Beleidsontwikkelingen in tabaksontmoediging

Beleidsontwikkelingen
in tabaksontmoediging
Marc Willemsen
Nascholingsavond Kwaliteitsregister Stoppen met Roken
Trimbos-instituut
17 September 2015
1. Inleiding: Tabaksontmoediging in
Nederland
2. Symposium op SRNT-E over ondermijnen
van tabaksbeleid door de industrie
3. Symposium of SRNT-E over de nieuwste
resultaten uit het ITC Nederland project
4. Symposium of SRNT-E over
kankerpreventie: vergoeding van stoppen
met roken
Framework Convention on
Tobacco Control (FCTC)
• Wat: WHO-Kaderverdrag inzake
tabaksontmoediging
• Doel: Wereldbevolking beschermen tegen de
schadelijke effecten van tabak
• Middel: samenhangend pakket van effectieve
maatregelen
• Start: geratificeerd door Nederland op 27 januari
2005
Schaduwrapport 2011
Schaduwrapport 2011
Niet in overeenstemming
met FCTC verplichtingen
Niet in overeenstemming
met FCTC aanbevelingen,
maar wel met (eventuele)
verplichtingen
Niet in overeenstemming
met FCTC suggesties, maar
wel met (eventuele)
verplichtingen en/of
aanbevelingen
In overeenstemming met
FCTC verplichtingen,
aanbevelingen en/of
suggesties
Samenvattend:
Alomvattende strategie en
centrale coördinatie
(Art. 5.1 & 5.2)
Bescherming tegen
belangen tabaksindustrie
(Art. 5.3)
Prijs- en
belastingmaatregelen
(Art. 6)
Bescherming tegen
blootstelling aan
tabaksrook (Art. 8)
Inhoud tabaksproducten
en informatieverschaffing
(Art. 9 & 10)
Verpakking en etikettering
(Art. 11)
Educatie, communicatie
en training (Art. 12)
Reclame, promotie en
sponsoring (Art. 13)
Tabaksverslaving en
stoppen met roken
(Art. 14)
Illegale handel (Art. 15)
Verkoop aan en door
minderjarigen (Art. 16)
Onderzoek en monitoring
(Art. 20)
Financiële middelen
(Art. 26)
Nog weinig
vooruitgang in
termen van
voldoen aan
FCTC
Positieve ontwikkelingen sinds 2011
• Leeftijdsgrens verkoop tabak van 16 naar 18 jaar
• Herintroductie van de rookvrije (kleine) horeca
• Terugkeer van vergoeding van stopondersteuning in het
basispakket
• Weer aandacht voor campagnes
• Publieke informatievoorziening t.a.v. tabaksingrediënten
• Grote accijnsverhoging in 2013
• Steun voor de Europese Tabaksproductenrichtlijn (grafische
gezondheidswaarschuwingen en maatregelen t.a.v.
additieven)
Zorgpunten
• Tabaksontmoediging onvoldoende prioriteit
• Gebrek aan een alomvattend tabaksbeleid
• Onvoldoende maatregelen tegen de invloed van de
tabaksindustrie
• Nog geen volledige bescherming tegen meeroken
• Gebrek aan voorlichting (en kennis) over de schadelijkheid
van (mee)roken
• Geen algeheel reclameverbod op verkooppunten
• Accijnsinstrument niet vanwege de volksgezondheid
• Verslechteringen: minder budget, minder monitoring
Aanbevelingen
• Ontwikkel een omvattend
tabaksontmoedigingsbeleid met substantieel
budget, ondersteund met structurele inzet van het
accijnsinstrument
• Start bewustwordingscampagne over de
schadelijkheid van roken
• Elimineer alle tabaksreclame en promotie: ‘display
ban’ en ‘plain packaging’
Symposium 1
“Preventing tobacco industry interference in
health policymaking: challenges, successess,
and missed opportunities”
Implementing WHO Framework
Convention on Tobacco Control Article
5.3 in the EU: Challenges and
Opportunities
Heide Weishaar
MRC/CSO Social and Public Health Sciences Unit, University of
Glasgow
FCTC Article 5.3
“In setting and implementing their public health
policies with respect to tobacco control, Parties
shall act to protect these policies from commercial
and other vested interests of the tobacco industry
in accordance with national law.”
Nederland
•
September 2014: Stichting Rookpreventie Jeugd
dagvaardt Overheid om artikel 5.3 na te komen
•
Mei 2015: Advies van ANR aan de Overheid over
implementatie van artikel 5.3
•
Kamerbrief van Rijn over artikel 5.3 verwacht
BAT interests for impact assessment and
stakeholder consultation hidden behind credible
third parties
Group 1 included*:
Business groups (British
Chambers of Commerce,
CBI & Federation of Small
Businesses) and
companies (BAT, Enron,
KPMG, NTL, Rolls Royce,
Telewest, Zurich financial
services).
British American
Tobacco
Lobbying groups
Public Policy
Unit
Fair Regulation
Campaign
Member States
EU Policymaking
institutions
UK
government
German
government
European
Council
Irish
government
Trade &
economic
organisations
(including OECD,
CBI, UNICE & IBEC)
Dutch
government
European
Parliament
and MEPs
Group 2 included**:
Baxter, Bayer, Bouygues,
British Petroleum, Coca
Cola, Dow, Du Pont de
Nemours, Edelman, Elf
Aquitaine, GCPF (Crop
Protection Association),
HSBC, ICI, Johnson &
Johnson, Marks &
Spencer, Mars, NatWest,
Pirelli, Shell, Siemens,
SmithKline Beecham,
Solvay, Tesco, Zeneca
European
Policy Centre
Risk Assessment
Forum
Weinbergs
European
Commission
•Smith KE, Fooks G, Collin J, Weishaar H, Mandal S, Gilmore AB. “Working the System”—British
American Tobacco's Influence on the European Union Treaty and Its Implications for Policy: An
Analysis of Internal Tobacco Industry Documents. PLoS Medicine 2010; 7(1): e1000202
Corporations
Tobacco industry’s assault
on democratic policy making:
the case of the
EU Tobacco Products Directive
Co-researchers: H. Costa, D. Stuckler, M. McKee, & A.B. Gilmore
Silvy Peeters
R01CA160695
SRNT Europe 16th Annual Conference
Maastricht, 10 September 2015
Belangrijkste TPD maatregelen per mei
2016
•
Verbod op tabaksproducten met kenmerkend aroma
•
Gezondheidswaarschuwingen (tekst + plaatje) 65% op voor – en
achterzijde verpakking + stoppen met roken informatie
•
Nadere eisen misleidende eisen etikettering (geen additief vrij, geen
nicotine, teer en CO gehaltes)
•
Verbod promotie elektronische sigaretten
•
Maximaal nicotinegehalte en volume, verschillende veiligheidseisen
•
Keuze ‘plain packaging’ wordt aan de lidstaten overgelaten
•
Overgangstermijn 1 jaar (mei 2016 – mei 2017).
•
Nederland: E-sig onderdeel tabakswet (wat betreft leeftijdsgrens en
reclameverbod)
Context
2001:
Tobacco Products Directive (TPD)1 adopted1
2009:
Revision TPD1 started
2014:
TPD2 adopted
WHO
Framework
Convention
on Tobacco
Control
(FCTC)
1
Better
Regulation2
Impact
Assessment,
Stakeholder
Consultation
Mandal S, Gilmore A, Collin J, Weishaar H, Smith K, McKee M, Block, amend, delay: tobacco industry efforts to influence the European Union’s
Tobacco Products Directive (2001/37/EC). Other. Brussels: Smokefree Partnership/CRUK, 2009
2 Smith KE, Fooks G, Collin J, Weishaar H, Mandal S, Gilmore A. "Working the system": PLOS Medicine 2010
Overall TI strategy
• AMEND, DELAY, & BLOCK “extreme” policy options
• Shift debate away from health to economic consequences
Commission
Block DG SANCO’s
“extreme” policy options
Parliament
Break Health Committee’s
control over TPD2
EU Council
Create blocking minority to
“extreme” measures
Significant delays
TPD1
2.5 years
TPD2
5.5 years
1
1.5
4
Commission █
1.5
Parliament & Council █
Impact Assessment:
 Additional studies
 Public consultation flooded: 85,000+ submissions
Inter-Service Consultation (ISC):
 Postponed 3 times (25 Jul, 23 Sept, 22 Oct 2012)
•ITC Netherlands Wave 1 to 8 National Report
(2008-2014)
•Summary of Findings
•Marc C. Willemsen
•Maastricht University
Department of Health Promotion
ITC Netherlands Team

ITC Netherlands Investigators
— Dr. Marc Willemsen*— Maastricht University (CAPHRI)
— Dr. Gera Nagelhout — Maastricht University (CAPHRI)
— Dr. Hein de Vries — Maastricht University (CAPHRI)
— Karin Hummel — PhD Student, Maastricht University (CAPHRI)
— Dr. Ciska Hoving — Maastricht University (CAPHRI)
— Dr. Bas van den Putte — University of Amsterdam (ASCoR)

ITC International Team
— Dr. Geoffrey T. Fong*
— Dr. Mary E. Thompson
— Dr. Christian Boudreau

ITC Netherlands Project Management
— Thomas Agar — Project Manager, University of Waterloo, Canada
— Ruth Loewen — Survey Manager, University of Waterloo, Canada
— Dr. Gera Nagelhout — Maastricht University (CAPHRI)
— Karin Hummel — PhD Student, Maastricht University (CAPHRI)
•
*Principal Investigators
Department of Health Promotion
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•29
Methods

Longitudinal study: survey waves over 6 years (2008-14)
—


Telephone (Waves 1 & 3) and web (Waves 1-8) surveys
Representative random sample
—
Cohort of about 2,000 youth (15-17) and adult (18+) smokers
—
Replenishment of respondents lost to attrition at Waves 4-8
Survey questions
—
Adapted from ITC Project surveys across 22 countries
—
Measures relevant to each FCTC policy domain
—
New questions adapted for Netherlands tobacco control policy
environment
—
e.g. E-cigarettes, mass media campaigns, insurance reimbursement for
SSMs
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•30
Kennis gezondheidsschade
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•31
Kennis: roken en hartziekten
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•32
Kennis: hartaanval
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•33
Denken over gevolgen van het roken
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•34
Denken over schade van roken aan anderen
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•35
Beeldvorming
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•36
Gebrekkige blootstelling aan voorlichting
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•37
Prijs als reden om te stoppen
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•38
Opmerken van de waarschuwingslabels
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Aanbevelingen
1) Promoot meer bewustzijn van de schade van het roken
en voordelen van stoppen middels goedgefinancierde
voorlichtingscampagnes
2) Verminder blootstelling aan tabaksmarketing in winkels
3) Verhoog tabaksaccijns tot minimal 70% van de verkoopprijs
4) Verminder prijsverschil tussen shag en sigaretten.
Department of Health Promotion
•40
Symposium 7
• “Preventing cancer through smoking
cessation: A symposium supported by the
Dutch Cancer society (KWF) and Cancer
Research UK”
• -> Mijn presentatie: “Should governments pay for
smoking cessation?”
Department of Health Promotion
FCTC Article 14
“Tobacco users who need cessation support should be
offered intensive specialised support, delivered by
specially trained practitioners. Such services should
offer behavioural support, and where appropriate,
medications (…). Where possible they should be
provided free or at an affordable cost.”
Department of Health Promotion
Vergoeding
• 2011: vergoeding voor stoppen met roken
behandeling ingevoerd + campagne
• 2012: geen vergoeding
• 2013 – 2015: vergoeding opnieuw mogelijk.
Department of Health Promotion
Methode
• Literature search PubMed: “reimbursement” and
“Netherlands”
• Inclusion:
– Before – after comparison data available (covering 2010 - 2012)
– National level data
– All outcome measures
Department of Health Promotion
Bevindingen: 6 studies
1. Willemsen MC, et al. Population impact of reimbursement for smoking cessation: a
natural experiment in The Netherlands. Addict 2012;108(3):602-4.
2. Troelstra, S., et al. Effect of tobacco control policies on information seeking for smoking
cessation in the Netherlands: A Google Trends study. Eur J Public Health 2014;24(Suppl
2): 214
3. Verbiest, ME. et al. An increase in primary care prescriptions of stop-smoking medication
as a result of health insurance coverage in the Netherlands: population based study."
Addiction 2013;108:2183-192
4. Van Boven JFM, Vemer P. Higher Adherence during Reimbursement of Pharmacological
Smoking Cessation Treatments. Nicotine Tob Res. First published online: March 16,
2015
5. Nagelhout, G. E., et al. Effectiveness of a national reimbursement policy and
accompanying media attention on use of cessation treatment and on smoking cessation:
a real-world study in the Netherlands. Tobacco Control 2014;24:455-61
6. Nagelhout, G., et al. Are there income differences in the impact of a national
reimbursement policy for smoking cessation treatment and accompanying media
attention? Findings from the International Tobacco Control (ITC) Netherlands Survey.
Drug Alcohol Dependency 2014;140:183–90.
Department of Health Promotion
1. Willemsen et al (2012)
Increases in calls to the national telephone quit line
2011
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2. Troelstra
Increase Google “Quit smoking” searches in 2011
and 2013 in the Netherlands
2004 - 2010
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2011
2012
2013
2. Troelstra (cont’d)
No increase Google “Quit smoking” searches in
2011 and 2013 in Belgium
2006 - 2010
Department of Health Promotion
2011
2012
2013
3. Verbiest et al
More prescriptions and less smokers
Department of Health Promotion
Proportion smokers in adult population
(TNS-NIPO)
28
27,5
27
26,5
26
25,5
25
24,5
24
23,5
23
2007
2008
2007
2009
2008
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2009
2010
2010
2011
2011
2012
2012
2013
2013
4. Van Boven & Vemer
• Number of prescriptions by pharmacies
• 2011 - 2014
• Adherence = at least 80% of the recommended
number of tablets prescribed
Recommended:
Varenicline: 143 pills, 12 weeks
Bupropion: 83 pills, 7 weeks.
Department of Health Promotion
4 . Van Boven & Vemer(cont’d)
15.4%
20.1%
Department of Health Promotion
13.9%
18.9%
5. Nagelhout (2014a)
20
Reimbursement
18
16
14
12
10
8
6
4
2
0
wave 1
wave 2
% Quit Attempt
Department of Health Promotion
wave 3
% Quit Success
wave 4
5. Nagelhout (2014a) (cont’d)
• Attention to media about reimbursement
significantly associated with more quit attempts
(Or=1.18) and more quit success (OR = 1.20).
• Awareness of reimbursement policy not a
significant predictor, when controlling for media
attention.
Department of Health Promotion
6. Nagelhout et al (2014b)
ITC survey data
Department of Health Promotion
4. Nagelhout et al (2014b)
• Main findings of Nagelhout et al (2014a) were confirmed:
– Effect of reimbursement on quit attempts and quit success.
– Awareness of media campaign associated with more quit
attempts.
• No differences according to income level
Department of Health Promotion
Conclusions
• More use of behavioural support
• More use of pharmaco-therapy
• Greater adherence to treatment regime
 more successful quitting
• more quitting activity in the population
-> Impact on national smoking rate
• Impact is very much dependent on promotion of
reimbursement through media campaign
• National reimbursement for smoking cessation will help
governments in reaching national tobacco control
targets, if properly executed
Department of Health Promotion
Bedankt!
marc.willemsen@maastrichtuniversity.nl
Department of Health Promotion