The perspectives of politicians on tobacco control in Turkey

Background

Tobacco use is a leading but preventable cause of non-communicable diseases and premature death. The legislature has a key role in setting tobacco control policies. Smoking trends are decreasing thanks to the introduction of effective tobacco control policies in Turkey and these policies may have been shaped by how politicians' interpreted social problems that were prominent during the development and implementation of tobacco regulations.

Aim

This paper explores the long-term national relationship between tobacco consumption, tobacco control policies and the associated political discourse in Turkey, considering the varying influences through national leadership on this important public health agenda. This relationship is studied by comparing a time series analysis of tobacco consumption trends with a policy analysis of the minutes of deliberations at the Grand National Assembly of Turkey (GNAT).

Methods

This study uses Bayesian time series analysis in order investigate whether the tobacco control policies and related activities influenced the annual per adult cigarette consumption in Turkey. We used a novel method to identify change points in tobacco trends and whether they correspond with key policy changes intended to alter usage after adjusting for the effect of other non-policy related covariates, such as the purchasing power. The policy analysis included an examination of the minutes of deliberations at the GNAT-which is the Turkish parliament and unicameral Turkish legislature-1 year before and 1 year after the break years associated with an increase or decrease in tobacco consumption.

Results and recommendations

Tobacco consumption increased with the encouragement of tobacco production and the entrance of multinational companies in the country in 1976 and 1993, respectively. The National Tobacco Law of 1996 and comprehensive amendments in 2008, including smoke-free public places and tax increases, appear to have helped reduce tobacco consumption in Turkey. The focus of Parliamentary discussions throughout this period changed, becoming less supportive of tobacco over time. However, throughout the period there remained discussions focussing on concerns around the implications for the economy and the privatization agenda, national agriculture and the welfare of farmers. Effective control appears to require certain political ingredients to be implemented: politicians who are well informed on tobacco control measures and understand the range of issues surrounding the policies (not only those directly health-related); and supportive public health information in the community. Evidence-based public health policy should be introduced to the politicians.

Effects of tobacco control policy on cardiovascular morbidity and mortality in Russia

Background

According to the Global Adult Tobacco Survey carried out in Russia in 2009, the country had one of the highest smoking prevalence rates in Europe. In response to this health and economic burden, Russia implemented a comprehensive Tobacco Control Law (TCL) in 2013, which has been associated with a 21.5% relative decline in adult smoking prevalence in 2016 compared with 2009. This study tests the impact of the TCL on cardiovascular disease (CVD) related health outcomes, including morbidity and mortality.

Method

The study evaluated the TCL as an intervention in a natural experiment during the period 2003-2015. A synthetic control was created as a comparator, using data from countries that did not have a comparable comprehensive tobacco control intervention. Changes in trends in CVD outcomes - hospital discharge rates (HDRs) and standardized death rates (SDRs) - were then compared to test for an impact associated with the TCL.

Results

Pre-intervention trends in CVD-related HDRs were similar between Russia and the synthetic control, but became divergent after the TCL with greater benefit observed in Russia. This implies a beneficial impact of the TCL on CVD related morbidity in the Russian population. Whilst SDRs continued to reduce in both Russia and the control, the impact of TCL is less clear.

Conclusion

This study provides further evidence to support comprehensive tobacco control in line with the WHO Framework Convention for Tobacco Control (WHO FCTC). Alongside a reduction in tobacco consumption, smoking-related CVD morbidity appears to benefit quite soon after implementation, whilst smoking-related deaths might need a longer post-intervention period to be detectable.

Variation across Romania in the health impact of increasing tobacco taxation

Background

Tobacco is the leading preventable cause of death globally and tobacco taxation is a cost-effective method of reducing tobacco use in countries and increasing revenue. However, without adequate enforcement some argue the risk of increasing illicit trade in cheap tobacco makes taxation ineffective. We explore this by testing sub-national variations in the impact of tobacco tax increases from 2009 to 2011, on seven smoking-related diseases in adults in Romania, to see if regions that are prone to cigarette smuggling due to bordering other countries see less benefit.

Method

We use a pragmatic natural experiment study approach to analyse the study period 2009-15. Findings from hospital episodes data relating to smoking-attributable diseases are analysed for six regional subgroups which are compared according to border characteristics with other countries.

Results

At a national level smoking-attributable diseases reduced over the study period especially around the tax increase years, with asthma showing the most significant decline. Sub-nationally there was no statistically significant correlation in variations between central regions and those bordering other countries.

Conclusion

There is a reassuring decline in hospitalizations for smoking-related diseases associated with the tax increases, and no sub-national association with smuggling risk measured by variation in the size of this effect and regions that border other countries. More comprehensive and progressive tobacco control in Romania should be implemented in line with the WHO Framework Convention for Tobacco Control.

Science organisations and Coca-Cola's 'war' with the public health community: insights from an internal industry document

Critics have long accused food and beverage companies of trying to exonerate their products from blame for obesity by funding organisations that highlight alternative causes. Yet, conclusions about the intentions of food and beverage companies in funding scientific organisations have been prevented by limited access to industry's internal documents. Here we allow the words of Coca-Cola employees to speak about how the corporation intended to advance its interests by funding the Global Energy Balance Network (GEBN). The documents reveal that Coca-Cola funded and supported the GEBN because it would serve as a 'weapon' to 'change the conversation' about obesity amidst a 'growing war between the public health community and private industry'. Despite its close links to the Coca-Cola company, the GEBN was to be portrayed as an 'honest broker' in this 'war'. The GEBN's message was to be promoted via an extensive advocacy campaign linking researchers, policy-makers, health professionals, journalists and the general public. Ultimately, these activities were intended to advance Coca-Cola's corporate interests: as they note, their purpose was to 'promote practices that are effective in terms of both policy and profit'. Coca-Cola's proposal for establishing the GEBN corroborates concerns about food and beverage corporations' involvement in scientific organisations and their similarities with Big Tobacco.

Revisiting the Corporate and Commercial Determinants of Health

We trace the development of the concept of the corporate determinants of health. We argue that these determinants are predicated on the unchecked power of corporations and that the means by which corporations exert power is increasingly unseen. We identify four of the ways corporations influence health: defining the dominant narrative; setting the rules by which society, especially trade, operates; commodifying knowledge; and undermining political, social, and economic rights. We identify how public health professionals can respond to these manifestations of power.

A conceptual framework for investigating the impacts of international trade and investment agreements on noncommunicable disease risk factors

We developed a conceptual framework exploring pathways between trade and investment and noncommunicable disease (NCD) outcomes. Despite increased knowledge of the relevance of social and structural determinants of health, the discourse on NCD prevention has been dominated by individualizing paradigms targeted at lifestyle interventions. We situate individual risk factors, alongside key social determinants of health, as being conditioned and constrained by trade and investment policy, with the aim of creating a more comprehensive approach to investigations of the health impacts of trade and investment agreements, and to encourage upstream approaches to combating rising rates of NCDs. To develop the framework we employed causal chain analysis, a technique which sequences the immediate causes, underlying causes, and root causes of an outcome; and realist review, a type of literature review focussed on explaining the underlying mechanisms connecting two events. The results explore how facilitating trade in goods can increase flows of affordable unhealthy imports; while potentially altering revenues for public service provision and reshaping domestic economies and labour markets-both of which distribute and redistribute resources for healthy lifestyles. The facilitation of cross-border trade in services and investment can drive foreign investment in unhealthy commodities, which in turn, influences consumption of these products; while altering accessibility to pharmaceuticals that may mediate NCDs outcomes that result from increased consumption. Furthermore, trade and investment provisions that influence the policy-making process, set international standards, and restrict policy-space, may alter a state's propensity for regulating unhealthy commodities and the efficacy of those regulations. It is the hope that the development of this conceptual framework will encourage capacity and inclination among a greater number of researchers to investigate a more comprehensive range of potential health impacts of trade and investment agreements to generate an extensive and robust evidence-base to guide future policy actions in this area.

Time-discounting and tobacco smoking: a systematic review and network analysis

Background: Tobacco smoking harms health, so why do people smoke and fail to quit? An explanation originating in behavioural economics suggests a role for time-discounting, which describes how the value of a reward, such as better health, decreases with delay to its receipt. A large number of studies test the relationship of time-discounting with tobacco outcomes but the temporal pattern of this relationship and its variation according to measurement methods remain unclear. We review the association between time-discounting and smoking across (i) the life course, from initiation to cessation, and (ii) diverse discount measures.

Methods: We identified 69 relevant studies in Web of Science and PubMed. We synthesized findings across methodologies and evaluated discount measures, study quality and cross-disciplinary fertilization.

Results: In 44 out of 54 studies, smokers more greatly discounted the future than non-smokers and, in longitudinal studies, higher discounting predicted future smoking. Smokers with lower time-discount rates achieved higher quit rates. Findings were consistent across studies measuring discount rates using hypothetical monetary or cigarette reward scenarios. The methodological quality of the majority of studies was rated as ‘moderate’ and co-citation analysis revealed an isolation of economics journals and a dearth of studies in public health.

Conclusion: There is moderate yet consistent evidence that high time-discounting is a risk factor for smoking and unsuccessful cessation. Policy scenarios assuming a flat rate of population discounting may inadequately capture smokers’ perceptions of costs and benefits.

Trade challenges at the World Trade Organization to national noncommunicable disease prevention policies: A thematic document analysis of trade and health policy space

BACKGROUND

It has long been contested that trade rules and agreements are used to dispute regulations aimed at preventing noncommunicable diseases (NCDs). Yet most analyses of trade rules and agreements focus on trade disputes, potentially overlooking how a challenge to a regulation's consistency with trade rules may lead to 'policy or regulatory chill' effects whereby countries delay, alter, or repeal regulations in order to avoid the costs of a dispute. Systematic empirical analysis of this pathway to impact was previously prevented by a dearth of systematically coded data.

METHODS AND FINDINGS

Here, we analyse a newly created dataset of trade challenges about food, beverage, and tobacco regulations among 122 World Trade Organization (WTO) members from January 1, 1995 to December 31, 2016. We thematically describe the scope and frequency of trade challenges, analyse economic asymmetries between countries raising and defending them, and summarise 4 cases of their possible influence. Between 1995 and 2016, 93 food, beverage, and tobacco regulations were challenged at the WTO. 'Unnecessary' trade costs were the focus of 16.4% of the challenges. Only one (1.1%) challenge remained unresolved and escalated to a trade dispute. Thirty-nine (41.9%) challenges focussed on labelling regulations, and 18 (19.4%) focussed on quality standards and restrictions on certain products like processed meats and cigarette flavourings. High-income countries raised 77.4% (n = 72) of all challenges raised against low- and lower-middle-income countries. We further identified 4 cases in Indonesia, Chile, Colombia, and Saudi Arabia in which challenges were associated with changes to food and beverage regulations. Data limitations precluded a comprehensive evaluation of policy impact and challenge validity.

CONCLUSIONS

Policy makers appear to face significant pressure to design food, beverage, and tobacco regulations that other countries will deem consistent with trade rules. Trade-related influence on public health policy is likely to be understated by analyses limited to formal trade disputes.

The Impact of U.S. Free Trade Agreements on Calorie Availability and Obesity: A Natural Experiment in Canada

INTRODUCTION

Globalization via free trade and investment agreements is often implicated in the obesity pandemic. Concerns center on how free trade and investment agreements increase population exposure to unhealthy, high-calorie diets, but existing studies preclude causal conclusions. Few studies of free trade and investment agreements and diets isolated their impact from confounding changes, and none examined any effect on caloric intake, despite its critical role in the etiology of obesity. This study addresses these limitations by analyzing a unique natural experiment arising from the exceptional circumstances surrounding the implementation of the 1989 Canada-U.S. Free Trade Agreement.

METHODS

Data from the UN (2017) were analyzed using fixed-effects regression models and the synthetic control method to estimate the impact of the Canada-U.S. Free Trade Agreement on calorie availability in Canada, 1978-2006, and coinciding increases in U.S. exports and investment in Canada's food and beverage sector. The impact of changes to calorie availability on body weights was then modeled.

RESULTS

Calorie availability increased by ≅170 kilocalories per capita per day in Canada after the Canada-U.S. Free Trade Agreement. There was a coinciding rise in U.S. trade and investment in the Canadian food and beverage sector. This rise in calorie availability is estimated to account for an average weight gain of between 1.8 kg and 12.2 kg in the Canadian population, depending on sex and physical activity levels.

CONCLUSIONS

The Canada-U.S. Free Trade Agreement was associated with a substantial rise in calorie availability in Canada. U.S. free trade and investment agreements can contribute to rising obesity and related diseases by pushing up caloric intake.

Policy, politics and public health

If public health is the field that diagnoses and strives to cure social ills, then understanding political causes and cures for health problems should be an intrinsic part of the field. In this article, we argue that there is no support for the simple and common, implicit model of politics in which scientific evidence plus political will produces healthy policies. Efforts to improve the translation of evidence into policy such as knowledge transfer work only under certain circumstances. These circumstances are frequently political, and to be understood through systematic inquiry into basic features of the political economy such as institutions, partisanship and the organization of labour markets.

Austerity and health: the impact in the UK and Europe

Austerity measures—reducing social spending and increasing taxation—hurts deprived groups the most. Less is known about the impact on health. In this short review, we evaluate the evidence of austerity’s impact on health, through two main mechanisms: a ‘social risk effect’ of increasing unemployment, poverty, homelessness and other socio-economic risk factors (indirect), and a ‘healthcare effect’ through cuts to healthcare services, as well as reductions in health coverage and restricting access to care (direct). We distinguish those impacts of economic crises from those of austerity as a response to it. Where possible, data from across Europe will be drawn upon, as well as more extensive analysis of the UK’s austerity measures performed by the authors of this review.

Evidence Points To 'Gaming' At Hospitals Subject To National Health Service Cleanliness Inspections

Inspections are a key way to monitor and ensure quality of care and maintain high standards in the National Health Service (NHS) in England. Yet there is a perception that inspections can be gamed. This can happen, for example, when staff members know that an inspection will soon take place. Using data for 205 NHS hospitals for the period 2011-14, we tested whether patients' perceptions of cleanliness increased during periods when inspections occurred. Our results show that during the period within two months of an inspection, there was a significant elevation (2.5-11.0 percentage points) in the share of patients who reported "excellent" cleanliness. This association was consistent even after adjustment for secular time trends. The association was concentrated in hospitals that outsourced cleaning services and was not detected in those that used NHS cleaning services.

Inequalities in the use of secondary prevention of cardiovascular disease by socioeconomic status: evidence from the PURE observational study

BACKGROUND

There is little evidence on the use of secondary prevention medicines for cardiovascular disease by socioeconomic groups in countries at different levels of economic development.

METHODS

We assessed use of antiplatelet, cholesterol, and blood-pressure-lowering drugs in 8492 individuals with self-reported cardiovascular disease from 21 countries enrolled in the Prospective Urban Rural Epidemiology (PURE) study. Defining one or more drugs as a minimal level of secondary prevention, wealth-related inequality was measured using the Wagstaff concentration index, scaled from -1 (pro-poor) to 1 (pro-rich), standardised by age and sex. Correlations between inequalities and national health-related indicators were estimated.

FINDINGS

The proportion of patients with cardiovascular disease on three medications ranged from 0% in South Africa (95% CI 0-1·7), Tanzania (0-3·6), and Zimbabwe (0-5·1), to 49·3% in Canada (44·4-54·3). Proportions receiving at least one drug varied from 2·0% (95% CI 0·5-6·9) in Tanzania to 91·4% (86·6-94·6) in Sweden. There was significant (p<0·05) pro-rich inequality in Saudi Arabia, China, Colombia, India, Pakistan, and Zimbabwe. Pro-poor distributions were observed in Sweden, Brazil, Chile, Poland, and the occupied Palestinian territory. The strongest predictors of inequality were public expenditure on health and overall use of secondary prevention medicines.

INTERPRETATION

Use of medication for secondary prevention of cardiovascular disease is alarmingly low. In many countries with the lowest use, pro-rich inequality is greatest. Policies associated with an equal or pro-poor distribution include free medications and community health programmes to support adherence to medications.

FUNDING

Full funding sources listed at the end of the paper (see Acknowledgments).

Barriers and prospects of India's conditional cash transfer program to promote institutional delivery care: a qualitative analysis of the supply-side perspectives

BACKGROUND

Under the National Health Mission (NHM) of India, Janani Suraksha Yojana (JSY) offers conditional cash transfer and support services to pregnant women to use institutional delivery care facilities. This study aims to understand community health workers' (ASHAs) and program officials' perceptions regarding barriers to and prospects for the uptake of facilities offered under the JSY.

METHODS

Fifty in-depth interviews of a purposively selected sample of ASHAs (n = 12), members of Village Health and Sanitation Committees (n = 11), and officials at different tiers of healthcare facilities (n = 27) were conducted in three Indian states. The data were analyzed thematically using ATLAS.ti software.

RESULTS

Although the JSY has triggered considerable advancement on the Indian maternal and child health front, there are several barriers to be resolved pertaining to i) delivering quality care at health-facility; ii) linkages between home and health-facility; and iii) the community/household context. At the facility level, respondents cited an inability to treat birth complications as a barrier to JSY uptake, resulting in referrals to other (mostly private) facilities. Despite increased investment in health infrastructure under the program, shortages in emergency obstetric-care facilities, specialists and staff, essential drugs, diagnostics, and necessary equipment persisted. Weaker linkages between various vertical (standalone) elements of maternal and primary healthcare programs, and nearly uniform resource allocation to all facilities irrespective of caseloads and actual need also constrained the provision of quality healthcare. Barriers affecting the linkages between home and facility arose mainly due to the mismatch between the multiple demands and the availability of transport facilities, especially in emergency situations. Regarding community/household context, several socio-cultural issues such as resistance towards the ASHA's efforts of counselling, particularly from elderly family members, often adversely affected people's decision to seek healthcare.

CONCLUSION

Adequate interventions at the community level, capacity building for healthcare providers, and measures to address underlying structural and systemic barriers are needed to improve the uptake of institutional maternal healthcare.

Does greater individual social capital improve the management of hypertension? Cross-national analysis of 61 229 individuals in 21 countries

Introduction

Social capital, characterised by trust, reciprocity and cooperation, is positively associated with a number of health outcomes. We test the hypothesis that among hypertensive individuals, those with greater social capital are more likely to have their hypertension detected, treated and controlled.

Methods

Cross-sectional data from 21 countries in the Prospective Urban and Rural Epidemiology study were collected covering 61 229 hypertensive individuals aged 35–70 years, their households and the 656 communities in which they live. Outcomes include whether hypertensive participants have their condition detected, treated and/or controlled. Multivariate statistical models adjusting for community fixed effects were used to assess the associations of three social capital measures: (1) membership of any social organisation, (2) trust in other people and (3) trust in organisations, stratified into high-income and low-income country samples.

Results

In low-income countries, membership of any social organisation was associated with a 3% greater likelihood of having one’s hypertension detected and controlled, while greater trust in organisations significantly increased the likelihood of detection by 4%. These associations were not observed among participants in high-income countries.

Conclusion

Although the observed associations are modest, some aspects of social capital are associated with better management of hypertension in low-income countries where health systems are often weak. Given that hypertension affects millions in these countries, even modest gains at all points along the treatment pathway could improve management for many, and translate into the prevention of thousands of cardiovascular events each year.

How will Brexit affect health and health services in the UK? Evaluating three possible scenarios

The process of leaving the European Union (EU) will have profound consequences for health and the National Health Service (NHS) in the UK. In this paper, we use the WHO health system building blocks framework to assess the likely effects of three scenarios we term soft Brexit, hard Brexit, and failed Brexit. We conclude that each scenario poses substantial threats. The workforce of the NHS is heavily reliant on EU staff. Financing of health care for UK citizens in the EU and vice versa is threatened, as is access to some capital funds, while Brexit threatens overall economic performance. Access to pharmaceuticals, technology, blood, and organs for transplant is jeopardised. Information used for international comparisons is threatened, as is service delivery, especially in Northern Ireland. Governance concerns relate to public health, competition and trade law, and research. However, we identified a few potential opportunities for improvement in areas such as competition law and flexibility of training, should the UK Government take them. Overall, a soft version of Brexit would minimise health threats whereas failed Brexit would be the riskiest outcome. Effective parliamentary scrutiny of policy and legal changes will be essential, but the scale of the task risks overwhelming parliament and the civil service.

Patterns of mortality by occupation in the UK, 1991-2011: a comparative analysis of linked census and mortality records

BACKGROUND

Detailed assessments of mortality by occupation are scarce. We aimed to assess mortality by occupation in the UK, differences in rates between England and Wales and Scotland, and changes over time in Scotland.

METHODS

We analysed adults of working age (20-59 years) using linked census and death records. Main occupation was coded into more than 60 groups in the 2001 census, with mortality follow-up until Dec 31, 2011. Comparable occupation data were available for Scotland in 1991, allowing assessment of trends over time. We calculated age-standardised all-cause mortality rates (per 100 000 person-years), stratified by sex. We used Monte Carlo simulation to derive p values and 95% CIs for the difference in mortality over time and between England and Wales and Scotland.

FINDINGS

During 4·51 million person-years of follow-up, mortality rates by occupation differed by more than three times between the lowest and highest observed rates in both men and women. Among men in England and Wales, health professionals had the lowest mortality (225 deaths per 100 000 person-years [95% CI 145-304]), with low rates also shown in managers and teachers. The highest mortality rates were in elementary construction (701 deaths per 100 000 person-years [95% CI 593-809]), and housekeeping and factory workers. Among women, teachers and business professionals had low mortality, and factory workers and garment trade workers had high rates. Mortality rates have generally fallen, but have stagnated or even increased among women in some occupations, such as cleaners (337 deaths per 100 000 person years [95% CI 292-382] in 1991, rising to 426 deaths per 100 000 person years in 2001 [371-481]). Findings from simulation models suggested that if mortality rates by occupation in England and Wales applied to Scotland, 631 fewer men (95% CI 285-979; a 9·7% decrease) and 273 fewer women (26-513; 6·7% decrease) of working age would die in Scotland every year. Excess deaths in Scotland were concentrated among lower skilled occupations (eg, female cleaners).

INTERPRETATION

Mortality rates differ greatly by occupation. The excess mortality in Scotland is concentrated among low-skilled workers and, although mortality has improved in men and women in most occupational groups, some groups have experienced increased rates. Future research investigating the specific causes of death at the detailed occupational level will be valuable, particularly with a view to understanding the health implications of precarious employment and the need to improve working conditions in very specific occupational groups.

FUNDING

None.

"Enemies of the People?" Public Health in the Era of Populist Politics Comment on "The Rise of Post-truth Populism in Pluralist Liberal Democracies: Challenges for Health Policy"

In this commentary, we review the growth of populist politics, associated with exploitation of what has been termed fake news. We explore how certain words have been used in similar contexts historically, in particular the term "enemy of the people," especially with regard to public health. We then set out 6 principles for public health professionals faced with these situations. First, using their epidemiological skills, they can provide insights into the reasons underlying the growth of populist politics. Second using their expertise in modelling and health impact assessment, they can anticipate and warn about the consequences of populist policies. Third, they can support the institutions that are necessary for effective public health. Fourth they can reclaim the narrative, rejecting hatred and division, to promote social solidarity. Fifth, they can support fact checking and the use of evidence. Finally, they should always remember the lessons of history, and in particular, the way that public health has, on occasions, collaborated with totalitarian and genocidal regimes.

Do clinicians receive adequate training to identify trafficked persons? A scoping review of NHS Foundation Trusts

Objective

We investigate whether physicians in secondary care in the English NHS receive adequate training to recognise and appropriately refer for services those persons suspected to be victims of human trafficking.

Design

Freedom of Information requests were sent to the 105 England’s NHS Trusts delivering acute care in England.

Setting

NHS Trusts providing secondary care in England.

Participants

English NHS Trusts.

Main outcome measures

We requested data about the training provided on human trafficking to clinicians, including the nature, delivery, and format of any education, and any planned training.

Results

A total of 89.5% of the 105 Trusts responded. Of these Trusts, 69% provide education to physicians on human trafficking, and a further 6% provide training but did not specify who received it. The majority of Trusts providing training did so within wider safeguarding provision (91%). Only one trust reported that it provides stand-alone training on trafficking to all its staff, including physicians. Within training offered by Trusts, 54% observed best practice providing training on the clinical indicators of trafficking, while 16% referenced the National Referral Mechanism. Amongst those not providing training, 39% of Trusts report provision is in development.

Conclusions

Our results find that 25% of NHS Foundation Trusts appear to lack training for physicians around human trafficking. It is also of concern that of the Trusts who currently do not provide training, only 39% are developing training or planning to do so. There is an urgent need to review and update the scope of available training and bring it into alignment with current legislation.