Protecting Children and Families from Tobacco: Leadership Training. Panama

Transcripción

1 Click here for the Table of Contents! Protecting Children and Families from Tobacco: Leadership Training Panama XVI Congreso Latinoamericano de Pediatría November 14, 2012 La Asociación Latinoamericana de Pediatría-ALAPE

2 Table of Contents Click on the links below to access the reports included in this document. WHO Country Profile WHO NCDs CTFK Advertising, Promotion & Sponsorship CTFK Packaging & Labeling CTFK Smoke Free Places CDC MMWR_Changes in Tobacco Use Among Youth in Panama Estudio de la Demanda de Tabaco CIET Panama Abril 2010 Informe sobre Control del Tabaco 2011 Treatment Guidelines 2005 Additional Resources

3 WHO Report on the Global Tobacco Epidemic, 2011 Country profile Panama Note: Where no data were available, " " shows in the table. Where data were not required, " " shows in the table. WHO Framework Convention on Tobacco Control (WHO FCTC) status Date of signature 26 September 2003 Date of ratification (or legal equivalent) 16 August 2004 Socioeconomic context Population (thousands) 3508 Income group Middle income Prevalence of tobacco use Tobacco use data as provided by the country from the latest survey result available to WHO as at 1 November 2010 Any smoked tobacco Cigarettes Adult prevalence, smoking (%)* Current Daily Current Daily Male Female Total Adult prevalence, smokeless tobacco use (%)*... Male... Female... Total... * Ages 15+, Encuesta Nacional de Salud y Calidad de Vida (ENSCAVI), 2007 " " Data not reported/not available. WHO age-standardized estimated prevalence of smoking among those aged 15 years or more: Year 2009 Adult prevalence, smoking (%) Any smoked tobacco Cigarettes Current Daily Current Daily Male Female Total " " Estimate not available.

4 Country Profile: Panama Tobacco control measures and programmes as at 31 December 2010 Smoke-free environments 2010 Public places with smoke-free legislation: Health-care facilities Educational facilities except universities Universities Government facilities Indoor offices Restaurants Pubs and bars Public transport All other public places Compliance score 9 National law requires fines for smoking Fines levied on the establishment Fines levied on the smoker Dedicated funds for enforcement Citizen complaints and investigations A score of 0 10, where 0 is low compliance. Subnational laws on smoke-free environments Subnational jurisdictions do not have the authority to adopt and implement smoke-free laws. 2

5 Country Profile: Panama Treatment of tobacco dependence Is there a toll-free telephone quit line/help line with a live person available to discuss cessation with callers in your country? No 2010 Nicotine replacement therapy (e.g., patch, gum, lozenge, spray or inhaler) Bupropion (e.g., Zyban, Wellbutrin) Varenicline Is this product legally sold in the country? Where and how can this product be legally purchased in your country? Does the national/federal health insurance or the national health service cover the cost of this product? Is any NRT on the country's essential drugs list? Is this product legally sold in your country? Where and how can this product be legally purchased in your country? Does the national/federal health insurance or the national health service cover the cost of this product? Is this product legally sold in your country? In a pharmacy without a prescription Fully In a pharmacy with a prescription Fully Is smoking cessation support available in the following places in your country? Does the national/federal health insurance or the national health service cover the cost of this support? Where and how can this product be legally purchased in your country? In a pharmacy with a prescription Does the national/federal health insurance or the Fully national health service cover the cost of this product? Health clinics or other primary care facilities in some Hospitals in some Office of a health professional in some In the community No Other No Health clinics or other primary care facilities Partially Hospitals Partially Office of a health professional No In the community Other No 3

6 Country Profile: Panama Health warnings on tobacco packages Cigarettes 2010 Smokeless tobacco Does the law mandate that health warnings appear on tobacco packages? What percentage of the principal display areas of the package is legally mandated to be covered by health warnings? FRONT AND REAR COMBINED What percentage of the principal display areas of the FRONT of the package is legally mandated to be covered by health warnings? What percentage of the principal display areas of the REAR of the package is legally mandated to be covered by health warnings? Does the law mandate that the warning be placed at the top of the principle display areas No No of the package? Does the law mandate font style, font size and colour for package warnings? Are the health warnings rotating on packages? Are the health warnings on packages written in the principal language(s) of the country? Does the law require that health warnings on packages are not obscured in any way, including by required markings such as tax stamps? Do the health warnings on packages include a photograph or graphic? Do health warnings appear on each package and any outside packaging and labelling used in the retail sale? Does the law on health warnings apply to products whether manufactured domestically, imported, AND for duty-free sale? Does the law state that warnings on packages do not remove or diminish the liability of the tobacco industry? Do health warnings on packages describe the harmful effects of tobacco use on health? Does the law mandate specific health warnings on cigarette packages? How many specific health warnings are approved by the law? 5 5 Does the law require or establish fines for violations regarding health warnings on packages? Are there any laws requiring that cigarette packaging and labelling do not use misleading terms which imply the product is less harmful than other similar products, such as low tar, light, ultra-light, or mild? Are there any laws requiring that cigarette packaging and labelling do not use figurative or other signs, including colours or numbers, as substitutes for prohibited misleading terms and descriptors? Are there any laws requiring that cigarette packaging and labelling do not use descriptors depicting flavours? Does the law ban the display of quantitative information on emission yields (such as tar, nicotine and carbon monoxide) on cigarette packaging, including when used as part of a brand name or trademark? Does the law mandate the display of qualitative information on relevant constituents and emissions of tobacco products on cigarette packaging? Does the law mandate that this information is displayed on one or more of the principal No No display areas (front, rear) of the package? Does the law prevent the display of expiry dates on cigarette packaging? Is it mandatory for the quit line number to appear on packaging or labelling? No No Does the law mandate plain packaging (ie. prohibit the use of logos, colours, brand images or promotional information on packaging other than brand names and product names displayed in a standard colour and font style)? No No 4

7 Country Profile: Panama Bans on tobacco advertising, promotion and sponsorship 2010 Direct bans National TV and radio International TV and radio Local magazines and newspapers International magazines and newspapers Billboards and outdoor advertising Point of sale Internet Other direct bans No Compliance score of direct bans 9 Indirect bans Free distribution Promotional discounts Non-tobacco goods and services identified with tobacco brand names Brand name of non-tobacco products used for tobacco product Appearance of tobacco brands in TV and/or films (product placement) Appearance of tobacco products in TV and/or films Sponsored events Other indirect bans No Compliance score of indirect bans 9 Are there subnational laws or regulations banning some or all types No of tobacco advertising, promotion and sponsorship mentioned in the above questions? A score of 0 10, where 0 is low compliance. 5

8 Country Profile: Panama Tobacco taxation policy as at 31 July 2010 Price of lowest-cost brand of cigarettes (Viceroy) A Tax inclusive retail sales price (TIRSP) for a pack of 20 cigarettes USD USD Price of Marlboro or similar brand of cigarettes (Marlboro) A Tax inclusive retail sales price (TIRSP) for a pack of 20 cigarettes USD USD Taxes on the most popular brand of cigarettes (Viceroy) ᄌ Price of most sold brand, pack of 20 cigarettes In currency reported by country In US$ at official exchange rate Taxes on this brand (% of retail price) 6 WHO's comparable estimate for 2008 WHO's comparable estimate for 2010 USD USD USD USD Total ᄌ taxes Specific excise 0 0 Ad valorem excise Value added tax (VAT) 7 4 Import duty 2 Other taxes Individual categories of tax may not add to total due to rounding. National tobacco control programme 2010 Specific national government objectives in tobacco control National agency or technical unit for tobacco control Number of full-time equivalent staff... Government expenditure on tobacco control: In currency reported by country... Year of expenditure... In US$ at official exchange rate US$... *****

9 NCDs IN PANAMA Sociodemographic indicators Men Women Total population (thousands): 3,571.2 Average annual deaths (thousands): 18.1 Life expectancy at birth (years): Total: 76.2 Male: 73.7 Female: 78.9 Adult literacy rate (%): 93.6 Gross National Income US$ per capita: 6,570.0 % of population covered by any type health insurance: 65.7 Burden of disease PREMATURE DEATHS (2007) RISK FACTORS 41.0 % Cancer 3,416 premature deaths (<70 yrs) 10.2 % Diabetes Mellitus 7.6 % Chronic Respiratory Disease 41.2 % Cardiovascular Disease Premature deaths from NCDs (<70 yrs) account for 18.9% of all deaths Prevalence (%) of: Total Males Females Current adult tobacco smokers Adolescent tobacco smokers Fruit and vegetable intake in adults a Fruit and vegetable intake in adolescents a Binge drinking among adults Low physical activity in adults b Low physical activity in adolescents c Overweight among adults (BMI ) Obesity among adults (BMI 30) Overweight among adolescents (BMI>+1SD) Obesity among adolescents (BMI>+2SD) Children <5 overweight Adults with diabetes mellitus Adults with raised BP and/or taking medication Notes: a: % who eat 5 servings of fruit and vegetables per day; b: physically active for <600 met minutes; c: physically active less than 60 min per day in 5-7 of the last 7 days; BP: Blood pressure. Country capacity POLICIES & ACTION PLANS SURVEILLANCE Is there an integrated NCD policy? No Is there a budget? No Is there an operational multisectoral mechanism to coordinate the NCD policies? Is there an integrated NCD action plan? If the answer is yes, does it have: Budget? Measurable outcomes? Monitoring and evaluation component? Communications component? N/A No N/A N/A N/A N/A Is there dedicated staff? Does the information system include specific data on? Specific cause of mortality Hospital based morbidity No Risk factors surveys Are there disease specific registries? Is there a unique personal identifier? Use of data for policy making and planning? No Are there plans for specific diseases? NS Established mechanisms for data dissemination? No Notes: NA: Not applicable; NS: Not specified. 43

10 Country capacity PREVENTIVE HEALTH SERVICES AT THE PRIMARY LEVEL OF CARE CVD RISK ASSESSMENT BMI Blood pressure Blood glucose Blood lipids Individual risk management with a validated CV risk score DM AND CVD MANAGEMENT Blood pressure monitoring Blood glucose monitoring Blood lipids monitoring HbA1C Diabetic foot examination Electrocardiogram Available? All patients Free? Limited resources CERVICAL CANCER Cervical cytology or PAP Available? All patients Free? Notes: HPV: Human Papillomavirus; DM: Diabetes mellitus; CVD: Cardiovascular disease; CV: Cardiovascular Limited resources HPV DNA testing No Not applicable Visual inspection techniques (VIA) VIA & cryotherapy in a single visit BREAST CANCER Clinical examination Mammography COLORECTAL CANCER Fecal occult blood test No Not applicable Digital exam No Not applicable SPECIALIZED CARE CANCER DIAGNOSIS AND TREATMENT Colposcopy Diagnostic mammography Chemotherapy Radiotherapy CVD MANAGEMENT Available? All patients Free? Limited resources DIABETES MANAGEMENT Eye exams Photocoagulation for retinopahty Dialysis OTHER Available? All patients Free? Limited resources Cardiac bypass Not specified Angioplasty Not specified Home care for patients with terminal or advanced disease NON COMMUNICABLE DISEASES MEDICINES Insulin Aspirin Metformin Glibenclamide Thiazide diuretics ACE inhibitors Available? All patients Free? Limited resources Calcium channels blockers Beta blockers Statins Tamoxifen Oral morphine Available? All patients Free? Limited resources 44 Sources:»» Sociodemographic indicators and risk factors: Pan American Health Organization. Non communicable disease project, health information and analysis project and sustainable development and environment area: Non communicable diseases in the Americas: Basic indicators 2011, Washington DC, USA, 2011.»» Premature mortality: PAHO/WHO Mortality Information System (updated on May 2011).»» Country capacity: 2012 Country Capacity Survey in preparation for the CARMEN meeting, completed by Elsa Cristina Arenas de Kant, NCDs National Program Coordinator, Ministry of Health, Panamá.

11 Tobacco Control Policy Fact Sheet Panama: Advertising, Promotion & Sponsorship Regulated Forms of Tobacco Advertising, Promotion and Sponsorship Regulated Forms of Tobacco Advertising, Promotion and Sponsorship (cont'd) Banned Some Restrictions Allowed Uncertain N/A Banned Some Restrictions Allowed Uncertain N/A Domestic TV and radio Domestic newspapers and magazines Other domestic print media Domestic internet communications Domestic internet sales International TV and radio International newspapers and magazines International internet communications International internet sales Outdoor advertising Point of sale advertising Point of sale product display Vending machines Conventional mail Telephone and cellular phone Brand marking Tobacco packaging, labeling and inserts Free distribution of tobacco products Promotional gifts in conjunction with product purchase Competitions associated with products Direct targeting of individuals Brand stretching Reverse brand stretching Toys resembling tobacco products Paid placement in TV, film, or other media Unpaid depiction in TV, film, or other media Financial support to groups, events, etc. Publicity of financial support to groups, etc. Financial support to venues for decorations, renovations Financial support to venues for direct customer sales Payments for exclusive sale or prominent display Promotion by false, misleading, or deceptive means Definitions of Key Terms - Alignment with the FCTC Tobacco Sponsorship Tobacco Advertising and Promotion Tobacco Product Aligns Does Not Align Actions Required for Forms of Advertising, Promotion & Sponsorship Not Banned Disclosure to the govt. of info on APS activities and expenditures Health warning messages required on permitted forms of APS Disclosed information readily available to the public Required Not Required N/A Uncertain or N/A Candy resembling tobacco products Penalties Retailer incentive programs No Violation of advertising and promotion provisions Violation of sponsorship provisions Last updated: August 13, 2012

12 Tobacco Control Policy Fact Sheet Panama: Packaging & Labeling Health Warnings/Messages Features Other Packaging and Labeling Requirements Smoked Tobacco Products Type of Warnings Pictures (Photos), Pictograms (Illustrations/Cartoons), Text Warnings/Messages Warnings on unit packaging and labeling (e.g. packs) Required Some Restrictions Not Required Uncertain On front and back of packages % of principal display areas covered 50 Rotation required? Warnings on outside packaging and labeling (e.g. cartons) Warning texts iin the principal language(s) of the country Number of messages 5 Smokeless Tobacco Products Type of Warnings Pictures (Photos), Pictograms (Illustrations/Cartoons), Text Warnings/Messages % of principal display areas covered 50 Warnings may not be placed where they may be concealed or damaged when opening the pack Warnings may not be placed where they may be concealed by tax stamps or other required markings Qualitative (descriptive) constituents and emissions disclosures Rotation required? Number of messages 5 Definitions of Key Terms - Alignment with the FCTC and its guidelines Tobacco Product Outside Packaging and Labeling Penalties Aligns Does Not Align N/A Ban on display of figures for emission yields (including tar, nicotine, etc.) Plain or standardized packaging Prohibition on misleading packaging and labeling Content of the Warnings/Messages Health impacts Advice on cessation No No The addictive nature of tobacco Manufacturer Importer Wholesaler Adverse economic and social outcomes The impact of tobacco use on friends and family A quitline phone number Retailer Last updated: August 13, 2012

13 Tobacco Control Policy Fact Sheet Panama: Smoke Free Places Smoke Free Status of Indoor Workplaces, Indoor Public Places, and Public Transport Definitions of Key Terms - Alignment with the FCTC and its guidelines 100% Smoke Free Some Restrictions Smoking Not Restricted Uncertain N/A Aligns Does Not Align N/A All workplaces Government facilities Hospitals Residential healthcare facilities - public areas Residential healthcare facilities - patient rooms Non-residential healthcare facilities Childcare facilities/preschools Primary and secondary schools Universities/vocational facilities Shops Cultural facilities Indoor stadium/arenas Restaurants Bars/pubs/nightclubs Casinos Hotels/lodging - public areas Hotels/lodgings - guest rooms Prisons/detention facilities - public areas Prisons/detention facilities - cells Trains, buses and other shared ground transportation Taxis Aircraft Watercraft Transport facilities Second Hand Smoke Smoking or Smoke Public Place Workplace Public Transport Indoor or Enclosed Tobacco Product Smoke Free Status of Outdoor Places Is one or more outdoor place required to be smoke free? Enforcement Authority Is an enforcement authority identified? Duties and Penalties Imposed on Owner/Employer? Post signs Remove ashtrays Steps to require a person to stop smoking Imposed on smoker? Not to smoke where prohibited No Uncertain No Duty Penalty Neither Last updated: August 13, 2012

14 Changes in Tobacco Use Among Youths Aged Years --- Panama, 2002 and 2008 Weekly January 9, 2009 / 57(53); Changes in Tobacco Use Among Youths Aged Years --- Panama, 2002 and 2008 Tobacco use is the single most preventable cause of death in the world today (1), and the majority of smokers begin using tobacco products before age 18 years (2). However, before the late 1990s, few countries had reliable data on youth tobacco use. In 1999, the World Health Organization (WHO), CDC, and the Canadian Public Health Association developed the Global Youth Tobacco Survey (GYTS) to help countries monitor youth tobacco use (3). At the same time, WHO initiated the Framework Convention on Tobacco Control (WHO FCTC), the first international public health treaty on tobacco control (4). Panama ratified WHO FCTC in 2004 and enacted two key antitobacco regulations in 2005 and To evaluate progress toward attaining tobacco control goals in Panama, Panama's Ministry of Health, CDC, and WHO compared results from GYTS surveys conducted in Panama in 2002 and This report summarizes the results of that comparison, which revealed substantial decreases from 2002 to 2008 in youth current cigarette smoking (13.2% versus 4.3%), current use of tobacco products other than cigarettes (9.8% versus 5.8%), and likely initiation of smoking by never smokers (13.8% versus 10.0%). In addition, factors influencing tobacco use showed substantial decreases, including 1) exposure to secondhand smoke (SHS) at home and in public places, 2) best friends smoking, 3) protobacco advertising in newspapers and magazines, and 4) having an object with a tobacco company logo on it. These results suggest that comprehensive regulations in Panama helped reduce tobacco use among adolescents and further gains are possible. GYTS is a school-based survey that collects data from students aged years and has been completed in 163 countries, with repeat surveys in 100 countries. GYTS uses a two-stage cluster sample design that produces representative samples of students in grades associated with students aged years (3). GYTS uses a standardized methodology for constructing sampling frames, selecting schools and classes, preparing questionnaires, conducting field procedures, and processing data. At the first stage, the probability of schools being selected is proportional to the number of students enrolled in the specific grades. At the second sampling stage, classes within the selected schools are randomly selected. All enrolled students in selected classes the day the survey is administered are eligible to participate. Student participation is voluntary and kept anonymous by using self-administered data collection procedures. GYTS was conducted in Panama in 2002 and In both years, GYTS sampling included all public and private schools with grades In 2002, a total of 2,017 students completed the Panama GYTS from 50 selected schools. Of these students, 1,296 indicated that they were aged years. In 2008, a total of 3,534 students completed the Panama GYTS from 50 selected schools, of whom 2,716 indicated that they were aged years. The school response rate (number of participating schools divided by the number of selected schools) was 98.0% in 2002 and 96.0% in 2008; the class response rate (number of participating classes divided by the number of selected classes) was 100.0% in 2002 and 99.3% in 2008; the student response rate (number of participating students divided by the number of students enrolled in the class) was 89.1% in 2002 and 83.9% in 2008; and the overall response rate (product of the school response rate, the class response rate, and the student response rate) was 87.3% and 80.0%, respectively. This report summarizes the results from 10 key GYTS tobacco-use indicators: 1) current cigarette smoking; 2) current use of tobacco products other than cigarettes; 3) likely initiation of cigarette smoking in the next year among never smokers (i.e., susceptibility) (5); 4) exposure to SHS at home and in public places; 5) one or more best friends smoke 11:13:03 AM]

15 Changes in Tobacco Use Among Youths Aged Years --- Panama, 2002 and 2008 cigarettes; 6) in favor of banning cigarette smoking in public places; 7) exposure to protobacco advertising in newspapers and magazines, having protobacco promotional items, having been offered free cigarettes, and exposure to antitobacco media messages; 8) among current cigarette smokers, the desire to stop smoking; 9) among current cigarette smokers, those who bought their cigarettes in a store and were not refused the purchase because of their age; and 10) students who were taught in school about the dangers of smoking.* T-tests were used to determine differences between subpopulations (6). Differences between prevalence estimates were considered statistically significant at p<0.05. From 2002 to 2008, prevalence of current cigarette smoking among students aged years in Panama decreased 60% for boys, 75% for girls, and 67% overall (from 13.2% to 4.3%) (Table 1). The level of current cigarette smoking in 2002 and in 2008 did not differ by sex. Current use of other tobacco products decreased 41% overall from 2002 (9.8%) to 2008 (5.8%). The percentage of never smokers who were susceptible to initiation of smoking decreased 43% from 2002 to 2008 for girls (from 14.5% to 8.3%). From 2002 to 2008, the percentage of students who reported exposure to SHS decreased 32% at home (from 32.0% to 21.9%) and 22% in public places (from 51.8% to 40.3%); and the percentage of students whose best friends smoke decreased 58% (from 14.5% to 6.1%) (Table 2). Support among students aged years for a ban on smoking in public places increased 12% from 2002 (80.5%) to 2008 (89.9%). The percentage of students who saw protobacco advertisements in newspapers or magazines decreased 16% (from 67.4% in 2002 to 56.7% in 2008) (Table 2). The percentage of students who owned an item with a tobacco logo on it decreased 47% from 2002 to 2008 (from 12.0% to 6.4%). The percentage of students reporting having been offered free cigarettes by a tobacco company representative did not change significantly over time (8.1% in 2002 and 5.9% in 2008). The percentage of students who saw antismoking mass media messages increased 7% from 2002 to 2008 (from 77.3% to 82.5%). The percentage of current smokers who wanted to stop smoking did not change over time, nor did the percentage of smokers who bought their cigarettes in a store and were not refused purchase because of their age. The percentage of students who were taught in school regarding the dangers of smoking also did not change over time. Reported by: R Roa, MD, Ministry of Health, Panama. R Franklin-Peroune, World Health Organization, Pan American Health Organization. NR Jones, PhD, Univ of Wisconsin-Madison. CW Warren, PhD, J Lee, MPH, V Lea, MPH, A Goding, MSPH, S Asma, DDS, National Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note: The findings in this report indicate that cigarette smoking, other tobacco use, and the likely initiation of smoking in the next year by never smokers declined substantially among Panama youths from 2002 to The Panama Ministry of Health has made tobacco control a priority and has established a national tobacco control agency (1). Panama is one of four Latin American countries (along with Bolivia, Costa Rica, and Paraguay) that has reported a significant decrease in adolescent tobacco use since 1999 (CDC, unpublished data, 2008). In all four countries, the enactment of antitobacco laws and regulations have proven important in leading to this behavior change among adolescents. WHO notes that reductions in tobacco use most often are the result of measures such as 1) raising taxes on tobacco, 2) banning advertising promotion and sponsorship, 3) reducing exposure of the population to SHS, 4) informing the public regarding the dangers of tobacco, and 5) establishing tobacco cessation programs (1). Certain of the results in this report (e.g., significant declines from 2002 to 2008 in exposure to SHS at home and in public places, best friends smoking, having seen protobacco advertisements in newspapers and magazines, and having an object with a tobacco company logo on it) likely resulted from enactment of regulations in Panama in 2005 and 2008: the Ministry decree and Law No. 13. The 2005 Ministry decree required health warnings on all tobacco product packages, banned the sale of individual cigarettes, prohibited use of vending machines for cigarettes, and banned protobacco advertising on billboards. The 2005 decree is believed to have had limited effect because of moderate enforcement (1). In January 2008, Panama adopted Law No. 13, which intensified tobacco control measures by banning protobacco statements on cigarette packages; requiring complete prohibition of any form of protobacco advertising, promotion, or sponsorship 11:13:03 AM]

16 Changes in Tobacco Use Among Youths Aged Years --- Panama, 2002 and 2008 of all kinds in all venues, including sports venues; prohibiting tobacco consumption in all enclosed work environments; and requiring the integration of content on the health consequences of tobacco consumption into the curricula of general education and basic secondary education. Law No. 13 also included policies and penalties for violations of the law and its regulations. The 2008 GYTS was conducted in June, only 6 months after the law went into force in January; thus the results likely do not fully reflect the effects of Law No.13. The findings in this report are subject to at least three limitations. First, because the sample surveyed was limited to youths attending school, they might not be representative of all persons age years in Panama. Ministry of Education data by age show that 85% of youths aged 13 years, 80% of youths aged 14 years, and 69% of youths aged 15 years are enrolled in school (R. Roa, Panama Ministry of Health, personal communication, 2008). Second, these data apply only to youths who were in school the day the survey was administered and completed the survey. However, student response was 89% in 2002 and 85% in 2008, suggesting minimal bias resulting from absence or nonresponse. Finally, data are based on self-reports of students, which might result in underreporting or overreporting of tobacco use. However, responses to tobacco questions on surveys similar to GYTS have shown good test-retest reliability in the United States (7). The ideal goal in Panama, as for all countries that ratify the WHO FCTC, is zero tobacco use among adolescents. To attain this goal, Panama's Ministry of Health should continue to make youth tobacco use prevention a programmatic priority and broaden the program to include excise tax increases, a complete ban on smoking in all indoor work places, and a complete ban on protobacco advertising. Repeating the GYTS in the future will be important for tracking the trend in adolescent tobacco use in Panama and monitoring the effect of the obligations of WHO FCTC. References 1. World Health Organization. WHO report on the global tobacco epidemic, Geneva, Switzerland: World Health Organization; Available at 2. CDC. Preventing tobacco use among young people: a report of the Surgeon General, Atlanta, GA: US Department of Health and Human Services, CDC; Available at 3. CDC. Global youth tobacco surveillance, MMWR 2008;57(No.SS-1). 4. World Health Organization. WHO framework convention on tobacco control. Geneva, Switzerland: World Health Organization; Available at 5. Pierce JP, Choi WS, Gilpin EA, Farkas AJ, Merritt RK. Validation of susceptibility as a predictor of which adolescents take up smoking in the United States. Health Psychol 1999;15: Hinkle DE, Wiersma W, Jurs SG. Applied statistics for the behavioral sciences. 5th ed. Boston, MA: Houghton Mifflin; Brener ND, Kann L, McMannus T, Kinchen SA, Sundberg EC, Ross JG. Reliability of the 1999 Youth Risk Behaviors Survey questionnaire. J Adolesc Health 2002;31: * Results are based on specific responses to the following questions: 1) A response of "1 or more days" to the question, "During the past 30 days on how many days did you smoke cigarettes?" 2) A positive response to the question, "During the past 30 days did you smoke any tobacco product other than cigarettes?" 3) A negative response to the question, "Have you ever tried or experimented with cigarette smoking, even one or two puffs?" and a response of anything but "definitely no" to the questions, "If one of your best friends offered you a cigarette, would you smoke it?" and "Do you think you will try smoking a cigarette in the next year?" 4) A response of "1 or more days" to the questions: "During the past 7 days, on how many days have people smoked in your presence in your home?" and "During the past 7 days, on how many days have people smoked in your presence, in places other than your home?" 5) A response of "most" or "all" to the question, "Do most or all of your best friends smoke?" 6) A positive response to the question, "Are you in favor of banning smoking in public places (such as in restaurants; in buses, streetcars, and trains; in schools; on playgrounds; in gyms and sports arenas; in discos?)" 7) A response of "a lot" or "a few" to the questions, "During the past 30 days (1 month), how many advertisements or promotions for cigarettes have you seen in newspapers or magazines?" and "During the past 30 days (1 month), how many anti-smoking media messages (e.g. television, radio, billboards, posters, newspapers, magazines, movies, drama) have you seen or heard," and a positive response to the questions, "Do you have something (T-shirt, pen, backpack, etc.) with a cigarette brand logo on it?" or "Has a cigarette company representative ever offered you a free cigarette?" 8) For current cigarette smokers, a positive response to the question, "Do you want to stop smoking now?" 9) For current cigarette smokers, a response of "bought them in a store" to the question, "During the past 30 days, how did you usually get your own cigarettes?" and a negative response to the question, "During the past 30 days, did anyone ever refuse to sell you cigarettes because of your age?" 10) A positive response to the question, "During this school year, were you taught in any of your classes about the dangers of smoking?" 11:13:03 AM]

17 Changes in Tobacco Use Among Youths Aged Years --- Panama, 2002 and 2008 Measures for preventing and reducing the consumption of tobacco and exposure to smoke from tobacco, because of its harmful effects on people's health [Spanish]. Executive Decree No. 17 (March 17, 2005). Republic of Panama. Official Gazette No ; March 22, Measures for control of tobacco and its adverse health effects [Spanish]. Law No. 13 (January 13, 2008). Republic of Panama. Digital Official Gazette No ; January 25, Table 1 Return to top. Table 2 Return to top. Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services. 11:13:03 AM]

18 Changes in Tobacco Use Among Youths Aged Years --- Panama, 2002 and 2008 References to non-cdc sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of pages found at these sites. URL addresses listed in MMWR were current as of the date of publication. All MMWR HTML versions of articles are electronic conversions from typeset documents. This conversion might result in character translation or format errors in the HTML version. Users are referred to the electronic PDF version ( and/or the original MMWR paper copy for printable versions of official text, figures, and tables. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Printing Office (GPO), Washington, DC ; telephone: (202) Contact GPO for current prices. **Questions or messages regarding errors in formatting should be addressed to mmwrq@cdc.gov. Date last reviewed: 1/7/2009 HOME ABOUT MMWR MMWR SEARCH DOWNLOADS RSS CONTACT POLICY DISCLAIMER ACCESSIBILITY Morbidity and Mortality Weekly Report Centers for Disease Control and Prevention 1600 Clifton Rd, MailStop E-90, Atlanta, GA 30333, U.S.A Department of Health and Human Services 11:13:03 AM]

19 LA DEMANDA DE CIGARRILLOS EN PANAMÁ MSc. Víctor Hugo Herrera Ballesteros CENTRO DE INVESTIGACIÓN PARA LA EPIDEMIA DEL TABAQUISMO - CIET Panamá, Abril de 2010 Todos los derechos de esta investigación pertenecen al CIET-Ministerio de Salud de Panamá (MINSA). El uso o reproducción total o parcial de este documento requiere el consentimiento de CIET-MINSA.

20 Contenido Página Introducción Antecedentes a. Marco legal de control del tabaco... 5 b. Aspectos fiscales... 6 c. Antecedentes productivos... 8 d. Antecedentes de comercialización... 9 e. Aspectos institucionales del control del tabaco Estimación de la demanda de cigarrillos a. Análisis de la demanda y variables explicativas b. Construcción de la base de datos c. Metodología y construcción del modelo d. Resultados y análisis Simulaciones y recomendaciones de políticas fiscales sobre el tabaco a. Simulación y análisis de alternativas empleando la curva de Laffer b. Validación respecto de otras alternativas c. Simulación sobre la asequibilidad Conclusiones Bibliografía Anexos 2

21 Introducción Han sido notables los avances de Panamá en materia de medidas de control de consumo de tabaco, especialmente en la década actual, con legislación de última generación que ha puesto al país a la vanguardia en la región al adoptar los estándares internacionales en la materia. También han sido observables los efectos sobre el consumo y el precio de los cigarrillos, principal producto derivado del tabaco y de consumo masivo en el país. Las prevalencias de vida y mensuales se han reducido considerablemente entre 2002 y 2008, según los resultados de la encuesta de tabaco en jóvenes. Sin embargo, la encuesta de propósitos múltiples de 2006, aún arroja resultados alarmantes de prevalencia mensual en grupos de edades disponibles para la actividad laboral plena, que va desde los 20 hasta los 59 años, en adición al consumo de tabaco en el hogar, donde todavía las medidas de control no alcanzan su mayor eficacia. En adición a lo señalado, en el caso de Panamá la asequibilidad de los productos de tabaco resulta relativamente alta respecto de los países en desarrollo, los cuales en general han experimentado un retroceso en la presente década. El período de investigación cubierto va desde 1999 hasta 2009, trabajando con datos trimestrales. Como introducción se analiza de un modo descriptivo la evolución del consumo de tabaco y sus variables explicativas, el precio de los productos de tabaco y el ingreso de los hogares. Este análisis sirve para contextualizar el efecto de las medidas de control de tabaco aplicadas en los últimos años, relacionando los cambios estructurales en la demanda de productos de tabaco debido a cambios en la legislación en el marco de la política de control de tabaco y a otros factores. Luego del análisis descriptivo se realizará la modelización del mercado de cigarrillos, y se estimarán cuatro modelos 1 : un modelo estático inicial, un modelo de ajuste parcial a los efectos de testear la hipótesis de adicción miope, un modelo con la variable precio adelantada para testear la hipótesis de adicción racional y finalmente un modelo de corrección de errores. La modelización exige testear las hipótesis de exogeneidad de las variables explicativas, en especial del precio del cigarrillo. De acuerdo a los resultados obtenidos de los test de exogeneidad, serán los métodos de estimación que se adopte en la modelización. Desde finales de la década pasada Panamá no tiene industria tabacalera, siendo un importador neto de cigarrillos y por ende tomador del precio internacional, este hecho puede ser determinante para que el precio de los cigarrillos sea una variable exógena. 1 Ver herramientas de la economía del tabaco del Banco Mundial. 3

22 Por otro lado, y mediante el uso de variables ficticias, se espera poder capturar el efecto a corto plazo de las medidas de control de tabaco tomadas en Panamá y sus posibles implicaciones a largo plazo. Utilizando el modelo de corrección de errores se estimarán las elasticidades precio e ingreso de la demanda, de corto y largo plazo, mediante las cuales se harán los análisis sobre los efectos a corto y largo plazo que puedan tener las medidas de aumentos de impuestos a los cigarrillos, tanto en términos del efecto sobre el consumo de cigarrillos como de recaudación de impuestos. Asimismo la elasticidad ingreso se empleará para un análisis sobre la asequibilidad de los consumidores de los productos de tabaco y las políticas de aumentos periódicos que se pueden plantear con el objetivo de mantener un cierto poder de compra de cigarrillos de los consumidores 2. Con las estimaciones efectuadas, en particular con la elasticidad precio de la demanda de largo plazo del modelo de corrección de errores, se realizará un análisis en materia fiscal, utilizando como herramienta la Curva de Laffer; para ello se calcula el umbral de la tasa de imposición hasta el cual es posible combatir el consumo de cigarrillos a través del aumento de la tasa del impuesto sin afectar negativamente los ingresos tributarios. Este análisis se empleará para evaluar las medidas fiscales tomadas por el gobierno en noviembre de 2009, mediante la Ley N 69. Además se analizará la asequibilidad o poder de compra de productos de tabaco de los consumidores, con el objetivo de establecer una política de control de tabaco vía aumento de impuestos que tome en consideración este aspecto. Esto plantea la necesidad de tener una política impositiva que tome en cuenta los diversos aspectos en juego si se desea tener eficiencia en el control del consumo de tabaco a través de aumentos impositivos. En función de estos elementos, es dable señalar que las medidas de control y fiscales, ameritan una revisión objetiva cada cierto tiempo, toda vez que existen distintos tipos de fumadores, prevalencias de vida y mensuales, entre otros aspectos, que evidencian la necesidad de actualizar continuamente la legislación de control y fiscal en esta materia, dado que las condiciones que afectan el consumo y a la propia industria no son estáticas en el tiempo. 2 Ver Guidan y De Kan, Relative Income Price (2008) 4

23 1. Antecedentes. A los efectos de tener una visión general del tema del control del consumo de tabaco, se hace una revisión del marco legal de control del consumo de tabaco y sus avances recientes, una relación descriptiva de la constitución económica de la actividad productiva y comercial en torno a este producto, los aspectos institucionales y los resultados del combate al comercio ilegal de productos de tabaco. a. Marco legal de control del tabaco En Panamá las medidas de control para el consumo de tabaco inicialmente se concentraron en prohibir la venta de derivados del tabaco a los menores de edad, a prohibir fumar en oficinas públicas y lugares cerrados tales como cines, transporte público y selectivo, teatros, escuelas e instalaciones de salud entre otras. La publicidad estaba dirigida a desincentivar a los jóvenes en el inicio del consumo de productos de tabaco, sin embargo, éstas han sido reforzadas con legislaciones recientes de finales del periodo investigado. Mediante el Decreto Ejecutivo N 86 de 27 de mayo de 1999 se reglamentan las restricciones y disposiciones sobre la venta de cigarrillos y tabacos a los menores de edad y la impresión de advertencias sobre su uso. Se establece la rotulación obligatoria en la cajetilla de cigarrillos y envoltorios no externos de tabaco, que sean puestos a la venta en el territorio nacional, con las siguientes advertencias: Prohibida la venta a menores de edad y Fumar es nocivo para La salud. Con la ratificación del Convenio Marco de la Organización Mundial de la Salud (OMS), mediante la Ley 40 del 16 de agosto 2004, se promulga el Decreto Ejecutivo N 17 del 11 de marzo de 2005, en el que se introducen medidas tales como: prohibir fumar en restaurantes, las advertencias sanitarias y pictogramas que deben ocupar el 50% en los paquetes de productos del tabaco, se prohibió la venta de cigarrillos sueltos y en paquetes de menos de 20 unidades, la prohibición del uso de máquinas expendedoras de cigarrillos, se prohíbe la publicidad en vallas y en medios de comunicación masivos, se circunscribe la publicidad únicamente en los puntos de venta y la promoción y el patrocinio solo a actividades de participación de la población adulta (mayores de 18 años). El 11 enero de 2008 se crea la Ley Nº 13, mediante la cual se adoptan medidas para el control del tabaco y sus efectos nocivos en la salud, la cual fue reglamentada mediante el 5

24 Decreto Ejecutivo Nº 230 del 6 de mayo de 2008, y establece restricciones adicionales, en refuerzo de las medidas aprobadas y adoptadas en el año 2005, tales como: intensificar las medidas de control de tabaco mediante la prohibición del uso de términos que sugieran que un producto de tabaco es menos dañino que otro en todos los paquetes de productos de tabaco; se prohíbe totalmente cualquier forma de publicidad, promoción y patrocinio de los productos de tabaco, incluida la transfronteriza; se prohíbe el consumo de tabaco en todos los ambientes laborales cerrados, áreas comunes de edificios públicos y privados e incluso en aquellos espacios abiertos dedicados a las actividades deportivas; se fortalece la participación de la sociedad civil en el control del tabaco; se obliga al Estado a poner al acceso del público programas de promoción y abandono del consumo de tabaco, a informar sobre las consecuencias sanitarias, la naturaleza adictiva y la amenaza mortal del consumo de tabaco y de la exposición al humo de tabaco y a integrar en los planes de educación general básica y de la educación media contenidos sobre control de tabaco. En la misma también quedan tipificadas las violaciones y sanciones a la ley y a su reglamento. Es de esperarse que estas medidas de control, que refuerzan las de 2005, tengan un efecto directo en reducir el consumo de tabaco. Con este conjunto de medidas de control del consumo de tabaco, Panamá se pone a la vanguardia en el control de la epidemia del tabaquismo, con reformas de última generación mediante las cuales el país se ha puesto al día en la política de control del tabaco, adoptando los estándares internacionales, recomendados por los organismos internacionales. b. Aspectos fiscales La imposición a los cigarrillos y cigarros siguió la siguiente evolución: I. El decreto de gabinete Nº 35 de 1970 en su artículo primero, establecía el impuesto a la producción nacional de cigarrillos, de acuerdo a los precios límites al por menor, establecido por la entones oficina de regulación de precios, respecto de las cajetillas de 20 cigarrillos, con base en una escala gradual. II. Mediante el decreto de gabinete Nº 22 de 1972, se reformó el artículo 1º del decreto de gabinete Nº 35 de 1970, estableciendo que el impuesto a la producción nacional de cigarrillos sería del 30% del precio de venta al consumidor, establecido por la entonces Oficina de Regulación de Precios, respecto a cada cajetilla de cigarrillos. III. La ley Nº 75 del 22 de diciembre de 1975 establece el Impuesto sobre la Transferencia de Bienes Corporales Muebles y la Prestación de Servicios (ITBMS), la que modifica el 6

25 artículo v del Código Fiscal. Este impuesto es un impuesto al valor agregado y la tasa del mismo es de 5 %. La base imponible es el precio de venta en el caso de los cigarrillos producidos localmente y el valor CIF más el arancel en el caso de los cigarrillos importados. IV. La ley Nº 31 de 1991 en su artículo 20 eleva la tasa del ITBMS a los cigarrillos al 10 % del precio de venta o del valor CIF más arancel según sea producto local o importado respectivamente. V. La ley N 45 del 14 de noviembre de 1995 deroga los títulos VI y XXI del libro cuarto del código fiscal y los decretos de gabinete N 35 de 1970 y N 22 de 1972; se modifican y derogan otras disposiciones. VI. La ley Nº 45 del 14 de noviembre de 1995, en el artículo 28 crea el Impuesto Selectivo al Consumo de cigarrillos (ISC) del 32.5% del precio de venta al consumidor declarado por el productor o el importador, con el cual quedaba establecida la base impositiva. VII. La reforma arancelaria de enero de 1998 determina que los cigarrillos y otros productos derivados del tabaco pagan el 15% de arancel de importación. VIII. La ley 28 de 27 de junio de 2001 aumentó al 15% el ITBMS de importación para cigarrillos, también se establece que el ingreso que genere el aumento de 5% de este impuesto se destina al Instituto Oncológico Nacional. IX. Dicha ley además modificó el parágrafo 6 del artículo 1057-V del Código Fiscal sobre el impuesto al cigarrillo y el artículo 24 de la Ley 30 de 1984, sobre contrabando y defraudación aduanera. La nueva ley de 2001 además reglamenta las áreas para fumadores en los restaurantes y cafeterías. X. El decreto ejecutivo Nº 84 del 26 de agosto de 2005 reglamenta el ITBMS y el decreto ejecutivo Nº 85 también del 26 de agosto de 2005 reglamenta el ISC. XI. Con la Ley Nº 49 de 17 de septiembre de 2009 la base impositiva del ISC se elevó del 32.5% al 50% y finalmente mediante la Ley Nº 69 de 6 de noviembre de 2009, al 100%. El artículo 32 de esta ley modificó el artículo 28 de la Ley Nº 45 de 1995 de la siguiente manera: Artículo 32. El artículo 28 de la Ley Nº 45 de 1995 queda así: Artículo 28. La tarifa del impuesto selectivo al consumo de cigarrillos será del ciento por ciento (100%) del precio de venta al consumidor declarado por el productor nacional o el importador al Ministerio de Economía y Finanzas, con un mínimo de un balboa con cincuenta centavos (B/. 1.50), por cajetilla. La tarifa del impuesto selectivo al consumo de tabacos, habanos y otros productos derivados del tabaco será del ciento por ciento (100%) del precio de venta al consumidor declarado por el productor nacional o el importador al Ministerio de Economía y Finanzas. 7