enforcing bans on tobacco advertising, promotion and sponsorship R: raising tobacco taxes to discourage consumption

Source: World Health Organization 2008.

Smoking cessation interventions that have a potential for population-level impact include smoking cessation counselling or brief advice provided by health care professionals, and the availability of pharmacotherapy, quitlines and other technology-based interventions (Internet, mobile phone support). Brief advice to quit smoking from a doctor can increase the likelihood that smokers will successfully quit and stay abstinent (Stead et al. 2008a), while offering more intensive support (behavioural counselling or prescription for pharmacotherapy) can increase quit rates (Aveyard et al. 2012). The use of pharmacotherapy increases the odds of successful cessation; recent meta-analyses found average odds ratios of 1.58 with nicotine replacement therapies (Stead et al. 2008b), 1.69 for bupropion (Hughes et al. 2007) and 2.31 for varenicline (Cahill et al. 2011;

Zhu et al. 2012). Use of pharmacotherapy is infl uenced by the extent to which health care providers recommend it, how widely it is otherwise marketed, and its cost. Smokers’ quitlines provide an accessible behavioural counselling service;

however, their uptake is also dependent on how effectively they are promoted.

Warning about the dangers of tobacco use

Mass media campaigns reach large numbers of people through print and bro adcast media with anti-tobacco messages that discourage tobacco use.

Before the widespread implementation of bans on tobacco advertising, the primary aim of mass media campaigns was to counter industry advertising and change smoking behaviour by discouraging smoking. Campaigns aimed to discourage initiation among young people and encourage smoking cessation among adults, often promoting available cessation services. More recently, campaigns also aim to change social norms and build support for other tobacco control policies.

Reviews suggest that well-funded and implemented mass media campaigns, as part of comprehensive tobacco control programmes, are associated with reductions in smoking rates among both adults and youths (Friend and Levy 2002; Bala et al. 2008; Durkin et al. 2012). Youths who are exposed to anti-tobacco mass media campaigns are less than half as likely to become established smokers (Siegel and Biener 2000), and adults are more likely to quit (Durkin et al. 2012). The intensity and duration of campaigns is important as higher exposure is associated with less smoking (Emery et al. 2012).

Tobacco product warning labels communicate the risks associated with tobacco use and reach all tobacco users (Hammond et al. 2006). The extent to which smokers understand the risks associated with their use of tobacco infl uences their smoking behaviour; those who perceive greater health risk from smoking are more likely to intend to quit and to quit successfully (Hammond et al. 2006).

Enforcing bans on advertising, promotion and sponsorship While the tobacco industry claims that their advertising activities are designed to maintain or increase relative market shares of individual brands among adult consumers rather than to increase overall consumption, evidence from analysis

of industry documents shows that these campaigns are targeted towards young people to attract new ‘replacement’ smokers (Pollay 2000; Cummings et al. 2002;

Ling and Glantz 2002). Advertising and promotions have been identifi ed as a causal determinant of tobacco consumption, and exposure to these activities increases the likelihood that adolescents will start to smoke (Lovato et al. 2011).

Comprehensive bans on tobacco advertising, promotion and sponsorship are highly effective in reducing smoking (Saffer and Chaloupka 2000; Blecher 2008), while partial bans have little or no effect as advertising shifts from mediums that are restricted to those that are not restricted (Saffer 2000; Saffer and Chaloupka 2000).

Raising tobacco prices through taxation

Governments can discourage tobacco consumption by increasing tobacco prices through taxation. A recent comprehensive review of the vast literature on the effectiveness of tobacco taxation (Chaloupka et al. 2011; IARC 2011) concluded that increasing tobacco prices through increased taxation reduces overall consumption and prevalence of tobacco use among adults and young people and has a greater impact on younger people, who are particularly price responsive. It also induces current users to quit, reduces initiation and uptake among young people, with a greater impact on the transition to regular use, and lowers tobacco use among continuing users. Recent analysis of demand for tobacco products in 11 European countries (Austria, Finland, France, Germany, Ireland, Italy, the Netherlands, Portugal, Spain, Sweden, United Kingdom) using time-series data spanning over 50 years found that, on average, a 10%

increase in the real price of cigarettes reduces tobacco consumption by 3–4%

(Nguyen et al. 2012). However, this same study suggested that a 10% increase in income increases consumption by 3–4%, suggesting the importance of regular tax increases that outpace infl ation and growth in incomes.

Successes and failures of tobacco control policy in Europe Tobacco control policy and population health outcomes

Success of tobacco control policy can be defi ned in three ways: (1) implementing (and enforcing) evidence-based tobacco control policies; (2) achieving improve-ments in intermediate outcomes, such as reductions in smoking prevalence (through reduced initiation and/or increased cessation), reductions in consump-tion of cigarettes or, in the case of smoke-free policies, reducconsump-tions in exposure to SHS through the implementation of such policies; and (3) achieving improve-ments in distal health outcomes from both active smoking (e.g. reductions in lung cancer or smoking-related mortality and morbidity) and passive smoking (e.g. reductions in hospital admissions from heart attacks or asthma).

Measuring the success of tobacco control policies in terms of distal health outcomes is complex because the timing between the onset of smoking and development of disease, and in turn between quitting and reduction in disease

risk, varies among the numerous diseases linked to tobacco use. With lung cancer, health effects are not generally apparent until 20 to 30 years after smoking becomes widespread in a population, and they do not reach their peak until 30 to 40 years after the peak in prevalence, whereas the impact on cardiovascular diseases is apparent sooner. Likewise, the reversal of risk after quitting smoking occurs more quickly for coronary heart disease than for lung cancer. This can make interpretation of trends in disease outcomes complex, particularly the interpretation of how they refl ect the impact of tobacco control policies implemented in the past.

A four-stage model of the smoking epidemic has been described, based on observations of trends in cigarette consumption and tobacco-related diseases (Lopez et al. 1994). Early on, smoking prevalence among men is relatively low but increasing, while prevalence among women is very low and there is no apparent difference in patterns of mortality by smoking status. As the epidemic progresses, male smoking prevalence increases rapidly and peaks at 50–80% of the population, while the prevalence of ex-smokers is relatively low. By the end of this phase, mortality among male smokers begins to rise. Meanwhile, there are slight increases among women, but these increases lag behind those in men.

In the next phase, tobacco control policies are implemented and strengthened and smoking becomes less socially acceptable. Male smoking prevalence reaches a plateau at a high level and then starts to decline, with declines faster among the most highly educated. Female rates plateau at a lower level than men, but for a more prolonged period. Higher rates of smoking are seen among younger women and declines in prevalence are faster among more educated women. In the last phase, smoking prevalence among both males and females continues to decline slowly and social differences persist. Male smoking-related mortality peaks at 30–35% of all deaths and begins to decline about ten years later, while for women smoking-related mortality peaks at around 20–25% of all deaths and begins to decline 10 to 20 years after the decline for men.

Trends in lung cancer mortality across Europe since the early 1970s mirror these patterns, although different countries are in different phases of this epidemic, and the interval between peaks in male and female smoking prevalence is shorter in some countries. An examination of lung cancer mortality data from the WHO Mortality Databank by age, sex and year of death from 1970 to 2007 for 36 countries in Europe shows that, by 2003, the highest lung cancer mortality rates were seen among men in Hungary, Poland and Estonia, with lowest rates in Sweden, Iceland and Portugal (Bray and Weiderpass 2010). For women, the highest rates were in Denmark, Iceland and Hungary and the lowest in Spain and the Ukraine (Bray and Weiderpass 2010). Lung cancer mortality rates in men have shown decline in most European countries since the early 1990s, particularly in the Nordic countries, in Britain and Ireland (United Kingdom and Eire) and in the continental region; however, overall male rates are still increasing in parts of the southern region (Portugal), the western Balkans (the former Yugoslav Republic of Macedonia), the central and eastern region (Bulgaria and Romania) and the former USSR (Republic of Moldova) (Bray and Weiderpass 2010). For women, overall lung cancer mortality rates are still increasing in most countries, although rates are beginning to stabilize in some countries in the central and eastern region (Hungary, Poland, Czech Republic),

the Nordic countries and Britain and Ireland (Denmark, Iceland and the United Kingdom) (Bray and Weiderpass 2010). Lower lung cancer mortality rates seen among more recent birth cohorts may refl ect recent changes in smoking habits partly attributable to policies introduced in the last two decades and suggest that a plateau may be on the horizon for some of those countries where rates are still on the rise (Bray and Weiderpass 2010).

Given the complexity of interpreting the impact of tobacco control policy implementation on distal health outcomes, such as reductions in smoking-related mortality, the focus here is largely on intermediate outcomes, notably reductions in smoking prevalence and cigarette consumption, although the impact of smoke-free policies on heart attacks is discussed in Box 2.2. First, how European countries differ in the implementation of tobacco control policies is considered, and then the impact of tobacco control on smoking prevalence and cigarette consumption is analysed.

Implementation of tobacco control in Europe

As noted above, MPOWER recommends completely smoke-free environments in all health care and educational facilities and indoor public places, including workplaces, bars and restaurants. European countries differ signifi cantly, however, in the degree to which they have implemented this (Fig. 2.1), with Hungary, Bulgaria, the Czech Republic, Romania and Austria lagging behind most other European countries, and Ireland and the United Kingdom being the European front-runners. This fi gure also shows the relationship between the percentage of residents in each European country who report never (or almost never) being exposed to tobacco smoke in their workplace (European Commission 2009) and the smoke-free policy in their country (Joossens and Raw 2011). There is a positive association between protection from workplace tobacco smoke exposure and smoke-free policy scores, suggesting that citizens in countries with more comprehensive smoke-free policies tend to be more adequately protected from workplace exposure.

Large variations between countries are also found in the availability of quit-line services, free or low-cost pharmacological treatment and smoking cessa-tion support through primary health care services, as shown by a study of the availability of measures to help dependent smokers to quit in 31 European countries. The measures were ranked according to (1) the provision of fi nan-cial incentives for recording patients’ smoking status in medical notes, (2) reimbursement for providing brief advice in primary care, (3) the geo-graphical coverage of the network of cessation support, (4) the cost of access-ing these services, (5) the presence of a national quitline, and (6) whether pharmacotherapy was freely available or partially reimbursed. The United Kingdom had the most comprehensive smoking cessation services in Europe, followed by Denmark, Romania, Poland and Luxembourg, while treatment in Latvia, Bulgaria, Iceland and Lithuania were ranked lowest (Joossens and Raw 2011).

MPOWER recommends highly visible and sustained anti-tobacco campaigns in the mass media (World Health Organization 2008). Monitoring of MPOWER policies in 2011 by WHO indicates that many European countries did not

implement even one national mass media campaign during 2009 or 2010 (defi ning a national mass media campaign as a communication activity lasting at least one 3-week period during a year and that utilizes television, radio, print, outdoor billboards or the Internet to inform and educate the public about tobacco control issues). Countries which did not have such a campaign included Armenia, Austria, Azerbaijan, Belarus, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Iceland, Kyrgyzstan, Latvia, Lithuania, Montenegro, Norway, Portugal, Slovakia, Slovenia, Spain, Tajikistan, Ukraine and Uzbekistan. Only 9 of the 53 European countries implemented a mass media campaign that fully met MPOWER standards: Denmark, Greece, Ireland, the Netherlands, the Russian Federation, Serbia, Sweden, Turkey and the United Kingdom (World Health Organization 2011).

Box 2.2 Smoke-free policies and distal health outcomes: myocardial infarctions

Passive smoking, or exposure to second-hand smoke, increases the risk of coronary heart disease by as much as 60% (Glantz and Parmley 1991, 1995; He et al. 1999; Thun et al. 1999; Whincup et al. 2004; Barnoya and Glantz 2005; Institute of Medicine 2010). The observed increase is higher in more recent studies that have used more accurate measures of exposure. Successfully implemented and enforced smoke-free air laws reduce population-level exposure to second-hand smoke considerably (

IARC

2009). Consequently, smoke-free air laws could be expected to reduce the incidence of acute coronary events, including myocardial infarction, with almost immediate effect.

A large body of evidence supports a reduction in acute coronary events following the implementation of comprehensive smoke-free legislation (Glantz 2008; Meyers et al. 2009; Mackay et al. 2010; Sims et al. 2010;

Cronin et al. 2012), with some indication that the effects increase over time (Mackay et al. 2010; Cronin et al. 2012). A recent meta-analysis of the effect of comprehensive smoke-free legislation suggests that acute coronary events fall by around 10% following the implementation of legislation (Mackay et al. 2010). While earlier studies, fi nding larger effects, may not have adequately controlled for other factors that might infl uence the incidence of acute coronary events, Sims et al. (2010) found a small but signifi cant reduction in the number of emergency admissions for myocardial infarction following the implementation of comprehensive legislation in England, using a more robust study design accounting for potential confounders and secular trends. The smaller effect size found in this study may be partly explained by the relatively low levels of exposure resulting from the partial smoke-free restrictions in place prior to the introduction of the comprehensive law in 2007.

Even conservative estimates of the declines in hospital admissions for acute coronary syndromes following the implementation of smoke-free air laws suggest important public health implications of this intervention given the scale of the cardiovascular disease burden in the population (Sims et al. 2010).

MPOWER recommends legislatively mandated clear, visible health warnings covering at least half of the principal display area of tobacco product packages, with specifi c and rotating warnings regarding the health risks of smoking including graphic images. While all European countries require rotating health warnings on tobacco product packages with content, print and language specifi cations, only ten countries have implemented graphic health warnings: Belgium, France, Georgia, Latvia, Romania, Spain, Switzerland, the former Yugoslav Republic of Macedonia, Turkey and the United Kingdom (World Health Organization 2011).

MPOWER recommends comprehensive bans on tobacco advertising with suffi cient penalties to deter circumvention. Most European countries have a ban on national television, radio and print media as well as on some but not all other forms of direct and indirect advertising, with moderate to high compliance (World Health Organization 2011). Notable exceptions are Figure 2.1 Protection from workplace tobacco smoke exposure and smoke-free policy score in 28 European countries

Sources: Self reported exposure (European Commission 2009), Smoke-free policy implementation score (Joossens and Raw 2011)

Notes: Smoke-free policies are scored from 0 to 22, according to the places covered by the legislation (workplaces; cafes, bars and restaurants; public transport; educational and health facilities) and the degree of coverage (complete ban with no smoking rooms, partial ban with allowance for smoking rooms, or meaningful restrictions). AT, Austria; BE, Belgium;

BG, Bulgaria; CZ, Czech Republic; DK, Denmark; DE, Germany; EE, Estonia; IE, Ireland; GR, Greece; ES, Spain; FR, France; IT, Italy; CY, Cyprus; LV, Latvia; LT, Lithuania; LU, Luxembourg;

HU, Hungary; MT, Malta; NL, Netherlands; PL, Poland; PT, Portugal; RO, Romania; SI, Slovenia; SK, Slovakia; FI, Finland; SE, Sweden; TR, Turkey; UK, the United Kingdom

Andorra, Armenia, Austria, Azerbaijan, Georgia, Monaco, the Russian Federation and Switzerland, which have failed to implement a ban that extends to at least national television, radio and print media (World Health Organization 2011).

Finally, MPOWER recommends that excise tax should constitute at least 70%

of the fi nal retail price of tobacco, that incentives for trading down to cheaper tobacco products be minimized and that tobacco tax increases exceed increases in infl ation to prevent tobacco from becoming more affordable (World Health Organization 2008). Figure 2.2 shows the weighted average retail sales price for a pack of 20 cigarettes and the tax as a percentage of this price across the EU. Few countries have reached the MPOWER target and the weighted average retail price for a pack of cigarettes varies from as low as €2.14 in Lithuania to as high as €8.50 in Ireland (as of March 2011).

The ratifi cation of the Framework Convention on Tobacco Control by almost all European countries (notable exceptions being Andorra, the Czech Republic, Monaco and Switzerland) has brought some degree of convergence of tobacco control policies across the EU (Studlar et al. 2011). However, as noted above, there is still considerable variation between European countries in the implementation of policies. A study by Joossens and Raw (2006) quantifi ed the implementation of the six key tobacco control policies at country level using a comprehensive Tobacco Control Scale (TCS), which ranked 30 countries by their total score on a 100-point scale. Policies included are cigarette prices (maximum of 30 points), smoke-free workplaces and public places including

Figure 2.2 Overall excise duty as a percentage of total price and current weighted average price for 20 cigarettes in the European Union

Source: Joossens and Raw 2011

Notes: TIRSP, tax inclusive retail sales price; see Fig. 2.1 for country abbreviations

bars and restaurants and public transport (22), spending on public information campaigns (15), comprehensive bans on advertising and promotion (13), large direct health warning labels (10) and cessation treatment including the operation of a national quitline and reimbursement of pharmaceutical treatment products (10).

In 2005, only four countries scored 70 or more (Ireland, United Kingdom, Norway and Iceland); two countries scored above 60 (Malta and Sweden); seven scored above 50 (Finland, Italy, France, the Netherlands, Cyprus, Poland and Belgium), and the rest scored 49 or below (Joossens and Raw 2006). By 2007, the average score on the scale increased by 5%, suggesting some improvement in the implementation of measures across the region. States in the central and eastern region and the former USSR continued to be well represented among the countries scoring lowest on this scale in 2007. When repeated in 2010, the United Kingdom, Ireland and Norway were among the leaders, while the Czech Republic, Luxembourg, Austria and Greece were among the laggards. Slovenia has made good progress, rising in the rankings, but Bulgaria has fallen. Country rankings and the contribution of each policy to the overall score are shown in Fig. 2.3 (Joossens and Raw 2011).

Impact of tobacco control on smoking

Martínez-Sánchez et al. (2010) examined the correlation between implementation of tobacco control policies as measured by the TCS in 2007 and smoking prevalence from the Eurobarometer survey in 2008 in the countries belonging to the EU after January 2007 (EU27). They found that high TCS scores, refl ecting more tobacco control policies having been implemented, were signifi cantly associated with a lower population prevalence of smokers;

however, while there was also an association with self-reported exposure to SHS at home and at work, it fell short of statistical signifi cance. Using a sample of almost 60,000 non-smokers from across the EU27 in 2006–2007, Tual et al. (2010) examined the relationship between tobacco control policy

however, while there was also an association with self-reported exposure to SHS at home and at work, it fell short of statistical signifi cance. Using a sample of almost 60,000 non-smokers from across the EU27 in 2006–2007, Tual et al. (2010) examined the relationship between tobacco control policy

Dans le document Erfolg und Scheitern der Gesundheitspolitik in Europa. Vier Jahrzehnte divergierender Trends und konvergierender Herausforderungen (Page 50-67)