Tobacco!Cessation:!Costs!and!Benefits!of! Smokeless!Tobacco!Cessation!during! Pregnancy!in!Bangladesh!

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3 TobaccoCessation:CostsandBenefitsof SmokelessTobaccoCessationduring PregnancyinBangladesh M.EnamulHoque University*of*Queensland,*Brisbane* BangladeshNutrition

4 2016 Copenhagen Consensus Center This work has been produced as a part of the Bangladesh Nutrition Priorities project, made possible by a generous grant from the Children s Investment Fund Foundation (CIFF). Some rights reserved This work is available under the Creative Commons Attribution 4.0 International license (CC BY 4.0). Under the Creative Commons Attribution license, you are free to copy, distribute, transmit, and adapt this work, including for commercial purposes, under the following conditions: Attribution Please cite the work as follows: #AUTHOR NAME#, #PAPER TITLE#, Bangladesh Priorities, Copenhagen Consensus Center, License: Creative Commons Attribution CC BY 4.0. Third-party-content Copenhagen Consensus Center does not necessarily own each component of the content contained within the work. If you wish to re-use a component of the work, it is your responsibility to determine whether permission is needed for that re-use and to obtain permission from the copyright owner. Examples of components can include, but are not limited to, tables, figures, or images.

5 BACKGROUND...1 FORMSOFSMOKELESSTOBACCO...2 HEALTHCONSEQUENCESOFSLTCONSUMPTION:...2 RATIONALEFORCONDUCTINGBENEFITCOSTRATIOOFSLTDURINGPREGNANCY...2 METHODS...3 DEMOGRAPHICANALYSIS...3 COSTDATA...4 BENEFITDATA...5 BENEFITANALYSIS...6 BENEFITCOSTRATIOANALYSIS...6 SENSITIVITYANALYSIS...7 DISCUSSION...7 REFERENCES...9

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7 Background Thetobaccoepidemicisaleadingdangertoglobalhealth.Nearlysixmillionpeopledieeachyearas a consequence of tobacco use (1). Tobacco exposure is the single greatest preventable cause of morbidity,disabilityandmortality(2,3).smokingisthemostcommonwayofconsumingtobacco, andtobaccoisthemostcommonlyknownsubstancesmoked.however,tobaccocanbeconsumed bothinsmokeandsmokelessform.smokelesstobacco(slt)isknownaschewingtobaccoororal tobacco, including a large variety of commercially available products and mixtures that contain tobaccoastheprincipalconstituentandareusedeitherorallyornasallywithoutcombustion(4i6). SLTisalsoknownas Shadapata inbangladesh(6).itreferstoaformofchewingtobaccofurnished intolongstrandsofwholeleavesandconsumedbyplacingaportionofthetobaccobetweenthe cheekandgumorteethandchewing(6). MorethanonethirdoftotaltobaccoconsumptioninSouthAsiaisintheformofsmokelesstobacco (5,7).SLTiscommonamongmenandwomeninSouthAsianandSouthandWesternPacificIsland countries(1,4,6,8,9).theworldhealthorganization(who)estimatesthattherearenearly250 million adult smokeless tobacco users in South East Asia (including 26 million in Bangladesh) representing90%ofglobalsmokelesstobaccoconsumers(1). InBangladeshtherearemorethan25millionSLTuser(1).Menarethemaintobaccosmokersin Bangladesh,whereasbothmenandwomenconsumesmokelesstobacco(1).Comparedtomen,the prevalence of smoking among women (1.5%) is very low in Bangladesh (44.7%). Among women, prevalence of current tobacco consumption, both smoking and smokeless, is 28.7% (1) and the prevalenceofsltconsumptionamongwomenis27.9%(1).bangladeshhasthehighestprevalence ofsltamongwomenintheworld.insouthasia,traditionalvaluesandsocialnormsdonotfavour smoking by the young or by women, but there is no such taboo against SLT (4). SLT is a cultural practiceofvarioussouthasianpeoples,includingbangladeshis(4,10).sltisintegraltosouthasian culture(6),beingincorporatedintraditionalvalues,spirituality,beliefs,festivals,lifestyle,andrituals such as marriage and popular entertainment (4, 10). Its perceived medical value for curing toothaches,headachesandstomachachesleadsmanyadultstobecomeusers.someparentseven encouragetheirchildrentousesmokelesstobacco(4).curiosity,peerpressure,andoffersbyfriends andacquaintancescontributetoinitiationofuse(10,11). 1

8 Formsofsmokelesstobacco Therearevariousformsofsmokelesstobacco,suchasbetelquid,zarda,gutka,paanmasala,paan parag, tobacco with lime, tobacco with areca nut, tobacco tooth powder(gul), anddriedtobacco leaves. A commercial mixture of tobacco, lime and spices is known as zarda which is typically flavoredwithcardamomandsaffronandoftenchewedinbetelquid,andispopularinnorthindia, PakistanandBangladesh(4,12,13).InBangladesh,commonlyusedsmokelesstobaccosareShada, zardaandgul.theseareusuallytakenwithbetelquid,arecanutandlime.theuseofsmokeless tobaccomixedwitharecanutisverypopularinsouthandsouthieastasia(4,14). HealthconsequencesofSLTconsumption: A number of studies indicate that SLT is a major risk factor for cancers of the oral cavity, throat, head, and neck (4, 15, 16). It also increases the risk of pancreatic cancer, diabetes, metabolic disease,cardiovasculardisease,stroke,highcholesterol,andadversepregnancyoutcomes(2,5,17). Tobacco contains thousands of compounds that may have adverse effects on the human body. Nicotine is the major compound of significance. Nicotine is metabolized to many different compounds,themostnotablebeingcotinine.nicotineanditsactivemetabolitecotinineincreases maternalbloodpressureandheartrate.foetalheartrateisalsoincreasedandthereisconcomitant reductioninbloodflowintheuterinearteryandumbilicalartery(5,18,19).nicotinealsoimpairs placental transfer of amino acids and affects foetal brain development which may cause foetal hypoxiaandgrowthretardation(18,19). RationaleforconductingbenefitcostratioofSLTduringpregnancy Although Bangladesh has made great achievements in maternal and child health improvement, adverse pregnancy outcomes remain a major public health issue in the country. The search for preventablecausesandrelatedhealthandeconomicbenefitsduetoprojectsaimingtoreducesuch adversepregnancyoutcomesisoftheutmostimportance. DespitethehighprevalenceofSLTconsumptionandwidespreadrecognitionoftheimportanceof adverse pregnancy outcomes, the scientific community has paid relatively little attention to its effects on pregnancy outcomes and health and economic benefits through smokeless cessation interventions during pregnancy. As a consequence, little is known about the economic benefit of tobaccocessationprogramduringpregnancyintheasiaipacificregion,especiallyinbangladesh.as nosuchknowninterventionhasbeenpursuedinbangladesh,itisworthytoundertakecostbenefit analysistounderstandtheeconomicbenefitofsuchanintervention. 2

9 AswomeninBangladeshconsumeSLTingeneral(1),itisimportanttomakeanattempttoinitiatea SLTcessationprogramduringpregnancyratherthaninvestingmoneyforcessationprogramonboth smokingandsltforpregnantwomen.consumingsltduringpregnancymaycontributetolowbirth weights and still births (20). It is essential to pursue tobacco cessation during pregnancy, as behavioural intervention can assist womenin stopping consumption of tobacco during pregnancy (21).Thefindingshaveimportantimplicationsforintroducingnewpublichealthinterventionsinthis area. Methods Thecostandbenefitdataoftheinterventionwereextractedfromrevieweddocuments.Asnosuch intervention has taken place in Bangladesh before, and the information related to SLT cessation programisrareintheliterature,asimulationmethodwasusedtomeasurethebenefitofsuchan intervention. As the target group of the intervention are pregnant women, demographic analysis wasconductedtomeasurethetotalnumberofpregnantwomeninthecountryin2015. Demographicanalysis Accordingtoa2011census,49%ofthetotalpopulationofBangladesharewomen(22).Thetotal populationin2015wasestimatedat160,300,000million.assumingthatthemaletofemaleratioin 2011continuesuntil2015,thetotalnumberofwomeninBangladeshin2015wasestimatedtobe 78,547,000million.TheBangladeshDemographicandHealthSurvey(BDHS)2014reportedthatthe birthratewas22.2per1000people(23).the2011censusalsoreportedthat78.6%ofthefemale reproductive age (15I 49 years) were married and among these married women, 6.1% were pregnant. Considering the aforementioned information, the total number of pregnant women in 2015wascalculatedas3,766,014million. TheprevalenceofSLTconsumptionamongwomenis27.9%.Thereisnosuchinformationonthe prevalenceofsltconsumptionamongpregnantwomeninbangladesh.however,weassumedthat all women who consumed SLT before pregnancy also continue the consumption of SLT during pregnancyaswell.onemayarguethatthepopulationofpregnantwomeninbangladeshisyounger than the average age and as a result, probably consume less SLT. Thus, the prevalence of SLT consumption among pregnant women should be lower than the prevalence of SLT consumption amongwomen.ontheotherhand,rahmanetal(2012)mentionedthatsometimesoldermembers of the family, such as mothers and mothersiinilaw advise pregnant women to consume SLT with betelleafasameanstorelievemorningsickness.thus,theprevalenceofsltconsumptionamong 3

10 pregnantwomenmightbehigherthantheprevalenceofsltconsumptionamongwomen.keeping bothscenariosinmind,itcanbeassumedthattheprevalenceofsltconsumptionamongpregnant womenisequaltotheprevalenceofsltconsumptionamongwomen. Costdata The goal of the smoking cessation intervention during pregnancy is to change the behaviour of pregnant women to stop consuming SLT during pregnancy. Most tobacco cessation intervention studiescomefromdevelopedcountriesandfocusoncigarettesmoking.inthecaseofthesmokeless tobaccocessationprogram,thebehaviouralinterventionisassumedtobebestforbangladesh,asa pharmacologicalinterventionforquittingsmokelesstobaccoisnotwidelyavailable.thebehavioural intervention includes face to face counselling by a health care provider and printed materials. However,thecostforsmokelesstobaccocessationinterventionduringpregnancyisnotavailablein the literature. Consequently, for the costing data, the best possible information would be information from maternal health programs. The cost of behavioural change and communication related to maternal health programs in Bangladesh is available from Sarker BK et al (24). The behaviouralinterventionwillberunbycommunityhealthworkerswhovisitthehouseholdinthe community to deliver several behavioural change and communication (BCC) messages. When the pregnantwomenfirstmeetthehealthcareproviderorcommunityhealthworkerstoreceivethe ANC,thewomenwillbeaskediftheyconsumeSLT.Thus,determiningwhetherthepregnantwomen consumesltcouldbedonefreeofcost.thecostitemrelatingtothesltcessationinterventionis consideredbasedonthreedifferentchannelsifacetofacecounselling(ffc),groupcounselling(gc) andmassmedia(mm).communityhealthworkersprovideffctothepregnantwomenandtheir family during their regular field visits. Along with maternal and child health services, the FFC will includesltcessationmessages.thegcisexpectedtobeconductedbimonthlyinthecommunity. Thus,pregnantwomenaresupposedtohavethechancetoattendsuchmeetingsfourtimesduring theirpregnancy.duringthismeeting,themessagesrelatedtosltcessationwillbeprovided.the MM channel includes four sub channels folk song performance, street drama, TV spots and billboards. The BCC messages will be provided through artist singing folk songs and performing dramasinpublicplacesatleastonceinayear.aoneminutetvspotwillbebroadcastedtothe communitythroughvideochannelsoflocalcablenetworks,atleast10timesaday.thebillboards fortheprogramwillbesetupinhighlyvisibleareasbesidemajorstreetsorinpublicplacessuchas markets.detailsoftheinterventionwillbeprovidedelsewhere(24). Allcostdatainthispaperwasreportedascostsin2011andthetotalcostperpersonforthesethree itemswas$2.25in2011.convertingdollarsintotakaandthenusingtheconsumerpriceindexand 4

11 afterconvertingtakabacktousdollar,thiscostingdatawasconvertedin2015values(25).using thecpi(25),thetotalcostperpersonwas$2.88in2015.table1providestheunitcostperbccitem duringpregnancyinus$. Table1.UnitcostperBCCiteminUS$ Intervention Unitcostin2011^ Unit cost in 2015* Facetofacecounselling Groupcounselling Massmedia Total ^Source:Sarkeratel(2013);*convertedinto2015usingCPIandexchangerate Benefitdata Identification*of*co7morbidities* A literature search was carried out to identify coimorbidities of smokeless tobacco consumption, especiallyduringpregnancy.studiesfromvariouscountriesindicatethatsltconsumptionisarisk factorforadversepregnancyoutcomes(20,26,27).adversepregnancyoutcomesassociatedwith SLTconsumptionduringpregnancyincludeslowbirthweightduetopretermbirth,andintrauterine growth restriction, congenital anomalies, spontaneous abortion, and stillbirth (5, 20, 26, 28). SLT consumptionduringpregnancyisalsoassociatedwithinfertility,menstrualproblems,osteoporosis andearlymenopause(7). Estimating*the*risk*factor*attributable*burden* ToallocatetheproportionofthetotalcostsofthediseasesattributabletoSLTconsumption,the populationattributablefraction(paf)wasused(29).thiswascalculatedusingtheformula: PAF=Px(RRI1)/[Px(RRI1)+1], Where P is the probability of a pregnant women using SLT in a given population and RR is the relativeriskforthediseaseofthepregnantwomenconsuming SLT, therelativeriskforstillbirth duetosltconsumption,whichis2.87,wasobtainedfromhossainsetal,2015(30).incontrast,the relativeriskforlbwduetosltconsumption,whichis3.3,wasobtainedfromhossainmm,2014 (31). 5

12 TheprevalenceofstillbirthsinBangladeshin2015was25.4per1000livebirthsandwascollected fromblencowehetal,2016(32).theprevalenceoflbw,13.2%,wasacquiredfromthebangladesh DemographicandHealthSurvey(BDHS),2014(23).TheLBWwascollectedfromtheBDHSbasedon mother sestimatesofbabysizeatbirth. Benefitanalysis There are two broad classes of benefits attributed to pregnant women from a cessation of smokeless tobacco. Firstly, the reduced possibility of giving birth to a low birth weight baby. Secondly,therewillbeasmallerchanceofastillbirthduringdelivery.Basedontheinformation that 7.5% of income loss occurs due to LBW (33), it was assumed that if the intervention is implemented,then7.5%ofextraincomeperpersonwillbeaddedtotheeconomy.whilemeasuring thebenefitrelatedtostillbirthswasconsidered,itisassumedthatiftheinfantissavedin2016, thens/hewillenterthelabourmarketatage18in2034.consideringtheretirementageis60in Bangladesh, this person will be in the labour market until As a result, this person will contributetogdpfrom2034to2076.atrendanalysisofthewagepercapita;i.e.outputperworker ofbangladesh,wasconductedtogetthewagepercapitaduring2034to2076inbangladesh.the outputperworkerwascalculatedconsidering54%ofdependencyrateand65%oftheworkingage peopleinthecountry.afterconsideringthediscountrateandsummingupthetotalcontributionof thepersoningdpduringthisperiod,thetotalbenefitofsltcessationduringpregnancyperperson was measured. Finally, economic gain due to reducing still births and LBW was calculated using differentdiscountingvalues(3%,5%and10%). Regardingtheeffectivenessoftheintervention,onemust considerthatsmokingisveryaddictive anddifficulttoquitwithinashortperiodoftime.however,ifthepropermessagecanbegivento pregnantwomenrelatedtolbwandstillbirthsasaresultofsltconsumptionduringpregnancy,the effectivenessisassumedtobehigh.basedontheassumptionmadebymarksjsetal(34)ofa15% efficacyrateofatypicalsmokingcessationprogram,itisalsoassumedthat15%ofthebenefitsare realised from SLT cessation during pregnancy. A worst case scenario of 10% efficacy and best practicescenarioof25%efficacyrateareassumedfortheanalysis. Benefitcostratioanalysis CostIbenefit analysis is a method of economic evaluation that answers whether the costs of an intervention can be justified by the value of the benefits it provides. To estimate the costs and benefitsofsmokingcessationprogramsacrossthecountry,thetotalannualcostsandbenefitswere 6

13 first measured and then translated into a benefit cost ratio of smokeless tobacco cessation per pregnant woman. Finally, considering 15% of the benefit are realised, benefit cost ratio was calculatedto13.8,7and1.9at3%,5%and10%discountingvaluesrespectively.itmeansthatevery dollar invested into SLT cessation through BCC during pregnancy is estimated to generate $7 in economicreturns,usinga5%discountrate. Sensitivityanalysis Asensitivityanalysiswascarriedoutusingdifferentdiscountratesinmeasuringthebenefitasthe economicreturnsareexplicitabouttherateused.table2providesasensitivityanalysis,showing thebenefitcostestimatesunderthedifferentestimatesofeffectivenessofthetobaccocessation interventionduringpregnancyanddiscountrate. Table2:Asensitivityanalysisofbenefitcostratioestimatestoassumetheimpactofthesmokelesstobaccocessation interventionduringpregnancyanddifferentdiscountrate Effectiveness of the intervention(%) Discountrate 3% 5% 10% 10% % % Thesensitivityanalysisindicatesthatthebenefitcostratioofthetobaccocessationprogramduring pregnancy in Bangladesh can range from 1.3 to 23 based on the different discount rate and the effectivenessoftheintervention. Discussion The objective of this study is to determine whether the cost of adopting a smokeless tobacco cessationprogramduringpregnancyinbangladeshcouldbejustifiedbythebenefits.accordingly, we adopt a costibenefit analysis framework and estimate the costs and benefits of behavioural programs. The current paper has outlined the economic rationale for investing in a SLT cessation program during pregnancy in Bangladesh. The overall goal of the paper was to create credible estimatesofbenefitcostratioforsuchanintervention. Thestudyhasseveralpotentiallimitations.Thecostoftheinterventiontomeasurethebenefitcost ratioherehasbeencollectedfromaninterventionwhichwastargetedforraisingmaternalhealth 7

14 awareness.therealcostofasmokingcessationinterventionduringpregnancycouldbedifferent, andthus, adifferentbenefitcostratiomightemerge. However, based on the higher benefit cost ratioofthecurrentanalysis,itcanbeassumedthatthebenefitcostratioinachangesscenariowill bepositive.again,noconfidenceintervalhasbeenprovidedforthecostdatausedforthisanalysis. In fact, the cost data extracted from the source, i.e. Sarker et al (2013) failed to report the confidenceintervalofcostdataduetothequalitativenatureofthecostdatacollectionmethod.in addition, the cost data was collected from a provider perspective and thus, the cost incurred by households or individuals receiving BCC, such as time spent group counselling at health care facilities, was not included in the analysis. If the societal cost was included, the cost of the interventionwouldbehigherandinturn,wouldleadtoalowerbenefitcostratio. Sincethebenefitcalculationcarriedoutinthispaperhasnottakenintoaccountthehealthimpact onpregnantmothersduetosecondhandsmoking,eventhehigherbenefitcostratioobtainedfrom thisanalysisseemstobelowerthantherealfigure.however,basedontheanalysisoftheavailable evidence,theinvestmentmadeforsmokingcessationduringpregnancycanbejudgedtobehighly productive.asthebenefitcostratioshowsapositiveimpactontheeconomy,thepolicymakerand health program managers should consider a health intervention program targeting SLT cessation duringpregnancyinbangladesh. The findings of this study have implications for evidenceibased public health interventions to preventandmanagethetobaccocessationduringpregnancy.thiswillalsohelpthepolicymakersof Bangladesh to introduce national policies for prevention and to control the use of SLT during pregnancy. The findings of the study will also guide the healthifinancing decision makers, developmentpartnersanddonorsinfinancingandallocatingresourcesforreducingsltuseduring pregnancyinbangladeshandinothercountriesoftheindiansubcontinent. 8

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