Changes to the littered cigarette pack environment in New York City between 2011 and 2015.

INTRODUCTION: Imposing policies that increase tobacco prices is a key strategy for reducing smoking prevalence, although it may result in more cigarette trafficking. In 2013, New York City (NYC) passed the Sensible Tobacco Enforcement (STE) law requiring cigarettes be sold for a minimum price of $10.50 per pack. To evaluate whether cigarette price increases changed patterns of behaviour related to cigarette tax evasion, we examined littered pack study data from 2011 and 2015. METHODS: Littered cigarette packs were collected from a random sample of NYC census tracts in 2011 and 2015. The proportions of cigarette packs with proper local, known non-local, foreign or unknown, and no tax stamp were calculated. Changes in volume, source and consumption of domestically trafficked cigarettes over time were estimated. RESULTS: In 2011, 255 packs with cellophane were collected; in 2015, 226 packs with cellophane were collected. Packs without proper local stamp increased from 60.7% in 2011 to 76.3% in 2015 (p<0.05) and those with foreign or unknown stamp increased from 11.6% in 2011 to 31.4% in 2015 (p<0.05). The percentage of domestically sourced packs attributed to domestic trafficking increased significantly from a range of 47.9% to 52.8% in 2011 to a range of 59.4% to 63.2% in 2015. CONCLUSION: While the trafficking rate among domestically sourced cigarettes increased between 2011 and 2015 (before and after the STE minimum price floor on cigarette packs was in place), there was a decline in total consumption of domestically trafficked cigarettes due to a significant increase in consumption of foreign-sourced cigarettes. Jurisdictions considering price measures should bolster monitoring and enforcement efforts to maximise public health impact. Given the interstate nature of cigarette trafficking in the USA, Federal intervention would be optimal.

Smoking Social Norms Among Young Adults in New York City.

More than half of young adult (YA) (ages 18-26) smokers are non-daily smokers. While standard cessation methods are generally successful with adults and daily smokers, there is evidence that they are not as successful among non-daily smokers or young adults. Additionally, YA smokers are also in a transition period to regular smoking, making research on understanding how interpersonal and environmental factors affect this group of smokers critical. Randomized time location sampling was used to create a sample of New York City YA bar patrons between June and November 2013, who completed a self-administered survey (1,916 surveys). Questions were asked about perceived smoking social norms, stigma, behaviors, and demographics. Overall, almost half of the YA reported being current smokers (44.1%); one-third were non-daily smokers (36.7%) and less than ten percent were daily smokers (7.4%). Non-daily smokers compared with daily smokers had greater odds of believing New Yorkers disapproved of smoking [adjusted odds ratio (ORadj 1.76, 95 % CI 1.10-2.79)], keeping tobacco a secret from certain people (ORadj 1.84, 1.14-2.96) and feeling guilty when smoking (ORadj: 2.54; 1.45-4.45). Non-daily smokers had 41% lower odds of reporting how people who are important to you disapproved of smoking than daily smokers (ORadj: 0.59; 0.38-0.94). Further studies of interpersonal/environmental factors among YA smokers may support modifications to cessation programs that result in more successful YA quit attempts.

Development of Culturally Appropriate Support Strategies to Increase Uptake of Nicotine Replacement Therapy Among Russian- and Chinese-Speaking Smokers in New York City.

Approximately 80,000 New York City smokers are Chinese or Russian speakers. To increase utilization of smoking cessation services among these populations, the Department of Health and Mental Hygiene developed linguistically and culturally tailored outreach strategies to promote and enhance its annual Nicotine Patch and Gum Program. In 2010, online web applications in Chinese and Russian were introduced. In 2011, input was sought from the community to develop Russian-language radio and newspaper ads, and a Russian-speaking liaison provided phone-assisted online enrollment support. In 2012, Chinese newspaper ads were introduced, and a Cantonese- and Mandarin-speaking liaison was hired to provide enrollment support. In 2010, 51 Russian speakers and 40 Chinese speakers enrolled in the program via web application. In 2011, 510 Russian speakers applied via the web application, with 463 assisted by the Russian-speaking liaison; forty-four Chinese speakers applied online. In 2012, 394 Russian speakers applied via the web application; 363 were assisted by the Russian-speaking liaison. Eighty-five Chinese smokers applied online via the web application; seventy were assisted by the Chinese-speaking liaison. Following the implementation of culturally tailored cessation support interventions, ethnic Russian smokers' uptake of cessation support increased tenfold, while Chinese smokers' uptake doubled. Although linguistically appropriate resources are an essential foundation for reaching immigrant communities with high smoking rates, devising culturally tailored strategies to increase quit rates is critical to programmatic success.

Evaluation of the Farmers' Markets for Kids programme.

OBJECTIVE: To assess the impact of Farmers' Markets for Kids, a farmers' market-based, child-oriented nutrition education programme, on attitudes and behaviours related to preparing and consuming produce among child participants and their caregivers in New York City (NYC). DESIGN: Retrospective pre-test/post-test cross-sectional survey with caregivers of children participating in Farmers' Markets for Kids classes. SETTING: Four NYC farmers' markets where Farmers' Markets for Kids classes are implemented; these markets serve low-income communities. SUBJECTS: Two hundred and twelve adult caregivers of children who participated in Farmers' Markets for Kids classes. RESULTS: Caregivers reported that children's consumption of fruits and vegetables had increased since participating in Farmers' Markets for Kids and that their children more frequently assisted with food preparation; both of these improvements were statistically significant. Caregivers also reported significant improvements in attitudes: since participating in Farmers' Markets for Kids, their children were more willing to try new fruits and vegetables and caregivers found it easier to prepare fruits and vegetables for their children. Almost all respondents (99 %) reported purchasing more fruits and vegetables since participating in Farmers' Markets for Kids and 95 % had prepared the programme's recipes at home. CONCLUSIONS: Findings suggest that Farmers' Markets for Kids may be an effective approach for increasing produce consumption among participating children and improving related attitudes among children and caregivers. This evaluation provides support for future efforts to undertake more rigorous evaluations of such programmes.

Commentary: Persistence and Health-Related Consequences of the Model Minority Stereotype for Asian Americans.

Fifty years ago, the term model minority was coined to describe the extraordinary ability of Asian Americans to overcome hardship to succeed in American society. Less well-known is how the model minority stereotype was cultivated within the context of Black-White race relations during the second half of the 20th century, and how this stereotype, in turn, has contributed to the understanding and prioritization of health disparities experienced by Asian Americans. The objectives of this article are to define the model minority stereotype, present its controversies, and provide examples of its social and health-related consequences (ie, implications for obesity and tobacco) across multiple levels of society and institutions. A salient theme throughout the examples provided is the limitation of data presented at the aggregate level across all Asian subgroups which masks meaningful disparities. The intent is to increase the visibility of Asian Americans as a racial/ethnic minority group experiencing chronic disease health disparities and deserving of health-related resources and consideration.

Increasing access to fruits and vegetables: perspectives from the New York City experience.

Broad recognition now exists that price, availability, and other structural factors are meaningful barriers to fruit and vegetable consumption, particularly among low-income adults. Beginning in 2005, the New York City Department of Health and Mental Hygiene used the social-ecological model to develop a multifaceted effort to increase fruit and vegetable access citywide, with emphasis in low-income neighborhoods. Overall, the percentage of New York City adults who reported consuming no fruits and vegetables in the previous day decreased slightly over a 10-year period (2002: 14.3% [95% confidence interval = 13.4%, 15.2%]; 2012: 12.5% [95% confidence interval = 11.4%, 13.6%]; P for trend < .001). Our approach hypothesizes that complementary initiatives, implemented simultaneously, will create a citywide food environment that fuels changes in social norms and cultural preferences, increases consumer demand, and supports sustainable access to affordable produce.

The impact of a temporary recurrent street closure on physical activity in New York City.

At least 70 US cities have now introduced ciclovías-large-scale street closures to promote physical activity-joining numerous other cities worldwide that have implemented ciclovías in efforts to improve population health. We assessed the impact of Summer Streets, a New York City program in which 6.9 contiguous miles of urban streets were closed to traffic and opened for walking, cycling, and group activities, such as dancing and yoga, on population physical activity levels. Screen line counts were used to estimate attendance, and a street intercept survey was conducted to assess demographic characteristics of participants, baseline adherence to physical activity recommendations, and type and duration of physical activity at Summer Streets. In addition, a traffic study was used to determine if there were vehicular traffic delays as a result of the program. About 50,000 people participated in Summer Streets; among participating New Yorkers, bicyclists averaged 6.7 miles, runners 4.3 miles, and walkers 3.6 miles, equivalent to 72-86 min of moderate physical activity. Among New Yorkers attending Summer Streets, 24 % reported that they did not routinely engage in moderate- or vigorous-intensity physical activity. These non-routine exercisers engaged in the equivalent of 26-68 min of moderate-intensity physical activity at Summer Streets. Summer Streets served as an enticement for New Yorkers, including those who did not ordinarily meet physical activity recommendations, to engage in physical activity. There were no significant vehicular traffic delays during the program.

Uptake of the HPV vaccination programme in England: a cross-sectional survey of young women attending sexual health services.

OBJECTIVES: The U.K. human papilloma virus (HPV) vaccination programme requires 80% uptake to have a significant impact on cervical cancer rates. Uptake in the first three years of the programme was 66%. We report the results of a cross-sectional survey of young women attending sexual health services (SHS) in England, reviewing HPV vaccination uptake and prevalence of HPV-related risk factors. METHODS: An anonymous questionnaire surveyed women aged 13-19 attending 19 hospital-based and 13 community-based SHS across England, March-August 2011. Data were analysed using multiple logistic regression. RESULTS: 2247 questionnaires were completed. Compared with national data, respondents had higher smoking rates (48% vs. 14% of 15 year olds), coitarche under-16 (52% vs. 38%), previous sexually transmitted infections (STIs) (25% vs. 4%) and a higher proportion not in education, employment or training (NEETs) (8% vs. 2% of 16 year olds). Seventy-four per cent had been offered the vaccination, with significantly lower offer rates in London, non-white ethnicities, 17-19 year olds, NEETs, smokers and those with previous STIs (all p<0.05 in multivariate analysis). Sixty-five per cent of those offered, completed, with significantly lower completion rates in London, non-white ethnicities, 17-19 year olds, NEETs, smokers and those with previous STIs (all p<0.05 in multivariate analysis). Overall completion rate was 47%. CONCLUSIONS: We observed lower vaccination offer and completion rates and higher prevalence of HPV-related risk factors compared with national data. The highest risk individuals were the least likely to have been offered or to have completed the course. This survey highlights an opportunity for primary prevention by routinely offering the HPV vaccine to eligible women attending SHS.

Developing built environment programs in local health departments: lessons learned from a nationwide mentoring program.

Local health departments (LHDs) have a key role to play in developing built environment policies and programs to encourage physical activity and combat obesity and related chronic diseases. However, information to guide LHDs' effective engagement in this arena is lacking. During 2011-2012, the New York City Department of Health and Mental Hygiene (DOHMH) facilitated a built environment peer mentoring program for 14 LHDs nationwide. Program objectives included supporting LHDs in their efforts to achieve built environment goals, offering examples from DOHMH's built environment work to guide LHDs, and building a healthy built environment learning network. We share lessons learned that can guide LHDs in developing successful healthy built environment agendas.

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.

Comparing sugary drinks in the food retail environment in six NYC neighborhoods.

Obesity is a national public health concern linked to numerous chronic health conditions among Americans of all age groups. Evidence suggests that discretionary calories from sugary drink consumption have been a significant contributor to excess caloric intake among both children and adults. Research has established strong links between retail food environments and purchasing habits of consumers, but little information exists on the sugary drink retail environment in urban neighborhoods. The objective of this assessment was to compare various aspects of the sugary drink retail environment across New York City (NYC) neighborhoods with disparate self-reported sugary drink consumption patterns. In-store retail audits were conducted at 883 corner stores, chain pharmacies, and grocery stores in 12 zip codes throughout NYC. Results showed that among all beverage types assessed, sugary drinks had the most prominent presence in the retail environment overall, which was even more pronounced in higher-consumption neighborhoods. In higher- versus lower-consumption neighborhoods, the mean number of sugary drink varieties available at stores was higher (11.4 vs. 10.4 varieties), stores were more likely to feature sugary drink advertising (97 vs. 89 %) and advertising at multiple places throughout the store (78 vs. 57 %), and several sugary drinks, including 20-oz Coke® or Pepsi®, were less expensive ($1.38 vs. $1.60). These results, all statistically significant, indicate that neighborhoods characterized by higher levels of sugary drink consumption expose shoppers to sugary drinks to a greater extent than lower-consumption neighborhoods. This builds upon evidence documenting the association between the environment and individual behavior.

Institution-to-institution mentoring to build capacity in 24 local US health departments: best practices and lessons learned.

INTRODUCTION: Institutional mentoring may be a useful capacity-building model to support local health departments facing public health challenges. The New York City Department of Health and Mental Hygiene conducted a qualitative evaluation of an institutional mentoring program designed to increase capacity of health departments seeking to address chronic disease prevention. The mentoring program included 2 program models, a one-to-one model and a collaborative model, developed and implemented for 24 Communities Putting Prevention to Work grantee communities nationwide. METHODS: We conducted semi-structured telephone interviews to assess grantees' perspectives on the effectiveness of the mentoring program in supporting their work. Two interviews were conducted with key informants from each participating community. Three evaluators coded and analyzed data using ATLAS.ti software and using grounded theory to identify emerging themes. RESULTS: We completed 90 interviews with 44 mentees. We identified 7 key program strengths: learning from the New York City health department's experience, adapting resources to local needs, incorporating new approaches and sharing strategies, developing the mentor-mentee relationship, creating momentum for action, establishing regular communication, and encouraging peer interaction. CONCLUSION: Participants overwhelmingly indicated that the mentoring program's key strengths improved their capacity to address chronic disease prevention in their communities. We recommend dissemination of the results achieved, emphasizing the need to adapt the institutional mentoring model to local needs to achieve successful outcomes. We also recommend future research to consider whether a hybrid programmatic model that includes regular one-on-one communication and in-person conferences could be used as a standard framework for institutional mentoring.

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.

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 New York City's Health Bucks Program on electronic benefit transfer spending at farmers markets, 2006-2009.

INTRODUCTION: Increasing the accessibility and affordability of fresh produce is an important strategy for municipalities combatting obesity and related health conditions. Farmers markets offer a promising venue for intervention in urban settings, and in recent years, an increasing number of programs have provided financial incentives to Supplemental Nutrition Assistance Program (SNAP) recipients. However, few studies have explored the impact of these programs on use of SNAP benefits at farmers markets. METHODS: New York City's Health Bucks Program provides SNAP recipients with a $2 coupon for every $5 spent using SNAP benefits at participating farmers markets. We analyzed approximately 4 years of electronic benefit transfer (EBT) sales data, from July 2006 through November 2009, to develop a preliminary assessment of the effect of the Health Bucks Program on EBT spending at participating markets. RESULTS: Farmers markets that offered Health Bucks coupons to SNAP recipients averaged higher daily EBT sales than markets without the incentive ($383.07, 95% confidence interval [CI], 333.1-433.1, vs $273.97, 95% CI, 243.4-304.5, P < 0.001) following the introduction of a direct point-of-purchase incentive. Multivariate analysis indicated this difference remained after adjusting for the year the market was held and the neighborhood poverty level. CONCLUSION: When a $2 financial incentive was distributed with EBT, use of SNAP benefits increased at participating New York City farmers markets. We encourage other urban jurisdictions to consider adapting the Health Bucks Program to encourage low-income shoppers to purchase fresh produce as one potential strategy in a comprehensive approach to increasing healthful food access and affordability in low-income neighborhoods.

Lessons learned from the implementation of a time-limited, large-scale nicotine replacement therapy giveaway program in New York City.

Since 2006, the New York City (NYC) Department of Health and Mental Hygiene has conducted the Nicotine Patch and Gum Program (NPGP) in collaboration with 311, NYC's non-emergency information line. In two prior years, the program was conducted in collaboration with the New York State (NYS) Smokers' Quitline and with community-based organizations. The NPGP is an annual, brief, population-based nicotine replacement therapy (NRT) giveaway for NYC residents, complementing the NYS Quitline's year-round NRT distribution program. Since 2006, 168,000 smokers have enrolled, with the largest number of enrollees in 2010 (n = 40,000) and the smallest number in 2009 (n = 28,000). A 2003 program evaluation demonstrated that smokers who received NRT through the NPGP had higher quit rates than smokers who did not receive NRT; these results were replicated in 2006 and 2008. Lessons learned from implementing the NPGP include: 1) time-limited NRT interventions are important complements to year-round NRT distribution; 2) expanding NRT distribution to light smokers increases treatment reach; and 3) employing multiple enrollment mechanisms, including telephone and online options, extends program reach to diverse groups of smokers. The NPGP provides a model for other jurisdictions considering implementing time-limited, population-based NRT programs as a complementary strategy to enhance ongoing tobacco control efforts.

Public health detailing of primary care providers: New York City's experience, 2003-2010.

OBJECTIVES: We evaluated the effectiveness of the Public Health Detailing Program in helping primary care providers and their staff to improve patient care on public health challenges. METHODS: We analyzed reported changes in clinical practice or behavior by examining providers' retention and implementation of recommendations for campaigns. RESULTS: During each campaign, 170 to 443 providers and 136 to 221 sites were reached. Among assessed providers who indicated changes in their practice behavior, the following statistically significant increases occurred from baseline to follow-up. Reported screening for clinical preventive services increased, including routinely screening for intimate partner violence (14%-42%). Clinical management increased, such as prescribing longer-lasting supplies of medicine (29%-42%). Lifestyle modification and behavior change, such as recommending increased physical activity to patients with high cholesterol levels, rose from 52% to 73%. Self-management goal setting with patients increased, such as using a clinical checkbook to track hemoglobin A1c goals (28% to 43%). CONCLUSIONS: Data suggest that public health detailing can be effective for linking public health agencies and their recommendations to providers and influencing reported changes in clinical practice behavior.

"Come with us for a week, for a month, and see how much food lasts for you:" A Qualitative Exploration of Food Insecurity in East Harlem, New York City.

BACKGROUND: Food insecurity refers to uncertain access to food on a consistent basis and the stress experienced by families who worry about having sufficient resources to provide balanced meals in their households. Food insecurity has a disproportionate influence on people of color. A robust body of evidence links food insecurity to poor health outcomes. OBJECTIVE: To document experiences of food insecurity among linguistically and ethnically diverse residents of the East Harlem neighborhood of New York City by exploring the ways in which food availability and cost intersect with household budgets, personal preferences, and shopping strategies. DESIGN: In-depth qualitative interviews were conducted with adult residents of New York City's East Harlem neighborhood to provide insights about the links between food insecurity, well-being, and quality of life. PARTICIPANTS/SETTING: Thirty-seven adult residents of East Harlem were recruited through purposive sampling. Eligibility requirements included living in an East Harlem zip code (10029 or 10035); being aged 18 years or older; being the main food shopper and food decision-maker in the household; and speaking English, Spanish, or Mandarin Chinese. The study was conducted from February to May 2018. STATISTICAL ANALYSES PERFORMED: Interviews were analyzed using a grounded theory approach. Codes were organized into broad thematic topics and cross-case analyses were conducted. RESULTS: Participants discussed overall perceptions of food insecurity and seven themes related to the challenges of and strategies for coping with food insecurity: intermittent vs chronic food insecurity, shopping and budgeting strategies, pantries as a vital community resource, social support systems, food insecurity and health, frustration with an unjust system, and pride in "making it work." CONCLUSIONS: To manage food insecurity, many study participants carefully managed food spending, dedicated substantial time to visiting stores and accessing food pantries, and relied on a public benefits cycle that left many without sufficient financial resources at the end of each month.

The primary care nutrition training program: an approach to communication on behavior change.

The New York City Department of Health has designed a Primary Care Nutrition Training program for implementation in high-need neighborhoods that face growing diet-related epidemics of diabetes and obesity and a heavy burden of cardiovascular disease. Seven hundred fifty-six primary care team members complete pretest surveys and 665 complete posttest surveys at 45 training sessions between January and July 2007. Skills-building sessions center on the innovative application of visual aids and manipulatives and the provision of specific language for addressing nutritional issues with patients in busy primary care settings. Program evaluation data indicate that the training was well received by participants of all education levels, including medical assistants, physicians, nurses, and others, with 91% noting that the training content was pitched at about the right comprehension level for them. The Primary Care Nutrition Training Program offers a practical approach to continuing education for health professionals that may help to address the dearth of nutrition services currently in urban primary care.