improving the health of manitobans: economic analysis and business case heart and stroke foundation...

Improving the Health of Manitobans:

Economic Analysis and Business Case

Heart and Stroke Foundation of

Manitoba

October 14, 2009

Overview of Presentation

• Understanding the Manitoba Context

• Prevalence and Historical Trends in the Risk Factors

• Risk Factors and the Burden of Disease

• The Economic Burden of the Risk Factors in Manitoba

• The Benefits of Reducing Risk Factors

2

Overview of Presentation

• Identify ‘Best Practices’ for Reducing the Risk Factors

• Estimating the Cost of Implementing ‘Best Practices’

• Cost-Benefit Analysis

3

Caveats• Research Project(s)?

Each step could be it’s own research project

• Business Case?Need to convince decision-makers

• Business Plan?Detailed plan for moving forward in a certain direction

• Focus on Tobacco consumptionUnhealthy eating / ObesityPhysical inactivity

4

Understanding the Manitoba Context

• Relevant policies/legislation/regulations in Manitoba

• Manitoba’s partners in healthy living

• Current programs with a focus on the risk factors in Manitoba

5

Understanding the Manitoba Context

• ProcessReview websites, grey literature, etc. E.g.

CPAC PPAG review of policy and legislation as it relates to food, physical activity, etc. in Canada

Input from Steering Committee and Reference Group

Interviews – personal and telephone

6

Prevalence and Historical Trends in the Risk Factors (or, What’s the Problem?)

• Recent study completed for CPAC – “An Overview of Selected Cancers and Modifiable Cancer Risk Factors in Canada”

• Covers the current risk factors as well as a few others (alcohol, breastfeeding)

• Full report available at www.krueger.ca

7

Canada BC AB SK MB ON QC NB NS PE NL YK/NT/NU

Males 21.5% 17.3% 23.7% 22.7% 19.4% 21.0% 23.3% 23.1% 22.0% 23.4% 21.9% 34.6%Females 17.8% 14.1% 18.4% 21.3% 17.8% 16.2% 20.9% 19.3% 20.5% 17.2% 20.8% 34.7%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

% o

f Pop

ulati

on A

ge 1

5+

Provinces and Territories

Figure 2: Prevalence of Current SmokersCanada and its Provinces and Territories, by Males and Females, 2005

Males

Females

Source: Canadian Community Health Survey, 2005

Canada BC AB SK MB ON QC NB NS PE NLYK/NT/

NU

Males 34.5% 36.5% 30.5% 28.1% 30.8% 35.8% 36.6% 27.4% 27.3% 25.4% 23.6% 32.2%

Females 48.0% 48.4% 47.9% 45.6% 42.3% 47.6% 53.3% 39.5% 38.3% 37.3% 29.4% 41.9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% o

f Pop

ulati

on A

ge 1

2+


Figure 5: Vegetable and Fruit Consumption5 or More Times per Day, By Males and Females

Canada and its Provinces and Territories, 2003

MalesFemales


Canada BC AB SK MB ON QC NB NS PE NL YK/NT/NU

Males 16.9% 14.2% 17.7% 23.1% 20.0% 16.5% 15.8% 22.7% 21.0% 24.2% 25.6% 21.6%

Females 14.7% 12.7% 14.5% 19.1% 17.1% 14.5% 13.0% 23.4% 21.5% 22.1% 23.2% 24.6%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

% o

f Pop

ulati

on A

ge 1

8+


Figure 9: Prevalence of Obesity Among AdultsCanada and its Provinces and Territories, 2005

Males

Females

Source: Canadian Community Health Survey, 2005Note: Obesity = BMI 30

1985 1990 1994/95 1996/97 1998/99 2000/01 2003

Class III Obesity(BMI ≥ 40) 0.3% 0.4% 1.0% 0.7% 0.8% 1.0% 1.3%

Class II Obesity(BMI = 35-39.99) 0.8% 1.4% 2.2% 2.1% 2.9% 3.0% 3.0%

Class I Obesity(BMI = 30-34.99) 5.1% 7.9% 10.4% 10.2% 11.2% 11.3% 11.5%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

% o

f Adu

lts

Year

Figure 8: Prevalence of Obesity Among AdultsCanada, 1985 to 2003

Class III Obesity(BMI ≥ 40)

Class II Obesity(BMI = 35-39.99)

Class I Obesity(BMI = 30-34.99)

Source: Katzmarzyk and Mason, Canadian Medical Association Journal, 2006

Canada BC AB SK MB ON QC NB NS PE NLYK/NT/

NU

Males 54.8% 60.0% 53.6% 51.8% 51.4% 56.2% 52.3% 49.5% 51.0% 45.1% 50.0% 55.8%

Females 49.7% 58.1% 55.5% 48.9% 45.8% 49.6% 45.0% 43.7% 47.4% 43.1% 41.4% 50.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% o

f Pop

ulati

on A

ge 1

2+


Figure 7: Leisure-Time Physical Activity by Males and Females% Physically Active

Canada and its Provinces and Territories, 2005

Males

Females


Selected Factors NotesSmoking % of population aged 15+ who are current smokersVegetable/Fruit Consumption % of population aged 12+ eating V/F at least 5 times per dayPhysical Activity % of population aged 12+ physically active during leisure timeObesity % of population aged 18+ (excluding pregnant women) with a BMI of 30+Alcohol Consumption (males) % of male population aged 12+ who consume three or more drinks per dayAlcohol Consumption (females) % of female population aged 12+ who consume two or more drinks per dayBreastfeeding % of new mothers breastfeeding at least 4 months

Selected CancersAll Cancers Lung Cancers Colorectal Cancers Pancreatic Cancers Age-standardized incidence rate / 100,000, five-year average (2000-2004)Kidney CancersOesophageal CancersBreast Cancers Corpus Uteri Cancers

13

BC AB SK MB ON QC NB NS PESelected Factors

Smoking 17.3% 23.7% 22.7% 19.4% 21.0% 23.3% 23.1% 22.0% 23.4%Vegetable/Fruit Consumption 36.5% 30.5% 28.1% 30.8% 35.8% 36.6% 27.4% 27.3% 25.4%Physical Activity 60.0% 53.6% 51.8% 51.4% 56.2% 52.3% 49.5% 51.0% 45.1%Obesity 14.2% 17.7% 23.1% 20.0% 16.5% 15.8% 22.7% 21.0% 24.2%Alcohol Consumption 8.4% 8.2% 6.4% 6.3% 9.3% 8.0% 8.1% 8.7% 4.7%

Selected CancersAll Cancers 430.3 481.7 474.3 472.6 456.9 487.0 490.2 532.0 530.0 Lung Cancers 58.6 61.1 63.5 70.9 64.3 99.3 93.4 88.7 83.0 Colorectal Cancers 54.0 58.6 61.0 64.9 59.9 67.9 59.4 76.1 66.0 Pancreatic Cancers 9.59 10.92 10.20 10.84 9.06 12.45 12.58 11.40 11.20 Kidney Cancers 10.26 14.57 15.69 17.87 12.21 15.64 17.74 18.12 14.62 Oesophageal Cancers 6.56 5.60 5.32 5.29 6.14 5.62 6.20 7.85 9.27

Most Favourable Least Favourable

Table 10: An Overview of Selected Factors that Modify Cancer Risk and Cancers in Canada: Males

Province

14

BC AB SK MB ON QC NB NS PESelected Factors

Smoking 14.1% 18.4% 21.3% 17.8% 16.2% 20.9% 19.3% 20.5% 17.2%Vegetable/Fruit Consumption 48.4% 47.9% 45.6% 42.3% 47.6% 53.3% 39.5% 38.3% 37.3%Physical Activity 58.1% 55.5% 48.9% 45.8% 49.6% 45.0% 43.7% 47.4% 43.1%Obesity 12.7% 14.5% 19.1% 17.1% 14.5% 13.0% 23.4% 21.5% 22.1%Alcohol Consumption 6.6% 5.8% 5.1% 4.9% 5.7% 5.9% 3.4% 4.1% 4.2%Breastfeeding 60.2% 54.0% 45.0% 48.6% 48.0% 39.8% 37.7% 36.5% 31.6%

Selected CancersAll Cancers 326.5 358.8 338.7 366.6 353.2 357.6 347.8 374.3 366.9 Lung Cancers 43.6 43.3 42.5 52.0 41.6 50.5 48.6 52.4 48.4 Colorectal Cancers 37.8 38.1 41.2 43.3 41.4 43.3 42.1 50.1 52.0 Pancreatic Cancers 8.69 8.75 7.42 8.42 7.49 9.21 9.51 8.11 7.32 Kidney Cancers 5.44 8.30 7.86 9.13 7.30 8.44 10.49 10.29 8.57 Oesophageal Cancers 2.34 1.59 1.60 1.66 1.89 1.32 1.95 1.65 NABreast Cancers 92.9 103.2 95.4 101.4 99.1 101.8 94.4 99.6 102.3 Corpus Uteri Cancers 17.7 21.0 19.7 24.0 19.8 16.8 16.2 18.0 21.3

Most Favourable Least Favourable

Province

Table 11: An Overview of Selected Factors that Modify Cancer Risk and Cancers in Canada: Females

15

Risk Factors and the Burden of Disease

• What evidence is there for the relationship between the risk factors and the burden of disease?

• Review from “The Health Impact of Smoking & Obesity and What to Do About It” (2007) by Krueger, Williams, Kaminsky and McLean

16

Population Attributable Fraction of Disease Burden due to Smoking

Category Disease Female PAF

Male PAF

Cancers Lip, Oral Cavity, Pharynx 47.8% 74.8%

Esophagus 58.1 72.8

Pancreas 23.8 22.8

Larynx 73.8 83.3

Trachea, Lung, Bronchus 71.8 88.3

Cervix Uteri 13.3 ---

Urinary Bladder 27.9 47.6

Kidney, Other Urinary 5.2 39.6

Circulatory Diseases Hypertension 10.8 18.9

Ischemic Heart Disease 12.9 21.0

Other Heart Diseases 9.0 19.2

Cerebrovascular Disease 9.2 14.1

Arteriosclerosis 8.8 27.4

Aortic Aneurysm 50.6 65.1

Other Arterial Diseases 15.2 14.1

Respiratory Disease Pneumonia, Influenza 14.3 23.0

Chronic Bronchitis, Emphysema 80.9 90.9

Chronic Airway Obstruction 75.1 81.7

Perinatal Conditions Short Gestation, Low Birth Weight 9.9 10.3

(< 1 Year Old) Respiratory Distress Syndrome 3.8 9.1

Other Respiratory Conditions of Newborn

5.1 9.2

Sudden Infant Death Syndrome 14.6 11.4

17

Disease Summary RR 95% CI PAF

Hypertension 4.50 4.15 - 4.84 34.0%Type 2 diabetes 3.73 3.45 - 4.06 28.6%Gall bladder disease 3.33 2.86 - 3.85 25.5%Coronary heart disease 2.24 2.04 - 2.45 15.4%Osteoarthritis 1.99 1.76 - 2.24 12.7%Stroke 1.50 1.28 - 1.77 6.8%Postmenopausal breast cancer 1.47 1.40 - 1.54 6.5%Colon cancer 1.45 1.23 - 1.71 6.2%

Source: Katzmarzyk and Janssen,Can J Appl Physiol (2004)

Relative Risk Estimates

Canada, 2001and Population Attributable Fraction For Obesity

18

0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

<21.0 21.0-22.9 23.0-24.9 25.0-26.9 27.0-29.9 30.0-32.9 33.0-34.9 35.0-39.9 ≥40

Rel

ativ

e R

isk

Body Mass Index

Body-Mass Index and Relative Risk of DeathFrom All Causes: Women

Note: The vertical bars represent the 95% CI

Overweight Obese

Source: Hu et al. NEJM (2004)

Disease Summary RR 95% CI PAF

Stroke 1.60 1.42 - 1.80 24.3%Osteoarthritis 1.59 1.40 - 1.80 24.0%Type 2 diabetes 1.50 1.37 - 1.63 21.1%Coronary heart disease 1.45 1.38 - 1.54 19.4%Colon cancer 1.41 1.31 - 1.53 18.0%Breast cancer 1.31 1.23 - 1.38 14.2%Hypertension 1.30 1.16 - 1.46 13.8%

Source: Katzmarzyk and Janssen,Can J Appl Physiol (2004)

Relative Risk Estimates

Canada, 2001and Population Attributable Fraction For Physical Inactivity

20

≥3.5 1.0 - 3.4 <1.0

BMI <25.0 1.00 1.18 1.55 BMI 25.0 - 29.9 1.28 1.33 1.64 BMI ≥30 1.91 2.05 2.42

≥3.5 1.0 - 3.4 <1.0

BMI <25.0 1.00 1.51 1.89 BMI 25.0 - 29.9 1.58 2.06 2.52 BMI ≥30 2.87 4.26 4.73

≥3.5 1.0 - 3.4 <1.0

BMI <25.0 1.00 1.09* 1.32 BMI 25.0 - 29.9 1.22 1.20 1.39 BMI ≥30 1.57 1.44 1.68

* Not significant, confidence interval includes 1.0Source Hu et al, NEJM, 2004.

Cardiovascular DiseasesPhysical Activity (hr/wk)

CancersPhysical Activity (hr/wk)

Physical Activity (hr/wk)

Relative Risk of DeathBy BMI and Physical Activity

All Causes

21

The Economic Burden of the Risk Factors (in Manitoba)

• Excess cost per individual with the risk factors

• Direct and indirect costs

• Annual cost to the province

23

B.C. N.B.Total Total

Direct Costs 525.00$ 120.00$ Indirect Costs

Losses in ProductivityIncreased Life Insurance Premiums 27.28$ 7.20$ Designated Smoking Areas 30.90$ 8.00$ Absenteeism 89.00$ 18.20$ Unscheduled Smoking Breaks 514.00$ 174.90$ Subtotal Losses in Productivity 661.18$ 208.30$

Premature Mortality 904.00$ 218.00$

Subtotal Indirect 1,565.18$ 426.30$

Total Costs 2,090.18$ 546.30$

Number of Smokers 542,240 153,500

Estimated Cost per Smoker (in $)Direct Cost 968.21$ 781.76$ Indirect Costs - Productivity 1,219.35$ 1,357.00$ Indirect Costs - Premature Mortality 1,667.16$ 1,420.20$ Total 3,854.71$ 3,558.96$

Year of Cost Estimate 2002 2001

Adjusting Costs to 2004$ (use 'Health and Personal Care' component of the Canadian CPI)Direct Costs 995.21$ 794.55$ Indirect Costs - Productivity 1,253.36$ 1,379.21$ Indirect Costs - Premature Mortality 1,713.66$ 1,443.44$ Total 3,962.23$ 3,617.20$

Smoking in British Columbia and New BrunswickEstimated Costs (in Million$) in 2001/02

B.C. estimates are based on Bridge J. and Turpin B. The cost of smoking in British Columbia and the economics of tobacco control . Health Canada, February 2004.

N.B. estimates are based on Coleman R., Rainer R. and Wilson J. The cost of smoking in New Brunswick and the economics of tobacco control . GPI Atlantic, April 2003.

24

PAF Direct Indirect Total Direct Indirect Total

Obesity (BMI ≥30)Coronary heart disease 15.4% 2,429.6$ 6,296.0$ 8,725.6$ 374.6$ 970.7$ 1,345.3$ Stroke 6.8% 1,691.5$ 1,458.4$ 3,149.9$ 115.8$ 99.9$ 215.7$ Hypertension 34.0% 1,530.2$ 1,352.9$ 2,883.1$ 519.8$ 459.6$ 979.4$ Colon cancer 6.2% 278.9$ 1,331.9$ 1,610.8$ 17.3$ 82.6$ 99.9$ Postmenopausal breast cancer 6.5% 350.1$ 1,671.5$ 2,021.6$ 22.6$ 108.0$ 130.6$ Type 2 diabetes 28.6% 800.8$ 588.7$ 1,389.5$ 229.3$ 168.6$ 397.9$ Gall bladder disease 25.5% 691.4$ 452.0$ 1,143.4$ 176.4$ 115.3$ 291.7$ Osteoarthritis 12.7% 1,121.3$ 5,814.4$ 6,935.7$ 142.5$ 738.7$ 881.2$

Total 15.6% 8,893.8$ 18,965.8$ 27,859.6$ 1,598.3$ 2,743.4$ 4,341.7$

Source:

2,787,406 2000/01 CCHS number of people in Canada who are obese (BMI ≥30)

Estimated Cost per Individual with the Risk Factor in CanadaDirect Indirect Total

2001$ 573.40$ 984.21$ 1,557.61$ 2004$ 598.00$ 1,026.44$ 1,624.45$

Estimated Cost for ObesityCanada, 2001 (in millions$)

(use 'Health and Personal Care' component of the Canadian CPI)

Attributable CostsTotal Costs

Katzmarzyk P.T. and I. Janssen. The economic cost associated with physical inactivity and obesity in Canada: An update, Canadian Journal of Applied Physiology . 2004, 29(1): 90-115.

25

PAF% Direct Indirect Total Direct Indirect Total

Physical InactivityCoronary heart disease 19.4% 2,429.6$ 6,296.0$ 8,725.6$ 471.4$ 1,221.7$ 1,693.1$ Stroke 24.3% 1,691.5$ 1,458.4$ 3,149.9$ 411.0$ 354.4$ 765.4$ Hypertension 13.8% 1,530.2$ 1,352.9$ 2,883.1$ 211.6$ 187.1$ 398.7$ Colon cancer 18.0% 278.9$ 1,331.9$ 1,610.8$ 50.2$ 239.6$ 289.8$ Breast cancer 14.2% 448.8$ 2,143.0$ 2,591.8$ 63.8$ 304.5$ 368.3$ Type 2 diabetes 21.1% 800.8$ 588.7$ 1,389.5$ 169.0$ 124.2$ 293.2$ Osteoporosis 24.0% 1,012.0$ 5,247.7$ 6,259.7$ 242.8$ 1,259.0$ 1,501.8$

Total 20.0% 8,191.8$ 18,418.6$ 26,610.4$ 1,619.8$ 3,690.5$ 5,310.3$

Source:

12,661,729 2000/01 CCHS number of people in Canada who are physically inactive.

Estimated Cost per Individual with the Risk Factor in CanadaDirect Indirect Total

2001$ 127.93$ 291.47$ 419.40$ 2004$ 133.42$ 303.97$ 437.39$

Estimated Cost for Physical InactivityCanada, 2001 (in millions$)

(use 'Health and Personal Care' component of the Canadian CPI)

Attributable CostsTotal Costs

Katzmarzyk P.T. and I. Janssen. The economic cost associated with physical inactivity and obesity in Canada: An update, Canadian Journal of Applied Physiology . 2004, 29(1): 90-115.

26

Est. Annual Est. Total$ per $ in 2004

Individual ($million)

Smoking Direct Costs 995$ 679$ Indirect Costs - Productivity 1,253$ 856$ Indirect Costs - Premature Mortality 1,714$ 1,170$ Total Smoking 3,962$ 2,705$

Physical Inactivity Direct Costs 133$ 189$ Indirect Costs 304$ 432$ Total Physical Inactivity 437$ 621$

Obesity (BMI ≥ 30, does not include overw eight w ith BMI of 25.0-29.9)

Direct Costs 598$ 180$ Indirect Costs 1,026$ 309$ Total Obesity 1,624$ 489$

Total 3,816$

Estimated Cost of Risk FactorsIn British Columbia, 2004

28

The Benefits of Reducing Risk Factors

• What evidence is there that a change in risk factors is associated with a change in health?

• Research complicated by the fact that changes in behavior (e.g. quitting smoking) often associated with diagnosis of a disease (e.g. cancer)

• Health improvements not always immediate

29

The Benefits of Reducing Risk Factors (cont’d)

• Weight loss – intentional (24% mortality rate)

vs. unintentional (31% mortality rate) (Greg et al. Ann Int Med (2003)

• Smoking cessation associated with a spike in costs

• Early death of smokers spares them from poor health during their later years (if they had not smoked)

30

-

0.20

0.40

0.60

0.80

1.00

1.20

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Fra

cti

on

of E

xc

es

s R

isk

Year Since Quitting

Reduced Risk of DeathAfter Quitting Smoking

By Cause of Death

CHD Lung Cancer COPD

31

Identify ‘Best Practices’ for Reducing the Risk Factors

• Review of the available literature

• Much more research on effective interventions for smoking cessation

• Identify ‘best’ and ‘promising’ interventions, particularly for other risk factors

32

Identify ‘Best Practices’ (cont’d)

What can we learn from the ‘Tobacco Wars’ about effective interventions?

1.Increasing Prices2.Reducing Opportunities to Promote the

Product3.Smoke-free Public Places4.Counter Advertising5.Primary Care Based Cessation Programs

33


What can we learn from the ‘Tobacco Wars’? 1. No single intervention can account for the successes

seen since the 1960s2. Each intervention is enhanced synergistically by other

components3. Required systemic changes (ban on advertising, price

increases, legislated smoke-free places) and social ‘denormalization’

4. Governments and communities must work together with adequate financial and organizational resources over the long haul

5. Interventions must be available for individuals who seek to make a lifestyle change

35


• Overweight: What Can we Learn from the ‘Tobacco Wars’ - DifferencesFood and activity are essential; tobacco is

notPossible negative consequences

(disordered eating)Underlying genetic/disease conditionsLimited research on effective interventions

36


Overweight: What Can we Learn from the ‘Tobacco Wars’ - SimilaritiesSocial influences and advertising

pressures influence what we eatEnvironmental constraints can lead to

limitations on physical activity‘Obesogenic environment’

37


• Regulatory and Economic Interventions (cont’d)

Consider restrictions on food advertising aimed at children

Consider a focused trial of taxation measures for specific unhealthy foods

Continue to protect against creative attempts by the tobacco industry to market their product, e.g., retail “power walls,” product placements, smoking in movies & magazines

Improve compliance with restrictions on tobacco sales to minors

39

Identify ‘Best Practices’ (cont’d)• Community-Based Interventions

Establish Community Action Coordinators (2 per electoral riding) to mobilize strategies for risk factor reduction

Provide modest funding for up to 1,200 community groups throughout the province with ideas on how to address risk factors

Develop a strategic media plan with clear, common messages for different at-risk populations with well-conceived short and long term advocacy goals

Consider subsidizing pedometers as a source of instant feedback to individuals who are attempting to become more physically active

Implement “point-of-decision” prompts to encourage healthy behaviours

Encourage and support walking groups and physical activity events Enhance access to places of physical activity; both indoor and

outdoor 40

Identify ‘Best Practices’ (cont’d)• School-Based Interventions

Expand Action Schools! BC program and encourage a more rapid implementation of some of its recommendations, plus coordination with anti-smoking resources, to move towards significant levels of primordial prevention among young people

Focus on environmental approaches to risk factor interventions, including options for promoting healthy foods, curtailing access to unhealthy foods, creating opportunities for physical activity and tobacco free sites.

• Workplace-Based Interventions In partnership with WCB, unions, business and others, offer

funding to assist employers and employees to create a healthier work environment, from stairway walking campaigns to exercise facilities and healthy food choices

41


• Clinical Interventions and Management Implement a program of ‘prevention detailing’ to provide

education and feedback to enable primary health care providers to more fully address risk factors

Cover out-of-pocket expenses for nicotine replacement therapy initiated within a recognized clinical program

Provide reimbursement for lifestyle counselling around physical activity, healthy eating and living smoke free

Provide compensation to primary health care providers for lifestyle counselling around physical activity, healthy eating and living smoke free

42

Estimating the Cost of Implementing ‘Best Practices’

• High level costing of implementing the major interventions

• E.g. from increased taxation to community-based action co-ordinators to prevention detailing, etc.

43

6 Year2005/06 2006/07 2007/08 2008/09 2009/2010 2010/11 Total

Regulatory and Economic InterventionsNet Taxation of Cigarettes (7.37)$ (12.16)$ (14.20)$ (13.03)$ (8.65)$ (0.95)$ (56.37)$ Tax Incentives - Physical Activity 4.42$ 4.38$ 4.34$ 4.30$ 4.27$ 4.24$ 25.95$

Community-based InterventionsMass Media Campaign 26.81$ 27.61$ 28.44$ 29.30$ 30.17$ 31.08$ 173.42$ Community Action Coordinators 6.93$ 13.63$ 14.04$ 14.46$ 14.89$ 15.34$ 79.28$ Community-Based Funding 4.50$ 9.27$ 9.55$ 9.83$ 10.13$ 10.43$ 53.72$ Pedometers 0.81$ 0.87$ 0.92$ 0.97$ 1.03$ 1.08$ 5.69$

School-based InterventionsAllocation to Schools 33.86$ 34.53$ 35.18$ 35.82$ 36.53$ 37.31$ 213.25$

Clinical Intervention & ManagementPrevention Detailing 2.35$ 2.50$ 2.66$ 2.83$ 3.02$ 3.14$ 16.49$ Primary Care Based Smoking 6.41$ 9.66$ 13.13$ 15.40$ 16.25$ 17.16$ 78.00$ Cost of NRT 6.51$ 9.51$ 12.56$ 14.30$ 14.65$ 15.02$ 72.54$ Lifestyle Counselling 8.42$ 13.49$ 19.04$ 25.12$ 26.50$ 27.95$ 120.52$

Special Populations 20.00$ 20.60$ 21.22$ 21.85$ 22.51$ 23.19$ 129.37$

Miscellaneous Costs 10.00$ 10.30$ 10.61$ 10.93$ 11.26$ 11.59$ 64.68$

Administration, Surveillance, Evaluation 12.37$ 14.42$ 15.75$ 17.21$ 18.25$ 19.66$ 97.65$

Total Cost 136.03$ 158.61$ 173.22$ 189.27$ 200.80$ 216.24$ 1,074.18$

Fiscal Year

SummaryEstimated Cost (in Million$)

44

Cost-Benefit Analysis

• Combining information onPotential TargetsCost of interventions required to achieve

targetsPotential costs avoided if the targets are

achieved

45

Current BCHLA %

Situation 2010 Target Change

B.C. Total (Positive)Non Smokers 0.81 0.87 7%

Healthy Diet 0.40 0.70 74%

Physically Active 0.58 0.70 20%

Healthy Weight 0.52 0.70 34%

B.C. Total (Negative)Smokers 0.19 0.13 -30%

LT 5 F&V / Day 0.54 0.30 -44%

Inactive 0.39 0.30 -23%

Overweight (BMI 25 - 29) 0.31 0.22 -29%Obese (BMI ≥ 30) 0.12 0.08 -29%

British ColumbiaBCHLA Risk Factor Targets

Based on 2003 Baseline Results

46

$0

$100

$200

$300

$400

$500

$600

$700

$800

$900

2005 2006 2007 2008 2008 2010

Do

llars

(Mill

ion

s)

Year

Estimated Cost AvoidanceAssociated with Achieving BCHLA Targets

By Cost Category

Productivity

Indirect

Direct

47

$0

$100

$200

$300

$400

$500

$600

$700

$800

$900

2005 2006 2007 2008 2008 2010

Do

llars

(Mill

ion

s)

Year

Estimated Cost AvoidanceAssociated with Achieving BCHLA Targets

By Risk Factor

Obesity

Inactivity

Smoking

48

6 Year2005/06 2006/07 2007/08 2008/09 2009/2010 2010/11 Total

Program Costs 136.0$ 158.6$ 173.2$ 189.3$ 200.8$ 216.2$ 1,074.2$

Costs AvoidedDirect 12.3$ 38.8$ 68.9$ 102.2$ 138.2$ 177.4$ 537.7$ Indirect 23.1$ 72.8$ 128.9$ 190.5$ 256.9$ 328.9$ 1,001.0$ Productivity 21.7$ 66.2$ 112.2$ 159.4$ 207.8$ 257.4$ 824.8$ Total 57.2$ 177.8$ 310.0$ 452.1$ 602.9$ 763.6$ 2,363.5$

Net Costs Avoided (78.9)$ 19.2$ 136.8$ 262.8$ 402.1$ 547.4$ 1,289.3$

Fiscal Year

SummaryEstimated Program Cost and Costs Avoided

(in Million$)

49

Logical Pathway

Public Investment

Interventions

Healthy Living Improvement

Chronic Disease Reduction

Cost Avoidance

50

Lessons Learned (What can we do better in Manitoba?)

• ‘Stretch’ targets too ambitious over too short a time frame – politically motivated

• Clearer linkage between the effectiveness of interventions and actual changes in population behavior required

51

Four Fundamentals: What Will it Take?

1. “A Long Obedience in the Same Direction”

2. Employing proven, comprehensive interventions

3. Risking innovation to increase knowledge4. Addressing behavioural factors in the

context of vital environmental changes

52

0%

10%

20%

30%

40%

50%

60%

% D

aily

Sm

oker

s Age

15+

Year

Prevalence of Daily Smokers by Males and FemalesCanada, 1964 to 2006

Males Females53

Employing Comprehensive Interventions

• Veugelers and Fitzgerald, March 2005, AJPH

• Nova Scotia 5th gradersComprehensive program

– Nutritious food– Encourages physical activity– Health promotion for teachers– Results 17.9% overweight; 4.1% obese

54

Employing Comprehensive Interventions (cont’d)

Limited nutrition program– Provide breakfast, or– Ban junk food– Results 34.2% overweight; 10.4% obese

No programs– Results 32.8% overweight; 9.9% obese

55

Risking Innovation to Increase Knowledge

• Implement promising interventions – incomplete knowledge

• But within a culture of continuous learning, administrative flexibility and program adaptability

56

The “Dance” Between the Environment and the Individual

• In the absence of changes to the environment, encouraging individual choice and goal-setting will not get you very far.

• Individuals must be supported in their behavioral change attempts.

57

Comments / Questions?

Further Details

• The Winning Legacy series of reports available at ww.krueger.ca

• Smoking & Obesity Monograph by Krueger et al.

59

http://www.krueger.ca/

Tobacco - Effective Interventions

• Tobacco Control

• 40+ years of experience and hundreds of studies can be summarized into five general areas of effective interventions

60


1) Increasing PricesThe single most effective intervention to

reduce initiation and increase cessation10% price increase leads to a 3-5%

reduction in demandAdolescents more sensitive to price (6-

10%)

61


2) Reducing Opportunities to Promote the ProductPromotion works! That is why companies

spend millions on advertisingPart of the ‘denormalization’ processCompanies continue to find ways e.g.

product placement in movies and TV

62


3) Smoke-free Public PlacesProtects non-smokers from the health

consequences of SHSResults in a number of positive spin-offsContinued ‘denormalization’Reduction in the number of cigarettes

smoked and possibly increases cessation attempts

63


4) Counter AdvertisingHigh impact media advocacyWorks best in the context of an overall

comprehensive strategyYoung people, a primary audience, discount

future health effectsFocus on the complicity and manipulation of

the tobacco industry e.g. Lovell’s You Are The Target Big Tobacco: Lies, Scams - Now the Truth

64


5) Primary Care Based Cessation ProgramsUnsupported quit attempts are

successful only 5-10% of the time4-8 sessions with NRT can increase this

to 20+%Reduce the number of quit attempts from

10-20 to less than 5 per successful cessation

65

improving the health of manitobans: economic analysis and business case heart and stroke foundation...

Documents

risk factors risk factors

current risk factors

modifiable cancer risk

economic interventions

effective interventions

economic burden

essential tobacco

tobacco industry