(and challenges) in tobacco control from Thailand

Transcription

1 1 Successes stories (and challenges) in tobacco control from Thailand Prof.Dr. Prakit Vathesatogkit, MD. FRCP Advisor International Network for Health Promotion Foundation August,2014 Bengaluru, India

2 2 Thailand s Tobacco Control: Key Events (Before FCTC) 1989: Total Ban on Tobacco Advertising 1992: Tobacco Product Control Act : Nonsmoker s Health Protection Acts 1993: Implementation of Tax for Health Policy (regular tax increase) 2001: Health Promotion Fund to fund tobacco control and health promotion

3 The Tobacco Product Control Act Ban sale to minors and by vending machines Total ban of advertising, promotion and sponsorship Ban of free sample cigarettes Ban of small packets of cigarettes Health warning provision Ingredient disclosure

4 Smoke Free areas ( ) 4 Health Facilities Education facilities Religious places Air-conditioned restaurants Private office buildings Internet shops All Public transport Public parks Airports Sport arenas Government buildings Certain designated smoking areas

5 Excise tax, cigarette sales and tax revenue Year Tax Sales Tax revenue (%) (million Pack) (million of Baht) ,843 14,664 Start tobacco control ,941 15, ,942 15, ,983 15, ,135 15, ,328 20,002 start tax for health policy ,171 20, ,463 24, ,415 29, ,810 26, ,826 28, ,727 29,627 Start health promotion fund ,716 31,247 Start UHI ,904 33, ,110 36,326 ASH THAILAND Source: the Excise Department, Ministry of Finance.Thailand 5

6 33% 25%

7 Have in placed : Two tobacco control law Tobacco tax for health policy Need funding to implement tobacco control program The Quest for a sustainable funding for tobacco control & health promotion 7

8 8 Reasons for Thailand to set up a health promotion fund in the late 90 s 1. Unable to secure adequate budget for tobacco control purposes (for education, campaign, research, law enforcement) through regular channel. 2. There are other emerging non communicable diseases facing the same problem as with tobacco control: no funding

9 Health financing reform policy (1996) MoF and MoPH 9 Appointed 2 Working Groups to Study: 1. Universal Health Insurance Coverage, - to provide health security 2. Setting up Health Promotion Fund - to prevent diseases/decrease health care cost. This was advocated as a package

10 10 Result: Two Complementary Acts Enacted

11 Health Promotion Foundation Act establishing Thaihealth Promotion Fund administer by an autonomous state agency, Requiring extra 2% of alcohol and tobacco surcharged taxes to this fund The funding is used for tobacco and alcohol control programs as well as other health promotion activities

12 = 50 million USD 2013 = 130 million USD 12

13 Impact of Tobacco control measures in Thailand ( ) Population > 15 year = 38.3 million Smoking prevalence Male = 59.3% Female = 4.9% % Tobacco Product control Act - Smoke-free law 1991: Tobacco Control Office No of smokers = million % 2003 ThaiHealth funding 6 tax increases % Population > 15 year = 53.9 million Graphic warning - Ban POS display - Ban CSR publicity Mass media campaign - Ban smoking in restaurant 2011 In 15 years - Smoking prevalence decease Male = 40.7% Female = 2.1% % % % No Smoker FCTC Annual Ratification death from tobacco 50,710 Smoking prevalence Ban smoking in all public places = 0.9 million Krongtip = 12 baht Tax = 55% tax revenue 15,898 million baht Sale = 1,941 million pack Tax revenue 36,326 million baht Sale = 2,110 million pack Krongtip = 58 baht Tax = 70% tax revenue 57,196 million baht Sale = 2,038 million 13 pack

14 Thailand s early successes 14 Push for policies & legislation, mainly through media advocacy & lobbying Work with limited budget (less than 300,000 USD annual) Lay down the Best buy intervention framework (tax increase / ad ban / smoke-free law & warning of danger) Established sustainable funding for tobacco control

15 15 Thaihealth s funding led to many more players in tobacco control. Ministry of Health NGO - ASH, THPI - policy development - advocacy,lobbying - public awareness campaign Tobacco control Research center. Mahidol U. Health Professional Network Teacher network National quitline Mass media campaign Community group - smoke free health facility - smoking cessation - smoke free school - smoking edu program Thai Health Promotion Foundation - funding to all party

16 16 On advertising / promotion / sponsorship : Thailand has ban 1. All form of advertising promotion and sponsorship including point of sale display of cigarette packet 2. Advertisement of CSR activities on TV and radio 3. Depiction of smoking on TV 4. Internet sale (administrative) 5. Implement movie rating system

17 Remaining FCTC(13) GAPs Ban CSR publicity in print and other medias. 2. Ban CSR activities. 3. Cross border advertising 4. Legislation to ban internet sale, 5. Plain packaging legislation 6. Enforcement problems

18 On warning of danger : % %

19 Labeling of toxic substances and cancer causing agent on side of packet 2007/ Rotating messages -Toxic Chemical: Carbon monoxide Cyanide -Cancer Causing agents: Formaldehyde Tar Nitrosamine 19

20 20 MOH s new regulation published in the Royal Gazette April 5, 2013 Requiring 85% GHW on both principle surfaces of cigarette packs Each carton must contain cigarette pack with 10 different GHW Effective date October 2, 2013 (6 months)

21 Thailand s MOH new regulation Effective October 2, ASH Thailand

22 BRAND BRAND BRAND BRAND BRAND BRAND BRAND BRAND BRAND BRAND Each carton must contain cigarette pack with 10 different GHW 22 ASH Thailand

23 23 Tobacco industries filed lawsuit against MOH JTI filed suit : June 20, 2013 PMI filed suit: June 26,2013 TTTA and two smokers filed suit: July 5, 2013 BAT filed suit: August 1, 2013 Request for 1. Court injunction (stay order) 2. Rule that the law is illegal

24 24 Request Court to rule that the regulation is unlawful 1. The reg. is unconstitutional/unlawful 2. It violate the Trademark Act 3. It violate TRIPS Agreement 4. It is disproportionate 5. It create excessive burden 6. Technically impossible (10 pictures per carton)

25 25 The Central Administrative Court issued stay order August 2013 MOH appeal to high court The High Administrative court lifted the stay order June 2014 MOH will enforce the regulation September 23,2014

26 CHINA Thailand REPUBLIC OF KOREA Effective September 23,

27 Regulation No 19 MOPH. June 28, Ban smoking Health Facilities Education facilities Religious places restaurants Private office buildings Government buildings Zoo Hotel lobby Internet shop All Public transport Public park All sport arena Night club and bar Non air con restaurants Open-air Market places International Airport : only place with Smoking room

28 Generating public support / compliance on smoke free law Respect the right of other by not smoking in public places Cigarette smoke is harmful to people close to you Cigarette smoke kill near-by people 28

29 Anti-Smoking TV Spot : Smoke free park Lady : You don t know me, but why you are hurting me? (with your cigarette smoke)

30 88.9 % 83.9 % 43.8 % 21.2 % 30

31 31 Exposure to second-hand smoke Comparison of the key finding (%) Indoor workplaces Healthcare facilities Public transportation Gov. Building GATS Thailand 2011 Relying on self enforcing is not enough

32 Excise tax(%), cigarette sales, excise tax revenue Year Excise Sales Excise Tax revenue Tax (%) (million Pack) (million of Baht) ,135 15, ,328 20, ,415 29, ,951 28, ,110 36, ,793 35, ,958 41, ,038 57, ,172 67,863 Total tax burden to retail price = 70%

33 Cigarette sale volume/ Excise tax revenue 33 Million Pack Million Baht Million Pack Million Baht

34 Additional revenue gained from tobacco tax = 261,824 million baht ( ) 34 Construction cost of MRT (Subway) = 120,000 million Baht Construction cost of sky train = 50,000 million Baht Combine = 170,000 million baht

35 Rooms for improvement tobacco tax structure 2. harmonization of taxes on different tobacco products 3. indexation to inflation 4. strengthen tax administration 5. strengthen illicit trade control

36 Impact of Tobacco control measures in Thailand ( ) Population > 15 year = 38.3 million Population > 15 year = 53.9 million Smoking prevalence Male = 59.3% Female = 4.9% % Tobacco Product control Act - Smoke-free law 1991: Tobacco Control Office No of smokers = million % 2003 ThaiHealth funding Annual death from tobacco 42,000 9 tax increases % Graphic warning - Ban POS display - Ban CSR publicity Mass media campaign - Ban smoking in restaurant Annual death from tobacco 45, FCTC Ratification 2009 Smoking prevalence Male = 40.7% Female = 2.1% % % % Ban smoking in all public places Annual death from tobacco 50, Krongtip = 12 baht Tax = 55% tax revenue 15,898 million baht Sale = 1,941 million pack If the rate of smoking in 2011 remain at 30% as in 1991, The number of smoker should be 17.2 million not 11.5 million. Thus the number of smoker in 2011 is 5.7 million less than it should be. Krongtip = 58 baht Tax = 85% tax revenue 57,196 million baht Sale = 2,038 million pack

37 Thaihealth funding for major NCDs risks reduction program 37 Issue based Million (USD) Tobacco Alcohol Traffic accident Physical activity Diet/ Nutrition Mass Media Total

38 Social Return on Investments of ThaiHealth Assessed Plan 1. Road Traffic Accidents ( ) 2. Tobacco-Consumption Control( ) Investment (million $USD) Outcomes (million $USD) Social Return on Investment ($ USD) Per $1 USD Investment of ThaiHealth ,

39 39 FCTC Article 26 Financial resources (2004) 1. The Parties recognize the important role that financial resources play in achieving the objective of this Convention. 2. Each party shall provide financial support in respect of its national activities intended to achieve the objective of the Convention.

40 40 Obstacle for FCTC implementation Report from 126 Parties (2012) 1. Tobacco industry interference 2. Lack of political will 3. Insufficient level of financial support for tobacco control 4. Lack of intersectoral coordination

41 Health Promotion Fund in WPRO country 41 Funding source 1. Vic Health Australia 1987 General budget 2. Health way Australia 1990 General budget 3. Singapore Health Promotion Board 2001 General budget 4. Mysihat (Malaysia) 2006 General budget 5. Tonga 2007 General budget 6. Mongolia 2007 Tobacco/alcohol tax 7. Republic of Korea 2011 General budget 8. Vietnam Tobacco Control Fund 2013 Tobacco tax 9. Laos Tobacco Control Fund 2013 Tobacco tax WPRO started the Prolead project 2004

42 Health Promotion Fund in other region 42 Funding source 1. SwissHealth 1994 Health insurance 2. AustrianHealth 1998 %VAT 1. Thaihealth 2001 Tobacco/alcohol tax 2. Indonesia 2014 Tobacco tax 3. Nepal 2014 Tobacco tax EURO SEARO SEARO is starting the Prolead project (2014)

43 Total tax rates levied by Parties on cigarettes by WHO region (% of average retail prices) 43 WHO region Total tax rates levied by Parties on cigarettes (%) Mean African 55.5 Americas 57.9 South East Asia 30.5 European 68.9 Eastern Mediterranean 49.8 Western Pacific 57.6 Global 59.4 FCTC Global Progress Report 2012

44 Mean average prices per pack of 20 cigarettes (US$) for different reporting periods, by WHO region. 44 WHO region Mean average prices per pack of 20 cigarettes (US$) 2012 African 1.94 Americas 3.20 South East Asia 0.79 European 5.87 Eastern Mediterranean 1.47 Western Pacific 5.54 Global 3.81 FCTC Global Progress Report 2012

45 A REPORT BY BILL GATES TO G20 LEADERS Cannes Summit, November Mobilizing Domestic Resources The World Health Organization (WHO) recommends tobacco excise taxes of at least 70 percent of the pack price.

46 Failure to convince Gov to support Smoking Cessation: 46 Cessation therapy was given low priority, cessation medication not cover by health insurance the most expensive and labour intensive intervention in tobacco control Thailand emphasis on changing the environment (population base) rather than dealing with individual smoker

47 Global NCD reduction targets by % reduction in NCDs mortality 2. 30% reduction in smoking prevalence 3. 10% reduction in alcohol use 4. 30% reduction in salt intake Tobacco control is most cost effective in reducing NCDs

48 Not possible to fight NCDs without sustainable funding Thailand NCDs Death (2009) 48 Ischemic heart disease = 34,384 Stroke = 50,829 Cancer = 80,711 COPD = 18,660 DM = 26,380 Total major NCDs = 210,963 Total death = 415,900 Death from NCDs = 50.7% Death from NCDs before 60 yrs. old = 27% = 56,960

49 49 What Thailand has gained from FCTC implementation 1. Stabilization of number of smokers (about 12 million) 2. Decrease smoking prevalence ( %) 3. Protection of million of Thai from second hand smoke 4. Government received huge amount of revenue from regular tax increase policy 5. Establishment of Thailand Health Promotion Fund to support NCDs control 6. Enhanced Universal Health Insurance coverage and quality of care.

50 Challenges 1. Tax- High prevalence of hand roll cigarette (50%) - excise tax structure trading down effect 2. Smoke free law - Weak enforcement 3. Marketing control - Selling of single stick cigarette - Violation of ad-ban 4. Tobacco industry interference - Opposing government initiative - CSR activities 5. Inadequate cessation support 6. Problem of new tobacco products 50

51 The way forward 51 Tobacco tax reform Include cessation services in UHI benefit. Strengthening of law enforcement Create tobacco control committee in provinces Incorporate FCTC provisions into related laws Increase tobacco control funding Ratification of Protocal to Eliminate Illicit Trade in Tobacco Products

52 52