Assessing Health Impacts of Pictorial Health Warning Labels on Cigarette Packs in Korea Using DYNAMO-HIA

Prospects and Perspectives of Health Impact Assessment: A Systematic Review of the Peer-Reviewed Literature From June 2007 to January 2023

Objectives

In 2008, an analysis investigating health impact assessment (HIA) practice found that only 6% of HIA-related peer-reviewed publications had a focus on low- and medium-developed countries, whereas 94% were conducted in countries with a high or very high development state. We aimed to update and deepen these observations.

Methods

We conducted a systematic review, searching PubMed and Web of Science for HIA-related papers published in the scientific literature from June 2007 to January 2023. Only applied HIA and papers with HIA as a subject were included.

Results

The search yielded 3,036 publications and the final selection consisted of 1,019 publications. The annual number of total publications increased considerably over the past 15 years. Whereas research-driven HIA (n = 460) showed a steep increase, step-by-step HIA (n = 71) did not show a clear trend.

Conclusion

The gap between the number of HIA-related peer-reviewed publications focusing on low/medium and high/very high developed countries has diminished from 6/94 to 11/89. There is a growing tendency to apply the terminology HIA for health impact modelling studies and quantitative health risk assessments.

Trends in Hospital Admissions for Chronic Obstructive Pulmonary Diseases After Comprehensive Tobacco Control Policies in Beijing, China

INTRODUCTION

Only a few studies have examined the effectiveness of tobacco control policies on respiratory conditions, and the results were less consistent. The 2015 Beijing tobacco control policy package incorporating all six components of MPOWER has been implemented since Jun 2015. The present study aimed to evaluate the impact of a comprehensive tobacco control policy package on hospital admissions for chronic obstructive pulmonary disease (COPD) in Beijing, China.

AIMS AND METHODS

An interrupted time-series study was conducted based on the hospital admission information for about 18 million residents, who were covered by the Beijing Medical Claim Data for Employees from January 2013 to June 2017. The average percentage change of COPD hospital admission rates and reductions in hospital admission numbers were estimated by segmented Poisson regression models.

RESULTS

There were 54 040 COPD hospital admissions with a crude rate of 67.2 per 100 000 residents during the observational period. After the implementation of the policy package, the hospital admission rates of COPD were reduced by -14.7% (95%CI: -17.8%, -11.5%) immediately. The secular trend was slowed down by -3.0% (95% CI: -5.6%, -0.4%) annually. A total of 5 581 reductions in COPD hospital admissions were estimated during the 25 months post-law period, accounting for 17.5% (95% CI: 12.5%, 22.5%) of overall COPD hospital admissions. More reductions were shown in males and those aged over 65 years old.

CONCLUSIONS

The results indicated significant protections against hospitalization of COPD after the 2015 Beijing comprehensive tobacco control policy package. The results provide support for public health benefits for respiratory conditions from WHO-recommended tobacco control measures.

IMPLICATIONS

Only a few studies have examined the effectiveness of tobacco control policies on respiratory conditions, and the results were less consistent. Based on medical records for about 18 million residents, this study showed an association between comprehensive tobacco control policies and significant reductions of hospital admissions for chronic obstructive pulmonary disease. The results provide support for public health benefits for respiratory conditions from WHO-recommended tobacco control measures.

Effects of public policies in the prevention of cardiovascular diseases: a systematic review of global literature

OBJECTIVES

Given the growing interest worldwide in applying public policies to improve human health, we undertook a systematic review of studies investigating whether public policies targeting unhealthy products could reduce cardiovascular diseases.

STUDY DESIGN

This study was a systematic review of the literature.

METHODS

We searched research studies published in 2000-2020 from major databases, including MEDLINE and Embase. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and narratively synthesized the studies based on vote counting and direction of the intervention effect.

RESULTS

Ninety-eight studies, mostly from high-income countries, met the inclusion criteria. Most studies were on public policies targeting sugar-sweetened beverages and tobacco, followed by alcohol, sugar, salt, and junk foods. Overall, many reported that several fiscal, regulatory, and educational policies generated beneficial effects of reducing the diseases. Those studies that reported no or limited effects highlighted several sociodemographic and health risk characteristics and design and implementation aspects of the policy interventions as factors limiting the policy effects; most of these are modifiable with appropriate policy interventions. For instance, low magnitude of tax, substitution with other unhealthy products, firms' competitive response strategies, pre-existence of smoking bans, incremental enactment of smoking regulations, degree of enforcement, and various sociocultural factors minimized the effects of the policies.

CONCLUSION

The literature supports a growing consensus on the beneficial effects of public policy for improving human health. The design and implementation of public policies must address various impeding factors and incorporate appropriate remedial measures. Further research is needed from low- and middle-income countries and on whether and how multiple policy instruments work in tandem.

Association Between Graphic Health Warning Labels on Cigarette Packs and Smoking Cessation Attempts in Korean Adolescent Smokers: A Cross-Sectional Study

Graphic health warning labels on cigarette packs inform smokers about the health risks associated with tobacco smoking. Adolescents are generally the main targets to influence by graphic health warning labels. This study investigated the association between graphic health warning labels on cigarette packs and attempts to quit smoking in South Korean adolescents. This cross-sectional study used data from the 2017 to 2019 Korea Youth Risk Behavior Web-based Survey, using multiple logistic regression for the analysis. The study population comprised 11,142 adolescents aged 12–18 years. The outcome variable was attempts to quit smoking among adolescent smokers who had seen graphic health warning labels. Attempts to quit smoking were higher among adolescent smokers who had seen graphic health warning labels compared to those who had not {boys, odds ratio (OR) = 1.72 [95% confidence interval (CI), 1.48–2.00]; girls, OR = 1.74 (95% CI, 1.33–2.28)}. The correlation was greater for adolescents who thought about the harm of smoking [boys, OR = 1.86 (95% CI, 1.60–2.16); girls, OR = 1.85 (95% CI, 1.41–2.43)] and the willingness to quit [boys, OR = 2.03 (95% CI, 1.74–2.36); girls, OR = 2.04 (95% CI, 1.55–2.68)] after seeing graphic health warning labels. Our findings indicate that graphic health warning labels on cigarette packs have the potential to lower smoking intentions of adolescents. We suggest that the use of graphic health warning labels is an effective policy-related intervention to reduce smoking in South Korean adolescents.

Reducing the Burden of Disease Through Tobacco Taxes in Mongolia: A Health Impact Analysis Using a Dynamic Public Health Model

BACKGROUND/OBJECTIVES

Smoking is the leading risk factor for many chronic diseases. The quantitative analysis of potential health gains from reduced smoking is important for establishing priorities in Mongolia's health policy. This study quantifies the effect of tobacco-tax increases on future smoking prevalence and the associated smoking-related burden of disease in Mongolia.

METHODS

The dynamic model for health impact assessment (DYNAMO-HIA) tool was used. The most recent data were used as input for evaluating tobacco-taxation scenarios. Demographic data were taken from the Mongolian Statistical Information Services. Smoking data came from a representative population-based STEPS survey, and smoking-related disease data were obtained from the health-information database of Mongolia's National Health Center. Simulation was used to evaluate various levels of one-time price increases on tobacco products (25% and 75%) in Mongolia. Conservative interpretation suggests that the population will eventually adjust to the higher tobacco price and return to baseline smoking behaviors.

RESULTS

Over a three-year period, smoking prevalence would be reduced by 1.2% points, corresponding to almost 40 thousand smokers at the population level for a price increase of 75%, compared to the baseline scenario. Projected health benefits of this scenario suggest that more than 137 thousand quality adjusted of life years would be gained by avoiding smoking-related diseases within a population of three million over a 30-year period.

DISCUSSION

Prevention through effective tobacco-control policy could yield considerable gains in population health in Mongolia. Compared to current policy, tax increases must be higher to have a significant effect on population health.

IMPLICATIONS

Tobacco taxation is an effective policy for reducing the harm of tobacco smoking, while benefiting population health in countries where the tobacco epidemic is still in an early stage. Smoking prevalence and smoking behaviors in these countries differ from those in Western countries. Reducing the uptake of smoking among young people could be a particularly worthwhile benefit of tobacco-tax increases.

Planning for tomorrow: global cancer incidence and the role of prevention 2020-2070

Cancer is currently the first or second most common contributor to premature mortality in most countries of the world. The global number of patients with cancer is expected to rise over the next 50 years owing to the strong influence of demographic changes, such as population ageing and growth, on the diverging trends in cancer incidence in different regions. Assuming that the latest incidence trends continue for the major cancer types, we predict a doubling of the incidence of all cancers combined by 2070 relative to 2020. The greatest increases are predicted in lower-resource settings, in countries currently assigned a low Human Development Index (HDI), whereas the predicted increases in national burden diminish with increasing levels of national HDI. Herein, we assess studies modelling the future burden of cancer that underscore how comprehensive cancer prevention strategies can markedly reduce the prevalence of major risk factors and, in so doing, the number of future cancer cases. Focusing on an in-depth assessment of prevention strategies that target tobacco smoking, overweight and obesity, and human papillomavirus infection, we discuss how stepwise, population-level approaches with amenable goals can avert millions of future cancer diagnoses worldwide. In the absence of a step-change in cancer prevention delivery, tobacco smoking will remain the leading preventable cause of cancer, and overweight and obesity might well present a comparable opportunity for prevention, given its increasing prevalence globally in the past few decades. Countries must therefore instigate national cancer control programmes aimed at preventing cancer, and with some urgency, if such programmes are to yield the desired public health and economic benefits in this century.

Health impact assessment to predict the impact of tobacco price increases on COPD burden in Italy, England and Sweden

Raising tobacco prices effectively reduces smoking, the main risk factor for chronic obstructive pulmonary disease (COPD). Using the Health Impact Assessment tool "DYNAMO-HIA", this study quantified the reduction in COPD burden that would occur in Italy, England and Sweden over 40 years if tobacco prices were increased by 5%, 10% and 20% over current local prices, with larger increases considered in secondary analyses. A dynamic Markov-based multi-state simulation modelling approach estimated the effect of changes in smoking prevalence states and probabilities of transitioning between smoking states on future smoking prevalence, COPD burden and life expectancy in each country. Data inputs included demographics, smoking prevalences and behaviour and COPD burden from national data resources, large observational cohorts and datasets within DYNAMO-HIA. In the 20% price increase scenario, the cumulative number of COPD incident cases saved over 40 years was 479,059 and 479,302 in Italy and England (populous countries with higher smoking prevalences) and 83,694 in Sweden (smaller country with lower smoking prevalence). Gains in overall life expectancy ranged from 0.25 to 0.45 years for a 20 year-old. Increasing tobacco prices would reduce COPD burden and increase life expectancy through smoking behavior changes, with modest but important public health benefits observed in all three countries.

Setting the policy agenda for graphic health warning labels: An analysis of online news media coverage in South Korea, 2016

INTRODUCTION

In South Korea, a bill requesting the implementation of graphic health warning labels (GHWLs) on tobacco products was adopted at the Assembly Plenary Session on 29 May 2015, and the law was implemented on 23 December 2016. During the period, a plan of the technical details of GHWLs, such as the making of graphic warnings, was examined by the Regulatory Reform Committee (RRC). This study aims to investigate what the media reported over that period and whether the RRC's policy decisions changed.

METHODS

We conducted a content analysis of online media reports from the first legislative examination (22 April 2016) to the re-examination (13 May 2016). We coded 150 news reports according to two types (news and opinions) and three slants in terms of being in favor of or opposed to the initially government's implementation plan of GHWLs: positive, negative, and neutral.

RESULTS

At the first legislative examination, some committee members recommended placing pictorial warnings at the bottom of a cigarette pack as opposed to the plan. Initially, the media reported the results of the committee decisions neutrally. However, over time, positive news and opinions on tobacco control policy and support for positioning the GHWLs at the top of packages increased before the committee carried out the re-examination. Only 15 (10.0%) news reports adopted a negative slant, while the reports with positive (n=101; 67.3%) and neutral slants (n=34; 22.7%) comprised the majority. At the re-examination, the committee withdrew their earlier recommendation to position the GHWLs at the bottom of cigarette packs, finally deciding that the pictorial warnings should be located at the top of the packs, as per the original government's plan.

CONCLUSIONS

The friendly media coverage of the tobacco control policy suggests that the media would be a major factor in the policymakers' decision. Because the media play an important role in defining social issues in the policy-decision process, garnering support from the media is important in the tobacco control legislative process.

To what extent could cardiovascular diseases be reduced if Germany applied fiscal policies to increase fruit and vegetable consumption? A quantitative health impact assessment

Objective:

This study aimed to dynamically model and quantify expected health effects of four scenarios: (i) a reference scenario with an unchanged fruit and vegetable intake, (ii) the removal of value-added tax (VAT) on fruits and vegetables, (iii) the implementation of a 20 % subsidy on fruits and vegetables and (iv) a guideline scenario with a population-wide fruit and vegetable intake of five portions per day.

Design:

Baseline fruit and vegetable intake data was derived from the GEDA 2012 study. We used price elasticities for Germany to calculate the change in fruit and vegetable consumption under the zero VAT and the 20 % subsidy scenario. All scenarios were modelled over a 10-year projection period using DYNAMO-HIA.

Setting:

Germany.

Participants:

A projected real-life population.

Results:

Cumulated over the 10-year projection period, an estimated 4450 incident ischaemic heart disease (IHD) cases, 7010 stroke cases and 13 960 deaths would be prevented under the zero VAT scenario. Under the 20 % subsidy scenario, 17 990 incident IHD cases, 27 390 stroke cases and 54 880 deaths would be averted. Although this corresponds to only a fraction of the incidents that would occur under the reference scenario, the averted cases translate to 2 % (for the zero VAT scenario) and 9 % (for the 20 % subsidy scenario) of IHD, stroke and death cases that would be prevented if the whole population consumed the recommended five portions of fruits and vegetables per day.

Conclusions:

Fiscal policies on fruits and vegetables provide a non-negligible step towards the removal of the health burden induced by low fruit and vegetable intake.

The association between new graphic health warning labels on tobacco products and attitudes toward smoking among south Korean adolescents: a national cross-sectional study

BACKGROUND

Graphic health warning labels (GHWLs) on tobacco products are more effective than text warnings for communicating the risk of smoking. The implementation of GHWLs can prevent adolescents from initiating smoking. Therefore, this study examined the association between GHWLs newly implemented on December 23, 2016, in South Korea and attitudes toward smoking among adolescents.

METHODS

This post-implementation cross-sectional analysis examined the responses of 62,276 students (31,624 boys and 30,652 girls) who participated in the 2017 Web-based Korean Youth Risk Behavior Survey, which was completed anonymously as a self-administered questionnaire by middle and high school students. Multinomial logistic regression was applied to explore the attitudes toward smoking among the youth (13-18 years old) who have been exposed to GHWLs in order to identify relationship of exposure to the GHWLs with smoking initiation and awareness of the danger of smoking.

RESULTS

Six months after implementation, 69.4% of adolescents reported having been exposed to GHWLs in the previous 30 days. Among those exposed to GHWLs both boys and girls in grade 7 were significantly more likely than grade 12 high school students to decide not to start smoking (boys: AOR = 3.96, 95% CI 3.31-4.75, p < 0.001; girls: AOR = 2.76, 95% CI 2.32-3.30, p < 0.001) and to think that smoking was dangerous to their health (boys: AOR = 3.01, 95% CI 2.52-3.58, p < 0.001; girls: AOR = 2.42, 95% CI 2.03-3.88, p < 0.001) after seeing GHWLs. These associations were greater for adolescents who had experienced smoking-prevention education or had been exposed to anti-tobacco advertisements. However, those who smoked, used e-cigarettes, or experienced secondhand smoking were significantly less likely to decide not to smoke and to view smoking as dangerous.

CONCLUSIONS

To maintain the perception of the harm of tobacco from childhood through adolescence, the government should implement both comprehensive tobacco controls, including smoking-prevention education in schools, and measures to encourage a smoke-free environment in homes.

Analysis of the legislative process related to the implementation of graphic health warning labels on tobacco products in South Korea

INTRODUCTION

Well-designed health warnings on tobacco packaging enhance cost-effectively public awareness of the risks of using tobacco products. However, many countries have experienced difficulties in implementing pictorial warnings. The purpose of this study is to present the topics that arose during the legislative process that preceded implementation of graphic health warning labels (GHWLs) on tobacco products in South Korea, and discuss the outcomes.

METHODS

We used qualitative content analysis to analyze lawmakers' statements, and those of committee members in meetings that preceded the drafting of the legislative document pertaining to GHWLs in South Korea.

RESULTS

In discussions surrounding the adoption of the GHWLs, the main point of contention was the level of disgust induced by pictorial warnings. When discussing how warnings should be inscribed on packaging after adoption of GHWLs, lawmakers disagreed regarding the physical position of the warnings. Because of continuous objections raised by some lawmakers, implementation of GHWLs was delayed, and, when actually introduced, the warnings were toned down. Some lawmakers communicated with tobacco companies; thus the companies participated in the legislative process in South Korea.

CONCLUSIONS

To prevent tobacco companies from negatively influencing tobacco control efforts, it is essential that all communications with such companies be publicly disclosed and that the tobacco industry be prohibited from contacting lawmakers involved in the legislative process of tobacco control.

Positive Effects of the National Cigarette Price Increase Policy on Smoking Cessation in South Korea

Background

In January 2015, South Korea's government raised the cigarette tax, and the retail price of cigarettes abruptly increased by 80% compared to the previous year. This research aimed to determine the effect of this increase on smoking cessation among South Korean smokers.

Methods

We analyzed data collected by the 2013–2015 South Korea National Health and Nutrition Examination Survey of 15,203 South Koreans over 19 years old using regression analysis. We examined the recent non-smoking period of nonsmoking people, prepared according to the survey, and analyzed the recent smoking cessation ratio.

Results

Among smokers, from 2013 to 2014, the smoking cessation rate was 7.2%, and it increased to 9.9% in 2015 after the increase in the cigarette tax. In 2015, the recent smoking cessation rate was higher among people over the age of 60 (odds ratio [OR], 2.67) compared to those between the ages of 40 and 49. The recent smoking cessation rate was higher among people with below elementary education (OR, 2.28) and above university education (OR, 1.94) compared to high school, higher for those with apartments (OR, 1.74) compared to general type residences, and higher among those with a household income in the low-middle quartile (Q2) (OR, 2.32) compared to the highest quartile (Q4).

Conclusion

This innovative policy including increase in cigarette prices affected smoking cessation, and its impact varied by sub-group of smokers in South Korea.

Differences in visual fixation duration according to the position of graphic health warning labels: An eye-tracking approach

INTRODUCTION

The Framework Convention on Tobacco Control (FCTC) recommends that graphic health warning labels (GHWLs) be positioned at the top of the principal area of cigarette packs, rather than at the bottom, to increase visibility. However, during the legislative process of introducing GHWLs in South Korea, the position of GHWLs has become a contested issue. The pro-tobacco industry group argued that the warnings should be placed at the bottom of cigarette packs because evidence for the effectiveness of the upper position was insufficient. Therefore, this study investigated whether the position of the GHWL affects eye movement.

METHODS

Participants (30 daily smokers and 24 non-smokers) were shown six cigarette packs in random order with different position combinations (top, middle, bottom) and image concepts (skin aging, toxic constituents). Participants’ eye movements were recorded using eye-tracking equipment to measure visual fixation duration in milliseconds (ms)

RESULTS

Participants visually fixated longer on the health warning area than on the tobacco branding area (p<0.05). Mean fixation duration on the health warning area was significantly longer at the top or middle positions compared to the bottom, by 28% (mean difference=340 ms, p=0.006) and by 30% (mean difference=368 ms, p=0.002), respectively. By contrast, mean fixation duration on the branding area was longer with the warning at the bottom compared to top or middle positions by 25% and 33%, with mean differences of 157 ms (p=0.100) and 212 ms (p=0.026), respectively. No significant difference in fixation time was observed between the top and middle positions (p>0.05)

CONCLUSIONS

The duration of visual fixation on GHWLs was longer when they were displayed at the top and middle, rather than at the bottom. Therefore, GHWLs should be positioned from the top to the middle of the tobacco package.