Assessment of School Staff Knowledge and Perceptions of Student E-cigarette Use and Resource Needs, and E-cigarettes Confiscated at 12 North Carolina High Schools - 2019.

BACKGROUND: E-cigarettes are the most commonly used tobacco product among US youth and are regularly used on school grounds. We assessed school staff's awareness of students' e-cigarette use, response by schools, and resources needed to address use, and examined e-cigarettes confiscated by school staff in North Carolina to guide prevention and identify needed resources. METHODS: In May 2019, staff from a random sample of 25 of 451 North Carolina public and charter high schools were invited to complete an online survey and semistructured interview; 12 schools consented to ≥ 1 component (survey, N = 514; interviews, N = 35). Staff knowledge and perceptions of students' e-cigarette use and school tobacco policies were assessed, including school efforts to address e-cigarette use. E-cigarette products confiscated by nine schools from students during the 2018-2019 school year were collected. LIMITATIONS: Only 12 public high schools participated, and these schools might not be representative of all North Carolina high schools. Quantitative surveys were not collected from all staff at participating schools; however, the response rate was 62% and included different staff positions and both urban and rural schools. Finally, e-cigarette products collected by schools might not be representative of all devices used by students. RESULTS: Among surveyed staff, 33% observed students using e-cigarettes on school grounds; 86% believed e-cigarette use somewhat or largely contributes to learning disruptions. Overall, 94% of respondents knew their school's policy prohibits student e-cigarette use on school grounds, and 57% were not confident their school has resources to help students quit. From 35 interviews, themes included concern that schools' tobacco-free policies do not deter use and additional resources are needed to address e-cigarette use in schools. Of 336 collected devices, there were different e-cigarette types and most (65%) e-liquid bottles were flavored. CONCLUSION: Efforts are warranted to incorporate evidence-based curricula; educate staff, parents, and youth regarding health risks of e-cigarette use; and help youth quit e-cigarettes.

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.

Trends in cigarette, cigar, and smokeless tobacco use among New York City public high school youth smokers, 2001-2013.

OBJECTIVE: This study aimed to describe the recent trends in youth smoking behaviors, and examine cigar and smokeless tobacco use patterns among youth smokers in New York City. METHODS: Data, analyzed in 2014, were from the New York City Youth Risk Behavior Survey, a cross-sectional survey conducted bi-annually since 1997 in a representative sample of New York City public high school students (2001-2013), n = 59,122. RESULTS: Cigarette smoking declined 53%, from 17.6% in 2001 to 8.2% in 2013 (p < 0.001). The proportion of cigar use among smokers doubled, from 22.2% in 2001 to 45.9% in 2013 (p < 0.001), while the proportion of smokeless tobacco use among smokers increased by 400% between 2001 and 2013 (4.2% vs. 21.2%, p < 0.001). CONCLUSIONS: Youth cigarette smoking rates in New York City decreased, while cigar smoking and smokeless tobacco use among smokers increased considerably. These data highlight trends in youth smoking behaviors within the context of New York City's comprehensive tobacco control program and stress the need for additional activity to spur further declines in cigarette smoking and reverse the trends in cigar and smokeless tobacco use among New York City youth. Results demonstrate the need for continuous surveillance and action by the public health community to counteract tobacco industry promotion of other products.

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.

Smoke-free parks and beaches: an interrupted time-series study of behavioural impact in New York City.

BACKGROUND: In 2011, New York City (NYC) parks and beaches became smoke-free. There is currently little research evaluating the impact of such laws on smoking behaviour at the population level. METHODS: We used an interrupted time-series study design to analyse data from the New York State Adult Tobacco Survey to assess the law's impact using the rest of New York State as a comparison. Trends in how frequently respondents noticed people smoking in parks and beaches were analysed between the third quarter of 2009 and the fourth quarter of 2012, comparing NYC to the rest of the state. RESULTS: The trend in the frequency of NYC residents noticing people smoking in local parks and beaches decreased significantly over the six quarters after the law took effect. There was no comparable decline among residents in the rest of the state. An increase in the number of respondents who never noticed people smoking in NYC contributed to this decline. CONCLUSIONS: These results are consistent with previous studies and provide population-level evidence that suggest the law has reduced smoking in parks and on beaches.

One cigarette is one too many: evaluating a light smoker-targeted media campaign.

BACKGROUND: Light smokers represent an increasing share of adult smokers in various parts of the world including New York City (NYC). Since 2007, the NYC Department of Health and Mental Hygiene has aired hard-hitting antitobacco media campaigns paired with time-limited nicotine replacement therapy (NRT) giveaways. We evaluated an original antitobacco media campaign, developed to increase awareness of smoking risks and encourage cessation service use among light smokers in NYC. METHODS: We compared cessation service request volume during the campaign to historical periods without ads targeting light smokers. We used a cross-sectional online panel survey to assess the ad's perceived effectiveness and its impact on learning something new, quit intentions and concern for smoking-related health risks among non-daily, light daily and heavy daily smokers. RESULTS: The proportion of light smokers among smokers requesting cessation services increased 50% (from 13% to 20%) relative to previous time-limited NRT giveaways. Compared to heavy daily smokers, non-daily (aOR: 1.95, p<0.05) and light daily (aOR: 2.27, p<0.05) smokers were more likely to express increased concern about smoking-related health risks after viewing the ad. Perceived effectiveness of the ad did not differ by smoker type. CONCLUSIONS: This study provides evidence that light smokers were receptive to a targeted antitobacco message encouraging use of cessation services. The campaign appears to have been particularly effective in increasing smoking-related health concerns in this group. The lack of difference in perceived ad effectiveness by smoker type suggests the potential to develop such ads without sacrificing broad impact.

Increases in smoking cessation interventions after a feedback and improvement initiative using electronic health records -- 19 community health centers, New York City, October 2010-March 2012.

Quitting smoking substantially reduces smokers' risk for smoking-related morbidity and mortality and can increase life expectancy by up to a decade. Most smokers want to quit and make at least one medical provider visit annually. Health care providers can play an important role in helping smokers quit by documenting patients' tobacco use, advising smokers to quit, and providing evidence-based cessation treatments or referrals for treatment, but many providers and practices do not regularly take these actions. Systems to increase provider screening and delivery of cessation interventions are available; in particular, electronic health records (EHRs) can be powerful tools to facilitate increased cessation interventions. This analysis reports on an EHR-based pay-for-improvement initiative in 19 community health centers (CHCs) in New York City (NYC) that sought to increase smoking status documentation and cessation interventions. At the end of the initiative, the mean proportion of patients who were documented as smokers in CHCs had increased from 24% to 27%, whereas the mean proportion of documented smokers who received a cessation intervention had increased from 23% to 54%. Public health programs and health systems should consider implementing strategies to equip and train clinical providers to use information technology to increase delivery of cessation interventions.

Making it harder to smoke and easier to quit: the effect of 10 years of tobacco control in New York City.

In 2002, New York City implemented a comprehensive tobacco control plan that discouraged smoking through excise taxes and smoke-free air laws and facilitated quitting through population-wide cessation services and hard-hitting media campaigns. Following the implementation of these activities through a well-funded and politically supported program, the adult smoking rate declined by 28% from 2002 to 2012, and the youth smoking rate declined by 52% from 2001 to 2011. These improvements indicate that local jurisdictions can have a significant positive effect on tobacco control.

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.

Cigarette trafficking in five northeastern US cities.

BACKGROUND: Cigarette taxation is effective in reducing tobacco use in the USA. However, these benefits are reduced when taxes are unpaid. Cigarette trafficking (ie, the illegal importation of cigarettes into a high-tax jurisdiction from a lower-tax jurisdiction) is well documented in high-tax places like New York City (NYC), but the extent of trafficking in other northeastern cities is relatively unknown. OBJECTIVE: To estimate the extent of cigarette trafficking in Boston, NYC, Philadelphia, Providence and Washington, DC, and project the benefits of reducing cigarette trafficking for recouping lost taxes and reducing smoking in these cities. METHODS: Littered cigarette packs were collected from a random sample of Census tracts in five US cities. Data collection yielded 1439 total littered packs. The share of cigarette packs bearing proper local, known non-local, foreign or unknown, or no tax stamp was calculated for each city. These data were used to estimate tax revenue recovery if cigarette trafficking could be eliminated. We also estimated the extent to which eliminating cigarette trafficking would reduce cigarette consumption. RESULTS: Overall, 58.7% of packs did not have a proper local tax stamp, and 30.5-42.1% were attributed to trafficking. We estimate that eliminating cigarette trafficking would result in declines in youth smoking prevalence ranging from negligible in low-tax cities like Philadelphia to up to 9.3% in higher-tax NYC. We estimate that these five cities could recoup $680-729 million annually in cigarette tax revenue if cigarette trafficking was eliminated. CONCLUSIONS: Reducing cigarette trafficking would increase the effectiveness of tobacco taxes in reducing smoking and generate additional tax revenue, particularly in higher-taxed cities. Federal action to reduce cigarette trafficking, such as a track-and-trace system, is needed.

Exposure to tobacco retail outlets and smoking initiation among New York City adolescents.

This study was designed to estimate the relationship between exposure to tobacco retail outlets and smoking initiation in a racially diverse urban setting. Using data from the 2011 NYC Youth Risk Behavior Survey, multivariable logistic regression analyses were conducted to estimate the exposure-initiation relationship and test for effect modification, while controlling for covariates. The predicted probability of smoking initiation from the multivariable model increased from 7.7 % for zero times a week exposed to tobacco retailers to 16.0 % for exposure seven times or more per week. The odds of initiation were significantly higher among adolescents exposed to tobacco retail outlets two times or more a week compared with those exposed less often (AOR = 1.41; 95 % CI: 1.08, 1.84). Risk-taking behavior modified the relationship between exposure and initiation, with the odds of initiation highest among those low in risk-taking (AOR = 1.78; 95 % CI: 1.14, 1.56). These results are consistent with past research, showing that frequent exposure to tobacco marketing in retail settings is associated with increased odds of initiation. Reducing exposure to tobacco retail marketing could play an important role in curtailing smoking among adolescents, especially those less prone to risk-taking.

The impact of cigarette excise tax increases on purchasing behaviors among New York city smokers.

OBJECTIVES: We examined the relationship between cigarette excise tax increases and tax-avoidant purchasing behaviors among New York City adult smokers. METHODS: We analyzed data from the city's annual Community Health Survey to assess changes in rates of tax avoidance over time (2003-2010) and smokers' responses to the 2008 state cigarette tax increase. Multivariable logistic regression analysis identified correlates of buying more cigarettes on the street in response to the increase. RESULTS: After the 2002 tax increase, the percentage of smokers engaged in tax-avoidant behavior decreased with time from 30% in 2003 to 13% in 2007. Following the 2008 tax increase, 21% of smokers reported buying more cigarettes from another person on the street. Low-income, younger, Black, and Hispanic smokers were more likely than respondents with other sociodemographic characteristics to purchase more cigarettes on the street. CONCLUSIONS: To maximize public health impact, cigarette tax increases should be paired with efforts to limit the flow of untaxed cigarettes entering jurisdictions with high cigarette pack prices.

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.

Exploring the next frontier for tobacco control: Nondaily smoking among New York City adults.

OBJECTIVE: Among current smokers, the proportion of Nondaily smokers is increasing. A better understanding of the characteristics and smoking behaviors of Nondaily smokers is needed. METHODS: We analyzed data from the New York City (NYC) Community Health Survey to explore Nondaily smoking among NYC adults. Univariate analyses assessed changes in Nondaily smoking over time (2002-2010) and identified unique characteristics of Nondaily smokers; multivariable logistic regression analysis identified correlates of Nondaily smoking in 2010. RESULTS: The proportion of smokers who engage in Nondaily smoking significantly increased between 2002 and 2010, from 31% to 36% (P = 0.05). A larger proportion of Nondaily smokers in 2010 were low income and made tax-avoidant cigarette purchases compared to 2002. Smoking behaviors significantly associated with Nondaily smoking in 2010 included smoking more than one hour after waking (AOR = 8.8, 95% CI (5.38-14.27)); buying "loosies" (AOR = 3.5, 95% CI (1.72-7.08)); attempting to quit (AOR = 2.3, 95% CI (1.36-3.96)). CONCLUSION: Nondaily smokers have changed over time and have characteristics distinct from daily smokers. Tobacco control efforts should be targeted towards "ready to quit" Nondaily smokers.

Trends in operator and hospital procedure volume and outcomes for percutaneous transluminal coronary angioplasty, 1996 to 2001.

Although the volume/outcome relation for percutaneous transluminal coronary angioplasty (PTCA) is well established, it is unclear how the relation has changed over time. To examine trends in hospital and operator volume and outcomes for PTCA, we conducted a retrospective cohort study of discharge records of patients who underwent PTCA at nonfederal hospitals in Florida and New York from 1996 to 2001. Hospital/operator pairs were divided into 4 classes using American College of Cardiology/American Heart Association volume classifications. Outcome measurements were operator and hospital procedure volume and a combined end point of inpatient mortality and emergency coronary artery bypass graft surgery. Of 452,404 patients, the number of patients who underwent PTCA from 1996 to 2001 increased from 58,180 to 92,277, with a mean annual increase of 9.1%. The risk-adjusted end point of mortality and emergency coronary artery bypass grafting decreased over time, occurring in 2.8% of admissions in 1996 and in 1.6% of admissions in 2001. Class 1 hospital/operator pairs, which were operators performing >or=75 procedures at hospitals performing >400 procedures, had the lowest occurrence of the end point overall and in each year. The risk-adjusted end point difference between classes narrowed over time. In conclusion, outcomes were best for patients receiving care from class 1 hospital/operator pairs, and an increasing proportion of patients received care from class 1 pairs. There were outcome differences within subpopulations of operators in classes 2 and 4, which suggest possibilities for alternative volume classification guidelines.