Презентация на Мартин Сметана от GLOBSEC за Трета медийна среща за намаляване на вредата от тютюна

Msquare T + 421 905 486 687 Martin Smatana martin.smatana@msquare.com

WHY SHOULD BE FOOD, ALCOHOL AND SMOKING CONSUMPTION A SUBJECT OF INTEREST OF PUBLIC POLICIES IN SLOVAKIA? Basic overview of Slovakia

2

Despite an improvement in most health indicators Life expectancy at birth, 2000 - 2020

3

...Slovakia records roughly 20 000 avoidable deaths per year

4

Due to COVID-19, care has been repeatedly postponed

5

...and our system has limited opportunities to increase capacities

We have a below-average number of doctors and nurses

The budget is per capita 6th lowest in the EU Government & compulsory insurance

EUR PPP per capita

Voluntary insurance & out-of-pocket payments

Share of GDP

% GDP

5 000

12.5

4 000

10.0

3 000

7.5

2 000

5.0

1 000

2.5

0

0.0

6

Slovakia has large "reserves" that do not cost a single euro

7

Behavioral / environmental factors affect more than 50% of deaths About half of all deaths in Slovakia in 2019 can be attributed to risk factors of behavior, such as:

dietary risks, tobacco smoking, alcohol consumption or low physical activity.

8

Behavioral / environmental factors affect more than 50% of deaths About half of all deaths in Slovakia in 2019 can be attributed to risk factors of behavior, such as:

dietary risks, tobacco smoking, alcohol consumption or low physical activity.

9

Hence, we prepared a study that analyzed key factors

10

Hence, we prepared a study that analyzed key factors How: by analysing policies from other countries and comparative calculations Why: 60-85% of a person's health does not affect healthcare and Slovakia is lagging behind the EU Process:

1.

We prepared a shot of possible measures inf first version of the paper (november 2021)

11

Why do we need several rounds of feedback?

12

Hence, we prepared a study that analyzed key factors How: by analysing policies from other countries and comparative calculations Why: 60-85% of a person's health does not affect healthcare and Slovakia is lagging behind the EU Process:

1.

We prepared a shot of possible measures inf first version of the paper (november 2021)

2.

Measures and policies have been developed with representatives of experts, politicians and

analysts (november – jun 2022) 3.

The second version of the material will be signed by key opinion makers and submitted

Goal: reduced preventable deaths, improved health status of the population and thus relieved HC system

13

Dietary risk factors: „An apple a day, keeps doctor away?“

14

Bad diet causes more than 2 million deaths across Europe 20% 18% 16%

14% 12% 10% 8% 6% 4% 2% 0%

15

Countries that are according to Bloomberg index TOP ...

16

...have in common not only significant expenditures on prevention Prevention spending as PPP / per capita in US dollars 160,0

x7 140,0

120,0

x 5-6 100,0

80,0

x3 60,0

40,0

20,0

0,0 2010

2011

2012 Iceland (3)

2013 Italy (2)

2014 Spain (1)

2015

2016

Slovak Republic (45-46)

2017

2018

17

But also dietary habits ...

Mediterranean diet, as part of a clinical trial of the PREDIMED project Olive oil

≥4 tbsp/day

Tree nuts and peanuts

≥3 servings/wk

Fresh fruits

≥3 servings/day

Vegetables

≥2 servings/wk

Fish (especially fatty fish), seafood

≥3 servings/wk

Legumes

≥3 servings/wk

Tomato and onion sauce cooked with olive oil

≥2 servings/wk

White meat

Instead of red meat

Wine with meals (optional)

≥7 glasses/wk

Discouraged Soda drinks

<1 drink/day

Commercial bakery goods, sweets, pastries

<3 servings/wk

Spread fats

<1 serving/day

Red and processed meats

<1 serving/day

18

What about dietary risk factors in Slovakia?

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In short: awful Ranking of countries by DALY loss (OECD) Slovakia is the second worst ... after Hungary.

Primarily beacuse of:

▪ High salt consumption ▪ Low fruit / fiber consumption ▪ High consumption of red meat ▪ Growing sugar consumption ...

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And we are not talking about small increases (2x increase) Consumption of soft drinks in Slovakia per capita (liters)

Sugar consumption per capita (kg) 100

160

90

140

80 120 70

100 60 80

50

60

40

40

30 20

20

10 0 0 Unflavoured, unsweetened drinks

Flavoured, sweetened drinks

Fruit and vegetable juices including nectars

Syrups for drinking

Czech Republic

Hungary

Slovakia

United States

21

What can Slovakia do about this?

There are countless ways to achieve the necessary dietary changes.

Based on the evaluation of effectiveness by Yi et al. (2021), the measures can be grouped into three macro "streams": 1. Changes in the composition of food 2. Changes in food pricing

3. Multilevel interventions within schools, workplaces or at several levels

4. ...and several micro local and target measures

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Changes in the composition of food

Trans-fat ban in Denmark

Virtually zero trans-fat

30 fewer deaths per 100,000

Hyseni et al.,

in 2003

consumption

inhabitants per year in Denmark

2017

Mandatory sodium reformulation for

1.45 g/day reduction in sodium A 1.6 g/day reduction in UK consumption (average from meta- associated with 19 320 life-years

producers

analysis)

Voluntary sodium reduction by producers

A 1.2 g/day reduction in UK 0.8 g/day reduction in sodium associated with 14 560 life-years consumption (average from metagained over 10 years. 6% reduction analysis) in relative CVD risk.

gained over 10 years

Collins et al., 2014 Collins et al., 2014; Mozaffarian and Capewell, 2011

23

Education is in terms of salt long distance race with little results...

Policy

Details of intervention

Reformulation - mandatory

Introducing a legislation to impose salt reduction targets on food manufacturers. Monitoring of salt intake levels through urinary

Estimated decrease in

sodium consumption 20%

analysis and monitoring of food labels would be required.

Salt targets set by the relevant regulator for the reformulation of food products by manufacturers to reach within a timeline. These targets Reformulation - voluntary

are set for food product categories, with subcategories where relevant. Monitoring of this policy is in progress using urinary analysis

15%

and monitoring of food labels.

Health promotion campaign

Labelling

Advertising (media) campaign promoting healthy eating and physical activity.

All food packaging would be required to carry labelling to show the salt content as well as other nutritional values using a uniform traffic light labelling system. Monitoring of labels would be required.

2%

2%

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Tax policies

Sugar-sweetened beverage tax

A 16% SSB tax in the US would over 10% increase in tax associated cohort's lifetime prevent 850 000 with

10%

consumption

fall

in

SSB CVD events, 166 000 CVD deaths, Lee et al., 2020 269 000 diabetes mellitus cases and

generate 2.44 million QALY. Increasing fruit and vegetable intake by 1 per day each reduces relative Mozaffarian

Fruit and subsidy

and 10% subsidy associated with vegetable CVD risk by 8% and 7% respectively. Capewell, 2011; 14% increase in fruit and Consuming 1 vegetable and fruit per Oyebode et al., vegetable consumption day compared to none decreases CVD 2014 risk by 16%.

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Multilevel interventions

Reducing sodium consumption by 0.8 g/day reduces relative CVD risk by 6%.

Education, voluntary sodium 4 g/day sodium reduction between reduction by producers, A reduction of sodium consumption by 1981 and 2007 in Finland 30% would delay 40 million deaths labelling changes

Improved availability of fruits and vegetables in schools, classroom curriculum, parent

Increase in fruit and vegetable intake by 2.5 daily servings for schoolchildren

involvement Voluntary limits by food producers and mandatory labelling for trans-fats

30% reduction in trans-fat consumption

Kontis et al., 2019

globally by 2040.

Increasing fruit and vegetable intake by Blanchette and 1 per day each reduces relative CVD Brug, 2005; risk by 8% and 7% respectively.

Mozaffarian and

Consuming 1 vegetable and fruit per

Capewell, 2011;

day compared to none decreases CVD risk by 16%.

Oyebode et al., 2014

30 fewer deaths per 100,000 inhabitants per year in Denmark after trans-fat ban

Hyseni et al., 2017

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Other micro-level policies and projects

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HOW SLOVAKIA COULD LOOK LIKE?

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If we applied 4 measures, we would save 4 thousand. lives and 40 mil. EUR* Policy

Trans fat bans Sodium reduction due to mandatory government reformulation SSB tax 30%

Fruit and veg subsidy 10%

Reduction in relative risk of CVD

Estimated fewer CVD deaths in Slovakia

Estimated healthcare savings (mil. Euros)*

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Behavioral / environmental factors affect more than 50% of deaths About half of all deaths in Slovakia in 2019 can be attributed to risk factors of behavior, such as:

dietary risks, tobacco smoking, alcohol consumption or low physical activity.

30

If we applied 4 measures, we would save 4 thousand lives and 40 mil. EUR*

„

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Smokingin Slovakia: a little more, but a little better?

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We do not know exactly the structure or "severity" of smokers Proportion of the population aged 15+ and older who smoke daily Proportion of daily smokers in population [%]

30

25

20

15

10

5

0 Slovakia

Czechia 2009

Hungary 2014

2019

Poland

33

We do not know exactly the structure or "severity" of smokers

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age group area of living

▪ 13% use pouches and HTP

education

▪ 16% of people registered advertising for e-cigarettes

sex

What we don't have information about, but Czechia has

heated tobacco products

nicotine pouches

[%]

cigarettes

electronic cigarettes

overall

23.1

4.8

4.1

1.7

men

28.3

6.1

4.3

2.2

women

18.2

3.5

4.0

1.2

15-24

24.2

10.0

3.7

6.3

25-44

26.5

7.3

7.1

2.0

45-64

23.6

2.7

3.1

0.7

65+

17.1

1.7

1.4

0.5

urban

22.3

5.2

4.1

1.8

rural

26.1

3.5

4.3

1.3

primary

30.9

3.5

4.1

1.1

secondary

20.6

4.7

4.7

1.3

university

15.2

4.4

3.6

1.0

Csémy et al. (2021)

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The relationship between smoking and health is known „Population attributable fraction“ of smoking in Slovakia (2019)

36

The relationship between smoking and health is known

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The relationship between smoking and health is known DALYs and the effects of diagnoses where tobacco is a risk factor

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Regulation of tobacco consumption is relatively strong across the world

39

Regulation of tobacco consumption is relatively strong across the world Specific taxes and duties on tobacco products: evergreen policies A 10% increase in cigarette prices has been shown to reduce cigarette consumption by 2.5 to 5% (Townsend, 1996, 1998). Research has further shown a higher long-term effect of tax increases if they keep pace with inflation, as well as higher price elasticity in lower- and middle-income countries (Jha and Chalopuka, 2000).

Regulation of marketing, packaging and distribution Australia, and in particular its most populous state, New South Wales: smoking is strictly prohibited in public smoking is prohibited within 10 meters of a playground, 4 meters from the entrance to a public building, railway platforms, taxi ranks and bus stops, and fines may apply be up to EUR 1 400..

Australia is also the first country in the world to introduce compulsory packaging for ordinary cigarettes - 75% of the front and 90% of the back of cigarettes must contain a graphic health warning.

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Regulation of tobacco consumption is relatively strong across the world In the Netherlands, there is an initiative led by a private initiative of the supermarket chain Lidl, which stopped selling cigarettes by October 2021 (Spiegel, 2021).

This is also with the aim of the Dutch government to limit the sale of cigarettes at petrol stations, newsstands and specialist shops after 2024. Smoking areas in public places are also disappearing - the ban on smoking in restaurants and bars came into force in 2008 and smoking areas at stations stopped in 2020. Smoking areas in workplaces are expected to disappear by 2022 (Mlinarić et al, 2020).

Advice, education and other policies to reduce tobacco consumption

A recent review of research has shown that group therapies have been most successful in the workplace and accompanied by pharmacotherapy (Mohamed et al, 2021). The NHS starts piloting e-cigarettes.

Less harmful tobacco products as an alternative or temporary solution (eg HTPs in the US, where the FDA has issued an IQOS authorization as a "modified risk" product)

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Policies for new products are not based on these older studies...

Nutt et al., 2014

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...but on ever growing evidence of updated meta studies

Pisinger et al. (2021)

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HOW SLOVAKIA COULD LOOK LIKE?

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If we were to replace / reduce the consumption of standard products

Disease

DALYs lost, today

Lung Cancer

46,400

COPD

DALYS lost, 50%

DALYs lost, 100% switch

DALYs lost, Full cessation

35,490 (10,900)

24,600 (21,790)

15,250 (31,140)

18,100

14,670 (3,420)

11,240 (6,850)

8,300 (9,790)

Ischemic heart disease

231,200

215,360 (15,860)

199,490 (31,730)

185,870 (45,350)

Stroke

76,300

71,940 (4,370)

67,570 (8,740)

63,820 (12,490)

Total

372,010

337,460 (34,550)

302,900 (69,110)

273,240 (98,770)

switch

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...we could save countless lives as well as millions of EUR* Savings from 50% switch

Savings from 100% switch in

Savings from full cessation in

in mil. EUR

mil. EUR

mil. EUR

Lung Cancer

1,090 – 1,340

2,190 – 2,670

3,140 – 3,840

COPD

2,135 – 2,600

4,270 – 5,220

6,100 – 7,460

Ischemic heart disease

1,360 – 1,660

2,700 – 3,310

3, 890 – 4,750

Stroke

9, 850 – 12,000

19,700 – 24,000

28,100 – 34, 400

Total

14,450 – 17,650

28,850 – 35,300

41,300 – 50,450

Disease

46

So the measures are working ... they just need to be updated and enforced

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So the measures are working ... they just need to be updated and enforced

48

And this is also one of the problems in Slovakia...

Yes, but...

Yes, but...

Yes, but...

Yes, but...

Yes, but...

Yes, but... Yes, but...

49

Alcohol: are we ashamed of drinking?

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Alcohol consumption is lower compared to V4 countries ...

Alcohol consumption per capita (15 rokov+ in litres

Amount of alcohol consumed per capita [litres]

14

13

12

11

10

9

8

7 2000

2001

2002

2003

2004

2005

2006

2007 Slovakia

2008

2009

Czechia

2010

2011

Hungary

2012 Poland

2013

2014

2015

2016

2017

2018

2019

51

And according to EU statistics, it looks like we are leading by example ...

According to Eurostat statistics, the frequency of alcohol consumption in Slovakia is below the European average. According to data from 2014 from European countries with available statistical data, Slovakia is: ▪ seventh lowest share of people who stated that they drink at least once a month (48.6%) ▪ the fifth lowest proportion of people who drink at least once a month ▪ the eighth lowest "bing drinking" per month This is in contrast to alcohol expenditure, where according to Eurostat data, household expenditure in Slovakia is above average, approximately 2.3% of household income

52

... however, a more detailed analysis will reveal slightly different picture Share of household expenditure on alcoholic beverages in the EU Proportion ofa ousehold income spent on alcohol [%]

6

5

4

4,8

4,7

3,7 3,4

3,4 3

3

2

1

0

2,9

2,9 2,5

2,3

2,2

2,2

2

1,7

1,7

1,6

1,6

1,6

1,6

1,5

1,4

1,4

1,3

1,2

1,1

0,9

0,9

53

... because the WHO and health data tell a different "story" Slovakia also has the fourth highest rate of alcohol-specific disorders and poisonings in the European Union, and according to WHO (2018), the average consumption of 11.5 liters of pure alcohol per year is 21st in the world, well above average.

Discrepancies in the data suggest that the frequency of alcohol consumption is underestimated in Eurostat data and that policy decisions should be based on other proxy data..

for the purposes of more detailed policy analyzes, a better database is needed, but ....

54

Compared to the "most effective" countries, we could: The three most effective policies that are relatively enforceable in Slovakia are:

▪ promotion of less harmful substitutes or alcoholic beverages with lower amounts of alcohol, ▪ restriction of alcohol sales after 22:00 ▪ raising the drinking age limit to 21 years with stricter enforcement.

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Conservative impact assessment Calculated impact of the three policies on Slovakia: Alcohol-attributable deaths

Potentially prevented deaths with a policy mix

Liver cirrhosis

1,118

45 - 112

Cancer

1,199

48 - 120

Cardiovascular diseases

1,008

40 - 81

Road traffic injuries

164

32 - 55

Other violence (including self-harm)

92

9 - 21

2,573

175 - 389

Total

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What should Slovakia do next?

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The key is addressability, not the quantity of measures The key findings of the study are:: ▪ A pandemic and a lack of staff and resources will put significant pressure on the availability of care ▪ Almost half of deaths in Slovakia are affected by factors that can be effectively eliminated.

▪ We could avert more than 4,100 deaths and tens of thousands of lost years of quality life.

▪ The savings would conservatively reach 90 mil. EUR*

▪ Slovakia has many measures. Most of them have not been historically analyzed since their introduction.

However, most effective policies and measures are beyond the reach of the Ministry of Health of the Slovak Republic and require not only a professional but also a political agreement.

▪ Our goal is to open a debate and finalize and prepare a workable proposal (july 2022)

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...so we will NOT have that many avoidable deaths

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Thank you