Balázs Ádám, Ágnes Molnár, Róza Ádány

University of DebrecenFaculty of Public Health

Department of Preventive Medicine

QUANTITATIVE RISK ASSESSMENT INTEGRATED IN

THE HIA OF THE ANTI-SMOKING POLICY PROPOSAL

IN HUNGARY

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

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

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

PUBLIC HEALTH IMPORTANCE OF SMOKING-

RELATED DISEASES IN HUNGARY

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

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

Healthdeterminant

Riskfactor

Healthoutcome

Policy

Exposureassessment

Outcomeassessment

FULL CHAIN ASSESSMENT

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

Amendment of Act No XLII of 1999

FULL IMPACT CHAIN

HEALTH DETERMINANTS

Determinants of healthPositive effect

Negative effect

No effect

Lifestyle Substance 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 careAccess to/quality of health services

+ +

HEALTH DETERMINANTS

Prioritization

• strength of evidence• size of effect• feasibility of impact quantification

Amendment of Act No XLII of 1999

substance use air built environm.

housing conditions

work environm. income employment social

contacts culture recreation

FULL IMPACT CHAIN

Amendment of Act No XLII of 1999

substance use air built environm.

housing conditions

work environm. income employment social

contacts culture recreation

FULL IMPACT CHAIN

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

environm. tobacco smoke healthy

recreation

Amendment of Act No XLII of 1999

substance use air built environm.

housing conditions

work environm. income employment social

contacts culture recreation

smokingaesthetic

valuesincome (tobacco and

catering industry, state) income (family) exclusion

FULL IMPACT CHAIN

environm. tobacco smoke healthy

recreation

Amendment of Act No XLII of 1999

substance use air built environm.

housing conditions

work environm. income employment social

contacts culture recreation

smokingaesthetic

valuesincome (tobacco and

catering industry, state) income (family) exclusion

FULL IMPACT CHAIN

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

HEALTH OUTCOMESPrioritization

• strength of evidence• severity• reversibility• frequency in the population• feasibility of outcome assessment

heart failure

environm. tobacco smoke healthy

recreation

Amendment of Act No XLII of 1999

substance use air built environm.

housing conditions

work environm. income employment social

contacts culture recreation

smokingaesthetic

valuesincome (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

heart failure

environm. tobacco smoke healthy

recreation

Amendment of Act No XLII of 1999

substance use air built environm.

housing conditions

work environm. income employment social

contacts culture recreation

smokingaesthetic

valuesincome (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

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

heart failure

environm. tobacco smoke healthy

recreation

Amendment of Act No XLII of 1999

substance use air built environm.

housing conditions

work environm. income employment social

contacts culture recreation

smokingaesthetic

valuesincome (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

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

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)

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)

HEALTH OUTCOME MEASURES

Measures of disease burden

• attributable death• potential years of life lost• years of life lived with disability• disability adjusted life years

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

active+former

0

50

100

150

200

250

lung cancer chronicpulmonarydiseases

coronary heartdiseases

stroke

Nu

mb

er

of

de

ath

Disease

Reduction in the attributable death of active smoking

0

50

100

150

200

250

lung cancer chronicpulmonarydiseases

coronary heartdiseases

stroke

active+formeractive

Nu

mb

er

of

de

ath

Disease

Reduction in the attributable death of active smoking

0

500

1000

1500

2000

2500

3000

3500

lung cancer chronicpulmonarydiseases

coronary heartdiseases

stroke

active+formerDisease

Lif

e y

ears

Reduction in the disability adjusted life years of active smoking

0

500

1000

1500

2000

2500

3000

3500

lung cancer chronicpulmonarydiseases

coronary heartdiseases

stroke

active+formeractiveDisease

Lif

e y

ears

Reduction in the disability adjusted life years of active smoking

Reduction in the attributable death of passive smoking

Nu

mb

er

of

de

ath

Disease

0

100

200

300

400

500

lung cancer chronicpulmonarydiseases

coronary heartdiseases

stroke

Reduction in the disability adjusted life years of passive smoking

Disease

Lif

e y

ears

0

1000

2000

3000

4000

5000

6000

lung cancer chronicpulmonarydiseases

coronary heartdiseases

stroke

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.

Thank you