1. SAY YES TO NO SMOKING Evidence-Based Public Health and HTA The World Bank PMU Conference Prof.dr. Stipe Oreskovic Vilnius, 26 September 2003

2. SAY YES TO NO SMOKING A Definition of EBM The conscientious, explicit, judicious use of the current best evidence in making decisions about the care of individual patients. (Ref: Sackett et al, 1996)

3. SAY YES TO NO SMOKING A Definition of EBPH The conscientious, explicit, judicious use of the current best evidence in making decisions in routine PH practice, and in developing PH policies and programs. (Ref: Sackett et al, 1996)

4. SAY YES TO NO SMOKING Increasing Knowledge

5. SAY YES TO NO SMOKING Rationale for Evidence-Based Practice for Public Health Project Increasing amount of high quality, relevant research in PH and in disciplines related to PH (medical, behavioral, social sciences). Great need for high quality, evidence-based information by PH practitioners. Access to best evidence limited

6. SAY YES TO NO SMOKING Public Health and HTA – Any Relation? HTA is a part/heart of public health (D. Banta)HTA is a part/heart of public health (D. Banta) Health promotion campaigns – medical, behavioral and economics changes Conscientious, explicit, judicious?

7. SAY YES TO NO SMOKING Public Health and HTA – Any Relation? Tobacco control policies involve different medical technologies including drugs (nicorette, zybane..) It is not only about traditional medical technologies – involve also communication technologies and their efficiency Cost-effectiveness of smoking cessation interventions?

8. SAY YES TO NO SMOKING Question no 1: What is priority? And how the priority setting works? Between 72 and 81% of citizens express they intention (need) to stop smoking It is the most cost-effective intervention The negative consequences are massive However...

9. SAY YES TO NO SMOKING Consequences of Smoking: 1 Titanic each 78 minutes!

10. SAY YES TO NO SMOKING

11. Questions about tobacco policies Can it work? –Efficacy Does it work? –Effectiveness Should it be used, given other calls on a fixed budget? –Economics Is it reaching those whom it should? –Availability EBM Policy Audit Development

12. SAY YES TO NO SMOKING Tobacco: Health and Economics Dr. Joy de Beyer World Bank

13. SAY YES TO NO SMOKING Cost effectiveness of the cessation strategies Mass media anti- smoking campaign which includes the telephone helpline, Smokeline. This type of mass media-led campaign appears to have been cost- effective (Ratcliffe et al 1997). Buck and colleagues estimate that costs per life year gained range from £21 to £711. Analysis shows that smoking cessation is more effective in producing population health gains than almost any other medical intervention.

14. SAY YES TO NO SMOKING Effectiveness and cost-effectiveness of smoking cessation interventions http://www.nelh.nhs.uk/guidelinesdb/html/ smoking-refs.htm

15. SAY YES TO NO SMOKING Evidence for Intervention Title AuthorsDate Publication Choosing the most effective health promotion options for reducing a nation's smoking prevalence Reid DJ, Killoran AJ, McNeill AD, et al.. 1998.Health Education Authority London Nicotine replacement therapy for smoking cessation (Cochrane review) AbstractAbstract Silagy C, Mant D, Fowler G, et al. Updated quarterly.The Cochrane Library Issue 2. : Effectiveness of training health professionals to provide smoking cessation interventions (Cochrane review) Silagy C, Lancaster T, Fowler G, et al. 1998. Updated quarterly.) The Cochrane Library Issue 2.Oxford: Update Software

16. SAY YES TO NO SMOKING Evidence for Intervention.Five hundred life saving interventions and their cost- effectiveness. Tengs TO, Adams ME, Pliskin JS, et al.. Risk Analysis 15 :369-390[Medline]..Clinical guidelines. Using clinical guidelines to improve patient care within the NHS. Mann T.. Leeds: National Health Service Executive.Promoting clinical effectiveness. A framework for action in and through the NHS. NHSE.. Leeds: National Health Service Executive :.Smoking cessation.NHS Centre for Reviews and Dissemination. Effectiveness Matters, York: NHS Centre for Reviews and Dissemination, University of York Vol 3, Issue 1. :.The new NHS.Secretary of State for Health.. London: Stationery Office :

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18. Alternative less effective and more costly E Alternative cheaper but less effective D Alternative more effective and less costly C E.g. £20,000 per QALY COST OUTCOME A B Alternative more effective but more costly

19. SAY YES TO NO SMOKING WHQ Most “supply side” actions do not reduce tobacco use / improve health Prohibition Youth access restrictions Trade restrictions Crop substitution Control of smuggling is the only exception and is the key supply-side measure

20. SAY YES TO NO SMOKING Comprehensive advertising bans reduce cigarette consumption Consumption trends in countries with strong bans compared with countries with no bans (102 countries)

21. SAY YES TO NO SMOKING Facts and evidence Policy-relevant global, regional and country-level evidence-based research Do strong tobacco control measures: Reduce tax revenues ? No Increase smuggling ? Depends Role of organized smuggling, corruption Cause net job/income losses ? Not necessarily, but needs more research Hurt poor people ? Some, benefit some

22. SAY YES TO NO SMOKING Economics of Tobacco in Croatia? Tobacco is the most profitable business in Croatia: generates tax revenues (7,6 % of the budget) provides jobs, incomes and large profits may attract foreign private investment (fight between TDR, BAT and PM generates export earnings (or smuggling?) gives smokers pleasure (for the timebeing)

23. SAY YES TO NO SMOKING As Cigarette Tax Rises Revenue Increases Tax per pack and cigarette tax revenues in Norway, 1990-1998

24. SAY YES TO NO SMOKING Successful Tobacco Control Broad partnership is the KEY –Join comparative advantages for effective policy dialogue Address concerns of key decision makers Policy relevant research, and Disseminate research evidence

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26. Mass Media Strategies ProsCons Reach large numbers of teens Can change social norms Can be linked to more intensive interventions Message may not be relevant Superficial prevention message Expensive on primary networks Needs frequent updating Types: Television counter-advertising, radio ads, print media, internet print media, internet

27. SAY YES TO NO SMOKING Mass Media Campaign Message Themes Consequences of Smoking: Social Norms and Imagery: n Short-term n Long-term n Family-related n Addiction n De-glamorization of smoking n Smoking not normative Role Models: n Smoker is negative role model n Celebrities promote non-smoking Industry and Product Focus: Second-Hand Smoke Adapted from Farrelly et al., 2002

28. SAY YES TO NO SMOKING CELEBRITIES IN ACTION! Janica Kostelić 3 olimpic Gold medals Ivica Kostelić World Ski Champion Lancet EJPH ZFG WHO Award Year 2001 and 2002

29. SAY YES TO NO SMOKING Free telefone help line 0800 2000 37 Stipe Mesić, president of Croatia

30. SAY YES TO NO SMOKING Media Communication Australian cartoons Croatian cartoons Logo completely recongnized

31. SAY YES TO NO SMOKING Public Health Experts Profile Participating in the Anti-Tobacco Campaign Epidemiologists Statisticians Environmental Engineers Sanitarians Food Scientists Health Care Administrators Health Economists Politicians Social Workers Mental Health Workers Substance Abuse Counselors Doctors Nurses Teachers Nutritionists Lab Technicians

32. SAY YES TO NO SMOKING INTERACTIVE INTERNET SITE 17 000 VISITS www.snz.hr/nepusenje

33. SAY YES TO NO SMOKING SCHOOL “HOW TO QUIT SMOKING” NETWORK OF 55 SCHOOL ARROUND COUNTRY – GP’s, PSYCHOLOGIST SPECIALY EDUCATED AND LICENCED

34. SAY YES TO NO SMOKING Have you ever smoked a whole cigarette? Ever tried – even a few puffs? Never Smoker No – Never Smoker Yes Trier No – Trier Smoked > 1 whole cigarette? Trier No – Trier Yes On how many of last 30 days did you smoke? < Monthly smoker None – < Monthly smoker < 20 days Established smoker > 20 days – Established smoker On how many of last 7 days did you smoke? Experimental Smoker None – Experimental Smoker Regular Smoker At least one – Regular Smoker 1 2 2 3 4 5 Stage Model of Smoking Acquisition 6

35. SAY YES TO NO SMOKING Decisions made because of the campaing? 12,36 39,69 25,99 0 5 10 15 20 25 30 35 40 45 % ispitanika Reduce number Of cigarettes cigareta Stop smokingStart healthy lifestile Other Female Male Total

36. SAY YES TO NO SMOKING Do you know and recognize the action “Say yes to no smoking”? Yes 88,92 % positive 1.724.866 270.814 1.595.132 247.034 3.320.121 517.725 0 500.000 1.000.000 1.500.000 2.000.000 2.500.000 3.000.000 3.500.000 Population FemaleMale Total Yes No

37. SAY YES TO NO SMOKING “Say yes to no smoking”: Yes or No? 15,31 19,75 35,06 66,71 0 10 20 30 40 50 60 70 % surveyed sample 12345 4 and 5 Marks Female Male Total

38. SAY YES TO NO SMOKING No of cigarettes per day 19,09 15,52 17,3 0 5 10 15 20 25 No of cigarettes per day Female Male Total

39. SAY YES TO NO SMOKING Number of packages sold in Croatia 100 94,59 78,24 83,76 60 65 70 75 80 85 90 95 100 1996199820002002 Years 1996 is 100

40. SAY YES TO NO SMOKING “Smoke Out Day” - Evaluation 26 % smokers quit for one day on 5. march HRT-a agency (2143 sample): 27,2 % smokers quit for one day on 5. march PULS agency (600 sample)

41. SAY YES TO NO SMOKING Why you stop smoking?

42. SAY YES TO NO SMOKING Have you had at least one cigarette today? (smokers only) 74% 26% YES NO

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44. Are you thinking about giving up smoking permanently? 69 31 1 0102030405060708090100 % DON'T KNOW NO YES

45. SAY YES TO NO SMOKING Final Thoughts Existing systems produce existing results. If something different is required, the system must be changed.” - Sir Christopher Ball “The world we have created today, as a result of our thinking thus far, has problems which cannot be solved by thinking the way we thought when we created them.” - Albert Einstein