Genuine Progress Index for Atlantic Canada Indice 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 35 30 25 % 20 15 10 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
35 30 25 % 20 15 Then: Smoking Prevalence, Age 15+, 2000 24 28 26 30 27 28 23 26 28 23 20 10 CAN NL PE NS NB QC ON MB SK AB BC
35 Now: Smoking Prevalence, Age 15+, 2005 30 25 % 20 15 19 21 20 21 22 22 16 22 22 21 15 10 CAN NL PE NS NB QC ON MB SK AB BC
Nova Scotia: Smoking Prevalence, Age 15+, 1999-2005 31 29 27 25 % 23 21 19 17 15 1999 2000 2001 2002 2003 2004 2005
Cigarette Sales in NS, 1991-2005 millions 1,600 1,500 1,400 1,300 1,200 1,100 1,000 900 800 (down 35% since 96) (consumption/risk) 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Smoking rates Canada and NS, Age 15-24 CANADA NS 35 30 % 25 20 15 1999 2000 2001 2002 2003 2004 2005
% Decline in Smoking: Can and NS, Ages 15-24 and 25+ (1999 to 2005) 15-24 25+ % 45 40 35 30 25 20 15 10 5 0 CAN NL PE NS NB QC ON MB SK AB BC
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 Less than 20 cigarettes a day 20+ cigarettes a day Excess Lung Cancer Risk 1.2 1 0.8 0.6 0.4 0.2 0 1 2 3 4 5 6 7 8 9 10 11 12 13 Years since Quitting
Chronic Heart Disease Risk Less than 20 cigarettes a day 20+ cigarettes a day Excess Risk of CH D 1 0.8 0.6 0.4 0.2 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Years since Quitting
Lifetime smoker costs and 140,000 120,000 cessation benefits, NS 132,280 $ 100,000 80,000 60,000 40,000 47,121 25,842 77,697 45,118 79,300 20,000 0 Costs Savings Costs Savings Costs Savings 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 $162m in 2003-04
Price Elasticity by age Price Elasticity 0-0.1-0.2-0.3-0.4-0.5-0.6-0.7-0.8-0.9 15-17 18-20 21-23 24-26 27-29 -0.1-0.2-0.37-0.52-0.83 Age
65 60 55 50 45 40 35 30 25 Cigarette Prices US & Canada, 2000 59.59 53.3 54.92 49.47 47.46 37.2 38.97 38.79 32.58 53.66 Quebec N.B. N.S. P.E.I. Nfld. Maine Vermont New Hampshire New York Michigan Price per Carton ($)
Cigarette Prices, Selected Provinces 2000.00 2006.00 Price per Carton ($) 95 85 75 65 55 45 35 32.58 63.58 37.20 71.67 38.97 80.34 38.79 78.88 53.30 84.89 25 Quebec N.B. N.S. P.E.I. Nfld.
Cigarette Prices 1997 2006 95 Price per Carton ($) 85 75 65 55 45 35 25 BC AB SK MB ON QC NB NS PE NL
% Change in Cigarette Prices, 1997-2006 140% 120% 100% 80% 60% 40% 20% 0% BC AB SK MB ON QC NB NS PE NL Percentage change, price for carton of cigarettes
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
OMA: The province is not forced to choose between social spending and responsible fiscal management it can accomplish both goals through one policy. 10% fall in prevalence 15% fall in prevalence 20% fall in prevalence Lives saved Avoided hosp. days Lives saved Avoided hosp. days Lives saved 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
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% smoking obesity smoking prevalence (%) 40 35 30 25 20 15 10 5 0 1985 1990 1995 1997 1999 2001 2003 2005 60 50 40 30 20 10 0 obesity prevalence (%)
NS - Smoking Down, Obesity Up BMI>30: NS = 20.7%, Can = 15.5% smoking obesity smoking prevalence (%) 31 29 27 25 23 21 19 17 15 1999 2001 2003 2005 23 22 21 20 19 18 17 16 15 obesity prevalence (%)
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 Canada Indice de progrès véritable - Atlantique www.gpiatlantic.org