Free nicotine replacement therapy programs vs implementing smoke-free workplaces: a cost-effectiveness comparison

We compared the cost-effectiveness of a free nicotine replacement therapy (NRT) program with a statewide smoke-free workplace policy in Minnesota. We conducted 1-year simulations of costs and benefits. The number of individuals who quit smoking and the quality-adjusted life years (QALYs) were the measures of benefits. After 1 year, a NRT program generated 18,500 quitters at a cost of 7020 dollars per quitter (4440 dollars per QALY), and a smoke-free workplace policy generated 10,400 quitters at a cost of 799 dollars per quitter (506 dollars per QALY). Smoke-free work-place policies are about 9 times more cost-effective per new nonsmoker than free NRT programs are. Smoke-free workplace policies should be a public health funding priority, even when the primary goal is to promote individual smoking cessation.     

The use of nicotine-replacement therapy by hospitalized smokers

BACKGROUND: No-smoking policies are mandatory in U.S. hospitals. Consequently, smokers who are hospitalized must temporarily stop smoking. Nicotine-replacement therapy (NRT) could help hospitalized smokers relieve nicotine withdrawal symptoms, comply with no-smoking policies, and sustain tobacco abstinence after discharge. The extent of NRT use in the hospital setting is unknown. We describe the prevalence and patterns of NRT use in hospitalized smokers. DESIGN: Prospective observational study within a randomized smoking-intervention trial. SETTING/PARTICIPANTS: Six hundred fifty adult smokers admitted to the medical and surgical services of a large urban teaching hospital that prohibits smoking in all indoor areas. Follow-up was at 6 months. MAIN OUTCOME MEASURE: Inpatient pharmacy records of nicotine patch or gum use. RESULTS: Only 34 of 650 smokers (5.2%) received NRT during their hospital stay, including only 9.6% of smokers who reported difficulty refraining from smoking while hospitalized and 9.0% of hospitalized smokers with nicotine withdrawal. NRT was more likely to be prescribed to patients with nicotine withdrawal (OR 2.23; 95% CI: 1.01, 4.90), a higher daily cigarette consumption (OR 1.04; 95% CI: 1.01, 1.06), and a longer hospitalization (OR 1.05; 95% CI: 1.00, 1.10). NRT use was independent of a patient's intention to quit smoking after discharge and was not associated with smoking cessation 1 and 6 months after discharge. CONCLUSIONS: NRT was rarely used in this hospital, even among those who could have benefited from it to treat nicotine-withdrawal symptoms. When NRT was used, relief of nicotine withdrawal, rather than assistance with smoking cessation, appeared to be the primary goal. Greater use of NRT could benefit the estimated 6.5 million smokers who are hospitalized annually by reducing nicotine withdrawal, encouraging smoking cessation, and ensuring compliance with hospital no-smoking policies.     

The Intended and Unintended Consequences of a Legal Measure to Cut the Flow of Illegal Cigarettes Into New York City: The Case of the South Bronx

Objectives. We examined the impact of a change in New York tax law on the numbers of untaxed cigarettes bootlegged from Native American reservations and resold in the South Bronx.Methods. Discarded cigarette packs were systematically collected in 30 randomized South Bronx census tracks before and after the amended tax law went into effect in 2011. Also, administrative data were gathered on the number of taxed cigarettes sold in New York State, including sales to Native American reservations.Results. Before the tax amendment, 42% of discarded cigarette packs collected in the South Bronx had no tax stamp. After the tax law went into effect, the percentage of cigarette packs without tax stamps declined to 6.2%. Simultaneously, the percentage of packs with out-of-state tax stamps rose from 18.3% to 66.3%. The percentage of packs with a combined New York State and New York City tax stamp did not change after the tax amendment.Conclusions. After the tax amendment, the supply of contraband cigarettes appears to have quickly shifted from one lower-priced jurisdiction to another without a change in the overall prevalence of contraband cigarettes.In June 2010, as part of an emergency budget measure, New York State raised its cigarette tax from $2.75 to $4.35 per pack and, in an effort to prevent smokers from circumventing state cigarette taxes, amended its tax law so that Native American reservations would no longer be able to sell untaxed cigarettes to non–tribal members. Since the 1980s, Native American reservations within New York State have imported billions of premium brand cigarettes, reselling them directly to smokers or to bootleggers who in turn supplied a thriving black market, particularly in New York City. This constituted a considerable challenge to smoking cessation policies that relied on high cigarette taxes as an economic disincentive for smokers. After a legal battle between several Native American tribes and the governor of New York, the tax amendment went into effect in June 2011.Our goal was to assess the effects of this tax amendment on the illegal cigarette market in economically disadvantaged neighborhoods in New York City, taking the South Bronx as an example. Specifically, we examined whether the measure has been successful in cutting off the supply of untaxed cigarettes from Native American reservations and whether it resulted in a reduction in the overall prevalence of illegal cigarettes, thus preventing a displacement to other sources of illegal cigarettes in response to increased cigarette taxes.     

Purchasing patterns and smoking behaviors after a large tobacco tax increase: a study of Chinese Americans living in New York City

OBJECTIVES: Tobacco taxes are one of the most effective policy interventions to reduce tobacco use. Tax avoidance, however, lessens the public health benefits of higher-priced cigarettes. Few studies examine responses to cigarette tax policies, particularly among high-risk minority populations. This study examined the prevalence and correlates of tax avoidance and changes in smoking behaviors among Chinese American smokers in New York City after a large tax increase. METHODS: We conducted a cross-sectional study with data for 614 male smokers from in-person and telephone interviews using a comprehensive household-based survey of 2,537 adults aged 18-74 years. Interviews were conducted in multiple Chinese dialects. RESULTS: A total of 54.7% of respondents reported engaging in at least one low- or no-tax strategy after the New York City and New York State tax increases. The more common strategies for tax avoidance were purchasing cigarettes from a private supplier/importer and purchasing duty free/overseas. Higher consumption, younger age, and number of years in the U.S. were consistently associated with engaging in tax avoidance. Younger and heavier continuing smokers were less likely to make a change in smoking behavior in response to the tax increase. Despite high levels of tax avoidance and varying prices, nearly half of continuing smokers made a positive change in smoking behavior after the tax increase. CONCLUSIONS: Expanded legislation and enforcement must be directed toward minimizing the availability of legal and illegal low- or no-tax cigarette outlets. Public education and cessation assistance customized for the Chinese American community is key to maximizing the effectiveness of tobacco tax policies in this population.     

The New York City Smoke-Free Air Act: second-hand smoke as a worker health and safety issue

BACKGROUND: Despite the provisions of a Smoke-Free Air Act (SFAA) enacted in 1995, more than 415,000 non-smoking New York City workers reported exposure to second-hand smoke in the workplace all or most of the time in 2002. Continued exposure to second-hand smoke in New York City prompted a renewed debate about a broader smoke-free air law. METHODS: The approach taken by the New York City Department of Health and Mental Hygiene to make the case for workplace protection from second-hand smoke, counter the opposition's arguments, and ultimately win the support of policymakers and the public for comprehensive smoke-free workplace legislation is described. RESULTS: On December 30, 2002, New York City's Mayor signed the SFAA of 2002 into law, making virtually all workplaces, including restaurants and bars, smoke-free. CONCLUSIONS: Proponents for a stronger law prevailed by defining greater protection from second-hand smoke as a matter of worker health and safety. Efforts to enact smoke-free workplace laws will inevitably encounter strong opposition, with the most common argument being that smoke-free measures will harm businesses. These challenges, however, can be effectively countered and public support for these measures is likely to increase over time by focusing the debate on worker protection from second-hand smoke exposure on the job.     

Smoking practices in New York City: The use of a population-based survey to guide policy-making and programming

To inform New York City’s (NYC’s) tobacco control program, we identified the neighborhoods with the highest smoking rates, estimated the burden of second-band smoke exposure, assessed the early response to state taxation, and examined cessation practices. We used a stratified random design to conduct a digit-dialed telephone survey in 2002 among 9,674 New York City adults. Our main outcome measures included prevalence of cigarette smoking, exposure to second-hand smoke, the response of smokers to state tax increases, and cessation practices. Even after controlling for sociodemographic factors (age, racelethnicity, income, education, marital status, employment status, and foreign-born status) smoking rates were highest in Central Harlem and in the South Bronx. Sixteen percent of nonsmokers reported frequent exposure to second-hand smoke at home or in a workplace. Among smokers with a child with asthma, only 33% reported having a no-smoking policy in their homes. More than one fifth of smokers reported reducing the number of cigarettes they smoked in response to the state tax increase. Of current smokers who tried to quit, 65% used no cessation aid. These data were used to inform New York City’s smoke-free legislation, taxation, public education, and a free nicotine patch give-away program. In conclusion, large, local surveys can provide essential data to effectively advocate for, plan, implement, and evaluate a comprehensive tobacco control program. Dr. Mostashari (the guarantor) made substantial contributions to the conception, design, and supervision of this paper, the analysis and interpretation of data, the drafting of the paper, critical revisions of the paper for important intellectual content, and the acquisition of data and funding for this research. Dr. Kerker made substantial contributions to the analysis and interpretation of data, the drafting of the paper and critical revisions of the paper for important intellectual content. Ms. Hajat made substantial contributions to the acquisition of data and critical revisions of the paper for important intellectual content. Dr. Miller made substantial contributions to the conception of this paper and critical revisions of the paper for important intellectual content. Dr. Frieden made substantial contributions to the conception, design, and supervision of this paper and critical revisions of the paper for important intellectual content.     

Increasing access to evidence-based smoking cessation treatment: effectiveness of a free nicotine patch program among Chinese immigrants

Pharmacotherapy substantially increases smoking cessation rates. However, programs to reduce barriers to this evidence-based treatment may not improve access among high risk immigrant non English speaking populations. This study estimates the effectiveness of a tailored free nicotine patch (NRT) program among Chinese American smokers living in New York City (NYC). Between July 2004 and May 2005 NRT was distributed to 375 smokers through two community-based organizations that serve the Asian American population in NYC. Participants completed an in person baseline survey and a 4-month follow-up telephone survey. Using an intention to treat analysis the abstinence rate at 4 months was 26.7% (100/375). Predictors of cessation included higher levels of self efficacy at baseline, not smoking while using the patch and concern about personal health risks. Distribution through easy to access, culturally competent local community organizations increased the reach of a free nicotine patch program and assisted smokers in quitting.     

Adult tobacco use levels after intensive tobacco control measures: New York City, 2002-2003

OBJECTIVES: We sought to determine the impact of comprehensive tobacco control measures in New York City. METHODS: In 2002, New York City implemented a tobacco control strategy of (1) increased cigarette excise taxes; (2) legal action that made virtually all work-places, including bars and restaurants, smoke free; (3) increased cessation services, including a large-scale free nicotine-patch program; (4) education; and (5) evaluation. The health department also began annual surveys on a broad array of health measures, including smoking. RESULTS: From 2002 to 2003, smoking prevalence among New York City adults decreased by 11% (from 21.6% to 19.2%, approximately 140000 fewer smokers). Smoking declined among all age groups, race/ethnicities, and education levels; in both genders; among both US-born and foreign-born persons; and in all 5 boroughs. Increased taxation appeared to account for the largest proportion of the decrease; however, between 2002 and 2003 the proportion of cigarettes purchased outside New York City doubled, reducing the effective price increase by a third. CONCLUSIONS: Concerted local action can sharply reduce smoking prevalence. However, further progress will require national action, particularly to increase cigarette taxes, reduce cigarette tax evasion, expand education and cessation services, and limit tobacco marketing.     

Impact of tobacco control policies and mass media campaigns on monthly adult smoking prevalence

Objectives. We sought to assess the impact of several tobacco control policies and televised antismoking advertising on adult smoking prevalence.Methods. We used a population survey in which smoking prevalence was measured each month from 1995 through 2006. Time-series analysis assessed the effect on smoking prevalence of televised antismoking advertising (with gross audience rating points [GRPs] per month), cigarette costliness, monthly sales of nicotine replacement therapy (NRT) and bupropion, and smoke-free restaurant laws.Results. Increases in cigarette costliness and exposure to tobacco control media campaigns significantly reduced smoking prevalence. We found a 0.3-percentage-point reduction in smoking prevalence by either exposing the population to televised antismoking ads an average of almost 4 times per month (390 GRPs) or by increasing the costliness of a pack of cigarettes by 0.03% of gross average weekly earnings. Monthly sales of NRT and bupropion, exposure to NRT advertising, and smoke-free restaurant laws had no detectable impact on smoking prevalence.Conclusions. Increases in the real price of cigarettes and tobacco control mass media campaigns broadcast at sufficient exposure levels and at regular intervals are critical for reducing population smoking prevalence.Population-wide interventions that can reduce adult smoking prevalence are important for curbing the pandemic of tobacco-related disease.1^–3 However, evaluating the effects of tobacco control policies and mass media interventions on populations is difficult.4^,5 Generally, there are few comparable control populations to which policy or media interventions are not delivered. Tobacco policies and media campaigns often co-occur, complicating assessment of the relative contribution of each. In addition, most studies in which smoking prevalence is the outcome measure rely on annual population surveys to track change over time, despite policy and media interventions being generally implemented throughout the year, and at differing strengths relative to the time of survey administration. Small or transient impacts on smoking prevalence are difficult to detect and may be underestimated.Over the past decade, the Australian population has been exposed to changes in several tobacco control policies, including changes in taxes on tobacco products resulting in increases in the real price of cigarettes, increasing availability of pharmaceutical smoking cessation products such as nicotine replacement therapies (NRT) and bupropion, and the introduction of smoke-free restaurant laws. In addition, there has been considerable variation in exposure to public health–sponsored mass media campaigns and pharmaceutical advertising for NRT. We have assessed the independent effect of each tobacco control policy and type of media campaign with a data series in which self-reported smoking prevalence was measured every month over a period of 11 years. This method has the advantage over annual population surveys of more closely matching the timing and extent of policy implementation and media exposure to smoking prevalence, and it has the ability to examine the pattern of change in prevalence, such as the lag time to a measurable impact and the duration of influence.     

The Effect of Cigarette Price Increases on Smoking Cessation in California

We investigated whether smoking cessation increased in California after a cigarette manufacturer’s retail price increase and an increase in the state cigarette excise tax. The sample for this study was drawn from the 1996 and 1999 California Tobacco Surveys. The rate of unsuccessful and successful quit attempts and the rate of abstinence were calculated for each month of the 14-month period preceding each survey administration. We combined the monthly rates for both surveys and used multiple regression modeling to test whether the proportion of smokers reporting a quit attempt and the proportion of smokers reporting abstinence increased during the period following the price increases. We included several covariates in our models to control for factors other than the price increases that could account for any increases observed in quit attempts and abstinence. Because smokers recall quits occurring closer to the date of the survey better than quits occurring further back in time, we included a term in the models representing the number of months elapsed between the survey administration and the reported quit. We also included terms in the models representing the months before and after the over-the-counter (OTC) availability of the nicotine patch and nicotine gum in 1996 to control for the increase in smoking cessation observed following the availability of OTC nicotine replacement therapy (NRT). Lastly, in order to control for increased quits made in January as a result of New Year’s resolutions, we included a term in our models for quit attempts and successful quits (abstinence) made during this month. Results of the regression analyses indicated a significantly greater proportion of smokers reported quit attempts (p < 0.05) in the months immediately following the cigarette price increases (after November 1998); however, a significant increase in abstinence was only observed from December 1998 through March 1999 (p < 0.05) relative to abstinence occurring before the price increases.     

Reach, efficacy, and cost-effectiveness of free nicotine medication giveaway programs.

In an effort to increase access to evidence-based smoking cessation therapies, regional tobacco control programs in New York State implemented different interventions to make free nicotine patches and gum available to smokers wishing to quit. In one region, eligible smokers were sent a voucher redeemable at a local pharmacy for a 2-week supply of either nicotine patches or gum. In other regions, smokers received either a 1-week supply or a 2-week supply of nicotine patches sent to their home. In New York City, eligible smokers received a 6-week supply of nicotine patches and a follow-up phone call. All of the programs utilized the state's Smokers' Quitline to screen and register eligible smokers for the free medication. The reach of the different programs was evaluated by computing the proportion of eligible smokers within a given area enrolled in the program and tracking call volume to the Quitline before, during, and after the free giveaway promotions. Efficacy was evaluated by a telephone follow-up survey of program participants conducted 4 months after enrollment to measure use of the medications and smoking behavior. The quit rate of program participants was contrasted with the quit rate computed from an earlier follow-up survey of Quitline callers who were not provided nicotine replacement therapy (NRT). Free nicotine patches or gum was sent to 40,090 smokers representing about 2.9 percent of eligible heavy smokers (10+ cigarettes per day) in the state. In each time period and location where free NRT was offered, call volume to the Quitline increased dramatically. Quit rates varied in relationship to the supply of NRT sent to participants, but in all cases was higher than the quit rate observed among smokers not sent NRT (21%-35% vs 12%). The offer of free NRT appears to be a cost-effective method to induce large numbers of smokers to make a quit attempt.     

Tobacco Policies in Louisiana: Recommendations for Future Tobacco Control Investment from SimSmoke,a Policy Simulation Model

Despite the presence of tobacco control policies, Louisiana continues to experience a high smoking burden and elevated smoking-attributable deaths. The SimSmoke model provides projections of these health outcomes in the face of existing and expanded (simulated) tobacco control polices. The SimSmoke model utilizes population data, smoking rates, and various tobacco control policy measures from Louisiana to predict smoking prevalence and smoking-attributable deaths. The model begins in 1993 and estimates are projected through 2054. The model is validated against existing Louisiana smoking prevalence data. The most powerful individual policy measure for reducing smoking prevalence is cigarette excise tax. However, a comprehensive cessation treatment policy is predicted to save the most lives. A combination of tobacco control policies provides the greatest reduction in smoking prevalence and smoking-attributable deaths. The existing Louisiana excise tax ranks as one of the lowest in the country and the legislature is against further increases. Alternative policy measures aimed at lowering prevalence and attributable deaths are: cessation treatments, comprehensive smoke-free policies, and limiting youth access. These three policies have a substantial effect on smoking prevalence and attributable deaths and are likely to encounter more favor in the Louisiana legislature than increasing the state excise tax.     

Correlates of Smoke-Free Housing Policies and Interest in Implementing Policies among Multiunit Housing Owners in New York City

Secondhand smoke exposure is a concern in multiunit housing, where smoke can migrate between apartments. In 2012, the New York City (NYC) Department of Health and Mental Hygiene conducted a cross-sectional mail and phone survey among a random sample of low-income and market-rate multiunit housing owners and managers in NYC. The study compared experiences and attitudes regarding smoke-free policies between owners/managers (owners) with and without low-income units. Logistic regression analysis was used to assess the correlates of smoke-free residential unit rules and interest in adopting new smoke-free rules. Perceived benefits and challenges of implementing smoke-free rules were also examined. Overall, one-third of owners prohibited smoking in individual units. Among owners, nearly one-third owned or managed buildings with designated certified low-income units. Owners with low-income units were less likely than those without to have a smoke-free unit policy (26 vs. 36 %, p < 0.01) or be aware that owners can legally adopt smoke-free building policies (60 vs. 70 %, p < 0.01). In the final model, owners who believed that owners could legally adopt smoke-free policies were more likely to have a smoke-free unit policy, while current smokers and owners of larger buildings were less likely to have a policy. Nearly three quarters of owners without smoke-free units were interested in prohibiting smoking in all of their building/units (73 %). Among owners, correlates of interest in prohibiting smoking included awareness that secondhand smoke is a health issue and knowledge of their legal rights to prohibit smoking in their buildings. Current smokers were less likely to be interested in future smoke-free policies. Educational programs promoting awareness of owners’ legal right to adopt smoke-free policies in residential buildings may improve the availability of smoke-free multiunit housing.     

State-specific prevalence of current cigarette smoking among adults and secondhand smoke rules and policies in homes and workplaces--United States, 2005

Smoking causes premature death and disease in children and adults who do not smoke but are exposed to secondhand smoke (SHS). To assess the state-specific prevalence of current smoking among adults in the United States and the proportions of adults who report having smoke-free home rules and smoke-free policies in their workplace, CDC analyzed data from the 2005 Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes the results of that analysis, which indicated a threefold difference (from lowest to highest) in self-reported cigarette smoking prevalence in 50 states, the District of Columbia (DC), Puerto Rico (PR), and the U.S. Virgin Islands (USVI) (range: 8.3%-28.7%). Wide variations also were observed in USVI and the 14 states that assessed prevalence of smoke-free home rules (from 63.6% [Kentucky] to 82.9% [Arizona]) and smoke-free workplace policies (from 54.8% [Nevada] to 85.8% [West Virginia]). Evidence-based, comprehensive tobacco prevention and control programs that focus on decreasing smoking initiation, increasing smoking cessation, and establishing smoke-free workplaces, homes, and other venues should be continued and expanded to reduce smoking prevalence, exposure of nonsmokers to SHS, and smoking-related morbidity and mortality.     

Tobacco control campaign in Uruguay: Impact on smoking cessation during pregnancy and birth weight

We analyzed a nationwide registry of all pregnancies in Uruguay during 2007–2013 to assess the impact of three types of tobacco control policies: (1) provider-level interventions aimed at the treatment of nicotine dependence, (2) national-level increases in cigarette taxes, and (3) national-level non-price regulation of cigarette packaging and marketing. We estimated models of smoking cessation during pregnancy at the individual, provider and national levels. The rate of smoking cessation during pregnancy increased from 15.4% in 2007 to 42.7% in 2013. National-level non-price policies had the largest estimated impact on cessation. The price response of the tobacco industry attenuated the effects of tax increases. While provider-level interventions had a significant effect, they were adopted by relatively few health centers. Quitting during pregnancy increased birth weight by an estimated 188 g. Tobacco control measures had no effect on the birth weight of newborns of non-smoking women.     

Decrease in smoking prevalence--Minnesota, 1999-2010

Following the landmark 1998 settlement of the lawsuit, State of Minnesota versus Philip Morris, Inc., et al., Minnesota implemented a series of tobacco control efforts to limit the harm caused by tobacco use. In 2001, quitline services for tobacco users without health insurance coverage for cessation services were introduced and statewide mass media campaigns publicizing them were initiated. In 2005, Minnesota imposed a $0.75 per pack tax on cigarettes, followed in 2009 by a $0.62 per pack increase in federal excise tax, contributing in large part to a more than $2 increase in the average price of cigarettes. In 2007, a comprehensive, statewide smoke-free law was passed. Using surveillance data from the Minnesota Adult Tobacco Survey (MATS) and cigarette pack sales data, this report examines the effects of these tobacco-related public health efforts. Compared with a 15% decline in national adult smoking prevalence since 1999, adult smoking prevalence in Minnesota decreased 27.1%, from 22.1% in 1999 to 16.1% in 2010. During the same period, per capita cigarette sales in Minnesota decreased 40%. In addition, in 2010 compared with 1999, a higher percentage of adults reported that smoking was restricted in their homes (87.2% versus 64.5%), and adults were less likely to report exposure to secondhand smoke (45.6% versus 67.2%). In the past decade, Minnesota has benefited from sustained tobacco control. Future progress in decreasing adult smoking and reducing exposure to secondhand smoke will depend on a concerted effort across the public health community to keep tobacco control a priority.     

The short-term impact of national smoke-free workplace legislation on passive smoking and tobacco use

OBJECTIVES: This study sought to evaluate the short-term impact of national smoke-free workplace legislation on employee exposure to environmental tobacco smoke at work and on employee smoking habits. METHODS: We performed 2 cross-sectional studies in 9 medium-sized and large Finnish workplaces, before and after implementation of national smoke-free workplace legislation. We assessed tobacco smoke exposure via questionnaire and indoor air nicotine measurements. RESULTS: Exposure to environmental tobacco smoke declined considerably after the legislation was implemented.Tobacco consumption among smokers diminished. Nicotine concentrations fell significantly. CONCLUSIONS: Legislation was more efficient than voluntary workplace-specific smoking restrictions in reducing passive smoking and cigarette consumption.     

Analysis of taxable sales receipts: was New York City's Smoke-Free Air Act bad for restaurant business?

This article examines the results of a study to determine if the New York City Smoke-Free Air Act has had an adverse economic impact on the taxable sales receipts from the city's restaurant and hotel industries. The study found that real taxable sales from eating and drinking places and hotels in New York City increased by 2.1 percent and 36.9 percent, respectively, compared with levels two years before the smoke-free law took effect. During the same period, real taxable sales for eating and drinking establishments and hotels in the rest of the state experienced a 3.8 percent decrease and a modest 2.4 percent increase in sales, respectively.