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 Ministry of Health Treasury International Agencies á Health Status â Tobacco Consumption TAX HEALTH PROMOTION LEGISLATION Ministry of Education

MINISTRY OF HEALTH á HEALTH STATUS FOR NEW ZEALANDERS

MINISTRY OF HEALTH á HEALTH STATUS FOR NEW ZEALANDERS POLICY PROGRAMMESFUNDING

MINISTRY OF HEALTH PROGRAMMES â TOBACCO CONSUMPTION á HEALTH STATUS FOR 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

MINISTRY OF HEALTH PROGRAMMES â TOBACCO CONSUMPTION á HEALTH STATUS FOR NEW ZEALANDERS EVIDENCE “reducing smoking (and the harm from second hand smoke)” Goal 6, Objective 28, NZHS FUNDING POLICY

MINISTRY OF HEALTH â TOBACCO CONSUMPTION TAXATION ON TOBACCO LEGISLATION CONCERNING TOBACCO HEALTH PROMOTION A1A1 B1B1 C1C1 B2B2 A2A2 C2C2

MINISTRY OF HEALTH â TOBACCO CONSUMPTION C1C1 C2C2 HEALTH PROMOTION: MEDIA NRT 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 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 â TOBACCO CONSUMPTION C1C1 C2C2 HEALTH PROMOTION: MEDIA NRT COUNSELLING

QUITLINE and NRT in NZ Quitline since mid-1998 Subsidised NRT in November 2000 Three-month evaluation

726,300 smokers 5,160 quitters 360 quitters NRT No NRT 2,232 YLLs saved 31,992 YLLs saved 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

MINISTRY OF HEALTH â TOBACCO CONSUMPTION TAXATION ON TOBACCO LEGISLATION CONCERNING TOBACCO HEALTH PROMOTION A1A1 B1B1 C1C1 B2B2 A2A2 C2C2

MINISTRY OF HEALTH â TOBACCO CONSUMPTION A1A1 A2A2 TAXATION (EXCISE) ON TOBACCO PRODUCTS

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 â TOBACCO CONSUMPTION A1A1 A2A2 HIGH TAXATION (EXCISE) ON TOBACCO PRODUCTS

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.

1,452 quitters 9,002 YLLs saved 810,550 YLLs saved x6.2 NRT net benefit: 801,548 YLLs saved 20,328 cigs/day 726,300 smokers 10,168,200 cigs/day 1,830,276 cigs/day 130,734 quitters  tax No  tax

$2,435,489 per day 10,147,872 cigs/day 726,300 smokers 10,168,200 cigs/day 8,337,924 cigs/day $2,334,618 per day  tax No  tax x $0.28 per cig x $0.24 per 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

MINISTRY OF HEALTH â TOBACCO CONSUMPTION TAXATION ON TOBACCO LEGISLATION CONCERNING TOBACCO HEALTH PROMOTION A1A1 B1B1 C1C1 B2B2 A2A2 C2C2

MINISTRY OF HEALTH â TOBACCO CONSUMPTION B1B1 B2B2 LEGISLATION CONCERNING 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

18,750 smokers 12.5 quitters 10 quitters BAN No BAN 62 YLLs saved 77.5 YLLs saved x6.2 net benefit of BAN: 15.5 YLLs saved 75,000 workers

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

MINISTRY OF HEALTH â TOBACCO CONSUMPTION TAXATION ON TOBACCO LEGISLATION CONCERNING TOBACCO HEALTH PROMOTION A1A1 B1B1 C1C1 B2B2 A2A2 C2C2 15 YLLs 810,550 YLLs 29,760 YLLs

NGOs Customs and Excise Ministry of Health Treasury International Agencies á Health Status â Tobacco Consumption TAX HEALTH PROMOTION LEGISLATION Ministry of Education

NGOs Customs and Excise Ministry of Health Treasury International Agencies á Health Status â Tobacco Consumption TAX HEALTH PROMOTION LEGISLATION Ministry of Education STATE OF THE ECONOMY á Life expectancy 5 years à  GDP £3-5 billion (Wanless Report)

NGOs Customs and Excise Ministry of Health Treasury International Agencies á Health Status â Tobacco Consumption TAX HEALTH PROMOTION LEGISLATION Ministry of Education STATE OF THE ECONOMY Inequality in income  â (self-reported) health status (independent of the effect of income) (Kennedy et al, 1998)

NGOs Customs and Excise Ministry of Health Treasury International Agencies á Health Status â Tobacco Consumption TAX HEALTH PROMOTION LEGISLATION Ministry of Education STATE OF THE ECONOMY Highest smoking prevalence  beneficiaries, low incomes (Tobacco Facts, 2001)

NGOs Customs and Excise Ministry of Health Treasury International Agencies á Health Status â Tobacco Consumption TAX LEGISLATION HEALTH PROMOTION Ministry of Education STATE OF THE ECONOMY “present levels of [tobacco] taxation appear indefensible on externality grounds” (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.