the case for global tobacco control.infranet.uwaterloo.ca/infranet/inftalks/2007/2007-05-23/... ·...
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Why Not Evidence-based Health Policies for Nations?
The Case for Global Tobacco Control.
Dr. Geoffrey FongAssociate Professor
Department of Psychology, University of Waterloo
University of WaterlooMay 23, 2007
Waterloo Smarter Health Seminar Series:
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Why Not Evidence-Based Health Policies for Nations?
The Case for Global Tobacco Control
Geoffrey T. Fong, Ph.D.Department of Psychology
University of Waterloo
Why Not? Smarter Health SeminarUniversity of Waterloo
May 23, 2007
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What are the major threats to global health?
For each threat: what can we do about it?
– What evidence is available to evaluate possible strategies for dealing with the threat?
How do we identify and promote evidence-based policies for global health?
1. System for surveillance of relevant health behavioursand for rigorous evaluation of ongoing interventions
2. System linked to policymakers/governments invested in its outputs with clear path to action.
Basic Questions in Global Health
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Cardiovascular disease
Stroke
Diabetes
Cancer
Chronic respiratory disease
What About Chronic Diseases?
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Of all deaths worldwide
(58M)
60% (35M) are due to
chronic diseases
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Chronic Diseases
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China: $588M of economic costs in next 10 years
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NOT just a malady of the rich, fat, and happy
80% of chronic disease death occurs in low and middle income countries
Chronic disease affects men and women equally
Large proportion of chronic disease cases is due to (or whose course is governed by) modifiable behaviours
– 80% of chronic disease incidence or outcome is governed by modifiable behaviour
Summary of Chronic Diseases
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“Tobacco is the most effective agent of death ever developed and deployed on a worldwide scale.”
– John Seffrin, President,ACS and UICC (2002)
Tobacco as a Global Problem
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Smoking Prevalence in Canada
Smoking Prevalence in Canada (15 years +)
0
10
20
30
40
50
60
1965 1970 1974 1975 1977 1979 1981 1983 1986 1991 1994 1997 1999 2000 2001 2003 2004
Year
%
Males
Females
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The Really Big Picture
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Stage 1 Stage 2 Stage 3 Stage 4
Adapted from Lopez AD, Collishaw NE, Piha T. Tobacco Control, 1994, 3:242-247.
Four Stages of the Tobacco Epidemic
•Sub-Saharan Africa
•China•Japan•Southeast Asia•Latin America•North Africa
•Eastern Europe•Southern Europe
•Western Europe•UK•USA•Canada•Australia
Male Smoking %
Female Smoking %
Female Death %
Male Death %
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Some Statistics on Global Tobacco Use
1.1 billion people smoke– 82% live in low-and middle-income countries– 500 million will die of tobacco-related causes
20th Century: 100 million tobacco-related deaths
21st Century: 1 billion tobacco-related deaths
5 million will die this year
By 2020: 10 million will die/year
WHO: Leading preventable cause of death and disability in the world
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Increase in Smoking-Attributable Deaths 1990 to 2020
India+1400%Middle
Eastern Crescent+700%
India+1400%Middle
Eastern Crescent+700%
Latin American
and Caribbean
+300%
India+1400%
India+1400%Middle
Eastern Crescent+700%
Latin American
and Caribbean
+300%
Other Asia and Islands
+250%India
+1400%Middle Eastern Crescent+700%
Latin American
and Caribbean
+300%
Sub-Saharan
Africa+200%
Other Asia and Islands
+250%India
+1400%Middle Eastern Crescent+700%
Latin American
and Caribbean
+300%
Sub-Saharan
Africa+200%
Other Asia and Islands
+250%
China+175%
India+1400%Middle
Eastern Crescent+700%
Latin American
and Caribbean
+300%
Sub-Saharan
Africa+200%
Other Asia and Islands
+250%
China+175%
Formerly Socialist Economies of Europe
+120%
India+1400%Middle
Eastern Crescent+700%
Latin American
and Caribbean
+300%
Sub-Saharan
Africa+200%
Other Asia and Islands
+250%
China+175%
Formerly Socialist Economies of Europe
+120%Established Market
Economies+18%
Murray and Lopez (1997): Global Burden of Disease Study
In 2020:1.5M deaths
In 2020:2.2M deaths
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About Tobacco Use (Smoking)
Smoking accounts for a high proportion of chronic disease incidence and severityInteracts with infectious diseases– Implicated in tuberculosis: about half of TB cases among men in India due to smoking
Research on smoking: very advanced
Research on population approaches (policies): much less-developed (but far more developed than other health domains)
Tobacco: leading edge for approaches to chronic disease prevention– Clinical approaches– Population approaches, including policies
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Ratio of heart attack rates:smokers vs. non-smokers of the same age
Ratio 2 4 6
Age 30-39 6.36.3 times as common in smokersas in non-smokers aged 30-39
Age 40-49 4.7
Age 50-59 3.1
Age 60-69 2.5
Age 70-79 1.9
Study of 3000heart attack
survivors
Not causedby smoking
Excess withcigarette use
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31Source: Jha et al, forthcoming
RGI-CGHR Million Death Study: Preliminary results of male mortality in India at ages 25-69
yrs, 2001-3
27%2.1 (1.7-2.4)154/502Stroke
30%2.2 (1.9-2.5)1877/6278All causes37%2.7 (2.1-3.5)188/504Cancer
25%2.0 (1.7-2.4)293/1158Heart attack48%3.5 (2.5-4.9)156/324COPD41%2.7 (2.3-3.2)311/755Tuberculosis
% attrib. smoking
RR (95% CI), smoker/ not
Smoking/total deaths
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If we can create effective methods for reducing the (global) tobacco epidemic,
this will provide strong guidance for how to reduce other threats to global health
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“Tobacco use in the developed nations will trend down slightly through the end of the century, while in the developing countries use could rise by about 3% annually. A bright picture indeed! Not a smoke-free society, but continued growth for the tobacco industry.”
– Document from 1989
The Global View of the Tobacco Industry
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“No discussion of the tobacco industry in the year 2000 would be complete without addressing what may be the most important feature on the landscape, the China market. In every respect, China confounds the imagination.”
– Rene Scull, VP-Philip Morris Asia (1986)
Tobacco Industry and China
“Thinking about Chinese smoking statistics is like trying to think about the limits of space.”
– Rothmans document (1990)
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Facing the Challenge
0
70
220
520
Estimated cumulative tobacco deaths1950-2050
300
400
500
2025 205020001950
100
200
Year
Toba
cco
deat
hs (m
illio
ns)
World Bank. Curbing the epidemic: Governments and the economics of tobacco control. World Bank Publications, 1999. p80.
What must we do to flatten the curve?
Population-level interventions
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The World Responds to the Growing Tobacco Epidemic
1999–2003: negotiations for an international response to the growing tobacco threat
Framework Convention on Tobacco Control
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FCTC: Unanimously Adopted—May 2003
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More prominent warning labels
Elimination of “misleading descriptors”
Bans/restrictions on advertising, promotion, sponsorship
Protection from exposure to tobacco smoke
Higher taxes
Support for cessation
Education, communication, public awareness
Demand Reduction Provisions of the FCTC
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Potential of Policies to Flatten the Curve
190
340
500
0
70
220
520
Estimated cumulative tobacco deaths1950-2050
300
400
500
2025 205020001950
100
200
Year
Toba
cco
deat
hs (m
illio
ns)
World Bank. Curbing the epidemic: Governments and the economics of tobacco control. World Bank Publications, 1999. p80.
Impact of policies depends on factors including:
– Intervention date
– Effect size
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Article 8 Protection from exposure to tobacco smoke
2. Each Party shall adopt and implement in areas of existing national jurisdiction as determined by national law and actively promote at other jurisdictional levels the adoption and implementation of effective legislative, executive, administrative and/or othermeasures, providing for protection from exposure to tobacco smoke in indoor workplaces, public transport, indoor public places and, as appropriate, other public places.
What does “effective” mean?
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Article 11—Warnings and messages
– should be 50% or more of the principal display areas but shall be no less than 30%...
– may be in the form of or include pictures or pictograms
– shall contain information on relevant constituents and emissions
Does size matter? Are graphic images effective?
“Each Party shall, within a period of three years after entry into force of this Convention for that Party, adopt and implement, in accordance with its national law,effective measures...”
What does “effective” mean?
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Opportunities Afforded by the FCTC
Opportunity for science:– Time-limited opportunity to study population-based interventions: (1) measure the impact of policies and (2) identify the causal mechanisms for policy impact
Opportunity for evidence-based policy: – Create the evidence base to inform the creation of effective tobacco control policies– Determine the relative strength of FCTC policies– Counteract disinformation and misinformation from the tobacco industry
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“Tobacco use is unlike other threats to global health. Infectious diseases do not employ multinational public relations firms. There are no front groups to promote the spread of cholera. Mosquitoes have no lobbyists.”
– WHO Zeltner Report (2000)
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Tobacco Industry: Distorting Science
Creation of front groups to cast doubt on the evidence of the harms of smoking and then of second-hand smoke
Payment to “neutral” scientists for results-directed research
Creation of entire research programs to “generate a body of scientific and technical knowledge [through research] undertaken by whitecoats.”
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• JunkScience.com founded by a front group created by Philip Morris in 1993
• To cover up the association with PM, the front group aimed to link scientific studies that cast smoking in a bad light with "broader questions about government research and regulations" - such as "global warming", "nuclear waste disposal" and "biotechnology".
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“Doubt is our product.”
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Challenges to Evaluating Policies
Not possible to conduct randomized controlled trials (RCTs) on policies
But it is possible to evaluate the impact of policies using natural experiments (“quasi-experiments”)
1. Multiple country comparisons: international studies
2. Common methods and measures across countries
3. Cohort studies: focus on impact on individuals
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What do we need?
An international system for measuring policy-relevant variables and variables over time
Common measures selected from a strong, theory-driven perspective
Common research designs and protocols
Strategic selection of countries to:
– evaluate policy via natural experiments
– test for generality vs. specificity of policy impact across countries and across implementation strength
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The International Tobacco Control Policy Evaluation Project
Canada United States Australia United Kingdom
Ireland Thailand Malaysia South Korea
China France
New Zealand
Mexico Uruguay
SudanIndia Netherlands
Bangladesh RussiaGermany
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ITC Survey Research TeamCanadaGeoffrey T. FongMary E. ThompsonChristian BoudreauK. Stephen BrownSharon CampbellDavid HammondPaul W. McDonaldChangbao WuMark P. Zanna
United StatesK. Michael CummingsGary A. GiovinoAndrew HylandRichard J. O’ConnorFrank J. ChaloupkaFritz L. LauxHana RossMaansi Travers
AustraliaRon BorlandMohammad SiahpushMelanie WakefieldHua YongDavid Young
United KingdomGerard HastingsAnn McNeillLouise HassanAnne Marie MackintoshFiona Harris
ThailandBuppha SirirassameeWarangkana PolprasertPhilip GuestSteve HamannPrakit Vateesatogkit
MalaysiaMaizurah OmarFoong KinRahmat Awang
Bangladesh*Nigar Nargis
KoreaHong Gwan SeoYoo-Seock CheongSeung-Kwon MyungWonkyong (Beth) Lee
ChinaJiang YuanYang YanFeng Guoze
MexicoJames Thrasher
UruguayMarcelo BoadoEduardo Bianco
India*Prakash GuptaDhirendra SinhaPrabhat Jha
FranceSylviane RattePierre ArwidsonFrançois Beck
New ZealandNick WilsonGeorge Thomson
* ITC Surveys currently in development
Sudan*Asma Elsony
Netherlands*Marc WillemsenRussia*Marine Gambaryan
GermanyMartina Pötschke-LangerSven Schneider
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Extensive surveys of representative samples of adult smokers in each country
ITC Methods: as rigorous as the conditions will allow
Identical/similar methods/measures in all countries
Measures of each FCTC demand policy
Cohort survey: same individuals surveyed every year
The ITC Surveys
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The ITC Surveys
Country Mode N (smokers) N (others) 2002 2003 2004 2005 2006 2007 2008 Canada 2,000 United States 2,000 United Kingdom 2,000 Australia 2,000 Ireland/Scotland 2,000 900 NS Thailand 2,000 1,000 Youth Malaysia 2,000 1,000 Youth South Korea 1,000 China 5,600 1,400 NS Mexico 1,000 Uruguay 1,000 New Zealand 2,000 France 1,700 500 NS Germany 1,700 1,000 NS Sudan 6,000 ? 2,000 SL,NS Bangladesh 3,000 ? 1,000 SL,NS India 12,000 ? 2,000 SL,NS
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Goal 1: Rigorous evaluation of national-level tobacco control policies of the FCTC:
Goal 2: To understand how and why these policies work (if they work)
?Policy Behavior
What’s inside the black box?
ITC Project Goals
Goal 3: Disseminate findings to policymakers– Build evidence base for FCTC– Promote evidence-based policies
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Policy
ModeratorsCountry
Sociodemographics(e.g., age, sex, SES, ethnic background)
Past Behavior(e.g., smoking history, CPD, quit attempts)
Personality(e.g., time perspective)Psychological State
(e.g., stress)Potential Exposure to
Policy(e.g.,employment status)
Policy-SpecificVariables
• Label salience• Perceived cost• Ad/promo awareness• Awareness of
alternative products• Proximal behaviors
(forgoing a cigarettebecause of labels)
Psychosocial Mediators
• Outcome expectancies• Beliefs & Attitudes• Perceived Risk• Perceived Severity• Self-Efficacy/
Perc. Beh Control• Normalization beliefs• Quit intentions
Policy-Relevant Outcomes
• Quit Attempts• Successful Quitting• Consumption changes
• Brand switching• Tax/price avoidance• Attitude/belief changes
(e.g., justifications)
EconomicImpact
PublicHealthImpact
Conceptual Model of the ITC Project
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Mediational Model(s) of Policy Effects
Proximal Variables(Policy-Specific)
Distal Variables(Psychosocial Mediators)Policy Behavior
Different policies operate differently, but can be described by the same general model
LabelsLabel Salience Perc EffectivenessDepth of Processing
Intentionsto Quit
QuitAttempt
Perceived risk Perceived severity
Ad Ban Advertising salience Positive assns
Intentionsto Quit
QuitAttempt
Denorm beliefsSocial acceptSubjective norms
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Warning Labels: Article 11 of the FCTCEvidence from the ITC Project
1. Quasi-experimental evaluation of the enhancement of warning labels in the U.K.
2. Comparing responses to warning labels across 7 ITC countries (including China)
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Tobacco Warning Labels as a Health Intervention
Frequency of exposure is high– Pack a day smoker: 7,300–9,125 possible exposures
Location and delivery of the intervention is ideal– Delivered at the time of the purchase– Delivered at the time of the behavior
Objectives of warning labels:– To inform the public about the (wide-ranging) harms of smoking– To inform the public about the severity of the health harms– To convey the information in a vivid manner
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Smokers notice information on warning labels
Smokers rank cigarette packs very highly as a source of information—and labels are very cost effective compared to television
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Warning Labels and the FCTC
Article 11—Warnings and messages:
– should be 50% or more of the principal display areas but shall be no less than 30%...
– may be in the form of or include pictures or pictograms
– shall contain information on relevant constituents and emissions
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Canadian Graphic Warning Labels
Warning
Explanation
Canada’s labels are not just about the graphic photos. The explanation enhances the text. The graphic image is integrated with the text.
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Warning Labels in the U.S. vs. Canada
United States Canada
– Since 1984– 4 messages– Side of pack
– Since 2001– 16 messages– 50% of front and back– New set coming in 2008
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Examples of Graphic Warnings
Canada (2001) Singapore (2004)
Venezuela (2005)
Thailand (2005)
Brazil (2002)
Australia (2006)European Union (Belgium 2007)
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United States Canada
Visual Impact of the Canadian Warning Labels
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October 2002 May 2003
U.K.
Canada
Australia
U.S.
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The enhancement of warning labels in the U.K. had a huge impact on labels salience/noticing. But this is a measure of noticing, where mere novelty alone would be expected to have a huge effect
Enhancing warning labels increases label salience/noticing
Results from Hammond et al. Am J Prev Med(2007)
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Labels and thinking about quitting
Initial advantage of the UK over Canada vanishes. And proper comparison of Canada vs. UK at the same point in time after the introduction of warnings (2.5 years) shows Canada > UK.
Hammond et al. Am J Prev Med(2007)
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Do warning labels increase knowledge?
Smoking causes impotence:
Canada Aus. U.K. U.S.
Wave 1 60 36 36 34
Wave 2
Only Canada had a warning label about impotence at Wave 1, but then U.K. added an impotence label between Wave 1 and Wave 2
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Do warning labels increase knowledge?
Smoking causes impotence:
Canada Aus. U.K. U.S.
Wave 1 60 36 36 34
Wave 2 63 45 50 33
Substantial increase in knowledge about impotence in the U.K. compared to the other three countries after the label
on impotence was introduced in the U.K.
In U.K.: 14% more smokers = About 1.5M smokersIn China: 14% more smokers = About 50M smokers
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Implications for FCTC Implementation
Minimal Standard vs. Recommendations:
– should be 50% or more of the principal display areas but shall be no less than 30%...
– may be in the form of or include pictures or pictograms
should be
Results from the ITC Project suggest that countries who implement the FCTC label policy at its highest level will experience greater impact, compared to the minimal standard
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Warning Labels of Seven ITC Countries at the Time of the 2005 Survey Wave
Canada U.S.U.K.Australia
ChinaThailandMalaysia
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And this is also true in China: the labels are noticed by a high proportion of the population (51%)
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And the same is true in China: although the potential is very high (high levels of noticing), the impact on this critical factor is low.
Warning labels should be strong to take advantage of the opportunity
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Relationship Between Labels and Quitting
Labels Make You Think About Risks
Quit Attempt
Controlling for Gender, Age, Income, Education, Ethnicity, Prior Quit Attempts, Intentions to Quit
Smokers who report that the labels make them more likelyto think about risks of smoking were:
— more likely to attempt to quit (OR = 1.14)*
— more likely to successfully quit (OR = 1.89)** Statistically significant at p < .05
Successful quit attempt
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The Impact of Comprehensive SmokefreeLegislation (Article 8):
Findings from the ITC-Ireland/UK Survey
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Tobacco Smoke Pollution: Facts and Figures
Scientific consensus that TSP (ETS):– is a known cause of cancers, cardiovascular
diseases, and respiratory diseases– contains 5 regulated hazardous air pollutants, 47
regulated (in the U.S.) hazardous wastes, 60 known or suspected carcinogens, and >100 chemical poisons
Third leading cause of preventable death in the U.S., accounting for one death among non-smokers for every eight deaths among smokers.
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US EPA Air Quality Index
People with heart or lung disease, older adults, and children should avoid all physical activity outdoors. Everyone else should avoid prolonged or heavy exertion.
151-250VeryUnhealthy
People with heart or lung disease, older adults, and children should avoid prolonged or heavy exertion. Everyone else should reduce prolonged or heavy exertion.
66-150Unhealthy
People with heart or lung disease, older adults, and children should remain indoors and keep activity levels low. Everyone else should avoid all physical activity outdoors.
≥251Hazardous
People with heart or lung disease, older adults, and children should reduce prolonged or heavy exertion.41-65
Unhealthy forSensitive Groups
Unusually sensitive people should consider reducing prolonged or heavy exertion.16-40Moderate
None.≤15Good
Health AdvisoryPM2.5(μg/m3)Air Quality
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International Tobacco Control Policy Evaluation Project: Ireland/UK Survey
Telephone Survey
– Ireland: 1,000 randomly selected adult smokers– U.K.: 600 randomly selected adult smokers
– Cohort design:
Wave 1: Dec 2003–Jan 2004
Workplace Ban: Mar 29, 2004Wave 2: Dec 2004–Jan 2005
DenverJune 9, 2002
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Denver’s visibility – before Hayman fire
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Denver’s visibility – 1 day after Hayman fireWorst PM 2.5 - 43 µg/m3 (24-hr max) or 200 µg/m3 (hourly max)
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0
100
200
300
400
500
600
700
800
900
0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0
Time (minutes)
PM2.5 Levels in Car 4: 2 cigarettes smoked in 30-min periodAll windows up and Air Conditioning On
Sendzik, Fong, Travers, & Hyland (2006)
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Article 8 Protection from exposure to tobacco smoke
2. Each Party shall adopt and implement in areas of existing national jurisdiction as determined by national law and actively promote at other jurisdictional levels the adoption and implementation of effective legislative, executive, administrative and/or othermeasures, providing for protection from exposure to tobacco smoke in indoor workplaces, public transport, indoor public places and, as appropriate, other public places.
What does “effective” mean?
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Ventilation is NOT a solution!
de minimus riskdeath risk of 1/100,000
ASHRAE Standard recommendation (10Lps/occ)
You need ~50,000 Lps/occ to get the risk of LC < de minimus
From Repace (2000)
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Smoke-Free Laws: Basic Questions
Do they work? Will people comply?
Will smokers accept the law?
What is the economic impact?
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International Tobacco Control Policy Evaluation Project: Ireland/UK Survey
Telephone Survey
– Ireland: 1,000 randomly selected adult smokers– U.K.: 600 randomly selected adult smokers
– Cohort design:
Wave 1: Dec 2003–Jan 2004
Workplace Ban: Mar 29, 2004Wave 2: Dec 2004–Jan 2005
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Other ITC findings showing that the Irish law reduced tobacco smoke pollution
94% of Irish smokers reported that pubs were enforcing the law “totally”
98% of Irish smokers (vs. 35% of UK smokers) said that there was less smoke in pubs than one year ago
Conclusions:1. The smoke-free law led to near-total
elimination of smoking in key public venues in Ireland (especially in pubs)
2. A very high proportion of U.K. workers continue to be exposed to tobacco smoke
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Smoke-free pubs lead to smoke-filled homes?
John Reid, former U.K. Secretary of State for Health, at a House of Commons Health Committee Evidence Hearing, Feb. 23, 2005:
In Scotland, for instance, they have decided to go for a complete ban on smoking. I came to the conclusion that that was not a good thing on health grounds, apart from anything else, because you get a displacement of smoking from some public areas to the home - and most of the evidence about passive smoking is about the home...
...what we do know, for instance in Ireland and we would anticipate in Scotland, is that a percentage of people who previously went to the pub to smoke will now get a carry-out and take it home. I think the percentage in Ireland is about 15 per cent.
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Proportion of homes allowing smoking has decreased in Ireland since the ban (p=.002):
Home bans have increased after the ban
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Substantial increase in support among adult smokers in Ireland after the ban was
implemented. Same results in other venues.
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Ireland’s Legislation: Massive Cultural Shift
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Smoke-Free Laws: Basic Questions
Do they work? Will people comply? YES: after initial adjustment, compliance is
very high
Will smokers accept the law?YES: majority of smokers
What is the economic impact?21 best-designed evaluation studies ofeconomic impact: 0 show negative impact
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Compensatory Model of Price Effects
Tax Increase
Quitting
Switch to discount brands
Switch to cheaper sources (e.g., Internet, Indian reservations, “Freddy’s van”)
More efficient smoking (e.g., smoking more of cig, deeper breaths, less time out of mouth)
Dissonance-reducing activities(e.g., self-exempting beliefs)
Reduction in consumption
Reduction in prevalence
50%
No effect
What factors predict which path(s) a smoker will take?Which paths are more prevalent? Does country matter?Does cutting back represent a real health benefit, or is it offset by compensation (smoking more of cigarette, inhaling more deeply)?
Cutting back
Change purchase volume (e.g., pack—>carton)
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“Tak Nak”: First-ever national anti-smoking campaign in Malaysia
Malaysian MOH partners with the ITC Project to evaluate the Tak Nak Campaign
Questions added to ITC Malaysia Survey to evaluate Tak Nak
Evaluating Non-Policy Population Interventions
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ITC China Project
Collaboration between the ITC Project and the Chinese Office of Tobacco Control (China CDC)
FTF cohort survey in 7 cities: Beijing, Shanghai, Changsha, Guangzhou, Yin Chuan, Shenyang, Zhengzhou. Total N = 5,600 smokers + 1,400 non-smokers
Being used by China Government for FCTC surveillance
Wave 1 survey fieldwork: May–November 2006
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Potential ITC Evaluation of Smoke-Free Initiative for the 2008 China Olympics
ITC City 2007 2008 2009 Beijing ITC ITC ? ? ? ITC
Shan ghai ITC ITC ? ? ? ITC
Shen yang ITC ITC ? ? ? ITC
Yinchua n ITC ITC ITC
Guang zhou ITC ITC ITC
Changsha ITC ITC ITC
Zheng zhou ITC ITC ITC
OlympicCities
Non-Olympic
Cities
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The individual-level approach to evaluation is the proper unit of analysis.
Any population-level approach to changing behaviour can be evaluated and its impact understood via this paradigm– Physical activity and eating behaviour– Conservation behaviour– Different mediating variables: same principles of evaluation!!
The ITC Paradigm: not just about tobacco
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Begins with the establishment of a surveillance and evaluation system of health behaviour at the population level
Must be at the individual level
Must be mutually informed by policymakers and stakeholders (of course) but in close collaboration with experts in health behaviour
The ITC paradigm offers a flexible approach to understanding the impact of population-level interventions across domains.
Evidence-Based Policies for Global Health
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Interventions for lessening the progression of global warming: What works? How can interventions be created for greater effectiveness?
How can we evaluate their effectiveness?
Future Possibilities?
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International Tobacco Control Policy Evaluation Projecthttp: //www.itcproject.org
http: //www.roswelltturc.org
ITC Project Research Support
Core support provided by the U.S. National Cancer Institute to the Roswell Park TTURC
(P50 CA111236)
Additional major funding provided by
the Canadian Institutes of Health Research
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