Public health policies and approaches for reducing 1.Prevalence of tobacco use 2. Harmful use of alcohol

Transcription

1 Public health policies and approaches for reducing 1.Prevalence of tobacco use 2. Harmful use of alcohol Thaksaphon(Mek) Thamarangsi, 1.Health Promotion Policy Research Center (HPR) 2. Thai NCD Network 3. International Health Policy Program (IHPP) 4.Ministry of Public Health, Thailand

2 Outline Revisiting tobacco and alcohol issues Understanding the targets Situation What can we do? 2

3 Alcohol and tobacco: why bundled? Similarities Intermediates Industry epidemic Coincidence & reinforcing each other Need actions outside conventional health sectors Facing same vulnerability in the liberalised world Dissimilarities Victims Health and societal consequences, linkage to NCDs 3

4 Varieties of tobacco & related products Tobacco E-cigarette, E-hookah, E-shisha Tobacco? 4

5 alcohol and tobacco business in the change Globalization of the industry Emerging markets with high opportunity Variety of tailored products Aggressive and sophisticated marketing, including cross border marketing Private operator? Market liberalization: Free Trade Increasingly limited policy spaces 5

6 Unrecorded Alcohol & Illicit Tobacco Illegal alcohol and informally produced alcohol Unrecorded status from registration system e.g. taxation/ production licenses/ sale / import Unrecorded may or may not mean illegal alcohol, e.g. duty free, legally homebrewed, surrogate alcohol Is unrecorded alcohol more harmful from NCD perspective? Variety of producers and sellers Industry interest on unrecorded alcohol and illicit tobacco 6

7 Alcohol and health benefit Regular light drinking may have protective benefit on health disease (coronary heart disease) But Exaggerated claim Only for some age groups Only for regular and light Only for short term (May be only for some ethnics) And most important At the same amount of benefit, it is more than enough to create harm There is no safe drinking 7

8 Are tobacco and alcohol use our cultural heritage? Above: cigarette per capita, globally Below: Adult per capita consumption, Thailand W i n e S p i r i t s B e e r

9 Industry Epidemic model Brand recognition/ loyalty Positioning to lifestyles Tailored market Agent: health-demoting commodities Host Knowledge Attitude Skill Vector: the industry Conflict of Interest management: FCTC Article 5.3 : WHO Technical resource Denormalization Regulatory capture Social capture/ stakeholder marketing Create industry-friendly environment Environment social norm, climate availability stakeholders 9

10 Throwing feathers against the wind: the poor David Market value of alcohol and tobacco, and budgets for alcohol and tobacco control programs in Thailand b$ Sources: Recalculated form ThaiHealth Master Plan , photo from internet 133 $ per capita 33 $ per capita VS 0.2 $ per capita 0.15 $ per capita 13 m$ 2 b$ VS Don t fight money with limited money, Fight gluttony with social spirit 9.5 m$ 10

11 Gain or loss: social cost study of alcoholrelated harms in Thailand 2006 Cost Thousand million baht Revenue from excise tax of alcohol Alcohol harm cost Total $ Society Government Drinkers Tax 1 $ 3 $ 2 $ Alcohol industry 11

12 What contribute to harms? Harm in a society is a function of Number of users = 1. current users, 2. former user= quitter How much they use = average consumption volume e.g. tobacco per capita, alcohol adult per capita consumption How long they use= initiation (first use), quit Use patterns e.g. place of use, frequency, context of use Toxicity-quality of products Collective Volume Pattern of use 12

13 Outline Revisiting tobacco and alcohol issues Understanding the targets Situation What can we do? 13

14 Target 5: Tobacco Definition - A 30% relative reduction in prevalence of current tobacco use in persons aged 15 + years What do we need? : population survey(s) Formula: Prevalence of current tobacco user = Number of users / 15 + population Age standardization Do we need time frame reference of use? 14

15 Smoker prevalence-cigarette per capita and lung cancer (from HICs) Lung cancer mortality Male Smoker prev. Male Cig per Capita Lung cancer death M Cigarette per capita Linear (Lung cancer death M) Linear (Cigarette per capita) Source: Pampel, F, 5Divergent Patterns of Smoking Across High-Income Nations 15

16 Most up to date Situation in SEAR MSs Prevalence of current tobacco users Note Any smoke Smokeless T M F T M F Bangladesh Bhutan DPR Korea (25.7) (52.3) (0) (daily smokers) India Indonesia Maldives (6.2) (9.2) (2.9) (youth) Myanmar Nepal Sri Lanka < Thailand Timor (56.5) (60.2) (53.4) (youth) Source: Tobacco control country profiles 16

17 Target 2: Alcohol Definition: 10% relative reduction of harmful use of alcohol Terminology Harmful use of alcohol : clinical and global health perspectives Indicators (3 to choose from/ combine from) Total Adult Per Capita Consumption (APC) Age standardized prevalence of Heavy Episodic Drinking (HED) among adolescents and adults Alcohol-related Morbidity & Mortality 17

18 1. Adult per capita consumption (APC) What do we need? : sale data (registered data on taxation/sale system)+ estimation Unit: litre of pure alcohol Formula: Total APC = Recorded APC + Unrecorded APC Recorded APC = [Domestic production volume + Import- Export] / 15 + population Unrecorded APC = from estimation (or survey)

19 1. Another view of APC formula APC = Consumption/ adult population APC = Average Consumption per drinkers x Drinker prevalence APC = Average consumption per occasion x average drinking frequency x Drinker prevalence Adjustment for tourist? 19

20 APC Strengths and Weaknesses Weaknesses of APC Based on volume-only and assumption: alcohol produced= alcohol consumed Extra consumers: Under-age drinking, non-residential (tourists, illegal/ short term migrants) Cross-border consumption & informal import and export Commercial techniques: stockpiling and aging process non-drinking purposes i.e. Cooking and unconsumed Technical/ Methodology factors including variation of alcohol content Strengths Reflect NCD-relevant patterns Largely driven by small group of consumers

21 Life Expectancy at birth Russia,

22 Russia : alcohol consumption and mortality All causes mortality yo M Recorded APC

23 2. Age standardized prevalence of Heavy episodic drinking Terminologies: binge drinker/ heavy drinker/ harmful drinker/ hazardous drinker What do we need? Population survey Clear & consistent definition of Heavy episodic drinking (HED) Formula: 1. Consumption per day (CPD) approach 2. Consumption per drinking day (Drinking intensity) approach 3. Prevalence of ever drink beyond certain level* Prevalence of HED = number of qualified drinkers/population Natures of this HED: poorly reflect NCD causation Does HED go along well with APC? 23

24 3. Alcohol-related morbidity/mortality Examples: morbidity& mortality of liver diseases- cirrhosis, alcohol dependence What do we need? A good registration of diseases, accuracy Coverage of services Strengths Might be specific to alcohol (if carefully selected) Weakness Time lag Confounders 24

25 Situation in SEAR MSs APC Drinker prev. (%) HED (%)* Recorded Unrecorded Total M F M F Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor Note: HED = drink >60 gram at least once a week, rate among drinker Source: WHO Global Status Report on Alcohol

26 Intermediates to achieve the targets Targets #2 Tobacco user prevalence Primary intermediate mechanisms Minimize initiation & restart Maximize quitting #5.1 APC Drinker prevalence (start & quit) Consumption per occasion Drinking frequency #5.2 HED Consumption per occasion #5.3 morbidity/mortality Coverage and quality of screening/care/ rehab. 26

27 Outline Revisiting tobacco and alcohol issues Understanding the targets Situation What can we do? 27

28 Comprehensive policy framework Policy-mixed, not a single stroke 1. Balance in individual and environmental approaches 2. Intermediate mechanisms Consumption control Harm deterrence Harm recovery 3. Jurisdictional scales; local, sub-national, national, regional, global Non-alternative to others 28

29 Tobacco and alcohol control intervention groups Alcohol Tobacco 1. Price and taxation Tax & subsidy 2. Physical availability = regulation on sale 3. Modify consumption/pa context = regulation on use Licensing & monopoly, Time of sale, place, sellers, sale condition, product distribution Ban/control of use in high-risk settings e.g. drink driving, drinking in vehicles, public places, work places 4. Marketing regulation Control of products & content & packages, promotion & advertising& marketing 5. Education & awareness raising Education in various settings including health care/education, public campaign 6. Screening and treatment Screening at population, health care, comprehensive care including cessation clinic, rehabilitation Modified from Babor, 2003, Alcohol No Ordinary Commodity 29

30 WHO Tools Global Action Plan Regional Action Plan WHO Global Status Report on NCD NCD Tools by Targets Objectives Risks Indicators www. who.int/nmh/ncd-tools/en/ 30

31 Tobacco& Alcohol Control tools by WHO Tobacco FCTC Mpower Intervention specific tools Alcohol Global Strategy to Reduce Harmful Use of Alcohol Intervention specific tools (tax, marketing, community actions, availability control), May

32 Health interventions in FCTC Part III: reduction of demand for tobacco Article 6 Price and tax measures Article 7 Non-price measures to reduce the demand for tobacco Article 8 Protection from exposure to tobacco smoke Article 9 Regulation of the contents of tobacco products Article 10 Regulation of tobacco product disclosures Article 11 Packaging and labelling Article 12 Education, communication, training and public awareness Article 13 Tobacco advertising, promotion and sponsorship Article 14 Demand reduction measures concerning tobacco dependence and cessation Part IV: reduction of the supply of tobacco Article 15 Illicit trade in tobacco products Article 16 Sales to and by minors Article 17 Provision of support for economically viable alternative activities 32

33 MPOWER M onitor tobacco use and prevention policies P rotect people from tobacco smoke O ffer help to quit tobacco use W arn about the dangers of tobacco E nforce bans on tobacco advertising, promotion and sponsorship (TAPS) R aise taxes on tobacco 33

34 10 areas of GS to reduce Harmful use of alcohol 1. leadership, awareness and commitment; 2. health services' response; 3. community action; 4. drink-driving policies and countermeasures; 5. availability of alcohol; 6. marketing of alcoholic beverages; 7. pricing policies; 8. reducing the negative consequences of drinking and alcohol intoxication; 9. reducing the public health impact of illicit alcohol and informally produced alcohol; 10. monitoring and surveillance. 34

35 Which intervention is effective and cost effective? Scream test The alcohol industry opposes only effective interventions Interventions that industry does not oppose is ineffective Interventions that industry support are even hopeless Business is business and business 35

36 BEST BUYS for Population-wide approach 1. Protecting people from tobacco smoke and banning smoking in public places; 2. Warning about the dangers of tobacco use; 3. Enforcing bans on tobacco advertising, promotion and sponsorship; 4. Raising taxes on tobacco; 5. Restricting access to retailed alcohol; 6. Enforcing bans on alcohol advertising; 7. Raising taxes on alcohol; 8. Reduce salt intake and salt content of food; 9. Replacing trans-fat in food with polyunsaturated fat; 10.Promoting public awareness about diet and physical activity, including through mass media. 11.Vaccination against Hepatitis B 36

37 Pop-wide: Good Buys With low cost 1. Nicotine dependence treatment; 2. Promoting adequate breastfeeding and complementary feeding; 3. Enforcing drink-driving laws; 4. Restrictions on marketing of foods and beverages high in salt, fats and sugar, especially to children; 5. Food taxes and subsidies to promote healthy diets. With shortage of info on cost 1. Healthy nutrition environments in schools; 2. Nutrition information and counselling in health care; 3. National physical activity guidelines; 4. School-based physical activity programmes for children; 5. Workplace programmes for physical activity and healthy diets; 6. Community programmes for physical activity and healthy diets; 7. Designing the built environment to promote physical activity. 37

38 Protecting people from tobacco smoke and banning smoking in public places (BB) What do we need? Clear regulations to promote consistency of smoke-free settings Adequate coverage of public places Public support Enforcement capacity Surveillance & monitoring Resources Harm to others/ Externality approach (Right of non-smokers) Ventilation 38

39 Warning about the dangers of tobacco use (BB) Can we aim beyond knowledge? Denormalization Where is our media? Media Products Warning at tobacco advertising Pictorial warning & plain package initiative Non-cigarette tobacco products Smart design, Rotation Compensation: sleeve-package 39

40 1. Enforcing bans on tobacco advertising, promotion and sponsorship (BB) 2. Enforcing bans on alcohol advertising (BB) Function (exposure, power of content) Comprehensiveness = total ban Loopholes Integrated marketing communication (IMC) Variety of marketing media Implementation Swiftness and consistency of enforcement Health-oriented process Surveillance mechanism 40

41 How the industry plays with loopholes on Thai partial ban on alcohol advertising 41

42 1. Raising taxes on tobacco (BB) 2. Raising taxes on alcohol (BB) Comprehensive coverage Tax system and tax rates Ad Valorem rate/ by value: % of price By Volume Specific tax rate: $ per gram of tobacco/ litre of pure alcohol Unitary tax rate: $ per bottle/package Combination tax rate Econometric information Keep pace with inflation/ economic situation Smuggling Enforcement capacity Where should the money go? 42

43 1. Nicotine dependence treatment (GB) 2. Brief advice and brief intervention (GB) At risk population/ affected population Comprehensive to minimise the high relapse Moral obligation Health system view Health care delivery system Human resources Technologies Financing Governance Information system 43

44 Restricting access to retailed alcohol (GB) Physical availability control = control of sale, in various dimensions; seller/purchaser/time/ place/condition Other accessed? social availability Identify high-risk settings Youth-oriented settings: minimum purchasing age, sport/music Injury-oriented: road side, gas station, entertainment, public transportation Public venues: health care, beach, park, road Culture: religion, festival, community events Pay day Enforcement capacity, surveillance, monitoring 44

45 Enforcing drink-driving laws (GB) Setting up legal Blood Alcohol Concentration (BAC) : 0.05 / 0.08 Gram/L Coverage: general driver/ high-risk drivers/ passengers Enforcement: BAC test: breath/blood/urine/ other symptoms Fixed point/ Random/ Roving Visibility of enforcement Swiftness and consistency 45

46 Not all love effective policy! Discourses from those who are naïve Those drinkers/smokers will drink anyway Drinking/smoking is our national culture/ heritage Drinkers/smokers intend to ruin their body From those with commercial benefit The industry can accept every thing if it is voluntary, not regulatory Education and treatment Problems come from few bad drinkers, it is personal problems Personal responsibility is the key Self regulation and public-private collaboration Industry can control itself 46

47 Supportive policy arguments Market failure Right(s) Tobacco and alcohol: Not only health Investment for human capital Prevention now yields the highest return! Conflict of interest: game theory Evidence: right information in the right format to the right persons at the right time Social climate 47

48 Investment for system preparedness: important but not urgent? Collective capacity 1. Capacity of academics 2. Capacity for authority 3. Capacity for civil society & of general public Other investments in need Institutionalization Human resources Planning Process & mechanism Regulatory capacities including how to best address Regulatory capture Social climate, working with media Media capture Sector coordination etc 48

49 Who can support you? WHO HQ/SEARO/ Country office International agencies SEATCA The Global Tobacco Surveillance System (GTSS) Global Alcohol Policy Alliance (GAPA), Asia- Pacific Alcohol Policy Alliance (APAPA) Thailand Thai Health Promotion Foundation (T, A) Tobacco Control Research (T) Health Promotion Policy Research (A) 49

50 Sleeping with the industry and its son? Voluntary approach Weak regulative approach 50

51 Thank you 51