The ITC Project and its Impact onPolicy ChangeGeoffrey T. Fong

University of Waterloo andOntario Institute for Cancer Research

Tobacco Control WorkshopTaipei, Taiwan

September 17, 2013

22

33

Dissemination of ITC Project Findings:Traditional academic dissemination/transfer

444

Some Indicators of Academic Productivity

Over 250 peer-reviewed articlesand over 700 presentations atscientific meetings

4 special ITC supplements inmajor scientific journals(+ 2 in preparation):– 4C + Ireland (Tob Control 2006)– Cessation (Nicotine Tob Res 2010)– China (Tob Control 2010)– Economics I (Tob Control Jan 2014)– Economics II (Tob Control late 2014)– China II (2014–15)

Contributions to major reports: USSurgeon General’s Reports, USInstitute of Medicine, WHO/NCIMonograph on Economics ofTobacco Control, UK Inquiry onSmoking in Private Vehicles

ITC researcher productivity in global tobacco control (2008)

55

ITC China Supplement in Tobacco Control (Oct 2010)

6

Creating Guidelines and Standards for Research

IARC Cancer PreventionHandbook (2008):

Methods for Evaluating TobaccoControl Policies

• Best practices in the evaluationof tobacco control policies

• Preparation of Handbook ledby ITC Project investigators

• Conceptual Model of the ITCProject used to frame theevaluation methods of theHandbook

77

Dissemination of ITC Project Findings:Knowledge Transfer and Utilization Productsfor researchers, policymakers, and advocates

888

ITC National Reports

14 ITC National/Country Reports across 11 countries:– France: Wave 1 National Report (Feb 2009)—English and French– France: Wave 2 National Report (Oct 2011)—English and French– Germany: Wave 1 and Wave 2 National Report (Jan 2010)– Bangladesh: Wave 1 National Report (Apr 2010)—English and Bengali– Mauritius: Wave 1 National Report (May 2010)– Mauritius: Wave 2 National Report (May 2011)– Mauritius: Wave 3 National Report (May 2012)– Netherlands: Waves 1–3 National Report (June 2010)– Bhutan: Wave 1 ITC Bhutan Report (May 2011)– Malaysia: Waves 1–4 National Report (March 2012)– Uruguay: Waves 1–3 National Report (August 2012)—English and Spanish– Republic of Korea: Waves 1–3 National Report (Nov 2012)—English, Korean– China: Waves 1–3 ITC China Report (Dec 2012)—English and Chinese– India: Wave 1 (Sep 2013)National Reports coming for: Zambia, Kenya, Canada, Brazil, United States

999

ITC National Reports: France

10

ITC National Reports: France (Feb 2009)

Preface from theMinister of Health

and Sports,Roselyne Bachelot-

Narquin

11

ITC National Reports: Bangladesh (April 2010)

Preface from the Prime Minister,Sheikh Hasina

12

ITC National Reports: Bhutan (May 2011)

Bhutan’s Minister of Health, Zangley Dukpa,at the release of the ITC Bhutan Report

13

ITC National Reports: China (Dec 2012)

China Report released in Beijing in Dec 2012 atthe Chinese Communist Party School and at the

China NCD Forum

14

ITC National Reports: India (Sept 2013)

India Report released in New Delhi at theEndgame Conference (Sept 2013)

15

161616

ITC Policy and Cross-Country Reports

7 ITC Policy Reports– ITC Policy Report on FCTC Article 11—Pictorial Warning Labels (May 2009)– ITC Policy Report on FCTC Article 14—Tobacco Dependence and Cessation(November 2010)– Bangladesh: Wave 1—Taxation Report (Apr 2010)– Bangladesh: Waves 1 and 2—Taxation Report (May 2011)– Bangladesh: Waves 1 and 2—Warning Label Report (May 2011)– Bangladesh: Waves 1 and 2—Smoke-Free Policy Report (May 2011)– Netherlands: Waves 1–3—Knowledge of harms of smoking and secondhandsmoke (Mar 2011)

3 ITC Cross-Country Policy Reports– ITC Cross Country Report—Health Warnings (March 2012)– ITC Cross Country Report—Smoke-Free Policies (March 2012)– ITC Cross Country Report—Tobacco Price and Taxation (March 2012)

1717

ITC Labels Report–WNTD 2009

The ITC Project released a report on pictorial warnings forWorld No Tobacco Day (May 31, 2009): 12 page report on ITC Project

findings in the domain of warning labels (in English and Chinese)

18

ITC Cessation Report: Released at COP-4(November 2010)

1919

ITC Working Paper on Tax in Bangladesh

Impact ofvarying taxlevels on

tobacco use

Impact ofvarying tax

levels on taxrevenue

202020

ITC Cross Country Report on Price/TaxationIn the last 6 months, has there been a timewhen the money you spent on cigarettesresulted in not having enough money for

household essentials such as food?

212121

Average annual change in affordability of cigarettesin 16 ITC countries over time

Cigarettes are becoming less affordable in HICs (except in Canada, South Korea)and MORE affordable in LMICs (except in Mexico and Mauritius)

Global Awareness that Smokingand Secondhand Smoke Cause

Cardiovascular Disease

Geoffrey T. Fong, Sara C. Hitchman, andLorraine V. CraigInternational Tobacco Control Policy EvaluationProject, University of Waterloo, Canada

Lubna Ishaq BhattiTobacco Free Initiative,World Health Organization, Geneva

Alice Grainger-GasserWorld Heart Federation, Geneva

“Tobacco Control to Reduce Cardiovascular Disease”Press Conference at the World Cardiology Congress—Thurs 19 April 2012, Dubai, UAE

23

“Evidence to Power”Using ITC Findings to Demonstrate:

1. Need for strong(er) policies2. Current policies are inadequate3. Even smokers would support a

strong tobacco control policy

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Dec 9, 2010: Hearing held by the Houseof Commons Health Committee on theGovt’s decision to shelve the revision.

ITC Canada Survey data show that everyindicator of label impact has declined

dramatically over the past 7 years

Dec 30, 2010: Health Ministerreverses decision—the revision of thewarnings will continue. New warningshave been introduced in 2012.

Sep 28, 2010: Health Canadaannounces that the ongoing initiativeto revise the 10-year-old tobaccowarnings is being shelved

25

Mauritius—Pictorial Warnings (May 2009)

2626

Wearout of warnings in Mauritius

2727

Wearout of warnings in Mauritius

COP5: Mauritius cites ITCfindings as the reason they will

be revising their warnings

The pictorial warnings showedleveling off or reductions ofimpact after 20-21 months

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ITC Data Used to Support Strong Smoke-Free Policies

Gave a talk for Alberta’s Celebration of World No-TobaccoDay, May 2007

Contacted advocates/insiders to find out how I could helpin their push for 100% smoke-free laws in Alberta:1. Legislators were not sure support was high enough2. Rumor: the cities are pushing this law on the rural areas,who are NOT supportive (a “hot button” issue in Alberta)

29

Using ITC Survey Data to Inform Policy Decisionsin Alberta, Canada

The ITC Four Country Survey has data on support forsmoke-free laws across key venues (restaurants, bars,workplaces).

In Canada, there were about 2,000 smokers in our cohortat the time, including about 200 smokers from Alberta.

We computed the overall support of these Albertasmokers for smoke-free laws and also separately forurban and rural Alberta smokers.

We then compared the level of support in Alberta with thelevel of support in Ireland before their successful smoke-free law.

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ITC Survey W5 (Fall 2006)Alberta Smokers:29% support(33% rural, 27% urban)

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ITC Wave 5 (Fall 2006)Alberta Smokers:74% support (77% rural, 73% urban)

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ITC Wave 5 (Fall 2006)Alberta Smokers:64% support (69% rural, 62% urban)

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ITC findings address both issues in Alberta

1. Legislators were not sure support was high enough

Support was HIGHER in Alberta than in Irelandbefore Ireland’s successful smoke-free law forall three venues (bars, restaurants, workplaces)

2. Rumor: the cities are pushing this law on the rural areas,who are NOT supportive (a “hot button” issue in Alberta)

Support was HIGHER in the rural areas for allthree venues

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Dave Hancock, the Health Minister of Alberta, was present at theevent. He asked for my slides comparing Alberta favorably toIreland, saying that “it was just what he needed.” Later that week,his caucus announced that they would go for 100% smoke-freelegislation in Alberta. And on Nov 14, Bill 45 was passed.

35

Research to demonstrate that currentpolicies are ineffective, and in need of

strengthening:How China and The Netherlands are alike

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On May 1, 2009, China increased cigarette taxesby 6-11%, claiming that they were doing so inaccordance with the FCTC.

BUT prices have still not increased (June 2012).

Affordability of cigarettes continues to increase.

The ITC China Survey: shows clearly that price isnot a factor in motivating quitting.

China’s warning labels changed in Oct 2008

OLD warning:Side of pack

Only one message

NEW warnings:Front/back of pack

Two messages

Until recently, on the back of everypack in China, the warnings appeared

in English!

< 10% of adult smokersunderstood bothEnglish warnings

40

Smoking Prevalence in Restaurants Before and After Smoke-Free Laws in Ireland(04), Scotland (06), UK (07), France (08), Germany (07-08), Netherlands (08),

Mexico City (08), Other Mexican Cities (08), Mauritius (09), 6 ITC China cities and4 Indian States 2-3 yrs > COTPA required restaurants to be smoke-free (Oct 2008)

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Complete bans work much better than partial bans

Smokers who were more supportive of the ban,were more aware of the harm of SHS, and whohad negative opinions of smoking were less likelyto smoke in bars post-ban.

42

The Dutch Health Minister isdetermined to eliminatetobacco control in her country."Well-informed people canmake their own choices." TheITC Project issues a reportshowing that Dutch smokersare the least knowledgeableand least concerned of all 19ITC countries about the harmsof secondhand smoke.

Geoffrey Fong gives aspeech in Xi’an China inApril 2011 to the leadingnational group of tobaccocontrol experts in China:“Things are bad in China,but at least they aren’t asbad as they are in theNetherlands.”

BMJ article—Apr 9, 2011

Letter to TheLancet(Friday, Dec 9,

2011):

From the ITC Projectand European healthorganizations andexperts on the Dutchtragedy-in-the-making

www.thelancet.comPublished online December 9, 2011

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Research to refute claims made about the“unintended consequences” of

FCTC policies:Will smoking bans in public places lead

to more smoking at home?

Smoke-free pubs lead to smoke-filled homes?

John  Reid,  former  U.K.  Secretary  of  State  for  Health,  at  a  House  ofCommons  Health  Commi>ee  Evidence  Hearing,  Feb.  23,  2005:

In Scotland, for instance, they have decided to go for acomplete ban on smoking. I came to the conclusion that thatwas not a good thing on health grounds, apart from anythingelse, because you get a displacement of smoking from somepublic areas to the home - and most of the evidence aboutpassive smoking is about the home...

...what we do know, for instance in Ireland and we wouldanticipate in Scotland, is that a percentage of people whopreviously went to the pub to smoke will now get a carry-outand take it home. I think the percentage in Ireland is about15 per cent.

Proportion of homes allowing smoking has decreased inIreland since the ban (p=.002): Home bans have increased

after the ban

After the implementation of national smoke-free laws:

The proportion of smokers with a total HSB increasedsignificantly in all four countries.

Among continuing smokers, the number of cigarettessmoked per day either remained stable or decreasedsignificantly.

Ute Mons, et al.—Tobacco Control(in press; online: Feb 2012):

Analyses of home smoking bans andself-reported number of cigarettessmoked in the home in Ireland,France, Germany, The Netherlands.

Compared to the “control” country ofUnited Kingdom (during the wavesused as control, the UK had not yetimplemented its own smoke-free law)

Presence of bans at Wave 1—>greater likelihoodof quit attempts AND success among those whotried to quit at Wave 2

Borland et al.Tobacco Control (2006):

Longitudinal analyses of ITCFour Country Survey data(W1 and W2): Canada,Australia, United States,United Kingdom

Consequences of smoke-free homes over a 7-monthperiod

Gera Nagelhout et al.(Nicotine & Tobacco

Research, 2012)

Path analytic model tracingthe impact of smoke-freelegislation on smokingcessation in the Netherlandsover three waves

Application of the ITCConceptual Model

ITC Project (March 2012). Smoke-freePolicies: ITC Cross-Country ComparisonReport. University of Waterloo,Waterloo, Ontario, Canada.

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Do graphic warning labels lead toreductions in prevalence?

US FDA Regulatory Impact Analysis

ITC Project demonstration that theanalysis is flawed

US FDA Proposes Graphic Warnings

Process of the US Graphic Warnings

Proposed Rule issued in November 2010

Regulatory Impact Statement

Estimated impact of graphic warnings on prevalence

Used Canadian data before and after the graphicwarnings introduced in 2000.

Controlled for TAXES, not price Concluded that the Canadian graphic warnings

ONLY DECREASED PREVALENCE BY .088%

Conducting analyses by price rather than taxes

Canadian Govt data:Price increased by

19.7% from 2002–11

ITC data: Actualprice paid in Canada

DECREASED by 4.0%

Huang, Chaloupka, and Fong—Reanalysis

Conducting analysis of impact of Canadian warnings onprevalence by using price, not taxes

Using ITC data on price paid, not official (store-only) data

Conclusions:

Original FDA estimate: Decrease of 0.088%

Huang et al. estimate: Decrease of 2.87% to 4.68%

• 33 to 53 times larger than the FDA estimate

• Implies a decrease of 5.3 to 8.6 million smokers in the United States.

Other Examples of ITC Data on Policy

Smoking in cars with children: support data—>UK(England, Scotland)

Electronic cigarettes: prevalence, quit rates, dual use Support for smoke-free laws—>many countries Point-of-sale bans—>New York City, other jurisdictions Cessation services—>UK Graphic warning labels—>many countries, especially

Malaysia, Mauritius, Brazil Light/mild bans are not sufficient to eliminate

misperceptions—>many countries

57 57

Policy domains where there has been action:– Warning labels: how are the graphic warnings working?– Smoke-free: how well is the smoke-free law working?

Important policy domains—current and in the future:– Taxation: studies needed of affordability and possible impact of future tax increases– Contraband (especially counterfeit): Possible to assess prevalence with pack collection and analysis– Betel quid use: importance of studying use patterns and its relation to tobacco use– Ongoing studies of the light/mild deception

Thoughts about a possible ITC Taiwan Project

5858

Taiwan 2014

Other Examples of ITC Data on Policy

Smoking in cars with children: support data—>UK(England, Scotland)

Electronic cigarettes: prevalence, quit rates, dual use Support for smoke-free laws—>many countries Point-of-sale bans—>New York City, other jurisdictions Cessation services—>UK Graphic warning labels—>many countries, especially

Malaysia, Mauritius, Brazil Light/mild bans are not sufficient to eliminate

misperceptions—>many countries