Tobacco Use Disparitiesin New York State

January 12, 2012

Copyright ©2010 American Public Health Association

Frieden, T. R. Am J Public Health 2010;100:590-595

The health impact pyramid

NYS Tobacco Control Program health impact pyramid

Quitline

Health provider 5As, EHR that document

tobacco screening and interventions.

Mass media campaigns.

Smoke-free policies, high prices for tobacco, restricting tobacco marketing, establishing and

reinforcing tobacco-free social norms.

Tobacco industry targeting of low-SES, racial/ethnic minorities, LGBT. Tobacco use to self-medicate for depression/stress caused by social disadvantage. Family and social networks supportive of

tobacco use.

Incr

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Pop

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Increasin

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ividu

al Effort N

eeded

NYS Tobacco Control Program health impact pyramid

Quitline

Health provider 5As, EHR that document

tobacco screening and interventions.

Mass media campaigns.

Smoke-free policies, high prices for tobacco, restricting tobacco marketing, establishing and

reinforcing tobacco-free social norms.

Tobacco industry targeting of low-SES, racial/ethnic minorities, LGBT. Tobacco use to self-medicate for depression/stress caused by social disadvantage. Family and social networks supportive of

tobacco use.

CessationInterventions

Health Communication & State/Community

Action

SocialContext

27.1%

20.4% 20.2%18.5%

16.2% 16.3%

13.8%14.7% 14.8%

12.6%

0%

10%

20%

30%

PERCENTAGE OF NEW YORK HIGH SCHOOL STUDENTS WHO CURRENTLY SMOKE, 2000-2010

21.6%23.2%

22.3%21.6%

19.9% 20.5%

18.2%18.9%

16.8%17.9%

15.5%

17.7%

0%

5%

10%

15%

20%

25%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

PERCENTAGE OF NEW YORK ADULTS WHO CURRENTLY SMOKE, BRFSS 2000-2011*

Source: Behavioral Risk Factor Surveillance System* Data through first 3 quarters of 2011 (raked weight)

Current Smoking By GenderBRFSS 2000-2011*

20.7%22.6%

16.5%

19.1%

0%

5%

10%

15%

20%

25%

30%

35%

Female Male

Source: Behavioral Risk Factor Surveillance System* Data through first 3 quarters of 2011 (raked weight)

Current Smoking By AgeBRFSS 2000-2011*

33.0%

27.1% 26.8%

19.1%

14.7%

9.4%

22.0% 22.4%

18.0%

21.1%

16.0%

8.2%

0%

5%

10%

15%

20%

25%

30%

35%

18 to 24 25-34 35-44 45-54 55-64 65+

Source: Behavioral Risk Factor Surveillance System* Data through first 3 quarters of 2011 (raked weight)

Current Smoking By Race/EthnicityBRFSS 2000-2011*

22.6%21.6%

18.1%

20.4%

17.9%

20.7%

15.4% 14.7%

0%

5%

10%

15%

20%

25%

30%

35%

White Black Hispanic Other

Source: Behavioral Risk Factor Surveillance System* Data through first 3 quarters of 2011 (raked weight)

Current Smoking By EducationBRFSS 2000-2011*

23.9%

26.6%

23.7%

14.2%

27.6%

22.8%

16.5%

8.2%

0%

10%

20%

30%

Less HS HS/GED Some post HS College Degree

Source: Behavioral Risk Factor Surveillance System* Data through first 3 quarters of 2011 (raked weight)

Current Smoking By IncomeBRFSS 2000-2011*

23.3%

28.5%

22.1%

25.7%

17.9%

29.7%

26.7%

19.4%18.1%

12.3%

0%

5%

10%

15%

20%

25%

30%

35%

< $15,000 $15,000-$24,999 $25,000-$34,999 $35,000-$49,999 $50,000+

Source: Behavioral Risk Factor Surveillance System* Data through first 3 quarters of 2011 (raked weight)

Current Smoking By Self-Reported Mental Health, ATS 2003-2010

19.2%

35.6%

15.2%

30.9%

0%

10%

20%

30%

40%

50%

MH Good MH Poor

2003 2010

Source: New York Adult Tobacco Survey

Health CommunicationsProviding motivation to quit/avoid tobacco use

• Higher rates of television viewing among those with low-SES and African-Americans*– African-Americans have greater recall of ads

– Individuals with less than $30k in household incomes have greater recall of ads

– No differences in ad recall by education

• Ad receptivity highest among African-Americans but lowest among those with low-incomes.

• Budget reductions have eroded our reach to all populations.

*Source: Bureau of Labor Statistics, American Time Use Survey (2009)

Facilitating TreatmentCessation Interventions and Policies

• Quitline– ~40% of enrollees are Medicaid beneficiaries or uninsured

– Studies found minimal benefit from additional calls/NRT for Medicaid beneficiaries.

• Health Systems Interventions– Office of Alcoholism and Substance Abuse Services

– Department of Corrections and Community Services

– Office of Mental Health

– Community Health Centers

• Health Benefits– Expansion of Medicaid smoking cessation benefit

– Challenges to benefit promotion after Medicaid redesign

Changing the ContextSocial Norm Change and Population-based Policy Interventions

• Smoke Free Air

– Strong state law

– Outdoor environments

– Smoke Free Housing

• Price Policies

– Highest cigarette tax in the nation

• Retail Environment

– Pursuing policy actions that would reduce density of tobacco retailers

Cigarette Tax Increases

• 2008 – NYS tax $1.25 to $2.75

• 2009 – Federal tax $0.39 to $1.01

• 2010 – NYS tax $2.75 to $4.35

• NYC has additional $1.50 tax

• Total tax

– $6.86 NYC

– $5.36 rest of state

• Tobacco Control Program Budget

– Cut 50% since the 2008 tax increase significantly reducing funding for health communications

11.8%

1.8%

19.5%

2.9%

0%

5%

10%

15%

20%

25%

30%

Income < $30,000 Income ≥ $30,000 Income < $30,000 Income ≥ $30,000

Taxes Prices

Perc

en

t o

f an

nu

al

inco

me

Share of Smokers’ Annual Income Going to Cigarette Taxes and Purchases (inclusive of excise taxes),

Adult Tobacco Survey 2010

38.5%($601.3M)

46.8%($730.9M)

14.7%($230.0M)

51.5%($804.2M)

48.1%($750.9M)

0.5%($7.2M)

0%

20%

40%

60%

80%

100%

< $30,000 ≥ $30,000 Unknown income

≤ High school

> High school

Unknown education

Income Education

Sh

are

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New

Yo

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tate

cig

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tte

excis

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axes p

aid

Percentage of New York State and City Cigarette Excise Taxes Paid by Smokers by Income and Education,

Adult Tobacco Survey 2010

Final Thoughts

• Sustained implementation of Best Practices funding level would allow program to better address disparities (adequate health communication and cessation interventions).

• Best practices interventions have greatest potential to address tobacco use disparities; focusing on tailored services/programs unlikely to have sustained population impact.

Final Thoughts

• Tax increases without adequate program funding can have a negative short-term impact on low-income smokers.

• Our potential to address tobacco use disparities is limited unless we effectively reduce exposure to pro-tobacco marketing.