Balázs Ádám, Ágnes Molnár, Róza Ádány University of Debrecen Faculty of Public Health

1. QUANTITATIVE RISK ASSESSMENT INTEGRATED IN THE HIA OF THE ANTI-SMOKING POLICY PROPOSAL IN HUNGARY Balázs Ádám, Ágnes Molnár, Róza Ádány University of Debrecen Faculty of Public Health Department of Preventive Medicine

2. 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

3. 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

4. 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

5. PUBLIC HEALTH IMPORTANCE OF SMOKING-RELATED DISEASES IN HUNGARY

6. 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

7. 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

8. FULL CHAIN ASSESSMENT Policy Health determinant Exposure assessment Risk factor Outcome assessment Health outcome

9. 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

10. FULL IMPACT CHAIN Amendment of Act No XLII of 1999

11. HEALTH DETERMINANTS

12. HEALTH DETERMINANTS • Prioritization • strength of evidence • size of effect • feasibility of impact quantification

13. 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

14. 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

15. RISK FACTORS • Prioritization • strength of evidence • significance of induced health effects • feasibility of exposure assessment • 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

16. 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 income (tobacco and catering industry, state) environm. tobacco smoke aesthetic values healthy recreation income (family) exclusion smoking

17. 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 income (tobacco and catering industry, state) environm. tobacco smoke aesthetic values healthy recreation income (family) exclusion smoking

18. EXPOSURE ASSESSMENT • Prevalence decrease of active smoking • 7% in the total population • Prevalence decrease of passive smoking • 66% in workplaces • 95% in hospitality venues • 5.9% in homes

19. HEALTH OUTCOMES • Prioritization • strength of evidence • severity • reversibility • frequency in the population • feasibility of outcome assessment

20. 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 income (tobacco and catering industry, state) environm. tobacco smoke aesthetic values healthy recreation income (family) exclusion smoking cancer respiratory circulatory gastrointestinal reproductive other mental lung oral asthma COPD coronary heart disease ulcer infertility (female) osteoporosis nasal and paranasal stroke arterial disease larynx Crohn disease preterm birth parodontitis heart failure stomach pharynx sudden cardiac death bile stone low birth weight cataract oesophagus liver sudden infant death myeloid leukaemia pancreas kidney urinary system cervix

21. 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 income (tobacco and catering industry, state) environm. tobacco smoke aesthetic values healthy recreation income (family) exclusion smoking cancer respiratory circulatory gastrointestinal reproductive other mental lung oral asthma COPD coronary heart disease ulcer infertility (female) osteoporosis nasal and paranasal stroke arterial disease larynx Crohn disease preterm birth parodontitis heart failure stomach pharynx sudden cardiac death bile stone low birth weight cataract oesophagus liver sudden infant death myeloid leukaemia pancreas kidney urinary system cervix

22. HEALTH OUTCOMES • Prioritization • strength of evidence • severity • reversibility • frequency in the population • feasibility of outcome assessment • Quantitative outcome assessment • applicable health measures • availability of baseline health data • availability of dose/exposure-response functions

23. 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 income (tobacco and catering industry, state) environm. tobacco smoke aesthetic values healthy recreation income (family) exclusion smoking cancer respiratory circulatory gastrointestinal reproductive other mental lung oral asthma COPD coronary heart disease ulcer infertility (female) osteoporosis nasal and paranasal stroke arterial disease larynx Crohn disease preterm birth parodontitis heart failure stomach pharynx sudden cardiac death bile stone low birth weight cataract oesophagus liver sudden infant death myeloid leukaemia pancreas kidney urinary system cervix

24. 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

25. 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)

26. 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)

27. HEALTH OUTCOME MEASURES • Measures of disease burden • attributable death • potential years of life lost • years of life lived with disability • disability adjusted life years

28. 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

29. Reduction in the attributable death of active smoking Number of death active+former Disease

30. Reduction in the attributable death of active smoking Number of death active+former Disease active

31. Reduction in the disability adjusted life years of active smoking Life years active+former Disease

32. Reduction in the disability adjusted life years of active smoking Life years active+former Disease active

33. Reduction in the attributable death of passive smoking Number of death Disease

34. Reduction in the disability adjusted life years of passive smoking Life years Disease

35. 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.

36. Thank you