HIA on vulnerable populations

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, Crohns 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
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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
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HEALTH DETERMINANTS
Determinants of health Positive effect Negative effect No effect
Lifestyle Substance use (tobacco)
Physical environment Air
Physical environment Built environment and land use
Physical environment Housing conditions
Physical environment Working environment
Socio-economic environment Income and social status
Socio-economic environment Employment
Socio-economic environment Social contacts
Socio-economic environment Culture
Socio-economic environment Recreation
Health care Access to/quality of health services
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
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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
smoking
income (family)
exclusion
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
smoking
income (family)
exclusion
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

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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
smoking
income (family)
exclusion
mental
other
reproductive
gastrointestinal
circulatory
respiratory
cancer
lung
oral
asthma
COPD
coronary heart disease
ulcer
infertility (female)
osteoporosis
nasal and paranasal
stroke
larynx
arterial disease
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
smoking
income (family)
exclusion
mental
other
reproductive
gastrointestinal
circulatory
respiratory
cancer
lung
oral
asthma
COPD
coronary heart disease
ulcer
infertility (female)
osteoporosis
nasal and paranasal
stroke
larynx
arterial disease
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
smoking
income (family)
exclusion
mental
other
reproductive
gastrointestinal
circulatory
respiratory
cancer
lung
oral
asthma
COPD
coronary heart disease
ulcer
infertility (female)
osteoporosis
nasal and paranasal
stroke
larynx
arterial disease
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
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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

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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)

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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)

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HEALTH OUTCOME MEASURES

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

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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

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Reduction in the attributable death of active
smoking
Number of death
activeformer
Disease
30
Reduction in the attributable death of active
smoking
Number of death
activeformer
Disease
active
31
Reduction in the disability adjusted life years
of active smoking
Life years
activeformer
Disease
32
Reduction in the disability adjusted life years
of active smoking
Life years
activeformer
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
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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.

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Thank you