Contemporary Advances in Evidenced Base Policy, Prevention, & Practice International Tobacco Policy and Policy Evaluation

Learning Objectives Acknowledge the importance of research in monitoring and evaluating policy Critically appraise different methods of assessing process in tobacco control policy implementation Understand the importance of the Framework Convention on Tobacco Control and the International Tobacco Control Policy Evaluation Project and its application

Tobacco Epidemic – The Global Picture Tobacco use is the single most preventable cause of death – Tobacco use causes an estimated 5 million deaths worldwide each year. (Mathers CD, et al., 2006) – Secondhand smoke is estimated to cause an additional 600,000 deaths. (Öberg M, et al., 2011) – Deaths caused by tobacco are expected to reach one billion during the 21st century, with 80% of these deaths occurring in low and middle income countries.

Why is tobacco different? : The Role of Scientific Evidence in Global Tobacco Control …tobacco use is unlike other threats to global health. Infectious diseases do not employ multinational public relations firms. There are no front groups to promote the spread of cholera. Mosquitoes have no lobbyists. The evidence presented here suggests that tobacco is a case unto itself, and that reversing its burden on global health will be not only about understanding addiction and curing disease, but, just as importantly, about overcoming a determined and powerful industry. – Tobacco Company Strategies to Undermine Tobacco Control Activities at the World Health Organization, Report of the Committee of Experts on Tobacco Industry Documents, July 2000.

Framework Convention on Tobacco Control (FCTC) International Treaty – the first treaty negotiated under auspices of the WHO – Developed to address the global tobacco epidemic – Seeks to reduce the demand and supply of tobacco Adopted by the World Health Assembly in 2003 – In force February of 2006 – As of September 2013: 177 countries are parties to the FCTC

Key FCTC Demand Articles Article 6: Price and tax measures Article 8: Protection from SHS Articles 9 & 10: Tobacco product regulation Article 12: Education, communication, training, and public awareness Article 13: Tobacco advertising, promotion and sponsorship Article 11: Packaging and labelling of tobacco products Article 14: Tobacco dependence and cessation

Key FCTC Supply Articles Article 15: Illicit trade in tobacco products Article 16: Sales to and by minors Article 17: Provision of support for economically viable alternative activities, – e.g., helping tobacco famers convert to another crop

Monitoring, Evaluation, and Surveillance Monitoring/Surveillance: – On-going, systematic collection and analysis and interpretation of data, normally for the purpose of signalling need for action, and where appropriate, the effect of an intervention (Nsubuga et al., 2006; Thacker et al., 1988), normally not hypothesis driven e.g., incidence of disease, health knowledge Evaluation: – Data collection typically targeted towards evaluating a program or policy, and may attempt to answer more specific questions, did the policy have its intended effect? Were there any negative outcomes? Were certain groups more affected than others? Why or why not did the policy work? The implementation of the policy/program may also be evaluated. e.g., the effect of a smoke-free policy, implementation evaluation may include enforcement of the smoke-free policy, outcomes may include exposure to SHS in public places and at home

Surveillance in Public Health Disease Control Priorities in Developing Countries. 2nd edition. Jamison DT, et al., World Bank; 2006.

Global Tobacco Surveillance System The GTSS consists of cross-sectional surveys that allow the surveillance and monitoring of outcomes related to the implementation of the FCTC – Global Adult Tobacco Survey (GATS, 15 yrs +) – Global Youth Tobacco Survey (GYTS, 13 – 15 yrs) – Global Health Professions Students Survey (GHPS) Third-year students in dentistry, medicine, nursing, and pharmacology – Global School Professionals Survey (GSPS) Teachers and administrators from the GYTS – Some data is freely available and may be used for student projects

What can surveillance data tell us? The GATS measures outcomes that are relevant to the implementation of the FCTC, for example: – What % of people are exposed to tobacco advertising Article 13: tobacco advertising, promotion, and sponsorship – What % of people are exposed to secondhand smoke in public places Article 8: Protection from secondhand smoke – What % of people know that smoking causes cardiovascular disease ? Article 14: Education, training, communication, and public awareness – Are fewer people exposed to SHS in countries with comprehensive smoke-free policies? Cross-country comparisons: The GATS collects data on tobacco use from approximately 20 countries, including China, Turkey, and Brazil

Case Study: Using Surveillance Data to Influence Policy and Practice This report brought together data from two on- going major global tobacco research and surveillance studies – GTSS and ITC – to examine smokers and non-smokers’ awareness of the cardiovascular risks of tobacco use, and secondhand smoke exposure. Data from the Global Health Professional Student Survey was also examined. The World Heart Federation led this initiative with the objective to actively engage cardiologists and heart specialists in tobacco control by informing them about significant gaps in public knowledge and perceptions of heart disease risks related to smoking and exposure to second-hand smoke. The report was disseminated to cardiologists and cardiology societies.

Awareness that secondhand causes heart disease, and lung cancer (GATS) The percentage of smokers who did not know or believe that exposure to secondhand smoke could cause heart disease ranged from 86% of smokers in Viet Nam to 9% of smokers in Egypt. Knowledge of the lung cancer risks were higher, the percentage of smokers who did not know or believe that secondhand smoke causes lung cancer ranged from a high of 45% in Viet Nam to a low of 6% in Egypt. Again, knowledge that SHS causes heart disease and was lower than knowledge that SHS causes lung cancer (with the exception of Ukraine).

Training, Attitudes, and Practices of Medical Students in Cessation(Global Health Professional Student Survey) In countries such as Jamaica and Saudi Arabia less than 10% of medical students reported receiving formal training in smoking cessation. Despite the low percentage of students reporting receiving training in tobacco cessation, the majority believe that health professionals should advise smokers to quit. This suggests that with proper training, and supportive programs in place, these future physicians could play an active role in smoking cessation. Unfortunately, GHPSS data shows a high proportion of current smoking among medical students. It is expected that these high rates of smoking among medical students will translate to similarly high rates of smoking among physicians in the future.

International Tobacco Control Policy Evaluation Longitudinal Cohort Surveys of smokers and non- smokers in over 20 countries Designed to evaluate the psychosocial and behavioural impact of the FCTC – Strong focus on disseminating results to policymakers Assess impact and identify the determinants of effective tobacco control policies, including: – health warning labels, price and taxation, tobacco advertising and promotion, smoke-free, and education and support for cessation

Survey Mode: Telephone (CATI), Web Administered Respondent Types: Smoker May 2003 Light/mild descriptors banned Ban on tobacco promotions Dec 2004 FCTC ratification Regulation of Point of Sale 2002 Ban on tobacco advertising Ban on tobacco event sponsorship Oct 2008 Graphic warnings introduced Feb 2003 Ban on conventional tobacco advertising Jul 2003 Ban on domestic tobacco sponsorship Jul 2005 Ban on tobacco sponsorship of international sports 17 UNITED KINGDOM Timeline of Tobacco Control Policies and ITC Surveys Wave 1 Oct-Dec 2002 Smoker N=2,000 Wave 2 May-Sep 2003 Smoker N=2,000 Wave 3 Jun-Dec 2004 Smoker N=2,000 Wave 4 Oct 2005-Jan 2006 Smoker N=2,000 Wave 5 Oct 2006-Feb 2007 Smoker N=2,000 Wave 6 Sept 2007-Feb 2008 Smoker N=2,000 Wave 7 Oct 2008-Feb 2009 Smoker N=1,750 Wave 7.5 Nov 2009-Jan 2010 Wave 8 Jul-Dec 2010 Mar Scotland Apr Wales & Northern Ireland Jul 2007-England Smoking banned in bars, restaurants, and other public places

Policy Moderators Country Sociodemographics (e.g., age, sex, SES, ethnic background) Past Behavior (e.g., smoking history, CPD, quit attempts) Personality (e.g., time perspective) Psychological State (e.g., stress) Potential Exposure to Policy (e.g.,employment status) Policy-Specific Variables Label salience Perceived cost Ad/promo awareness Awareness of alternative products Proximal behaviors (forgoing a cigarette because of labels) Psychosocial Mediators Outcome expectancies Beliefs & Attitudes Perceived Risk Perceived Severity Self-Efficacy/ Perc. Beh Control Normalization beliefs Quit intentions Policy-Relevant Outcomes Quit Attempts Successful Quitting Consumption changes Brand switching Tax/price avoidance Attitude/belief changes (e.g., justifications) Economic Impact Public Health Impact Conceptual Model of the ITC Project How do policies affect behaviour?

What can evaluation data tell us? Article 8: Do smoke-free policies reduce people’s exposure to tobacco smoke? – More downstream outcomes such as, do smoke- free laws encourage smoking cessation? Article 11: Are health warning labels on tobacco products effective at informing people about the harms of smoking? – More detailed analyses, does the effect of health warning labels differ by socioeconomic status?

Case Study: Smoke-free Ireland The world’s first national smoke-free law was introduced in Ireland in March 2004 – Those who opposed the law argued Public Support: The public did not want it Smoking in homes: Smoking would be displaced from restaurants and pubs into people’s homes, harming children. Profitability in the hospitality industry: Restaurants and pubs would go out of business

Case Study: Smoke-free Ireland Public Support: Public support for Ireland’s smoke-free law was high and increased after the law was implemented, e.g., among smokers themselves support for bans in restaurants changed from 45% to 77% after the law was implemented (Fong et al., 2006). Support for smoke-free laws generally rises after they are implemented.

Smoking Prevalence

Case Study: Smoke-free Ireland Homes allowing smoking: Using date from the ITC Ireland and UK studies, Fong et al., 2006 showed that there was no increase in homes allowing smoking inside, and a non- significant trend towards not allowing smoking inside homes (Fong et al., 2006). Further research showed there was no more drinking and smoking in Irish homes where there was a smoking ban compared to Scotland and the rest of the UK where no ban existed (Hyland, et al., 2007).

Case Study: Smoke-free Ireland Further research from the ITC Ireland, Scotland, UK studies showed there was no more drinking and smoking in Irish homes where there was a smoking ban compared to Scotland and the rest of the UK where no ban existed (Hyland, et al., 2007).

Case Study: Ireland Smoke-free Did the Smoke-free Policy in Ireland affect Pub Sales ?

Case Study: Smoke-free Ireland It depends on how you look at. This illustrates the importance of good evaluation data.

IARC – Methods for Evaluating Tobacco Control Policies IARC (International Agency for Research on Cancer), Lyon, France online/prev/handbook12/Tobacco_vol12.pdf online/prev/handbook12/Tobacco_vol12.pdf

Article 11 Health warnings – effective health education

Health Warnings - Examples United States Australia Taiwan Belgium Uruguay China Thailand

Brazil

Relationship Between Labels and Quitting Cognitive Responses to the Warnings, e.g., make you think about the health risks Quit Attempts Controlling for Country, Gender, Age, Income, Education, Daily Cigarette Consumption, Intentions to Quit Smokers who report greater cognitive responses to the warnings — more likely to attempt to quit (OR = 1.16), p<0.01 Borland, R., et al., (2009). Addiction.

Do warning labels increase knowledge? Only Canada had a warning label about impotence at Wave 1, but then U.K. added an impotence label between Wave 1 and Wave 2 Hammond et al, 2007

Do warning labels increase knowledge? Substantial increase in knowledge about impotence in the U.K. compared to the other three countries after the label on impotence was introduced in the U.K. Hammond et al, 2007

October 2002May 2003 U.K. Canada Australia U.S.

The enhancement of warning labels in the U.K. had a huge impact on labels salience/noticing, way above even Canada. Enhancing warning labels increases label salience/noticing Hammond et al, 2007

Enhancing warning labels leads to greater likelihood of forgoing smoking a cigarette Still a significant increase in U.K. compared to the other countries, but not above Canada at W2 Hammond et al, 2007