Principal investigator: Viviane Pires Ribeiro
Article title: The Burden of Tobacco Use in Brazil and the Potential Benefits of Increasing Cigarette Taxes for the Economy and for Reducing Deaths and Illness
Article authors: Marcia Pinto, Ariel Bardach, Alfredo Palacios, Aline Biz, Andrea Alcaraz, Belen Rodriguez, Federico Augustovski and Andres Pichon-Riviere
Location of the intervention: Brazilian semi-arid
Sample size: 558.789 deaths
Sector: Health Insurance
Type of InterventionAnalysis of direct and indirect costs associated with major tobacco-related diseases.
Primary variable of interest: The cost of smoking.
Evaluation method: Experimental Evaluation (RCT)
Evaluation Context
Smoking is the leading risk factor for death from chronic non-communicable diseases worldwide, responsible for 6 million deaths annually. Of this total, approximately 603 deaths are attributable to passive smoking, 28% of which are in children. In 2019, about 4 out of 5 smokers lived in low- and middle-income countries, resulting in losses related to reduced productivity and high household expenses, factors that contribute to the worsening of poverty.
In the global context, Brazil stands out for its National Tobacco Control Policy, which integrates the guidelines of the World Health Organization's Framework Convention on Tobacco Control, ratified by the country more than ten years ago. Despite being one of the leaders in the number of smokers, Brazil registered a significant reduction in prevalence among men and women, from 56,5% to 55,8% respectively, between 1990 and 2015. However, the magnitude of the disease burden associated with smoking remains high, with approximately 147 deaths and 2,69 million years of life lost annually, and an annual cost of 23,37 billion reais to the health system.
Intervention Details
Pinto et al. (2019) estimate the mortality, morbidity, and societal costs associated with smoking in 2015 and the potential impact on health outcomes and the economy resulting from increased cigarette prices through taxes. To do this, the authors used demographic data obtained from the 2015 population projection by the Brazilian Institute of Geography and Statistics (IBGE), considering each individual in the cohorts by sex and age between 35 and 100 years.
The relative risk of developing each disease in smokers and former smokers compared to non-smokers was obtained in the study. Cancer Prevention Study II (CPS-II). The case fatality rate calculated by the model for certain conditions such as acute myocardial infarction (AMI), angina pectoris, and stroke was compared with available national statistics on ischemic coronary heart disease or cerebrovascular diseases. By dividing the mortality data grouped by ICD-10 codes by the Brazilian population, the absolute risk of mortality by cause, sex, and age was obtained. For the case fatality rate of neoplasms, the authors obtained specific prognostic data by cancer type, age, and sex using Globocan. Due to the unavailability of hospitalization data by sex, age, and ICD-10 code from supplementary health insurance, it was necessary to correct the data from the Unified Health System (SUS) to include all hospitalizations in the country in 2015.
Methodology Details
To conduct the analysis, Pinto et al. (2019) used two models: (i) a disease burden model associated with smoking, which allowed them to estimate the impact in terms of mortality, morbidity, and cost to society; and (ii) a tax model, applied to measure how a price increase would prevent deaths, illness, and costs to society based on different scenarios of cigarette price increases over ten years. Subsequently, the authors estimated the increase in tax revenue for the government generated by the tax increase.
The first model is a first-order Monte Carlo microsimulation mathematical model that, through a probabilistic simulation of each individual, incorporated the natural history, direct and indirect costs, and loss of quality of life associated with the main tobacco-related diseases. The selected diseases were: ischemic and non-ischemic heart disease, chronic obstructive pulmonary disease (COPD), pneumonia and influenza, stroke, and the following types of cancer: lung, mouth and pharynx, esophagus, stomach, pancreas, kidneys and renal pelvis, larynx, bladder, cervix, and myeloid leukemia.
While the second model was developed based on the application of percentage increases to cigarette prices, the authors calculated the expected impact on health outcomes using the national context to define three price increase scenarios: short, medium, and long term. Thus, the impact on health outcomes was calculated as the observed difference between both estimates of deaths, occurrence of events, loss of years of life, disability, and direct and indirect costs.
Results
The results show that in 2015, smoking was responsible for 156.337 deaths, 4,2 million years of life lost, 229.071 acute myocardial infarctions, 59.509 strokes, and 77.500 cancer diagnoses. The total cost was R$ 56,9 billion, of which 70% corresponded to the direct cost associated with healthcare and the remainder to the indirect cost due to lost productivity from premature death and disability. Passive smoking and perinatal causes totaled a cost of R$ 4,5 billion.
Over ten years, the impact of increases in cigarette prices, expressed in economic benefits, would range from R$ 55,1 billion (a 25% increase) to R$ 128,8 billion (a 75% increase). A 50% increase in cigarette prices would prevent 136.482 deaths, 507.451 cases of cardiovascular disease, 64.382 cases of cancer, and 100.365 strokes. The estimated economic benefit would be R$ 97,9 billion.
Lessons in Public Policy
In recent years, Brazil has adopted a policy of increasing taxes on cigarettes. In 2011, a new tax rate came into effect in the country. ad valorem For cigarettes, in addition to a minimum price policy per pack. The results found by Pinto et al. (2019) indicate that increasing prices would generate benefits in revenue (an increase of up to R$ 50 billion in 10 years). However, the success of the price and tax policy in avoiding costs, deaths, and illness presupposes the joint involvement of the governmental areas of health, finance, and justice due to the volume of the illegal cigarette market in the country.
Therefore, cost-effective measures to prevent deaths and illnesses due to smoking should be intensified to generate benefits for Brazilian society. In this context, the authors emphasize that the costs to society reflect a significant opportunity cost, and compensation for damages is a timely topic for debate on the tobacco control agenda. Such resources can be invested in the full implementation of the World Health Organization's Framework Convention on Tobacco Control, but should not be limited to this purpose alone, as other public policies could benefit from this compensation.
Reference
PINTO, M. et al. Burden of smoking in Brazil and potential benefit of increased cigarette taxes for the economy and for reducing deaths and illness. Cadernos de Saúde Pública, v. 35, p. e00129118, 2019.
