A Cost-Effectiveness Analysis of India’s 2008 Prohibition of Smoking in Public Places in Gujarat
2.1. Model Overview
2.2. Parameter Estimates
Prevalence of Tobacco Smoking
Effectiveness of Complete Smoking Ban
Effectiveness of 2008 Rules (Partial Smoking Ban)
Cost of Tobacco-Attributable Disease in Adults
Cost of Complete Smoking Ban
Cost of Implementing 2008 Rules (Partial Smoking Ban)
2.4. Outcome Measures
2.5. Sensitivity Analysis
3. Results and Discussion
- Conflict of InterestThe authors declare no conflict of interest.
- WHO Report on the Global Tobacco Epidemic, 2008: The MPOWER Package; World Health Organization: Geneva, Switzerland, 2008.
- Mathers, CD; Loncar, D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS. Med 2006, 3, e442. [Google Scholar]
- International Institute for Population Sciences (IIPS). Global Adult Tobacco Survey India (GATS India) 2009–2010; Ministry of Health and Family Welfare, Government of India: New Delhi, India, 2010. [Google Scholar]
- Jha, P; Jacob, B; Gajalakshmi, V; Gupta, PC; Dhingra, N; Kumar, R; Sinha, DN; Dikshit, RP; Parida, DK; Kamadod, R; et al. A nationally representative case-control study of smoking and death in India. N. Engl. J. Med 2008, 358, 1137–1147. [Google Scholar]
- Mackay, J; Eriksen, M; Shafey, O. The Tobacco Atlas, 2nd ed; American Cancer Society: Atlanta, GA, USA, 2006. [Google Scholar]
- Framework Convention on Tobacco Control; World Health Organization: Geneva, Switzerland, 2005.
- Smoke-Free Rules Presentation, Ministry of Health and Family Welfare, Government of India: New Delhi, India, 2008, unpublished work.
- Ministry of Health and Family Welfare, Government of India. National Tobacco Control Programme. Available online: http://www.mohfw.nic.in/National%20Programme%20for%20Tobacco%20Control.htm (accessed on 7 November 2010).
- Gazette Notification. The Prohibition of Smoking in Public Places Rules 2008; Ministry of Health and Family Welfare, Government of India: New Delhi, India, 2008. [Google Scholar]
- Modi, B; Aghi, M; Baig, A; Breysse, P; Tamplin, S. Measuring SHS Exposure in Public Places in Ahmedabad, India in Support of Policy Development and Implementation. Presented at The Asia Pacific Conference on Tobacco or Health, Sydney, Australia, 6–9 October 2010.
- Fong, GT; Hyland, A; Borland, R; Hammond, D; Hastings, G; McNeill, A; Anderson, S; Cummings, KM; Allwright, S; Mulcahy, M; et al. Reductions in tobacco smoke pollution and increases in support for smoke-free public places following the implementation of comprehensive smoke-free workplace legislation in the Republic of Ireland: findings from the ITC Ireland/UK Survey. Tob Control 2006, 15, iii51–iii58. [Google Scholar]
- Goodman, P; Agnew, M; McCaffrey, M; Paul, G; Clancy, L. Effects of the Irish smoking ban on respiratory health of bar workers and air quality in Dublin pubs. Amer. J. Respir. Crit. Care Med 2007, 175, 840–845. [Google Scholar]
- Koh, HK; Joossens, LX; Connolly, GN. Making smoking history worldwide. N. Engl. J. Med 2007, 356, 1496–1498. [Google Scholar]
- Weber, MD; Bagwell, DA; Fielding, JE; Glantz, SA. Long term compliance with California’s smoke-Free workplace law among bars and restaurants in Los Angeles County. Tob. Control 2003, 12, 269–273. [Google Scholar]
- Villalbi, JR; Cusi, M; Madrueno, V; Duran, J; Balfagon, P; Portana, S; Salamero, M; Guix, J. Smoke-free areas: Persuasion and enforcement. Gac. Sanit 2008, 22, 614–617. [Google Scholar]
- Erazo, M; Iglesias, V; Droppelmann, A; Acuna, M; Peruga, A; Breysse, PN; Navas-Acien, A. Secondhand tobacco smoke in bars and restaurants in Santiago, Chile: Evaluation of partial smoking ban legislation in public places. Tob. Control 2010, 19, 469–474. [Google Scholar]
- Satterlund, TD; Lee, JP; Moore, RS; Antin, TMJ. Challenges to implementing and enforcing California’s smoke-free workplace act in bars. Drugs (Abingdon Engl.) 2009, 16, 422–435. [Google Scholar]
- Navas-Acien, A; Peruga, A; Breysse, P; Zavaleta, A; Blanco-Marquizo, A; Pitarque, R; Acuna, M; Jimenez-Reyes, K; Colombo, VL; Gamarra, G; et al. Secondhand tobacco smoke in public places in Latin America, 2002–2003. JAMA 2004, 291, 2741–2745. [Google Scholar]
- Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs—2007; US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health: Atlanta, GA, USA, 2007. [Google Scholar]
- WHO Report on the Global Tobacco Epidemic, 2009: Implementing Smoke-free Environments; World Health Organization: Geneva, Switzerland, 2009.
- Cost-Effectiveness in Health and Medicine; Gold, MR; Siegel, JE; Russell, LB; Weinstein, MC (Eds.) Oxford University Press: Oxford, UK, 1996.
- Government of Gujarat. Census, 2001. Available online: http://www.censusindia.gov.in (accessed on 1 October 2010).
- Kim, B. Workplace smoking ban policy and smoking behavior. J. Prev. Med. Public Health 2009, 42, 293–297. [Google Scholar]
- Levy, DT; Friend, K; Polishchuk, E. Effect of clean indoor air laws on smokers: the clean air module of the SimSmoke computer simulation model. Tob. Control 2001, 10, 345–351. [Google Scholar]
- Mullally, BJ; Greiner, BA; Allwright, S; Paul, G; Perry, IJ. The effect of the Irish smoke-free workplace legislation on smoking among bar workers. Eur. J. Public Health 2009, 19, 206–211. [Google Scholar]
- Fichtenberg, CM; Glantz, SA. Effect of smoke-free workplaces on smoking behaviour: Systematic review. BMJ 2002, 325, 188. [Google Scholar]
- Jimenez-Ruiz, CA; Miranda, JA; Hurt, RD; Pinedo, AR; Reina, SS; Valero, FC. Study of the impact of laws regulating tobacco consumption on the prevalence of passive smoking in Spain. Eur. J. Public Health 2008, 18, 622–625. [Google Scholar]
- Brownson, RC; Koffman, DM; Novotny, TE; Hughes, RG; Eriksen, MP. Environmental and policy interventions to control tobacco use and prevent cardiovascular disease. Health Educ. Quart 1995, 22, 478–498. [Google Scholar]
- Verdonk-Kleinjan, WM; Knibbe, RA; Tan, FE; Willemsen, MC; de Groot, HN; de Vries, H. Does the workplace-smoking ban eliminate differences in risk for environmental tobacco smoke exposure at work? Health Policy 2009, 92, 197–202. [Google Scholar]
- Semple, S; Creely, KS; Naji, A; Miller, BG; Ayres, JG. Secondhand smoke levels in Scottish pubs: The effect of smoke-free legislation. Tob. Control 2007, 16, 127–132. [Google Scholar]
- Ellingsen, DG; Fladseth, G; Daae, HL; Gjolstad, M; Kjaerheim, K; Skogstad, M; Olsen, R; Thorud, S; Molander, P. Airborne exposure and biological monitoring of bar and restaurant workers before and after the introduction of a smoking ban. J. Environ. Monit 2006, 8, 362–368. [Google Scholar]
- Blanco-Marquizo, A; Goja, B; Peruga, A; Jones, MR; Yuan, J; Samet, JM; Breysse, PN; Navas-Acien, A. Reduction of secondhand tobacco smoke in public places following national smoke-free legislation in Uruguay. Tob. Control 2010, 19, 231–234. [Google Scholar]
- Richiardi, L; Vizzini, L; Merletti, F; Barone-Adesi, F. Cardiovascular benefits of smoking regulations: The effect of decreased exposure to passive smoking. Prev. Med 2009, 48, 167–172. [Google Scholar]
- Lightwood, JM; Glantz, SA. Declines in acute myocardial infarction after smoke-free laws and individual risk attributable to secondhand smoke. Circulation 2009, 120, 1373–1379. [Google Scholar]
- Meyers, DG; Neuberger, JS; He, J. Cardiovascular effect of bans on smoking in public places: A systematic review and meta-analysis. J. Am. Coll. Cardiol 2009, 54, 1249–1255. [Google Scholar]
- Pell, JP; Haw, S; Cobbe, S; Newby, DE; Pell, AC; Fischbacher, C; McConnachie, A; Pringle, S; Murdoch, D; Dunn, F; et al. Smoke-free legislation and hospitalizations for acute coronary syndrome. N. Engl. J. Med 2008, 359, 482–491. [Google Scholar]
- Taylor, DH, Jr; Hasselblad, V; Henley, SJ; Thun, MJ; Sloan, FA. Benefits of smoking cessation for longevity. Am. J. Public Health 2002, 92, 990–996. [Google Scholar]
- Modi, B; Dave, P. Tobacco control cell of gujarat budget records. Unpublished work,. 2010. [Google Scholar]
- Asaria, P; Chisholm, D; Mathers, C; Ezzati, M; Beaglehole, R. Chronic disease prevention: Health effects and financial costs of strategies to reduce salt intake and control tobacco use. Lancet 2007, 370, 2044–2053. [Google Scholar]
- National Sample Survey Organisation, Ministry of Statistics and Programme Implementation. National Sample Survey Round 60 (NSS-R60), India. 2004. Available online: http://mospi.nic.in/Mospi_New/site/home.aspx (accessed on 1 November 2010).
- Mulcahy, M; Evans, DS; Hammond, SK; Repace, JL; Byrne, M. Secondhand smoke exposure and risk following the Irish smoking ban: An assessment of salivary Cotinine concentrations in hotel workers and air nicotine levels in bars. Tob. Control 2005, 14, 384–388. [Google Scholar]
- Travers, MJ; Cummings, KM; Hyland, A; Repace, J; Babb, S; Pechacek, T. Indoor air quality in hospitality venues before and after implementation of a clean indoor air law—Western New York, 2003. MMWR 2004, 53, 1038–1041. [Google Scholar]
- Callinan, JE; Clarke, A; Doherty, K; Kelleher, C. Legislative smoking bans for reducing secondhand smoke exposure, smoking prevalence and tobacco consumption. Cochrane Database Syst Rev 2010, 4, CD005992. [Google Scholar]
- Waters, HR; Foldes, SS; Alesci, NL. The Economic Impact of Exposure to Secondhand Tobacco Smoke in Minnesota: Final Report; Blue Cross/Blue Shield: Minneapolis, MN, USA, 2007. [Google Scholar]
- US Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General; US Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health: Atlanta, GA, USA, 2006. [Google Scholar]
- Woodward, A; Laugesen, M. How many deaths are caused by second hand cigarette smoke? Tob. Control 2001, 10, 383–388. [Google Scholar]
- American Cancer Society, Union for International Cancer Control. Enacting Strong Smoke-Free Laws: The Advocate’s Guide to Legislative Strategies. 2006. Available online: http://strategyguides.globalink.org/pdfs/Legislative_Strategies.pdf (accessed on 10 November 2010).
- Robberstad, B. QALYs vs DALYs vs LYs gained: What are the differences, and what differences do they make for health care priority setting? Nor. Epidemiol 2005, 15, 183–191. [Google Scholar]
- Jha, P; Chaloupka, F; Corrao, M; Jacob, B. Reducing the burden of smoking world-wide: Effectiveness of interventions and their coverage. Drug Alcohol Rev 2006, 25, 597–609. [Google Scholar]
- United Nations, Department of Economic and Social Affairs (DESA), Population Division. World Population Prospects: The 2008 Revision. [Online]; Available online: http://esa.un.org/unpd/wpp2008/index.htm (accessed on 1 November 2010).
- WHO. Choosing Interventions that Are Cost Effective (WHO-CHOICE). Available online: http://www.who.int/choice/en/ (accessed on 7 November 2010).
- International Monetary Fund. Data and Statistics. Available online: http://www.imf.org/external/pubs/ft/weo/2009/02/weodata/weoselco.aspx?g=2001&sg=All+countries (accessed on 1 November 2010).
- Shibuya, K; Ciecierski, C; Guindon, E; Bettcher, DW; Evans, DB; Murray, CJ. WHO framework convention on tobacco control: Development of an evidence based global public health treaty. BMJ 2003, 327, 154–157. [Google Scholar]
- Laxminarayan, R; Chow, J; Shahid-Salles, SA. Intervention Cost-Effectiveness: Overview of Main Message Disease Control Priorities in Developing Countries, 3rd ed; Oxford University Press: New York, NY, USA, 2006; pp. 35–86. [Google Scholar]
- Wang, LY; Crossett, LS; Lowry, R; Sussman, S; Dent, CW. Cost-effectiveness of a school-based tobacco-use prevention program. Arch. Pediatr. Adolesc. Med 2001, 155, 1043–1050. [Google Scholar]
- Waters, HR; Foldes, SS; Alesci, NL; Samet, J. The economic impact of exposure to secondhand smoke in Minnesota. Am. J. Public Health 2009, 99, 754–759. [Google Scholar]
|Parameter||Base Case||Sensitivity Analyses Range||References|
|2001 State of Gujarat, India Population (>age 20)||50,671,017||n/a|||
|Prevalence of Tobacco Smoking (age 15 and above)||0.198 males|
|Percent Change in Current Smoking Prevalence after Partial Bana||0.015||0.01–0.02||[median]; [23,24]|
|Percent Change in Current Smoking Prevalence after Complete Banb||0.0335||0.029–0.038||[median]; [25,26]|
|Percent Change in Exposure to SHS after Partial Banc||0.22||0.21–0.27||[27–29]|
|Percent Change in Exposure to SHS after Complete Band||0.86||0.70–0.91||[30–32]|
|Percent Change in Hospital Admissions for Acute Myocardial Infarction after Partial Ban||0.05||0.01–0.10|||
|Percent Change in Hospital Admissions for Acute Myocardial Infarction after Complete Ban||0.17||0.10–0.25||[33–36]|
|LYs Saved per Person that Quits Smoking||2.7||0.9–4.2|||
|Cost of Implementing Partial Ban||0.0012 per person (2008 USD)||0.0006–0.02|||
|Cost of Implementing Complete Ban||0.08 per person (2008 USD)||0.04–0.12||; [±50%]|
|Tobacco-related CHD Healthcare Costs per Person, incurred Annually for 10 years||2,291 (2008 USD)||124–4,459 (2008 USD)|||
|All Tobacco-related Healthcare Costs per Person, incurred Annually for 10 years||615 (2008 USD)||50–4,459 (2008 USD)|||
|SmokingBehavior||LYs Gained||LYs Gained|
|Quit at age 35||4.2||3.6|
|Quit at age 45||3.4||3.3|
|Quit at age 55||2.1||2.5|
|Incremental Difference: Complete Ban vs. Current Legislation||Incremental Difference: Optimistic Case||Incremental Difference: Worst Case|
|Gross Intervention Costs (C)||3,994,645||1,996,438||5,067,102|
|AMI Treatment Costs Saved (T)||40,051,602||237,927,598||1,626,740|
|All Tobacco-Attributable Treatment Costs Saved (T)||99,609,250||946,905,837||2,527,779|
|Net Costs (AMI Treatment) *(C-T)||–36,056,957||–235,931,160||3,440,362|
|Net Costs (All Tobacco-Attributable Disease Treatment) * (C-T)||–95,614,605||–944,909,399||2,539,322|
|AMI Cases Averted (A)||17,478||53,361||13,109|
|Smokers Quitting (Q)||221,154||385,100||46,060|
|Life Years Gained (L)||437,589||891,945||45,268|
|Incremental Cost-Effectiveness Ratios|
|Cost per LY Gained (C-T)/(L)||Cost Saving||Cost Saving||56 (USD) Highly Cost-Effective|
|Cost per LY Gained w/out Medical Treatment Saved (C/L)||9.13 (USD) Highly Cost-Effective||2.24(USD) Highly Cost-Effective||112 (USD) Highly Cost-Effective|
|Cost per AMI Case Averted (C-T)/A||Cost Saving||Cost Saving||262 (USD) Highly Cost-Effective|
|Cost per AMI Case Averted w/out Medical Treatment Saved (C/A)||229 (USD) Highly Cost-Effective||37 (USD) Highly Cost-Effective||387 (USD) Highly Cost-Effective|
© 2011 by the authors; licensee MDPI, Basel, Switzerland. This article is an open-access article distributed under the terms and conditions of the Creative Commons Attribution license (http://creativecommons.org/licenses/by/3.0/).
Share and Cite
Donaldson, E.A.; Waters, H.R.; Arora, M.; Varghese, B.; Dave, P.; Modi, B. A Cost-Effectiveness Analysis of India’s 2008 Prohibition of Smoking in Public Places in Gujarat. Int. J. Environ. Res. Public Health 2011, 8, 1271-1286. https://doi.org/10.3390/ijerph8051271
Donaldson EA, Waters HR, Arora M, Varghese B, Dave P, Modi B. A Cost-Effectiveness Analysis of India’s 2008 Prohibition of Smoking in Public Places in Gujarat. International Journal of Environmental Research and Public Health. 2011; 8(5):1271-1286. https://doi.org/10.3390/ijerph8051271Chicago/Turabian Style
Donaldson, Elisabeth A., Hugh R. Waters, Monika Arora, Beena Varghese, Paresh Dave, and Bhavesh Modi. 2011. "A Cost-Effectiveness Analysis of India’s 2008 Prohibition of Smoking in Public Places in Gujarat" International Journal of Environmental Research and Public Health 8, no. 5: 1271-1286. https://doi.org/10.3390/ijerph8051271