Effectiveness of a media campaign promoting health care provider tobacco dependence treatment.

The New York State Department of Health (NYSDOH) developed a provider-focused media campaign to encourage provision of evidence-based, clinical tobacco dependence treatment (TDT). The purpose of this study was to assess providers' awareness of the campaign and the relationship between campaign awareness and changes in campaign-related beliefs and clinical TDT intervention. We conducted a longitudinal, mailed survey of health care providers in New York State (n = 851; AAPOR3 RR: 24.6%). We estimated descriptive statistics and used multivariable regression analyses to assess whether changes in key outcomes (campaign-related beliefs and clinical TDT) from pre- to post-campaign vary by self-reported campaign awareness. Approximately 12% of providers were aware of the campaign. In multivariable analyses, changes from pre- to post-campaign in provider beliefs that the nicotine patch and gum are very effective at helping patients quit were greater for providers aware of the campaign compared with those not aware of the campaign (For patch: OR 2.17, CI 1.06-4.45, p = 0.03; for gum: OR 2.78, CI: 1.24-6.27, p = 0.01), but not for provider behavior. After seeing the NYSDOH campaign, providers' beliefs about the effectiveness of the patch and gum increased. Many state tobacco control programs and health care organizations are implementing tobacco-related policies and systems to facilitate the provision of clinical TDT; this study suggests that a digital and print provider-focused media campaign has the potential to complement health systems change interventions. Future studies should seek to identify ways to modify ad delivery to increase campaign awareness to maximize potential campaign impact.

Medicaid coverage for tobacco dependence treatment: Enrollee awareness and use.

Medicaid-insured adults smoke at twice the rate of privately insured adults. Insurance coverage for tobacco dependence treatments (TDTs) has been shown to increase quit attempts, but few published studies have measured enrollees' awareness of Medicaid coverage. We assessed awareness of Medicaid coverage for and use of TDTs among New York State (NYS) Medicaid-insured smokers and recent quitters. In July-August 2017, we conducted a probability-based online survey of Medicaid enrollees in NYS aged 18 to 65 in fee-for-service and managed care plans (n = 266; AAPOR 4RR = 22.5%). In 2017, we estimated descriptive statistics and used Adjusted Wald tests to assess differences in awareness and use of TDTs (p < 0.05). We used logistic regression to assess correlates of coverage awareness and use of TDTs. Most participants (94.3%) were aware of TDTs, but fewer were aware that Medicaid covers them (59.7%). Most participants believed TDTs are effective in helping smokers quit, although many also believed non-evidence-based methods are effective. Awareness of Medicaid coverage was associated with awareness of a Medicaid-related antitobacco television ad (p < 0.05), moderate nicotine dependence (p < 0.05), and believing that TDTs are effective (p < 0.01). Although awareness of Medicaid coverage for TDTs was found to be high, there remains room for improvement, even in a state that actively promotes these benefits. It is important for states to not only expand Medicaid coverage of TDTs but to also promote the benefits to improve the chances of quit success. Understanding Medicaid enrollees' awareness of and perceptions of covered TDTs can inform messaging to maximize utilization of evidence-based benefits.

The Potential Impact of the New York State Smokers' Quitline on Population-Level Smoking Rates in New York.

Receiving smoking cessation services from telephone quitlines significantly increases quit success compared with no intervention or other quitting methods. To affect population-level smoking, quitlines must provide a sufficient proportion of smokers with effective interventions. Nationally, quitlines reach around 1% of adult smokers annually. From 2011 through 2016, the average annual reach of the New York State Smokers' Quitline (NYSSQL) was 2.9%. We used data on the reach and cessation outcomes of NYSSQL to estimate its current impact on population-level smoking prevalence and to estimate how much reach would have to increase to achieve population-level smoking prevalence reductions. We estimate NYSSQL is associated with a 0.02 to 0.04 percentage point reduction in smoking prevalence in New York annually. If NYSSQL achieved the recommended annual reach of 8% (CDC Best Practices) and 16% (NAQC), state-level prevalence would decrease by an estimated 0.07-0.12 and 0.13-0.24 percentage points per year, respectively. To achieve those recommended levels of reach, NYSSQL would need to provide services to approximately 3.5 to 6.9 times more smokers annually. Given their reach, quitlines are limited in their ability to affect population-level smoking. Increasing quitline reach may not be feasible and would likely be cost-prohibitive. It may be necessary to re-think the role of quitlines in tobacco control efforts. In New York, the quitline is being integrated into larger efforts to promote cessation through health systems change.

A Media Campaign to Increase Health Care Provider Assistance for Patients Who Smoke Cigarettes.

Although most smokers visit a health care provider annually, only half report being provided evidence-based assistance with quitting, defined as brief counseling and an offer of medication. The New York State Department of Health designed a provider-targeted media campaign to increase provider-assisted quitting, which was implemented in 2016. Messaging focused on the addictive nature of tobacco products and evidence-based interventions. Online surveys of 400 New York State health care providers measured advertising awareness, associations between awareness and assistance with quit attempts, and perceptions that patients expect providers to assist with quitting. Forty-three percent of providers were aware of at least 1 advertisement, and providers who had seen an advertisement were more likely to provide evidence-based assistance (AOR = 2.55, P = .01), which includes recommending or prescribing cessation medications. Provider-targeted media is a promising approach to reach health care providers and encourage evidence-based smoking cessation treatment.

Trends in Cigarette Advertising, Price-Reducing Promotions, and Policy Compliance in New York State Licensed Tobacco Retailers, 2004 to 2015.

PURPOSE: To describe the presence of licensed tobacco retailers (LTRs), cigarette advertisements, price-reducing promotions, and compliance with tobacco control policies in New York State from 2004 to 2015 and to discuss implications and lessons learned from 11 years of experience conducting LTR surveys. DESIGN: Annual surveys of tobacco advertising from cross-sectional, stratified random samples of LTRs in New York State from 2004 to 2015 were conducted by professional data collectors. Data for 2013 were unavailable as the survey was not fielded in that year. SETTING: New York State. PARTICIPANTS: Licensed tobacco retailers, which are stores licensed to sell tobacco in the state of New York. Between 3.6% (n = 800) and 19.7% (n = 3945) of all LTRs were sampled annually. MEASURES: The presence and number of cigarette advertisements and the presence of price-reducing promotions, required age-of-sale signage, and self-service tobacco displays were documented. ANALYSIS: We tested for significant differences between 2014 and 2015 and significant trends overall and by outlet type. We used logistic regression for binary outcomes and Poisson regression for count variables. RESULTS: The number of LTRs in New York State decreased 22.9% from 2004 (n = 25 740) to 2015 (n = 19 855). The prevalence and number of cigarette advertisements and the prevalence of cigarette price-reducing promotions decreased significantly over time. Compliance with posting required age-of-sale signs increased significantly from 2004 to 2015 and from 2014 to 2015. Compliance with the ban on self-service tobacco displays was consistently near 100%. CONCLUSION: The tobacco retail environment in New York State improved substantially from 2004 to 2015. The implications of these findings for youth and adult smoking and the associated social costs are unknown; however, decreases in pro-tobacco marketing, decreases in the number of LTRs, and improvements in compliance are likely to have positive impacts on youth and adult smoking outcomes, such as reduced initiation and increased cessation, given previous research findings.

Comparing the New York State Smokers' Quitline Reach, Services Offered, and Quit Outcomes to 44 Other State Quitlines, 2010 to 2015.

PURPOSE: To summarize the reach, services offered, and cessation outcomes of the New York Quitline and compare with other state quitlines. DESIGN: Descriptive study. SETTING: Forty-five US states. PARTICIPANTS: State-sponsored tobacco cessation quitlines in 45 US states that provided complete data to the Centers for Disease Control and Prevention's National Quitline Data Warehouse (NQDW) for 24 quarters over 6 years (2010-Q1 through 2015-Q4). INTERVENTION: Telephone quitlines that offer tobacco use cessation services, including counseling, self-help materials, and nicotine replacement therapy (NRT), to smokers at no cost to them. MEASURES: Percentage of adult tobacco users in the state who received counseling and/or free NRT from state quitlines (reach), services offered by state quitlines, and cessation outcomes among quitline clients 7 months after using quitline services. ANALYSIS: Reach, services offered, and cessation outcomes for the New York Quitline were compared with similar measures for the other 44 state quitlines with complete NQDW data for all quarters from 2010 through 2015. RESULTS: New York's average annual quitline reach from 2010 through 2015 was 3.0% per year compared to 1.1% per year for the other 44 states examined. CONCLUSION: Although the New York Quitline was open fewer hours per week and offered fewer counseling sessions and a smaller amount of free NRT than most of the other 44 state quitlines, the New York Quitline had similar quit rates to most of those state quitlines.

Smoking Cessation Benefit Utilization: Comparing Methodologies for Measurement using New York State's Medicaid Data.

Introduction: Pharmacotherapy and counseling for tobacco cessation are evidence-based methods that increase successful smoking cessation attempts. Medicaid programs are required to provide coverage for smoking cessation services. Monitoring utilization is desirable for program evaluation and quality improvement. Various methodologies have been used to study utilization. Many factors can influence results, perhaps none more than how smokers are identified. This study evaluated the utilization of smoking cessation services using various methods to estimate the number of smokers within New York State's (NYS's) Medicaid program in 2015. Methods: Estimates of utilization were generated based on Medicaid claims and encounters and four sources of smoking prevalence: two population surveys, one Medicaid enrollee survey, and diagnosis codes. We compared the percentage of (estimated) smokers utilizing cessation services, and the average number of services used, across fee-for-service and managed care populations, and by cessation service category. Results: Statewide, smoking prevalence estimates ranged from 10.9% to 31.5%. Diagnosis codes identified less than 45% of smokers estimated by surveys. A similar number of cessation counseling (199106) and pharmacotherapy services (197728) were used, yet more members utilized counseling (126839) than pharmacotherapy (91433). The estimated percentage of smokers who used smoking cessation services ranged from 15.1% to 43.4%, and the estimated average number of cessation services used ranged from 0.31 to 0.90 per smoker. Conclusion: Smoking prevalence estimates obtained through surveys greatly exceed prevalence observed in diagnosis codes in NYS's Medicaid data. Use of diagnosis codes in the analysis of smoking cessation benefit utilization may result in overestimates. Implications: Selection of a smoking prevalence data source for similar analyses should ultimately be based on completeness of the data and applicability to the population of interest. Evaluation of smoking cessation benefit utilization and the effectiveness of tobacco control campaigns aimed to increase utilization requires a well-defined methodology which ensures reliable baseline data. Comparing utilization estimates across populations or state lines can be misleading, as differences in how estimations were generated can greatly bias observed results.

Improving Tobacco Dependence Treatment Delivery: Medical Student Training and Assessment.

Tobacco dependence is a chronic condition, with cigarette smoking considered the leading cause of preventable death, disease, and disability in the U.S. Currently, the U.S. adult smoking rate is 17.8%. National surveys reveal that approximately half of all smokers who have been treated by a healthcare provider in the last 12 months received Public Health Service-recommended guideline-concordant tobacco dependence treatment. Although smoking prevalence has been declining, several disparate groups continue to smoke at rates significantly higher than the national average, including those with low income, low educational attainment, or mental health disorders. To address these disparities and more effectively address tobacco use, provision of guideline-concordant tobacco dependence treatment within the healthcare system must improve. We discuss changes to the medical licensing examination that may result in enhanced tobacco dependence treatment education and skills training for students in medical school.

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.

The Haverstraw experience: the first tobacco product display ban in the United States.

In April 2012, the village of Haverstraw, New York, passed the first tobacco retail display ban in the United States. Community groups funded by the New York State Department of Health Tobacco Control Program mobilized community members to support an initiative to protect youths in their area from tobacco marketing via methods consistent with a community transformation framework. The law was soon rescinded after 7 tobacco companies and the New York Association of Convenience Stores filed a federal lawsuit against the village that challenged the law's constitutionality. We discuss lessons learned and next steps for adoption of local point-of-sale policies.

Quantifying the effect of changes in state-level adult smoking rates on youth smoking.

OBJECTIVE: Quantify the degree to which changes in state-level adult smoking prevalence subsequently influence youth smoking prevalence. DESIGN: Analysis of data from the Tobacco Use Supplement to the Current Population Survey (TUS-CPS) collected from 1995 to 2006 and the National Youth Tobacco Survey (NYTS) collected from 1999 to 2006. SETTING AND PARTICIPANTS: Adults 25 years or older who completed the TUS-CPS and youth in middle and high school who completed the NYTS. MAIN OUTCOME MEASURES: Current smoking among middle and high school students as a function of the change in state-level adult smoking, controlling for individual-level sociodemographic characteristics and state-level tobacco control policy variables. RESULTS: Among middle school students, declines in state-level adult smoking rates are associated with lower odds of current smoking (P < .05), and each doubling of the decline in adult smoking rates is associated with a 6.0% decrease in youth smoking. Among high school students, declines in state-level adult smoking rates are not associated with current smoking. Higher cigarette prices were associated with lower odds of smoking among middle and high school students. Greater population coverage by smoke-free air laws and greater funding for tobacco control programs were associated with lower odds of current smoking among high school students but not middle school students. Compliance with youth access laws was not associated with middle or high school smoking. CONCLUSION: By quantifying the effect of changes in state-level adult smoking rates on youth smoking, this study enhances the precision with which the tobacco control community can assess the return on investment for adult-focused tobacco control programs.

Public and policy maker support for point-of-sale tobacco policies in New York.

PURPOSE: To compare public and policy maker support for three point-of-sale tobacco policies. DESIGN: Two cross-sectional surveys--one of the public from the New York Adult Tobacco Survey and one of policy makers from the Local Opinion Leader Survey; both collected and analyzed in 2011. SETTING: Tobacco control programs focus on educating the public and policy makers about tobacco control policy solutions. SUBJECTS: Six hundred seventy-six county-level legislators in New York's 62 counties and New York City's five boroughs (response rate: 59%); 7439 New York residents aged 18 or older. Landline response rates: 20.2% to 22%. Cell phone response rates: 9.2% to 11.1%. MEASURES: Gender, age, smoking status, presence of a child aged 18 years or younger in the household, county of residence, and policy maker and public support for three potential policy solutions to point-of-sale tobacco marketing. ANALYSIS: t-tests to compare the demographic makeup for the two samples. Adjusted Wald tests to test for differences in policy support between samples. RESULTS: The public was significantly more supportive of point-of-sale policy solutions than were policy makers: cap on retailers (48.0% vs. 19.2%, respectively); ban on sales at pharmacies (49.1% vs. 38.8%); and ban on retailers near schools (53.3% vs. 42.5%). LIMITATIONS: cross-sectional data, sociodemographic differences, and variations in item wording. CONCLUSIONS: Tobacco control programs need to include information about implementation, enforcement, and potential effects on multiple constituencies (including businesses) in their efforts to educate policy makers about point-of-sale policy solutions.

Influence of retail cigarette advertising, price promotions, and retailer compliance on youth smoking-related attitudes and behaviors.

CONTEXT: Exposure to retail tobacco marketing is associated with youth smoking, but most studies have relied on self-reported measures of exposure, which are prone to recall bias. OBJECTIVE: To examine whether exposure to retail cigarette advertising, promotions, and retailer compliance is associated with youth smoking-related outcomes using observational estimates of exposure. DESIGN: Data on retail cigarette advertising and promotions were collected from a representative sample of licensed tobacco retailers in New York annually since 2004. County-level estimates of retail cigarette advertising and promotions and retailer compliance with youth access laws were calculated and linked to the New York Youth Tobacco Survey, administered to 54,671 middle and high school students in 2004, 2006, and 2008. Regression models examined whether cigarette advertising, promotions, and retailer compliance were associated with youth's awareness of retail cigarette advertising, attitudes about smoking, susceptibility to smoking, cigarette purchasing behaviors, and smoking behaviors. RESULTS: Living in counties with more retail cigarette advertisements is associated with youth having positive attitudes about smoking (odds ratio [OR] = 1.10, 95% confidence interval [CI] = 1.03-1.19, P < .01). Living in counties with more retail cigarette promotions is associated with youth current smoking (OR = 1.57, 95% CI = 1.01-2.44, P < .05). Living in counties with higher retailer compliance with youth access laws is associated with higher odds of youth being refused cigarettes when attempting to buy in stores (OR = 1.12, 95% CI = 1.01-1.25, P < .05) and lower odds of retail stores being youth's usual source of cigarettes (OR = 0.88, 95% CI = 0.80-0.97, P < .01). CONCLUSIONS: Strong retailer compliance programs and policies that eliminate cigarette advertising and promotions may help reduce youth smoking.

Promotion of smoking cessation with emotional and/or graphic antismoking advertising.

BACKGROUND: Antismoking campaigns can be effective in promoting cessation, but less is known about the dose of advertising related to behavioral change among adult smokers, which types of messages are most effective, and effects on populations disproportionately affected by tobacco use. PURPOSE: To assess the impact of emotional and/or graphic antismoking TV advertisements on quit attempts in the past 12 months among adult smokers in New York State. METHODS: Individual-level data come from the 2003 through 2010 New York Adult Tobacco Surveys. The influence of exposure to antismoking advertisements overall, emotional and/or graphic advertisements, and other types of advertisements on reported attempts to stop smoking was examined. Exposure was measured by self-reported confirmed recall and market-level gross rating points. Analyses conducted in Spring 2012 included 8780 smokers and were stratified by desire to quit, income, and education. RESULTS: Both measures of exposure to antismoking advertisements are positively associated with an increased odds of making a quit attempt among all smokers, among smokers who want to quit, and among smokers in different household income brackets (<$30,000 and ≥$30,000) and education levels (high-school degree or less education and at least some college education). Exposure to emotional and/or graphic advertisements is positively associated with making quit attempts among smokers overall and by desire to quit, income, and education. Exposure to advertisements without strong negative emotions or graphic images had no effect. CONCLUSIONS: Strongly emotional and graphic antismoking advertisements are effective in increasing population-level quit attempts among adult smokers.

The density of tobacco retailers and its association with attitudes toward smoking, exposure to point-of-sale tobacco advertising, cigarette purchasing, and smoking among New York youth.

OBJECTIVE: Estimate the association between the density of licensed tobacco retailers (LTRs) and smoking-related attitudes and behaviors among middle and high school students in New York. METHODS: The 2000-2008 New York Youth Tobacco Surveys were pooled (N=70,427) and linked with county-level density of LTRs and retailer compliance with laws restricting youth access to cigarettes. Logistic regressions tested for associations with attitudes toward smoking exposure to point-of-sale tobacco advertising, cigarette purchasing, and smoking prevalence. RESULTS: LTR density is associated with self-reported exposure to point-of-sale advertising in New York City (NYC) among all youth (OR=1.15; 95% CI: 1.02, 1.30) and nonsmokers (OR=1.14; 95% CI: 1.01, 1.30); youth believing that smoking makes them look cool, overall (OR=1.75; 95% CI: 1.22, 2.52) and among nonsmokers (OR=1.68; 95% CI: 1.11, 2.55); and a counter-intuitive negative relationship with frequent smoking in NYC (OR=0.50; 95% CI: 0.29, 0.84). Retailer compliance was negatively associated with youth reporting that a retail store is their usual source for cigarettes (OR=0.93; 95% CI: 0.88, 0.98). CONCLUSIONS: Restricting tobacco licenses and enforcing youth access laws are reasonable policy approaches for influencing youth smoking outcomes.

Association of indoor smoke-free air laws with hospital admissions for acute myocardial infarction and stroke in three states.

OBJECTIVE: To examine whether comprehensive smoke-free air laws enacted in Florida, New York, and Oregon are associated with reductions in hospital admissions for acute myocardial infarction (AMI) and stroke. METHODS: Analyzed trends in county-level, age-adjusted, hospital admission rates for AMI and stroke from 1990 to 2006 (quarterly) for Florida, 1995 to 2006 (monthly) for New York, and 1998 to 2006 (monthly) for Oregon to identify any association between admission rates and passage of comprehensive smoke-free air laws. Interrupted time series analysis was used to adjust for the effects of preexisting moderate local-level laws, seasonal variation in hospital admissions, differences across counties, and a secular time trend. RESULTS: More than 3 years after passage of statewide comprehensive smoke-free air laws, rates of hospitalization for AMI were reduced by 18.4% (95% CI: 8.8-28.0%) in Florida and 15.5% (95% CI: 11.0-20.1%) in New York. Rates of hospitalization for stroke were reduced by 18.1% (95% CI: 9.3-30.0%) in Florida. The few local comprehensive laws in Oregon were not associated with reductions in AMI or stroke statewide. CONCLUSION: Comprehensive smoke-free air laws are an effective policy tool for reducing the burden of AMI and stroke.

Developing approaches for evaluating smoke-free policies: a case study of a collaborative response to an emerging technical assistance need.

This article describes how several tobacco control organizations identified and responded to an emerging need for technical assistance on how to evaluate smoke-free policies. The authors outline the purposes of evaluating smoke-free policies and present examples of evaluation approaches and tools. Examples are provided of how evaluation has been used to advance the adoption, implementation, and defense of smoke-free policies. Opportunities for further research are identified. Finally, the authors review lessons learned and discuss their implications for evaluating policy initiatives addressing other public health issues.

Self-reported exposure to policy and environmental influences on smoking cessation and relapse: a 2-year longitudinal population-based study.

Although most smokers want to quit, the long-term success rate of quit attempts remains low; research is needed to understand the policy and environmental influences that can increase the success of cessation efforts. This paper uses regression methods to investigate self-reported exposure to policy and environmental influences on quit attempts, maintenance of a quit attempt for at least 6 months, and relapse in a longitudinal population-based sample, the New York Adult Cohort Survey, followed for 12 months (N = 3,261) and 24 months (N = 1,142). When policy or environmental influence variables were assessed independently of other policy or environmental influence variables, many were significant for at least some of the cessation outcomes. In the full models that included a full set of policy or environmental influence variables, many significant associations became nonsignificant. A number of policies may have an influence on multiple cessation outcomes. However, the effect varies by cessation outcome, and statistical significance is influenced by model specification.

Does offering more support calls to smokers influence quit success?

BACKGROUND: Previous studies have found that offering additional callback counseling support to smokers calling a telephone quit line increases quit rates. However, what is less certain is the most cost-efficient protocol for offering such a service. OBJECTIVE: This study compares the efficacy of offering 2 versus 4 counseling callbacks after an initial call from Medicaid/uninsured adult smokers contacting the New York State Smokers' Quit Line (NYSSQL). Outcomes compared are the 7- and 30-day nonsmoker prevalence rates measured at 3-month follow-up and the cost per quit. DESIGN: A 2-group randomized trial was conducted. SETTING AND PARTICIPANTS: The study population included 1923 adult (18+ years) Medicaid/uninsured current smokers (10+ cigarettes per day) who called the NYSSQL between February and March 2009 seeking help to stop smoking. At the time of the study, the NYSSQL provided Medicaid/uninsured callers with up to 6 weeks of free nicotine medications and up to 4 counseling callbacks. Half the subjects were randomized to standard care with up to 4 counseling callbacks with the remaining subjects offered only 2 counseling callbacks. All participants were sent a minimum of a 2-week supply of nicotine replacement therapy, with some receiving up to 6 weeks. Participants were recontacted 3 months after enrollment in the study to assess smoking status. MAIN OUTCOME MEASURES: Quit rates, total counseling callbacks completed, reductions in cigarette consumption, and cost per quit measures. RESULTS: There was not a significant difference between study groups in the number of callbacks completed. There was also no difference in 7- or 30-day nonsmoker prevalence rates measured after 3 months' follow-up or reported use of the free nicotine replacement therapy between those assigned to either the 2- or 4-callback protocols. The cost per quit was essentially the same in both groups (2 callbacks--$442 per quit vs 4 callbacks--$445 per quit). CONCLUSION: There was no advantage in terms of quit success or cost to offering up to 4 callbacks instead of 2 callbacks.

Costs of giving out free nicotine patches through a telephone quit line.

BACKGROUND: Many telephone quit lines provide free nicotine replacement therapy (NRT) to smokers who are trying to stop smoking. However, providing free NRT to smokers can be costly. OBJECTIVE: To compare NRT usage patterns, quit rate, and costs of giving smokers calling a telephone quit line different amounts of free NRT. DESIGN: A 3-group randomized trial was conducted. SETTING AND PARTICIPANTS: A total of 2806 adult smokers of 10+ cigarettes per day who called the New York State Smokers' Quit Line (NYSSQL) were sent different amounts of nicotine patches for free as follows: (1) a 2-week supply of nicotine patches, (2) a 4-week supply, and (3) a 6-week supply. In addition, all study participants received a free stop smoking guide plus 1 proactive follow-up call attempt conducted 2 weeks after initially contacting the NYSSQL. Of the 2806 enrolled participants, 1682 completed the 7-month follow-up to assess their use of the NRT sent to them and smoking status. MAIN OUTCOME MEASURES: Nicotine patch usage, quit rates, reductions in cigarette consumption, and cost-effectiveness measures. RESULTS: Most respondents (85%) reported using the nicotine patches sent to them, although the amount used varied in direct proportion to the amount sent. The 7- and 30-day nonsmoker prevalence rates measured at 7-month follow-up did not differ significantly between the 3 groups. The cost per attributable quit was also not significantly different between the 3 groups. CONCLUSION: Sending out more than a free 2-week supply of patches to smokers who contact a quit line is no more effective in achieving smoking cessation than sending just 2 weeks of patches.