Transcript 2. Health Presentation: Tobacco Control

PATHFINDER CASE STUDY
TOBACCO CONTROL
Points to ponder
• This is a model, not a definitive analysis
• Does this model reflect the way outcome is
attributed to policy in your organisation?
NGOs
Ministry of
Education
LEGISLATION
Customs
and Excise
Ministry
of Health
Treasury
International
Agencies
TAX
HEALTH
PROMOTION
 Tobacco
Consumption
 Health
Status
MINISTRY
OF HEALTH
 HEALTH STATUS
FOR NEW ZEALANDERS
FUNDING
MINISTRY
OF HEALTH
POLICY
PROGRAMMES
 HEALTH STATUS
FOR NEW ZEALANDERS
FUNDING
MINISTRY
OF HEALTH
POLICY
 TOBACCO
CONSUMPTION

HEALTH STATUS
FOR NEW ZEALANDERS
PROGRAMMES
EVIDENCE
THE LINK BETWEEN TOBACCO
CONSUMPTION AND HEALTH
STATUS
• 4,700 New Zealand smokers die from
smoking-related illnesses each year
• In terms of Years of Life Lost (YLLs) the
average smoker incurs 6.2
• In 1996, there were 49,960 YLLs
attributable to smoking
THE LINK BETWEEN TOBACCO
CONSUMPTION AND HEALTH
STATUS
• Secondhand smoke increases the risk of
SIDS and childhood respiratory disease,
and causes 388 deaths per year in NZ
• Tobacco is responsible for a large
proportion (~25%) of the inequality in
health status between Pakeha and NonPakeha
FUNDING
MINISTRY
OF HEALTH
POLICY
“reducing smoking (and the harm
from second hand smoke)”
Goal 6, Objective 28, NZHS
 TOBACCO
CONSUMPTION

HEALTH STATUS
FOR NEW ZEALANDERS
PROGRAMMES
EVIDENCE
TAXATION
ON TOBACCO
A1
B1
MINISTRY
OF HEALTH
LEGISLATION
CONCERNING
TOBACCO
A2
B2
 TOBACCO
CONSUMPTION
C2
C1
HEALTH
PROMOTION
MINISTRY
OF HEALTH
C1
HEALTH
PROMOTION:
MEDIA
NRT
COUNSELLING
C2
 TOBACCO
CONSUMPTION
MEDIA
• Media-led tobacco cessation campaigns can:
–  awareness of the harm of smoking
• For example, awareness that every cigarette is doing
damage from 75% to 82% (Australia)
–  the utilisation of cessation services and
products
• For example, a 34% increase in calls to Quitline
following media coverage of the link between
smoking and blindness (New Zealand)
MEDIA
• Media-led tobacco cessation campaigns can:
–  the frequency of quit attempts
• For example, an increase in one year quit rate from
8% to 11% among smokers and recent quitters
–  the prevalence of smoking
• For example, by 1.5% in Australia
COUNSELLING
• Various reviews by Cochrane TAG:
–
–
–
–
Physician or nurse advice
Telephone counselling
Self-help material
Individual or group therapy
ALL helpful for smoking cessation
 Of proven economic value is antenatal smoking cessation
for pregnant women: savings of $3.31 for every $1 spent
on counselling services.
NICOTINE REPLACEMENT
THERAPY
• Significantly more efficacious than placebo
– Odds ratio for abstinence with NRT compared to placebo
of 1.73 (95% CI 1.62 – 1.85)
• All forms of NRT effective
– Different forms have different odds ratios, and there is
some evidence that combinations are more effective
• NRT products increase quit rates ~ 1.5 to 2 fold
regardless of setting
MINISTRY
OF HEALTH
C1
HEALTH
PROMOTION:
MEDIA 
NRT
COUNSELLING
C2
 TOBACCO
CONSUMPTION
QUITLINE and NRT in NZ
• Quitline since mid-1998
• Subsidised NRT in November 2000
• Three-month evaluation
5,160
quitters
x6.2
NRT
31,992
YLLs
saved
NRT net benefit:
29,760 YLLs saved
726,300
smokers
No NRT
360
quitters
x6.2
2,232
YLLs
saved
QUITLINE and NRT in NZ
•
•
•
•
Coverage 20,600 smokers
Cost $2.5 million
Benefit 29,760 YLLs saved
Period: 3 months
TAXATION
ON TOBACCO
A1
B1
MINISTRY
OF HEALTH
LEGISLATION
CONCERNING
TOBACCO
A2
B2
 TOBACCO
CONSUMPTION
C2
C1
HEALTH
PROMOTION
MINISTRY
OF HEALTH
A1
TAXATION
(EXCISE) ON
TOBACCO
PRODUCTS
A2
 TOBACCO
CONSUMPTION
TAXATION
• WHO: most econometric studies show a
convincing decrease in consumption as tax
rates increase
• Tobacco Industry: strongly resistant to taxation
compared with other tobacco control
interventions (internal industry documents)
• World Bank: price increase of 10% would
reduce smoking by about 4% in high income
countries and by about 8% in low and middle
income countries.
TAXATION
• Groups most responsive to price
changes:
– young people
– people on low incomes
– people with less education
MINISTRY
OF HEALTH
A1
HIGH TAXATION
(EXCISE) ON
TOBACCO
PRODUCTS
A2
 TOBACCO
CONSUMPTION
TAXATION in NZ
• In December 1995:
– 38%  in the excise on loose tobacco  17%  in
consumption of loose tobacco.
– (This change equalised the excise on loose tobacco
with that of manufactured cigarettes – there was no
change in overall consumption).
• In May 1998:
– 13% 
in tax  6%  in total tobacco
consumption.
• In May 2000:
– 20%  in price (14%  in tax + 6%  in tobacco
company price)  18%  in total tobacco
consumption.
x6.2
726,300
smokers
1,830,276
cigs/day
130,734
quitters
 tax
810,550
YLLs
saved
NRT net benefit:
801,548 YLLs saved
10,168,200
cigs/day
No  tax
20,328
cigs/day
1,452
quitters
x6.2
9,002
YLLs
saved
x $0.28
per cig
726,300
smokers
8,337,924
cigs/day
 tax
10,168,200
cigs/day
$2,334,618
per day
Net Revenue 2º to 20%  in tax
($100,871) per day
($9,204,478) per quarter
No  tax
10,147,872
cigs/day
x $0.24
per cig
$2,435,489
per day
TAXATION in NZ
•
•
•
•
Consumption decreases 18%
Equivalent to ~130,000 fewer smokers
Equivalent to 810,550 YLLs saved
Cost $9.2 million in lost excise revenue per
quarter
TAXATION
ON TOBACCO
A1
B1
MINISTRY
OF HEALTH
LEGISLATION
CONCERNING
TOBACCO
A2
B2
 TOBACCO
CONSUMPTION
C2
C1
HEALTH
PROMOTION
MINISTRY
OF HEALTH
B1
LEGISLATION
CONCERNING
TOBACCO
B2
 TOBACCO
CONSUMPTION
LEGISLATION
• RESTRICTING TOBACCO SALES
– Legislation can  smoking participation
among young people
• The effect is especially apparent when retailer
education and enforcement is used in
conjunction with legislation
• In NZ, the number of sales to under-age
volunteers fell from 10% to 5% over two years
utilising a policy of retailer education,
surveillance, and enforcement
LEGISLATION
• SMOKEFREE WORKPLACES
–  smoking at work
• rate of smoking by heavy smokers  by 25% (Australia)
–  the cessation rate of workers by 25% (Australia)
–  exposure of workers to ETS
• In USA, exposure to ETS in a restaurant is ~1.8 x higher
than in an office, in a bar exposure is ~5 x than in an office
• In NZ, worker exposure to ETS decreased by ~50%
following the SEA 1990
75,000
workers
12.5
quitters
x6.2
77.5
YLLs
saved
BAN
net benefit of BAN:
15.5 YLLs saved
18,750
smokers
No BAN
10
quitters
x6.2
62
YLLs
saved
LEGISLATION
• SMOKEFREE WORKPLACES
– Effect of workplace ban:
•
•
•
•
25% increase in quit rate of workers
Equivalent to saving 15.5 YLLs
Period: 3 months
Cost: negligible (enforcement)
LEGISLATION
• PROPOSED EVALUATION OF
AMENDMENTS TO SEA 1990
•
•
•
•
•
the effect on total NZ tobacco consumption
the effect on barworkers’ respiratory health
analysis of nicotine exposure in hospitality workers
hospitality industry employment statistics
qualitative assessment of the attitudes and experiences of
hospitality venue owners and managers
• hospitality venue patrons attitudes to second hand
smoke/smoking in licensed premises
• community attitudes to bans on smoking in licensed
premises
810,550 YLLs
TAXATION
ON TOBACCO
A1
B1
MINISTRY
OF HEALTH
LEGISLATION
CONCERNING
TOBACCO
A2
B2
 TOBACCO
CONSUMPTION
15 YLLs
C2
C1
HEALTH
PROMOTION
29,760 YLLs
NGOs
Ministry of
Education
LEGISLATION
Customs
and Excise
Ministry
of Health
Treasury
International
Agencies
TAX
HEALTH
PROMOTION
 Tobacco
Consumption
 Health
Status
NGOs
 Life
Ministry of
Education
LEGISLATION
expectancy 5 years
  GDP £3-5 billion
(Wanless Report)
Customs
and Excise
Ministry
of Health
Treasury
International
Agencies
TAX
 Tobacco
Consumption
 Health
Status
HEALTH
PROMOTION
STATE OF
THE ECONOMY
NGOs
Inequality in income 
 (self-reported) health status
(independent of the effect of income)
(Kennedy et al, 1998)
Ministry of
Education
LEGISLATION
Customs
and Excise
Ministry
of Health
Treasury
International
Agencies
TAX
 Tobacco
Consumption
 Health
Status
HEALTH
PROMOTION
STATE OF
THE ECONOMY
NGOs
Ministry of
Education
LEGISLATION
Highest smoking prevalence 
beneficiaries, low incomes
(Tobacco Facts, 2001)
Customs
and Excise
Ministry
of Health
Treasury
International
Agencies
TAX
 Tobacco
Consumption
 Health
Status
HEALTH
PROMOTION
STATE OF
THE ECONOMY
NGOs
“present levels of [tobacco] taxation
appear indefensible on externality
grounds” (Tax Review 2001)
Ministry of
Education
LEGISLATION
Customs
and Excise
Ministry
of Health
Treasury
International
Agencies
TAX
HEALTH
PROMOTION
 Tobacco
Consumption
 Health
Status
STATE OF
THE ECONOMY
CONCLUSIONS
1. This model provides a way of thinking
about other influences on outcomes.
2. The policy framework involves many
subtle interactions on the path to
outcomes.
3. This model may be useful for directing
research around the attribution of
outcomes.