdictions considering implementing similar tobacco control policies.

Point-of-Sale Tobacco Marketing to Youth in New York State

PURPOSE To assess youth exposure to menthol versus nonmenthol cigarette advertising, we examined whether menthol cigarette promotions are more likely in neighborhoods with relatively high youth populations. METHODS We linked 2011 New York State Retail Advertising Tobacco Survey observational data with U.S. Census and American Community Survey demographic data. Multivariable models assessed the relationship between neighborhood youth population and point-of-sale cigarette promotions for three brands of cigarettes, adjusting for neighborhood demographic characteristics including race/ethnicity and poverty. RESULTS Menthol cigarette point-of-sale marketing was more likely in neighborhoods with higher proportions of youth, adjusting for presence of nonmenthol brand marketing, neighborhood race/ethnicity, neighborhood poverty, and urban geography. CONCLUSIONS Data from the 2011 Retail Advertising Tobacco Study linked to block level census data clearly indicate that price reduction promotions for menthol cigarettes are disproportionately targeted to youth markets in New York State.

Designing a Quality Improvement Program With Electronic Health Records New York City’s Health eQuits

Despite clear recommendations for identifying and intervening with smokers, clinical preventive practice is inconsistent in primary care. Use of electronic health records could facilitate improvement. Community health centers treating low-income and Medicaid recipients with greater smoking prevalence than the general population were recruited for a pilot program. Key design elements used to engage centers’ participation include designating a project champion at each organization, confirming ability to transmit data for reporting and participation, and offering money to facilitate initial engagement; however, financial incentives did not motivate all organizations. Other methods to elicit participation and to motivate practice change included building on centers’ previous experiences with similar programs, utilizing existing relationships with state cessation centers, and harnessing the “competitive” spirit—sharing both good news and areas for improvement to stimulate action. These experiences and observations may assist others in designing programs to improve clinical interventions with smokers.

Public Support for Smoke-Free Air Strategies Among Smokers and Nonsmokers, New York City, 2010–2012

Introduction From 2010 through 2012, the New York City Department of Health and Mental Hygiene engaged in multiple smoke-free-air activities in collaboration with community, institution, and government partners. These included implementing a law prohibiting smoking in all parks and beaches as well as working to increase compliance with existing Smoke-free Air Act provisions. Methods We investigated trends in awareness of existing smoke-free rules publicized with new signage and public support for new smoke-free air strategies by using 3 waves of survey data from population-based samples of smoking and nonsmoking adults in New York City (2010–2012). Analyses adjusted for the influence of sociodemographic characteristics. Results Among both smokers and nonsmokers, we observed increased awareness of smoke-free regulations in outdoor areas around hospital entrances and grounds and in lines in outdoor waiting areas for buses and taxis. Regardless of smoking status, women, racial/ethnic minorities, and adults aged 25 to 44 years were more likely than men, non-Hispanic whites, and adults aged 65 years or older to support smoke-free air strategies. Conclusion New signage was successful in increasing population-wide awareness of rules. Our analysis of the association between demographic characteristics and support for tobacco control over time provide important contextual information for community education efforts on secondhand smoke and smoke-free air strategies.

Going Tobacco-Free on 24 New York City University Campuses: A Public Health Agency's Partnership with a Large Urban Public University System.

ABSTRACT The New York City Department of Health and Mental Hygiene partnered with the nations largest university system, the City University of New York (CUNY), to provide technical assistance and resources to support the development and implementation of a system-wide tobacco-free policy. This effort formed one component of Healthy CUNY—a larger initiative to support health promotion and disease prevention across the university system and resulted in the successful introduction of a system-wide tobacco-free policy on all CUNY campuses. Glassman et al (J Am Coll Health. 2011;59:764–768) published a blueprint for action related to tobacco policies that informed our work. This paper describes the policy development and implementation process and presents lessons learned from the perspective of the Health Department, as a practical case study to inform and support other health departments who may be supporting colleges and universities to become tobacco-free.