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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.