Welcome!Health-related effects of

government tobacco control policies: What's

the evidence?

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What’s the evidence? Hoffman SJ, & Tan C. (2015). Overview of systematic reviews on the health-related effects of government tobacco control policies. BMC Public Health, 15(744).  

http://www.healthevidence.org/view-article.aspx?a=28889

Poll Question #1What sector are you from?1. Public Health Practitioner2. Health Practitioner (Other)3. Education4. Research5. Provincial/Territorial/Government/Ministry6. Municipality7. Policy Analyst (NGO, etc.)8. Other

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The Health Evidence Team

Maureen Dobbins Scientific Director

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Susannah WatsonProject Coordinator

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Students:Emily Belita(PhD candidate)

Jennifer YostAssistant Professor

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What is www.healthevidence.org?

Evidence

Decision Making

inform

Why use www.healthevidence.org?

1. Saves you time2. Relevant & current evidence 3. Transparent process4. Supports for EIDM available 5. Easy to use

A Model for Evidence-Informed Decision

Making

National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-Making in Public Health (Fact Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]

Stages in the process of Evidence-Informed Public Health

National Collaborating Centre for Methods and Tools. Evidence-Informed Public Health. [http://www.nccmt.ca/eiph/index-eng.html]

Poll Question #3

Have you heard of PICO(S) before?

1.Yes2.No

Searchable Questions Think “PICOS”

1. Population (situation)

2. Intervention (exposure)

3. Comparison (other group)

4. Outcomes

5. Setting

How often do you use Systematic Reviews to inform a program/services?

A.AlwaysB.OftenC.SometimesD.NeverE.I don’t know what a systematic review is

Poll Question #4

Steven J. Hoffman

Director of Global Strategy Lab and Associate Professor of Law,

University of Ottawa

Charlie TanMD Candidate, Michael G.

DeGroote School of Medicine, McMaster University

Government tobacco control policies improve health outcomes of the general populationA.Strongly agreeB.AgreeC.NeutralD.DisagreeE.Strongly disagree

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Poll Question #5

ReviewHoffman SJ, & Tan C. (2015). Overview of systematic reviews on the health-related effects of government tobacco control policies. BMC Public Health, 15(744).

Importance of Review• The global tobacco epidemic is a major

public health problem that continues to deepen– Nearly one billion smokers worldwide in 2012– Leading cause of preventable death– More than 600 000 annual deaths due to

secondhand smoke (SHS) exposure

Framework Convention on Tobacco Control (FCTC)• International treaty introduced by the

World Health Organization (WHO) in 2005• Aims to reduce tobacco consumption and

protect all people from tobacco exposure through provisions that direct countries to implement tobacco control programs

• 180 parties (as of December 2015)

MPOWER

Rationale of Review• To take stock of the global research

evidence base about the health effects of government tobacco control policies

• Provides policymakers with an evidence-based resource to help with deliberations and decision-making on setting priorities for national FCTC implementation

Overview of Systematic Reviews• This overview includes systematic reviews

evaluating government tobacco control policies

• Overviews of systematic reviews build on the strengths of individual reviews and add breadth by integrating the findings of many reviews together

Review Focus:• P Any individual who smokes and/or may be

affected by smoking (through SHS exposure)

• I Government tobacco control policies

• C Different interventions (e.g., clinical) or no intervention

• O Outcome measures relating to tobacco use, SHS exposure and primary health outcomes

Literature Search• Relevant reviews were identified through:– Electronic databases

• Health Evidence (HE), Health Systems Evidence (HSE), Rx for Change (RC), Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effects (DARE)

– References of other overviews of systematic reviews

– Monthly updates• HE, HSE, Quebec Public Health Research Network

– Two tobacco control experts

Study Selection

• Titles and abstracts screening• Full text review

• Two independent reviewers, with conflicts resolved through discussion

Exclusion Criteria• Reviews that did not follow a systematic

methodology• Other overviews of systematic reviews• Reviews evaluating clinical interventions• Reviews evaluating multicomponent tobacco control

programs if effects of individual interventions were not independently studied or could not be differentiated

• Reviews evaluating recall of media campaigns and perceptions of smoking as outcome measures

• No exclusions on the basis of language

Data Extraction• Following variables were extracted

from the reviews into a summary table:– Number of studies included– Year of last search– Key findings from review

Risk of Bias• Quality ratings given to each review by their

source databases were extracted– HE

• Independent quality assessment tool specific for public health intervention literature

– HSE and RC• AMSTAR

– CDSR and DARE• No numerical quality rating; quality assessment was

independently performed using the AMSTAR tool

Review Prioritization• In order to focus on most recent and

accurate evidence, we prioritized:– Strong and moderate quality reviews

(based on HE or AMSTAR tools); and– Reviews published since 2000

Findings• MPOWER components were used as

organizing framework, with an additional FCTC provision (Restrict sales to minors)– No reviews found for Monitor tobacco use and

prevention policies

• Outcomes grouped into seven categories:– Tobacco consumption, smoking prevalence,

smoking cessation, smoking initiation, SHS exposure, medical conditions, hospitalization

Findings

Protect people from tobacco smokeNumber of Reviews 12Quality 3 strong, 8 moderate, 1 moderate

(HE)/strong (HSE)Findings • 8 reviews on smoking behaviour; 6

reported beneficial effects• 3 reviews on SHS; all reported

reductions in SHS exposure• 6 reviews on health outcomes; all

reported reductions in adverse effects

Findings

Offer help to quit tobacco useNumber of Reviews 12Quality 8 strong, 4 moderateFindings • 2 reviews on financial assistance for

smokers; both reported beneficial effects on smoking behaviour

• 8 reviews on incentives and competitions for smokers; 4 reported beneficial effects on smoking behaviour

• 3 reviews on provider-directed financial interventions; all reported no effect on smoking behaviour

Findings

Warn about the dangers of tobaccoNumber of Reviews 9Quality 4 strong, 5 moderateFindings • 3 reviews on health warning labels or

plain packaging on tobacco products; 2 reported beneficial effects on smoking behaviour

• 7 reviews on mass media campaigns; 4 reported beneficial effects on smoking behaviour (as part of multicomponent tobacco control programs)

Findings

Enforce bans on tobacco advertising, promotion and sponsorshipNumber of Reviews 4Quality 4 moderateFindings • No reviews reported beneficial effects

on smoking behaviour• Large amount of evidence linking

advertisements and tobacco use• Individual studies suggest scope

and enforcement are critical

Findings

Raise taxes on tobaccoNumber of Reviews 6Quality 1 strong, 5 moderateFindings • 5 reported beneficial effects on

smoking behaviour• Negative price elasticities of

demand for increases in cigarette prices and smoking behaviour

Findings

Restrict sales to minorsNumber of Reviews 5Quality 5 moderateFindings • Inconsistent evidence on effects on

smoking behaviour• If effective, appear to depend on

robust enforcement

Principal Findings• Strongest evidence for smoking bans and price

increases of tobacco products • Positive results also found for mass media

campaigns (as part of multicomponent programs) and cigarette packaging interventions

• Financial assistance reducing the costs of smoking cessation interventions and financial incentives may be effective strategies

• Limited evidence found for advertising restrictions and youth access restrictions

Strengths and Limitations• Strengths

– Synthesis of large number of studies (over 1150)– Systematic and transparent search protocol– Reviews prioritized by quality and publication date

• Limitations– Search did not include unpublished reviews– Reviews in other disciplines may have been

excluded or have low quality ratings– Loss of study intricacies and details– Reviews on multicomponent interventions

excluded

Future Directions• Effectiveness of smoke-free policies and tobacco

price increases is well established• Further evaluations of the remaining interventions• Studies of the various factors that can influence

effectiveness and feasibility (cost, local context, political barriers and implementation strategies)

• Studies of the synergistic effects of multicomponent programs and which which combinations of policies are most effective and/or feasible

• “Endgame proposals” to eliminate tobacco use

Overall Summary and Implications• Countries should ideally implement policies

concurrently to develop multicomponent programs

• Regulations that ban smoking and increase tobacco product prices should be prioritized if needed when resources are constrained

• Other FCTC provisions can further strengthen and work synergistically with these priority policies

Government tobacco control policies improve health outcomes of the general populationA.Strongly agreeB.AgreeC.NeutralD.DisagreeE.Strongly disagree

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Poll Question #6

Poll Question #7Do you agree with the findings of this review?A.Strongly agreeB.AgreeC.NeutralD.DisagreeE.Strongly disagree

Questions?

A Model for Evidence-Informed Decision

Making

National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-Making in Public Health (Fact Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]

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