1. Balázs Ádám, Ágnes Molnár, Róza Ádány University of Debrecen Faculty of Public Health Department of Preventive Medicine QUANTITATIVE RISK ASSESSMENT INTEGRATED IN THE HIA OF THE ANTI- SMOKING POLICY PROPOSAL IN HUNGARY

2. HEALTH EFFECTS OF ACTIVE AND PASSIVE SMOKING ACTIVE SMOKING carcinogenesis impaired fertility, teratogenesis irritation, chronic inflammation atherosclerosis immunomodulation peptic ulcer, bile stone, Crohn’s disease PASSIVE SMOKING essentially the same lower concentrations, weaker evidence

3. ANTI-SMOKING POLICIES MPOWER policy package, WHO Monitor tobacco use and prevention policies Protect people from tobacco smoke Offer help to quit tobacco use Warn about the dangers of tobacco Enforce bans on tobacco advertising, promotion and sponsorship Raise taxes on tobacco

4. ANTI-SMOKING POLICIES MPOWER policy package, WHO Monitor tobacco use and prevention policies Protect people from tobacco smoke Offer help to quit tobacco use Warn about the dangers of tobacco Enforce bans on tobacco advertising, promotion and sponsorship Raise taxes on tobacco

5. PUBLIC HEALTH IMPORTANCE OF SMOKING-RELATED DISEASES IN HUNGARY

6. Act No XLII of 1999 on the protection of non- smokers and on certain rules of consumption and trade of tobacco products full prohibition of smoking in closed public- and workplaces and on public transport vehicles further restrictions of promotion and trade AGGRAVATION OF THE HUNGARIAN ANTI-SMOKING POLICY

7. Act No XLII of 1999 on the protection of non- smokers and on certain rules of consumption and trade of tobacco products full prohibition of smoking in closed public- and workplaces and on public transport vehicles further restrictions of promotion and trade AGGRAVATION OF THE HUNGARIAN ANTI-SMOKING POLICY

8. Health determinant Risk factor Health outcome Policy Exposure assessment Outcome assessment FULL CHAIN ASSESSMENT

9. POLICY Policy choice importance of the issue need of policy makers for assistance feasibility of assessment (quantitative) Context driving forces, policy actors target population international experience feasibility of implementation

10. Amendment of Act No XLII of 1999 FULL IMPACT CHAIN

11. HEALTH DETERMINANTS Determinants of health Positive effect Negative effect No effect LifestyleSubstance use (tobacco)+ Physical environment Air+ Built environment and land use++ Housing conditions++ Working environment+ Socio- economic environment Income and social status+++ Employment++ Social contacts +++ Culture+ Recreation + Health care Access to/quality of health services ++

12. HEALTH DETERMINANTS Prioritization strength of evidence size of effect feasibility of impact quantification

13. Amendment of Act No XLII of 1999 substance use air built environm. housing conditions work environm. incomeemployment social contacts culturerecreation FULL IMPACT CHAIN

14. Amendment of Act No XLII of 1999 substance use air built environm. housing conditions work environm. incomeemployment social contacts culturerecreation FULL IMPACT CHAIN

15. RISK FACTORS Quantitative exposure assessment availability of exposure measures information on baseline exposure levels information on expected changes of exposure level due to policy feasibility of health outcome quantification Prioritization strength of evidence significance of induced health effects feasibility of exposure assessment

16. environm. tobacco smoke healthy recreation Amendment of Act No XLII of 1999 substance use air built environm. housing conditions work environm. incomeemployment social contacts culturerecreation smoking aesthetic values income (tobacco and catering industry, state) income (family) exclusion FULL IMPACT CHAIN

17. environm. tobacco smoke healthy recreation Amendment of Act No XLII of 1999 substance use air built environm. housing conditions work environm. incomeemployment social contacts culturerecreation smoking aesthetic values income (tobacco and catering industry, state) income (family) exclusion FULL IMPACT CHAIN

18. EXPOSURE ASSESSMENT Prevalence decrease of passive smoking 66% in workplaces 95% in hospitality venues 5.9% in homes Prevalence decrease of active smoking 7% in the total population

19. HEALTH OUTCOMES Prioritization strength of evidence severity reversibility frequency in the population feasibility of outcome assessment

20. heart failure environm. tobacco smoke healthy recreation Amendment of Act No XLII of 1999 substance use air built environm. housing conditions work environm. incomeemployment social contacts culturerecreation smoking aesthetic values income (tobacco and catering industry, state) income (family) exclusion mentalotherreproductivegastrointestinalcirculatoryrespiratorycancer lung nasal and paranasal stomach liver myeloid leukaemia kidney urinary system pancreas oesophagus pharynx larynx oral asthma COPD stroke sudden cardiac death arterial disease coronary heart disease ulcer Crohn disease bile stone infertility (female) preterm birth low birth weight sudden infant death osteoporosis parodontitis cataract cervix FULL IMPACT CHAIN

21. heart failure environm. tobacco smoke healthy recreation Amendment of Act No XLII of 1999 substance use air built environm. housing conditions work environm. incomeemployment social contacts culturerecreation smoking aesthetic values income (tobacco and catering industry, state) income (family) exclusion mentalotherreproductivegastrointestinalcirculatoryrespiratorycancer lung nasal and paranasal stomach liver myeloid leukaemia kidney urinary system pancreas oesophagus pharynx larynx oral asthma COPD stroke sudden cardiac death arterial disease coronary heart disease ulcer Crohn disease bile stone infertility (female) preterm birth low birth weight sudden infant death osteoporosis parodontitis cataract cervix FULL IMPACT CHAIN

22. HEALTH OUTCOMES Quantitative outcome assessment applicable health measures availability of baseline health data availability of dose/exposure-response functions Prioritization strength of evidence severity reversibility frequency in the population feasibility of outcome assessment

23. heart failure environm. tobacco smoke healthy recreation Amendment of Act No XLII of 1999 substance use air built environm. housing conditions work environm. incomeemployment social contacts culturerecreation smoking aesthetic values income (tobacco and catering industry, state) income (family) exclusion mentalotherreproductivegastrointestinalcirculatoryrespiratorycancer lung nasal and paranasal stomach liver myeloid leukaemia kidney urinary system pancreas oesophagus pharynx larynx oral asthma COPD stroke sudden cardiac death arterial disease coronary heart disease ulcer Crohn disease bile stone infertility (female) preterm birth low birth weight sudden infant death osteoporosis parodontitis cataract cervix FULL IMPACT CHAIN

24. OUTCOME ASSESSMENT Calculation of disease burden related to active and passive smoking for the baseline and the predicted situation after the prohibition takes place. valid data valid functions

25. AVAILABLE DATA SOURCES Demographic and mortality data Central Statistical Office Morbidity data General Practitioners Morbidity Sentinel Stations Programme Cancer Registry Koranyi National Institute for Tuberculosis and Pulmonology Exposure data study on the aetiology of chronic liver disease (Univ. of Debrecen, School of Public Health)

26. APPLIED FUNCTIONS Association measures relative risks from the literature preferably from meta-analyses sex-specific when available distinction of active, former and never smokers Functions age-specific population attributable risk fractions WHO Global burden of disease study standard discount rate (0.03) standard age weights (  =0.04)

27. HEALTH OUTCOME MEASURES Measures of disease burden attributable death potential years of life lost years of life lived with disability disability adjusted life years

28. TIME CONSIDERATION Short term effect active and former smokers included initially the majority (85%) of reduction in active smoking is attributable to quitting risk of major diseases get back to normal in 15 years except for lung cancer Long term effects only active smokers included

29. active+former Number of death Disease Reduction in the attributable death of active smoking

30. active+former active Number of death Disease Reduction in the attributable death of active smoking

31. active+former Disease Life years Reduction in the disability adjusted life years of active smoking

32. active+former active Disease Life years Reduction in the disability adjusted life years of active smoking

33. Reduction in the attributable death of passive smoking Number of death Disease

34. Reduction in the disability adjusted life years of passive smoking Disease Life years

35. Discussion The health impact assessment of the proposal for smoking prohibition in closed public places in Hungary was carried out involving quantitative risk assessment. Quantitative assessment was integrated into the scheme of HIA in a structured way. Numerical prediction proved to be feasible and advantageous in the assessment process. The health gain of the policy for the four main, tobacco smoke exposure related diseases with the highest public health importance was calculated to be over 1560 lives and close to 20500 disability adjusted life years annually in long term.

36. Thank you