pathfinder case study tobacco control. points to ponder this is a model, not a definitive analysis...
TRANSCRIPT
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
Customs and Excise
Ministryof Health
Treasury
InternationalAgencies
HealthStatus
TobaccoConsumption
TAX
HEALTHPROMOTION
LEGISLATION
Ministry ofEducation
MINISTRYOF HEALTH
HEALTH STATUSFOR NEW ZEALANDERS
MINISTRYOF HEALTH
HEALTH STATUSFOR NEW ZEALANDERS
POLICY
PROGRAMMES
FUNDING
MINISTRYOF HEALTH
PROGRAMMES
TOBACCOCONSUMPTION
HEALTH STATUSFOR NEW ZEALANDERS
EVIDENCE
FUNDING
POLICY
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 Non-Pakeha
MINISTRYOF HEALTH
PROGRAMMES
TOBACCOCONSUMPTION
HEALTH STATUSFOR NEW ZEALANDERS
EVIDENCE
“reducing smoking (and the harm from second hand smoke)”
Goal 6, Objective 28, NZHS
FUNDING
POLICY
MINISTRYOF HEALTH
TOBACCOCONSUMPTION
TAXATIONON TOBACCO
LEGISLATIONCONCERNING
TOBACCO
HEALTHPROMOTION
A1
B1
C1
B2
A2
C2
MINISTRYOF HEALTH
TOBACCOCONSUMPTION
C1 C2
HEALTHPROMOTION:
MEDIANRT
COUNSELLING
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 cessationOf 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
MINISTRYOF HEALTH
TOBACCOCONSUMPTION
C1 C2
HEALTHPROMOTION:
MEDIA NRT
COUNSELLING
QUITLINE and NRT in NZ
• Quitline since mid-1998
• Subsidised NRT in November 2000
• Three-month evaluation
726,300smokers
5,160quitters
360quitters
NRT
No NRT 2,232YLLssaved
31,992YLLssaved
x6.2
x6.2
NRT net benefit:29,760 YLLs saved
QUITLINE and NRT in NZ
• Coverage 20,600 smokers
• Cost $2.5 million
• Benefit 29,760 YLLs saved
• Period: 3 months
MINISTRYOF HEALTH
TOBACCOCONSUMPTION
TAXATIONON TOBACCO
LEGISLATIONCONCERNING
TOBACCO
HEALTHPROMOTION
A1
B1
C1
B2
A2
C2
MINISTRYOF HEALTH
TOBACCOCONSUMPTION
A1 A2TAXATION (EXCISE) ON
TOBACCOPRODUCTS
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
MINISTRYOF HEALTH
TOBACCOCONSUMPTION
A1 A2HIGH TAXATION (EXCISE) ON
TOBACCOPRODUCTS
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.
1,452quitters
9,002YLLssaved
810,550YLLssaved
x6.2
x6.2
NRT net benefit:801,548 YLLs saved
20,328cigs/day
726,300smokers
10,168,200cigs/day
1,830,276cigs/day
130,734quitters
tax
No tax
$2,435,489per day
10,147,872cigs/day
726,300smokers
10,168,200cigs/day
8,337,924cigs/day
$2,334,618per day
tax
No tax
x $0.28per cig
x $0.24per cig
Net Revenue 2º to 20% in tax ($100,871) per day
($9,204,478) per quarter
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
MINISTRYOF HEALTH
TOBACCOCONSUMPTION
TAXATIONON TOBACCO
LEGISLATIONCONCERNING
TOBACCO
HEALTHPROMOTION
A1
B1
C1
B2
A2
C2
MINISTRYOF HEALTH
TOBACCOCONSUMPTION
B1 B2LEGISLATIONCONCERNING
TOBACCO
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
18,750smokers
12.5quitters
10quitters
BAN
No BAN
62YLLssaved
77.5YLLssaved
x6.2
x6.2
net benefit of BAN:15.5 YLLs saved
75,000workers
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
MINISTRYOF HEALTH
TOBACCOCONSUMPTION
TAXATIONON TOBACCO
LEGISLATIONCONCERNING
TOBACCO
HEALTHPROMOTION
A1
B1
C1
B2
A2
C2
15 YLLs
810,550 YLLs
29,760 YLLs
NGOs
Customs and Excise
Ministryof Health
Treasury
InternationalAgencies
HealthStatus
TobaccoConsumption
TAX
HEALTHPROMOTION
LEGISLATION
Ministry ofEducation
NGOs
Customs and Excise
Ministryof Health
Treasury
InternationalAgencies
HealthStatus
TobaccoConsumption
TAX
HEALTHPROMOTION
LEGISLATION
Ministry ofEducation
STATE OF THE ECONOMY
Life expectancy 5 years GDP £3-5 billion
(Wanless Report)
NGOs
Customs and Excise
Ministryof Health
Treasury
InternationalAgencies
HealthStatus
TobaccoConsumption
TAX
HEALTHPROMOTION
LEGISLATION
Ministry ofEducation
STATE OF THE ECONOMY
Inequality in income (self-reported) health status(independent of the effect of income)(Kennedy et al, 1998)
NGOs
Customs and Excise
Ministryof Health
Treasury
InternationalAgencies
HealthStatus
TobaccoConsumption
TAX
HEALTHPROMOTION
LEGISLATION
Ministry ofEducation
STATE OF THE ECONOMY
Highest smoking prevalence beneficiaries, low incomes(Tobacco Facts, 2001)
NGOs
Customs and Excise
Ministryof Health
Treasury
InternationalAgencies
HealthStatus
TobaccoConsumption
TAX
LEGISLATION
HEALTHPROMOTION
Ministry ofEducation
STATE OF THE ECONOMY
“present levels of [tobacco] taxation appear indefensible on externalitygrounds” (Tax Review 2001)
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.