STATE OF NEW YORK DEPARTMENT OF HEALTH Corning Tower The Governor Nelson A. Rockefeller Empire State Plaza Albany, New York 12237 Antonia C. Novello, M.D., M.P.H., Dr.P.H. Dennis P. Whalen Commissioner Executive Deputy Commissioner November 24, 2004 Dear Reader: I am pleased to provide to you the First Annual Independent Evaluation of New York’s Tobacco Control Program. The attached document presents a comprehensive review of New York’s substantial efforts to improve public health by helping more New Yorkers stop smoking. The report identifies our many successes, including: New York’s utilization of a “rigorous strategic plan and emphasis on evidenced-based interventions.” A decline in New York’s per capita cigarette consumption after 2000 that was faster than the national average. A steady decline in the rates of second hand smoke exposure both in the home and in the work place. Very high compliance (92.9 percent) with the Clean Indoor Air Act. An apparent significant reduction of second hand smoke exposure due to the implementation of the CIAA. The report also contains constructive criticisms of New York’s efforts, chiefly, our marketing efforts designed to counter the near limitless marketing resources of the tobacco industry. Prior to the publication of this report the Health Department took actions to improve and better coordinate its media and marketing efforts, which we believe will address this criticism. As you may know, New York has continuously committed tens of millions of dollars annually to tobacco control, more than almost every other state in the nation. And we maintained our high funding level even during the recent economic downturn, when many other states significantly reduced their tobacco control funding. As a public health official and a physician, I am gratified to see New York’s considerable funding and our aggressive actions, including the historic Clean Indoor Air Act and increased cigarette excise taxes, are measurably curbing tobacco usage and second hand smoke exposure. As the report itself states, it found “several results that suggest that trends in several smoking outcomes were more favorable in New York than the remaining United States.” We certainly agree. Thank you for your interest in this report and in New York’s successful tobacco control efforts. Sincerely, Antonia C. Novello, M.D., M.P.H., Dr.P.H. Commissioner of Health November 2004 First Annual Independent Evaluation of New York’s Tobacco Control Program Final Report Prepared for New York State Department of Health Corning Tower, Room 710 Albany, NY 12237-0676 Prepared by RTI International 3040 Cornwallis Road Research Triangle Park, NC 27709-2194 RTI Project Number 08800.002 RTI Project Number 08800.002.002 First Annual Independent Evaluation of New York’s Tobacco Control Program Final Report November 2004 Prepared for New York State Department of Health Corning Tower, Room 710 Albany, NY 12237-0676 Prepared by RTI International* 3040 Cornwallis Road Research Triangle Park, NC 27709-2194 *RTI International is a trade name of Research Triangle Institute. Contents Executive Summary ES-1 1. Overview and Purpose 1-1 2. The Burden of Tobacco in New York State 2-1 2.1 Health Consequences.............................................. 2-1 2.2 Economic Burden ................................................... 2-2 2.3 Social Causes of Smoking........................................ 2-2 2.3.1 History........................................................ 2-3 2.3.2 Recent Trends in Tobacco Industry Advertising and Promotion ............................. 2-4 2.3.3 Smoking in Movies........................................ 2-6 2.3.4 Other Forms of Tobacco Industry Influence ...... 2-7 2.3.5 Conclusions ................................................. 2-7 2.4 Investing in Tobacco Control to Curb the Burden of Tobacco ................................................................ 2-8 3. Tobacco Control in New York State 3-1 3.1 Brief History of Tobacco Control In New York.............. 3-1 3.2 New York Tobacco Control Program .......................... 3-4 4. Assessing New York’s Tobacco Control Program 4-1 4.1 Assessing the Evidence Base for the Program’s Strategy ............................................................... 4-1 4.1.1 Smoking Bans and Restrictions....................... 4-1 4.1.2 Multicomponent Mass Media Campaigns with Interventions ............................................... 4-3 4.1.3 Multicomponent Telephone Support Systems (Quitlines) ...................................... 4-4 iii 4.1.4 Health Care Provider Reminders Alone or With Provider Education to Promote Cessation .................................................... 4-5 4.1.5 Reducing Patient Costs for Treatments ............ 4-7 4.1.6 Increasing the Unit Price of Tobacco Products ..................................................... 4-7 4.1.7 Youth Access Law Enforcement....................... 4-9 4.2 Assessing the Implementation of the Program’s Strategies ............................................................4-11 4.2.1 State Documents on Program Implementation ..........................................4-12 4.2.2 Program Component Implementation and Quality.......................................................4-15 4.2.3 Stakeholder Comments ................................4-27 4.3 Summary of Programmatic Approach and Implementation ....................................................4-29 5. Independent Evaluation of New York’s Tobacco Control Program 5-1 5.1 Comprehensive Evaluation Plan Overview .................. 5-2 5.2 Evaluation Studies and Data Collection Activities......... 5-5 5.2.1 Cross-Cutting Evaluation Studies and Data Collection Activities....................................... 5-5 5.2.2 Evaluation Studies and Data Collection Activities in Support of Goal 1: Eliminate Exposure to Secondhand Smoke....................5-19 5.2.3 Evaluation Studies and Data Collection Activities in Support of Goal 2: Decrease the Social Acceptability of Tobacco Use...........5-27 5.2.4 Evaluation Studies and Data Collection Activities in Support of Goal 3: Promote Cessation from Tobacco Use .........................5-32 5.2.5 Evaluation Studies and Data Collection Activities in Support of Goal 4: Prevent the Initiation of Tobacco Use Among Youth and Young Adults ..............................................5-34 5.3 Evaluating Effectiveness.........................................5-37 5.3.1 Evaluating Program Effectiveness with Quantitative Data ........................................5-37 5.3.2 Evaluating Program Effectiveness with Qualitative Data ..........................................5-46 5.4 Dissemination.......................................................5-46 iv 6. Evaluation Findings 6-1 6.1 Overview .............................................................. 6-1 6.1.1 Comparisons with the Remaining United States......................................................... 6-2 6.1.2 Baseline Findings.......................................... 6-3 6.1.3 Evaluating the Clean Indoor Air Act................. 6-3 6.1.4 Organization of the Chapter ........................... 6-3 6.2 Cross-Cutting Measures of Program Progress— Prevalence of Smoking and Cigarette Consumption ..... 6-4 6.2.1 Simple Trend Analysis of Per Capita Cigarette Sales—New York versus the Remaining United States ............................... 6-4 6.2.2 Trends in the Prevalence of Adult Smoking....... 6-9 6.3 Goal 1: Eliminate Exposure to Secondhand Smoke ....6-15 6.3.1 Exposure to Secondhand Smoke....................6-16 6.3.2 Compliance with the Clean Indoor Air Act........6-21 6.3.3 Attitudes Toward the CIAA and Secondhand Smoke.......................................................6-33 6.3.4 News Media Coverage of the CIAA and Secondhand Smoke .....................................6-38 6.3.5 Behavior Change Related to Exposure to Secondhand Smoke .....................................6-42 6.3.6 Summary ...................................................6-57 6.3.7 Conclusions and Next Steps ..........................6-61 6.4 Goal 2: Decrease the Social Acceptability of Tobacco Use .........................................................6-62 6.4.1 Overview ...................................................6-62 6.4.2 Tobacco Knowledge, Attitudes, and Beliefs ......6-63 6.4.3 Awareness of Antitobacco Media Messages ......6-75 6.4.4 Awareness of Pro-Tobacco Advertising and Promotions.................................................6-80 6.4.5 Summary ...................................................6-88 6.4.6 Conclusions and Next Steps ..........................6-90 6.5 Goal 3: Promote Cessation from Tobacco Use...........6-93 6.5.1 Overview ...................................................6-93 6.6 Goal 4: Prevent the Initiation of Tobacco Use Among Youth and Young Adults.............................6-114 6.6.1 Overview .................................................6-114 6.6.2 Methods...................................................6-114 6.6.3 Results ....................................................6-115 v 6.6.4 Discussion................................................6-124 6.6.5 Conclusions and Next Steps ........................6-126 7. Summary and Conclusions 7-1 7.1 Overview .............................................................. 7-1 7.2 New York Tobacco Control History and Context........... 7-2 7.3 Program Strategy and Implementation ...................... 7-4 7.4 Evaluation Findings ................................................ 7-6 7.4.1 Goal