Genuine Progress Index for Atlantic CanadaIndice de progrès véritable - Atlantique

The Cost of Tobacco in Nova Scotia: An Update

Tobacco Control Summit, Halifax, NS

20 October, 2006

The larger context – GPI: 1)Tobacco, sickness as costs vs. $300m/yr

on tobacco + $168m sickness = make GDP grow

2)GPI Question: Creating a healthier NS? – 2000-06 – Are we getting healthier, making genuine progress?

To answer this question, what does the evidence

show:1. Then and now: Smoking since 2000 GPI report

2. Then and now: SAM & Costs - Why the Lag?

3. What has made the most difference?

4. Where to from here? – Effects of tobacco control investment on SAM and costs

5. Lessons for health promotion

1) Then… and Now… Smoking Prevalence, 15+,

2000  

10

15

20

25

30

35

CAN NL PE NS NB QC ON MB SK AB BC

%

2000: Smoking kills 1650/year = 21% of all deaths

in NS

• NS - highest rate of deaths from cancer and respiratory disease in Canada

• 2nd highest circulatory deaths, diabetes

• Highest use of disability days

• Highest smoking rate in Canada (30%) – 25% higher than Can., 50% above BC

Then: Smoking Prevalence, Age 15+, 2000  

24

2826

30

27 28

23

2628

23

20

10

15

20

25

30

35

CAN NL PE NS NB QC ON MB SK AB BC

%

Now: Smoking Prevalence, Age 15+, 2005  

1921 20 21 22 22

16

22 22 21

15

10

15

20

25

30

35

CAN NL PE NS NB QC ON MB SK AB BC

%

Nova Scotia: Smoking Prevalence, Age 15+, 1999-

2005

15

17

19

21

23

25

27

29

31

1999 2000 2001 2002 2003 2004 2005

%

Cigarette Sales in NS, 1991-2005 (down 35% since ’96)

(consumption/risk)

800

9001,000

1,1001,200

1,300

1,4001,500

1,600 millions

Smoking rates Canada and NS, Age 15- 24

15

20

25

30

35

1999 2000 2001 2002 2003 2004 2005

%

CANADA NS

% Decline in Smoking: Can and NS, Ages 15-24 and 25+

(1999 to 2005)   

05

1015202530354045

CAN NL PE NS NB QC ON MB SK AB BC

%

15-24 25+

2) 2000 – Costs of Smoking

• Chronic diseases cost NS $3 billion/yr (direct + indirect) = 13% GDP – huge burden

• Good news: 40% chronic disease; 50% premature death; $500 m./yr health care costs avoidable = small # risk factors -> OHP

• Tobacco – single largest preventable cause of death and sickness = $168m. in health care costs + $300m. In indirect costs +ETS costs

2006 Costs of Tobacco (preliminary estimates)

• 1,730 deaths (up from 1,650); $220 million health care costs + $550 million indirect costs (up since 2000 despite decline in prevalence)

• = Due to ‘backlog’ of older ex-smokers (former high smoking rates) + female lag

• Health Canada: Despite declining prevalence, SAM = 38,357 (1989), 45,000 (’96), 47,581 (’98)

• US: Lung cancer peaked early 90s despite drop in cig consumption: 3800 (1965) – 2800 (1993)

But benefits will accrue: Time lag (ACS study of 1

million)• 2-4 years: lung cancer death risk down - ex-

light smoker = 2/3; ex-heavy smoker = 13%; 5 years: ex-light smoker risk = non-smoker; ex-heavy smoker down 50%

• CHD death risk: ex-light smokers = down 50% in 5 years; 100% in 10 years; Ex-heavy smokers much longer = down 1/3 after 7 years; down 2/3 after 10+ years

• COPD – much longer, no return to normal

Lung Cancer Risk

0

0.2

0.4

0.6

0.8

1

1.2

1 2 3 4 5 6 7 8 9 10 11 12 13

Years since Quitting

Exce

ss L

ung

Canc

er

Ris

kLess than 20 cigarettes a day 20+ cigarettes a day

Chronic Heart Disease Risk

0

0.2

0.4

0.6

0.8

1

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Years since Quitting

Exce

ss R

isk

of C

HD

Less than 20 cigarettes a day 20+ cigarettes a day

 

47,121

25,842

77,697

45,118

79,300

132,280

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

Costs Savings Costs Savings Costs Savings

$

Lifetime smoker costs and cessation benefits,

NS

LIGHT MODERATE

HEAVY

3) Key changes since 2000

• BMJ + World Bank: Cigarette taxes = “single most effective intervention” to reduce tob. demand

• 10% increase in price -> 4% drop consumption -> 7% drop among youth, pregnant women

• NS price more than doubled since 2000; Consumption dropped by more than 30%

• NS tax: $9.64/carton = 2000 -> $31.04 (2004); Prov tax revenue more than doubled = $76m in 1999-2000 to $162m in 2003-04

 

-0.83

-0.52

-0.37

-0.2

-0.1

-0.9-0.8-0.7-0.6-0.5-0.4-0.3-0.2-0.1

015-17 18-20 21-23 24-26 27-29

Age

Pric

e El

astic

ityPrice Elasticity by age

 

38.97 38.79

54.92

49.47

59.59

53.66

32.58

37.2

47.46

53.3

253035404550556065

Pri

ce p

er C

arto

n ($

)Cigarette Prices – US &

Canada, 2000

 

63.58

78.8884.89

38.7938.9732.58

37.20

53.30

80.3471.67

25

35

45

55

65

75

85

95

Quebec N.B. N.S. P.E.I. Nfld.

Pri

ce p

er C

arto

n (

$)

2000.00 2006.00

Cigarette Prices, Selected Provinces

 

25

35

45

55

65

75

85

95

BC AB SK MB ON QC NB NS PE NL

Pri

ce p

er C

arto

n ($

)

1997 2006

Cigarette Prices

 

0%

20%

40%

60%

80%

100%

120%

140%

BC AB SK MB ON QC NB NS PE NLPer

cen

tage

cha

nge

, pri

ce fo

r ca

rton

of c

igar

ette

s% Change in Cigarette

Prices, 1997-2006

Other actions since 2000

• Smoke-free act - associated with 14% drop in prevalence; 25% drop in consumption

• Comprehensive tobacco control strategy - up 4x: $500,000 (2001-02) ->$1,960,000 (2003-04) + coordinated: OHP – DHPP

• Education: Package warnings; display bans; media campaign; school-based programs + Youth access denial + workplace programs

• Quit aids: Counselling/help line/support groups

4) Where to from here? Complacency or build on

success? • NS smoking rate = 21%; BC = 15%; Calif = 14%

• California Proposition 99 (1988); raised prices by 25c/pack; earmarked 25% of new revenue for tobacco control program

• Results: 50% drop in consumption = 50% faster than rest of US; 25% drop in prevalence; decline in lung and bronchus cancer = 3x US average; est. 33,000 fewer deaths from heart disease

Economics of tobacco control: All studies show

high ROI• Cal. saves $3 for every $1 on tobacco control

• Mass saves $2 in health care costs alone for every $1 spent on tobacco control

• School-based prevention = 15:1; physician advice = 12:1; prenatal counselling = 10:1; media advertising = 7:1; counsel/NRT = 3-4:1 (doubles quit rates)

• $1 per capita increase in education spending ->20% prevalence decline (BMJ)

Is NS tobacco control adequate?

• NS still 1 billion cigs/yr = 1 pack for every Nova Scotian – can reduce by 1/3 to Calif. rates

• NS collects $162m in tobacco tax revenues; spends 1.2% of that on tobacco control = $2pp

• CDC int’l best practices = $8-$23Cdn pp small states (<3m) = $7.5 m - $21.5 m in NS

• At min. CDC level, OMA estimates $90m Ontario program will reduce prevalence 15%, save $1.3b in health care, and add $2.4b sales and inc. tax (prod. incr), + $7.5b tobacco taxes

Estimated benefits of best practice strategy

• OMA = $3 saved in avoided health care costs for every $1 invested + $6 in sales, income tax (not count tob. tax revenue)

• If prevalence drops 20% then = 12:1 + Would save 116 NS lives/yr by year 5; 300+ lives/yr by year 10; 500+ lives/yr by year 15 + 26,000 avoided hosp. Days

• To justify $7.5m NS investment, using only health care savings as benefit, program need only induce 5% Nova Scotians to quit

+ Benefits to employers

• Empirical research using 10 objective measures of productivity shows ex- smokers = 5% more productive than current smokers

• Conference Board of Canada = Smoker costs employer $2,280/year more than non-smoker =$250m/yr in NS (smoke breaks, absenteeism)

• Extrapolating from OMA Ontario results - productivity gains from $7.5m NS program -> add $177m in higher income and sales taxes over program duration

  10% fall in prevalence

15% fall in prevalence

20% fall in prevalence

  Livessaved

Avoided hosp. days

Livessave

d

Avoided hosp. days

Livessaved

Avoided hosp. days

Year 5 56 3005 87 4,507 116 6,010

Year 10 154 8,035 232 10,539 309 16,069

Year 15 251 13,103 377 19.655 502 26,206

OMA: “The province is not forced to choose between social spending and responsible fiscal

management – it can accomplish both goals through one policy.”

5) Applying the lessons to other health promotion

strategies• Build on, expand success – comprehensive

program works; values change. E.g. CDC found cig sales drop 2+x as much in states with comprehensive programs cf US av.

• -> Comprehensive health promotion program = no smoking, healthy eating, healthy weights, physical activity

• + attention to social determinants. E.g. CDC found 10% price increase = low-income smokers 4x more likely quit cf higher-income (E.g. St Henri, Montreal)

Can: Smoking Down, O’wt+Obese Up BMI>25: Can = 48.9%, NS =

56.5%

0

510

1520

25

3035

40

1985 1990 1995 1997 1999 2001 2003 2005

smok

ing

prev

alen

ce (

%)

0

10

20

30

40

50

60

obes

ity

prev

alen

ce (

%)

smoking obesity

NS - Smoking Down, Obesity Up BMI>30: NS = 20.7%, Can

= 15.5%

15

1719

2123

25

2729

31

1999 2001 2003 2005

smok

ing

prev

alen

ce (%

)

15

1617

1819

20

2122

23

obes

ity

prev

alen

ce (%

)

smoking obesity

Costs of other risk factors

• RAND Health study found obesity costs for first time have passed smoking costs in US

• NS: Obesity and physical inactivity kill more than 1,000 Nova Scotians/ yr; diabetes up; cost NS health care system $150m+/yr + cost economy $250m+/yr productivity loss

• E.g. GPI estimate that 10% drop in physical inactivity would save 50 lives/year, $7.5m in avoided health care costs + $17.2m in economic productivity gains

As with comprehensive tobacco control program:

• DHPP school healthy eating program very positive. Now supplement with:- price measures (Brownell),- labelling (Finland), - education (Singapore – reduced youth

obesity by up to 50%), - regulatory mechanisms- media campaign, - physician advice, counselling etc.

Comprehensive tobacco control and health

promotion strategy will create a healthier Nova

Scotia for our children –

Genuine Progress Index for Atlantic CanadaIndice de progrès véritable - Atlantique

www.gpiatlantic.org