Article

Increasing tobacco taxes: A cheap tool to increase public health

Authors:
  • Groningen University; National Institute for Public Health and the Environment (RIVM)
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Abstract

Several studies have estimated health effects resulting from tobacco tax increases. However, studies on the cost effectiveness of tobacco taxes are scarce. The aim of this study was to estimate the cost effectiveness of tobacco tax increases from a health care perspective, explicitly considering medical costs in life years gained. The effects of a tax increase were translated into effects on smoking quit rates. A dynamic population model then projected incidence, prevalence and health care costs of the major chronic diseases conditional on smoking status over time. Comparing to a current practice scenario, the differences in healthcare costs, tax revenues, life years and QALYs from a tobacco tax increase resulting in a price increase of 10% increase were estimated. Including effects on health care costs in life years gained, the tax increase costs about 2500 euro per QALY gained. Only 3% of additional tax revenues are enough to compensate additional health care costs in life years gained. Even if the health care costs in life years gained are taken into account and even if additional tax revenues do not flow to the health care sector a tax increase is a cost-effective intervention to increase public health from a health care perspective.

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... Within tobacco prevention, 31 universal and 17 indicated preventive interventions were evaluated [38,41,[50][51][52][53][54][55][56][57][58][59]42,[60][61][62][63][64][65][66][43][44][45][46][47][48][49]. For alcohol prevention, 40 universal and two indicated preventive interventions were assessed [38,[67][68][69][70][71][72][73][74][75]95]. ...
... Rather than only focusing on key attributes, such as study population, intervention and comparator descriptions, measures of effects, costing information and methodological considerations, this review focused on the "business as usual" differences, feasibility of implementation and potential similarities in costing and intervention effectiveness. For instance, some of the studies rated as having high transferability evaluated the effects of increased excise tax on the consumption of alcohol and tobacco [45,49,67,68,95] in the Netherlands, the UK and Denmark. Hypothetical tax increases were modelled with an impact on consumption through price elasticities -the percentage decrease in consumption due to a percentage increase in prices. ...
... If price elasticities are similar between countries, effects could largely be transferred. The Swedish elasticities for alcohol and tobacco are estimated at 0.5−0.7 and 0.2 respectively [81], while the Danish [68] are lower, and the studies from the Netherlands use lower [45,49] or somewhat similar [67] elasticities. Lower elasticities mean lower effects; hence using the effect estimates from these studies in a Swedish setting would probably underestimate the true effects. ...
Article
Aims: To identify and assess the cost-effectiveness of public health interventions targeting the use of alcohol, illicit drugs and tobacco, as well as problematic gambling behavior (ANDTS), and consider whether the results from these evaluations are transferable to the Swedish setting. Methods: A systematic review of economic evaluations within the area of ANDTS was conducted including studies published between January 2000 and November 2018, identified through Medline, PsychINFO, Web of Science, the National Health Service Economic Evaluation Database and Health Technology Assessment. The quality of relevant studies and the possibilities of transferring results were assessed using criteria set out by the Swedish Agency for Health Technology Assessment. Results: Out of 54 relevant studies, 39 were of moderate to high quality and included in the review, however none for problematic gambling. Eighty-one out of a total of 91 interventions were cost-effective. The interventions largely focusing on taxed-based policies or screening and brief interventions. Thirteen of these studies were deemed to have high potential for transferability, with effect estimates considered relevant, and with good feasibility for implementation in Sweden. Conclusions: Interventions targeting alcohol- and illicit-drug use and tobacco use are cost-effective approaches, and results may be transferred to the Swedish setting. Caution must be taken regarding cost estimates and the quality of the evidence which the studies are based upon.
... In three studies the populations were described further as smoking 20 cigarettes per day or more [33][34][35], making or considering a single or first quit attempt [36][37][38][39] or had recently tried to quit smoking [40,41]. In five studies the population was described only as a dynamic and/or hypothetical cohort [42][43][44][45][46] and in nine studies the population was not reported at all [47][48][49][50][51][52][53][54][55]. ...
... A significant part of the intervention was smoking cessation programmes, either pharmacotherapy [4,5,[36][37][38]40,41,48,50,51,53,[55][56][57][58][59][60][61][62][63][64][65], behavioural therapy [6,42,47,[66][67][68][69] or a combination of these [33][34][35]43,45,46,49,52,54,[70][71][72][73][74][75]. Several studies evaluated wider tobacco control interventions [39,44,[76][77][78][79][80][81][82][83][84][85][86][87][88], whereas five studies included both smoking cessation programmes and tobacco control interventions [89][90][91][92][93]. ...
... The main measure of outcome used is the QALY. In total, 23 of 64 studies reported QALY as their main outcome [5,35,38,40,41,[47][48][49]56,58,59,[61][62][63]65,69,70,76,78,81,86,88,94], followed by life years (LY) gained (n = nine of 64) [33,43,46,[66][67][68]73,74,89] or a combination of these (n = 12 of 64) [4,6,[35][36][37]39,42,44,57,77,80,83]. Five of 64 studies reported disability adjusted life years (DALY) as their main outcome [60,82,[90][91][92], and only four of 64 (incremental) net benefit [52,53,55,71]. ...
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Article
Aims: To identify different types of models used in economic evaluations of smoking cessation, analyse the quality of the included models examining their attributes and ascertain their transferability to a new context. Methods: A systematic review of the literature on the economic evaluation of smoking cessation interventions published between 1996 and April 2015, identified via Medline, EMBASE, NHS EED, and HTA. Checklist-based quality of the included studies and transferability scores were based on European Network of Health Economic Evaluation Databases (EURONHEED) criteria. Studies that were not in smoking cessation, not an original research, not a model-based economic evaluation, that did not consider adult population and not from a high income country were excluded. Findings: Among the 64 economic evaluations included in the review, state-transition Markov model was the most frequently used method (n = 30/64) with Quality Adjusted Life Years (QALYs) being the most frequently used outcome measure in a lifetime horizon. A small number of the included studies (13/64) were eligible for EURONHEED transferability checklist. The overall transferability scores ranged from 0.50 to 0.97 with an average score of 0.75. The average score per section was 0.69 (range 0.35-0.92). Relative transferability of the studies could not be established due to a limitation present in the EURONHEED method. . Conclusion: All existing economic evaluations in smoking cessation lack in one or more key study attributes necessary to be fully transferable to a new context.
... Of the 1,845 reviewed abstracts, eight studies [16][17][18][19][20][21][22][23] were included in the analyses (Fig 1), conducted in 2012. All included studies were modeling studies and assessed cigarette tax increases only, although the search criteria accommodated any type of tobacco price increase. ...
... Appendix Table 2 (available online) summarizes the type of economic information provided by the included studies. Only one 20 provided an estimate for intervention cost, and seven [16][17][18][19][21][22][23] gave estimates of healthcare costs averted. ...
... One of the most important drivers of variation was measurement of healthcare costs. Six studies 16,17,19,[21][22][23] used static or dynamic cohort simulation to estimate changes in healthcare costs associated with tobacco tax increases. Healthcare costs were realized in each period of the model (corresponding to each year) and the difference between cumulative costs in the intervention and the status quo scenarios was calculated. ...
Article
Tobacco use is a leading cause of preventable death in the U.S. and around the world. Increasing tobacco price through higher taxes is an effective intervention both to reduce tobacco use in the population and generate government revenues. The goal of this paper is to review evidence on the economic impact of tobacco price increases through taxation with a focus on the likely healthcare cost savings and improvements in employee productivity. The search covered studies published in English from January 2000 to July 2012 and included evaluations of national, state, and local policies to increase the price of any type of tobacco product by raising taxes in high-income countries. Economic review methods developed for The Guide to Community Preventive Services were used to screen and abstract included studies. Economic impact estimates were standardized to summarize the available evidence. Analyses were conducted in 2012. The review included eight modeling studies, with seven providing estimates of the impact on healthcare costs and three providing estimates of the value of productivity gains. Only one study provided an estimate of intervention costs. The economic merit of tobacco product price increases through taxation was determined from the overall body of evidence on per capita annual cost savings from a conservative 20% price increase. The evidence indicates that interventions that raise the unit price of tobacco products through taxes generate substantial healthcare cost savings and can generate additional gains from improved productivity in the workplace. Published by Elsevier Inc.
... Zorguitgaven worden met het CZM geschat door kosten per patiënt per ziekte per jaar te koppelen aan het geschatte aantal ziektegevallen. 12,13 Daarbij wordt gebruik gemaakt van de resultaten van de studie Kosten van ziekten in Nederland 2003. 5 Tevens kunnen met het CZM de kosten van levensverlenging worden geschat. ...
... 5 Tevens kunnen met het CZM de kosten van levensverlenging worden geschat. Dit wordt gedaan door de kosten voor overige ziekten te koppelen aan de bevolkingsomvang naar leeftijdscategorieën. 12,13 Om de relatie tussen roken, overgewicht en zorguitgaven te onderzoeken hebben we de huidige verdeling en trends van deze risicofactoren op drie manieren vergeleken met een hypothetische situatie. ...
... 12 Maar ook wanneer al die kosten worden meegeteld, blijkt dat preventie een zeer doelmatige manier kan zijn om de volksgezondheid te bevorderen. 13,21,22 Daarboven heeft preventie ook nog eens een dubbele winst: de volksgezondheid wordt bevorderd zonder dat deze eerst schade oploopt, zoals bij de curatieve zorg wel het geval is. ...
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Article
Achtergrond: De invloed van leefstijl op zorguitgaven speelt een belangrijke rol in het debat rondom preventie. Doel van het onderzoek was te onderzoeken welk deel van de zorguitgaven in 2003 kan worden toegewezen aan roken en overgewicht, wat de invloed is van roken en overgewicht op toekomstige zorguitgaven en wat de invloed is van trends in roken en overgewicht op ontwikkelingen in zorguitgaven, in vergelijking met de invloed van demografische ontwikkelingen. Methode: Met behulp van het RIVM Chronische Ziekten Model (CZM) en data van de Kosten van Ziekten 2003 studie is geschat welk deel van de zorgkosten in 2003 toewijsbaar was aan roken en overgewicht. Vervolgens is geschat hoe de zorguitgaven zich zouden ontwikkelen als roken en overgewicht hypothetisch worden uitgebannen. Ten slotte is de invloed van trends in roken en overgewicht op zorguitgaven afgezet tegen de invloed van demografische ontwikkelingen op zorguitgaven. Resultaten: In 2003 was 3,7% van de zorguitgaven toewijsbaar aan roken en 2,0% aan overgewicht. Echter, uitbanning van roken en overgewicht zou leiden tot stijging van de zorguitgaven op lange termijn vanwege een stijging in de levensverwachting. Demografische ontwikkelingen verhogen de jaarlijkse groei van de zorguitgaven met ongeveer 1%. Trends in roken en overgewicht verhogen deze jaarlijkse groei van de zorguitgaven met maximaal 0,06%. Conclusie: Gezond gedrag is een belangrijke determinant van de volksgezondheid, voor de zorguitgaven is de betekenis echter gering.
... The model has its epidemiologic input data from a continuous burden of disease-like exercise performed by another department at the same RIVM, which systematically collects, analyses and interprets all available national study data. Recent publications by this group are on alcohol taxes [59], brief GP interventions for alcohol abuse [60], lifestyle modification in diabetic patients [61], weight reduction with low-calorie diet alone or diet and orlistat [62], smoking cessation [63], tobacco taxes [63] and smoking prevention and cessation among students [64]. While the work of the RIVM has similarities to the ACE-Prevention project, it seems to be functioning at a smaller scale and does not cover anywhere near the number of interventions, although it could accumulate more over the years, it being a continuing program. ...
... The model has its epidemiologic input data from a continuous burden of disease-like exercise performed by another department at the same RIVM, which systematically collects, analyses and interprets all available national study data. Recent publications by this group are on alcohol taxes [59], brief GP interventions for alcohol abuse [60], lifestyle modification in diabetic patients [61], weight reduction with low-calorie diet alone or diet and orlistat [62], smoking cessation [63], tobacco taxes [63] and smoking prevention and cessation among students [64]. While the work of the RIVM has similarities to the ACE-Prevention project, it seems to be functioning at a smaller scale and does not cover anywhere near the number of interventions, although it could accumulate more over the years, it being a continuing program. ...
Article
About 2 million Australians have prediabetes and are at high risk of developing type 2 diabetes. Type 2 diabetes is a fast-growing epidemic and the economic costs are estimated to be $14.6 billion per year in Australia. Strong evidence from randomised controlled trials shows type 2 diabetes can be prevented in up to 58% of people at high risk, through structured lifestyle intervention. Good evidence and experience obtained from translational studies in Australia shows we can deliver effective community-based prevention programs. To be effective, a national strategy for prevention of type 2 diabetes should involve two concurrent approaches - a targeted approach aimed at those most at risk (ie, with prediabetes) combined with an environments, systems and behaviour approach for the entire population. Australia's current efforts in both these areas are not nationwide, not large scale and often not sustained.
... Smoking There is substantial evidence on cost-effectiveness of policies to prevent and reduce tobacco consumption , even if much of this evidence comes from outside Germany [20]. In particular tobacco taxation has been identified as the most successful and cost-effective measure in smoking reduction [21,22]. The same studies also demonstrate the very favourable cost-effectiveness of banning smoking at work and in public places. ...
... Greater uncertainty surrounds the (cost-)effectiveness of so-called " social marketing " approaches, i.e., the idea of achieving social health goals without repressive legislation, but rather by influencing attitudes by publishing information and lobbying for " healthful " behaviour through different marketing instruments [24]. Nevertheless, health warnings on cigarette packs seem to have reduced consumption by a detectable, yet small amount [21,22]. The analysis of mass media campaigns has so far produced mixed results. ...
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Article
Recent years have seen a growing research and policy interest in prevention in many developed countries. However, the actual efforts and resources devoted to prevention appear to have lagged well behind the lip service paid to the topic. We review the evidence on the considerable existing scope for health gains from prevention as well as for greater prevention policy efforts in Germany. We also discuss the barriers to "more and better" prevention and provide modest suggestions about how some of the obstacles could be overcome. In Germany, there are substantial health gains to be reaped from the implementation of evidence-based, cost-effective preventive interventions and policies. Barriers to more prevention include social, historical, political, legal and economic factors. While there is sufficient evidence to scale up prevention efforts in some public health domains in Germany, in general there is a comparative shortage of research on non-clinical preventive interventions. Some of the existing barriers in Germany are at least in principle amenable to change, provided sufficient political will exists. More research on prevention by itself is no panacea, but could help facilitate more policy action. In particular, there is an economic efficiency-based case for public funding and promotion of research on non-clinical preventive interventions, in Germany and beyond, to confront the peculiar challenges that set this research apart from its clinical counterpart.
... To extrapolate from decreased alcohol consumption due to tax increases to effects on health-care costs, life-years gained and quality-adjusted life-years (QALYs) gained, the Dutch National Institute for Public Health and the Environment chronic disease model (CDM) was used1314151617 . The CDM is a tool to describe the morbidity and mortality effects of risk factors for chronic diseases, such as smoking and overweight, and has been used for projections of risk factor and disease prevalence, estimates of health-adjusted life expectancy and cost-effectiveness analysis. ...
... However, if alcohol taxes are seen as a health policy instrument, a portion of the additional tax revenues could be added to health care [7] . Consequently , it can be argued that in this case (part of) the administrative costs and costs of law enforcement associated with tax increases should also be taken into account [13]. All in all, we expect an alcohol tax increase to be even more cost-effective when a broader societal perspective is taken. ...
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Article
Excessive alcohol use increases risks of chronic diseases such as coronary heart disease and several types of cancer, with associated losses of quality of life and life-years. Alcohol taxes can be considered as a public health instrument as they are known to be able to decrease alcohol consumption. In this paper, we estimate the cost-effectiveness of an alcohol tax increase for the entire Dutch population from a health-care perspective focusing on health benefits and health-care costs in alcohol users. The chronic disease model of the National Institute for Public Health and the Environment was used to extrapolate from decreased alcohol consumption due to tax increases to effects on health-care costs, life-years gained and quality-adjusted life-years gained, A Dutch scenario in which tax increases for beer are planned, and a Swedish scenario representing one of the highest alcohol taxes in Europe, were compared with current practice in the Netherlands. To estimate cost-effectiveness ratios, yearly differences in model outcomes between intervention and current practice scenarios were discounted and added over the time horizon of 100 years to find net present values for incremental life-years gained, quality-adjusted life-years gained, and health-care costs. In the Swedish scenario, many more quality-adjusted life-years were gained than in the Dutch scenario, but both scenarios had almost equal incremental cost-effectiveness ratios: 5100 euros per quality-adjusted life-year and 5300 euros per quality-adjusted life-year, respectively. Focusing on health-care costs and health consequences for drinkers, an alcohol tax increase is a cost-effective policy instrument.
... Accordingly, extensive literature focused on the evaluation of public health policies that may produce and keep healthy lifestyle or change unhealthy lifestyle. Public interventions mainly involve the following policies on lifestyle determinants of health: policies on tobacco control [60][61][62][63], policies on alcohol, sugar-sweetened beverage, food and nutrition [64][65][66][67][68], and promoting physical activity [69][70][71][72]. ...
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Article
Health policies are regarded as a governance mechanism crucial for reducing health inequity and improving overall health outcomes. Policies that address chronic conditions or health inequity suggest a governance shift toward active health over past decades. However, the current literature in health policy largely focused on some specific health policy changes and their tangible outcomes, or on specific inequality of health policies in gender, age, racial, or economic status, short of comprehensively responding to and addressing the shift. This is exacerbated further by a common confusion that equates health policy with health care policy, which has been burdened by increased population ageing, growing inequalities, rising expenditures, and growing social expectations. This study conducted a narrative literature review to comprehensively and critically analyze the most current knowledge on health policy in order to help us establish a theoretical framework on active health governance. The comprehensive framework proposed in this paper identifies the main elements of a well-defined active health governance and the interactions between these elements. The proposed framework is composed of four elements (governance for health, social determinants of health, lifestyle determinants of health, and health system) and three approaches (whole-of-government approach, whole-of-society approach, and lifespan/life-course approach) that are dynamically interacted to achieve two active health outcomes (health equity and health improvement). The framework provides a conceptual solution to the issues of current literature on health policy and practically serves as a new guide for health policymaking.
... 1 Tax revenues are transfers of money from one place to the other and do not entail added production (van Baal et al., 2007), thus, they should only be included in the ICER computations when part of them are used to pay for public health. ...
Article
In this past decade alone, the Philippines has made major strides in increasing the price of cigarettes. This study estimated the cost-effectiveness of the most recent cigarette price increase of about 29% brought about by Republic Act (RA) 11346 in 2019. A static or a single cohort model was populated with locally-sourced inputs whenever possible. Public payer and societal perspectives were taken wherein the former only considered direct costs and tax revenue gained earmarked for the health sector while the latter adds indirect costs in the form of productivity losses. A 7% discount rate was applied. Increasing the price of cigarettes by about 29% was found to prevent about 1961 tobacco-related deaths which translate to about 34,571 disability adjusted life years (DALYs) saved. Savings incurred from hospitalizations prevented and additional excise tax revenues for health was about USD 367 Million. But when productivity losses averted due to the lives saved and the higher cost of hospitalizations were accounted for in the societal perspective, the excise tax reform yielded USD 415 Million net gain. It would save the public payer USD 10,612 per DALY averted while society at large stand to save USD 11,955 per DALY averted. Tax increases like RA 11346 yield significant revenue that can be used towards public health programs.
... In the Netherlands, the CDM has been used to examine the impact of tobacco control policies on smoking rates and health risks [25,29,[35][36][37] The SimSmoke model, which is internationally well accepted [33,[38][39][40][41][42][43][44][45][46][47][48] and has previously been adapted for use in the Netherlands [24] will be used in conjunction with the CDM to model the effect on smoking prevalence of the full set of multiple interventions. ...
Article
Background In the Netherlands approximately 23% of the population of 15 years and older smokes. The main research questions were to identify what social costs- and benefits can be expected when various tobacco control policies would be implemented in The Netherlands, how do costs and benefits change over time, and which sectors in society could expect to incur costs and in which sectors accrue profits. Methods A SCBA was conducted using a combination of the Chronic Disease Model developed by the National Institute for Public Health and the Environment (RIVM), the SimSmoke model and a specially designed excel model. Policies included both tax increases (i.e. increase of excise tax on tobacco of 5% or 10% each year) and a policy package as proposed by the World Health Organization (i.e. including mass media campaigns and mediabans). Results When no new policy measures are implemented, the prevalence of smoking will decrease by 2.3 percentage points over the next 35 years. The policies reviewed in this report have the potential to decrease smoking prevalence by 14.2 percentage points (and in a ‘smoking-free society scenario, by as much as 17.4 percentage points). Furthermore, the results show that the intervention costs for all scenarios are minimal, and that investing in health is beneficial as seen from both the public health and fiscal perspective. Conclusions This study demonstrated that reducing the prevalence of smoking has beneficial effects for various stakeholders within the Dutch society: such as employers (e.g. increased productivity) and consumers (e.g. increase quality of life).
... In the Netherlands, the CDM has been used to examine the impact of tobacco control policies on smoking rates and health risks [25,29,[35][36][37] The SimSmoke model, which is internationally well accepted [33,[38][39][40][41][42][43][44][45][46][47][48] and has previously been adapted for use in the Netherlands [24] will be used in conjunction with the CDM to model the effect on smoking prevalence of the full set of multiple interventions. ...
... Globalization of tobacco use and the ensuing disease burden challenges national governments' sovereignty to protect the health of their populations (Kickbusch 2002). Increases in tobacco taxes is perhaps the most effective intervention to reduce tobacco use (van Baal et al 2006). ...
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Article
The context of Globalization in health is viewed as a concerted global effort towards the prevention, elimination and eradication of disease, and the promotion of human health worldwide. As a result, the domestic and international spheres of public health policy are becoming more intertwined and inseparable. The spread of global tobacco products may indicate one of the instances of globalization of the spread of non-communicable diseases. The tobacco epidemic kills around six million people a year, and more than five million of those deaths are the result of direct tobacco consumption, while more than 600 000 are the result of non-smokers being exposed to secondhand smoke. This is one of the major public health challenges ever faced in the world. Tobacco and Cigarette smoking have negative effect on nearly every organ of the body, causes many diseases, and reduces the health of smokers in general. Smoking and passive smoking cause more than 20 major categories of fatal and disabling disease, including lung and other cancers. It is projected that tobacco use will cause 8.4 million deaths by 2020, 70% of which will occur in developing countries. Of the 100 million projected tobacco-related deaths over the next 20 years, about half will be of people in the productive ages of 35-69. In general, 9% of women in developing countries and about 22% in developed countries currently smoke. Without robust and sustained initiatives, these figures are expected to rise dramatically, with today's 250 million women smokers rising to 340 million by 2020. This article discusses the key problems and opportunities of globalization and how it could be used to control tobacco production within the global public health.
... In general, the state transition model is a suitable and accepted model to describe demographic / epidemiological processes 3 . Disease experts and modelers have cooperated in building and testing of the CDM and several studies with different applications of the model have already been published [4][5][6][7][8][9][10] . The CDM has been formulated as a set of time-continuous differential and is implemented in the software package Mathemetica. ...
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Data
Details on the Structure of the RIVM Chronic Disease Model (106 KB PDF)
... Tobacco taxes, meanwhile, have played an important role in reducing smoking. Studies find, for example, that a 10 percent increase in tobacco prices decreases consumption about 3-5 percent (van Baal et al. 2007;Kaplan et al. 2001;Townsend, Roderick, and Cooper 1994;Wilson and Thomson 2005). This is smaller than the effect of alcohol taxes, but still substantial, particularly given the large size of many tobacco taxes. ...
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Technical Report
What we eat and drink can cause obesity, diabetes, hypertension, and other conditions. In response, many governments have enacted or are considering taxes on unhealthy food and drinks. This report evaluates the rationale behind such taxes; reviews evidence on their effects; analyzes different ways of structuring them; draws lessons from taxes on tobacco, alcohol, and carbon emissions; and offers a framework for assessing their benefits and costs. Taxing can influence what people eat and drink, but it is not a silver bullet. Governments must balance potential health gains against taxes’ limits and costs.
... A recent study has concluded that tobacco tax is also a highly cost-effective public health measure. 240 The World Bank has estimated that, in high income countries like the UK, a 10 per cent increase in price leads to a four per cent reduction in demand. 241 Young people and low income smokers are particularly sensitive to increases in price. ...
... Governments could, for example, play a pivotal role in the implementation and consolidation of public smoking bans, increasing tobacco taxes, and the control of illegal import of (high amounts) of tobacco. 1,40 This study also highlights some important points for the healthcare provider. Previous studies have outlined the importance of training healthcare providers in providing effective smoking cessation support. ...
... Furthermore, there can be tremendous variations in the net health system cost depending on how diseases are costed, model structure assumptions, and how the timing of costs is dealt with (see van Baal et al for an analysis of many of these aspects [47]). For example, the full inclusion of residential care costs as per analyses for the Netherlands may contribute to making some preventive interventions relating to tobacco control [48], and obesity control [49], less likely to be net cost saving. ...
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Article
Background: Given the high importance of dietary sodium (salt) as a global disease risk factor, our objective was to compare the impact of eight sodium reduction interventions, including feasible and more theoretical ones, to assist prioritisation. Methods: Epidemiological modelling and cost-utility analysis were performed using a Markov macro-simulation model. The setting was New Zealand (NZ) (2.3 million citizens, aged 35+ years) which has detailed individual-level administrative cost data. Results: Of the most feasible interventions, the largest health gains were from (in descending order): (i) mandatory 25% reduction in sodium levels in all processed foods; (ii) the package of interventions performed in the United Kingdom (UK); (iii) mandatory 25% reduction in sodium levels in bread, processed meats and sauces; (iv) media campaign (as per a previous UK one); (v) voluntary food labelling as currently used in NZ; (vi) dietary counselling as currently used in NZ. Even larger health gains came from the more theoretical options of a "sinking lid" on the amount of food salt released to the national market to achieve an average adult intake of 2300 mg sodium/day (211,000 QALYs gained, 95% uncertainty interval: 170,000-255,000), and from a salt tax. All the interventions produced net cost savings (except counseling--albeit still cost-effective). Cost savings were especially large with the sinking lid (NZ$ 1.1 billion, US$ 0.7 billion). Also the salt tax would raise revenue (up to NZ$ 452 million/year). Health gain per person was greater for Māori (indigenous population) men and women compared to non-Māori. Conclusions: This study substantially expands on the range of previously modelled salt reduction interventions and suggests that some of these might achieve major health gains and major cost savings (particularly the regulatory interventions). They could also reduce ethnic inequalities in health.
... It seems that the most effective way to confront the growing obstacle of smoking is to ban the purchase, sale and use of tobacco by the governments and authorities. Also, the positive effects of annual increase of the cigarette tax have been reported in several scientific articles (15,16,17,18,19). ...
... However, this does not mean that no economic evidence in favour of broader population-based interventions exists, if we take the reviewed studies literally. One relatively strong area of evidence relates to tobacco consumption, in particular to smoking cessation and taxation, issues addressed in depth elsewhere (Ye, Lee and Chen 2006; van Baal, Brouwer, Hoogenveen et al. 2006). To cite but two studies from our systematic review, Wang, Crosset, Lowry et al. (2001) demonstrated that a project to prevent tobacco use among school children proved costsaving . ...
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This paper complements the current health policy debate, which is largely confined to the cost aspects of health systems, by considering explicitly the potential economic benefits of investing in health in general and via - chiefly primary - prevention. While concerns about high and rising health care costs are justified, we see a pressing need to also measure the benefits, ultimately enabling a complete economic assessment of the socially optimal level of resources for health. Despite the use of Germany as our point of reference, our approach and findings likely apply to a wider set of European highincome countries. Using new and already existing data, we find that in sheer health terms Germany has a lot to gain from more and better illness prevention. Assuming part of this existing burden can be reduced via effective preventive interventions, we find that the resulting economic benefits - expressed in people's willingness to pay for a reduction in mortality risk - would be substantial. We also gather Germany-specific evidence to suggest that the existing burden of ill health - whether caused by lack of prevention or treatment - negatively impacts a number of important economic outcomes at the individual and macro-economic level. Referring to work carried out in parallel to this project, we find that a number of cost-effective, primary preventive interventions exist to tackle part of the avoidable disease burden. Yet we note a deficit of economic evaluations, in particular in non-clinical interventions - a finding that underlines the role of government in the production of research on specifically non-clinical prevention. In light of the market failures discussed, from an economic perspective the role of government not only consists of research, but also - surprisingly to many - extends to actual interventions to address the health behaviour-related determinants of chronic disease. With the stakes as high and the economic justification for action in place, the case for scaling up preventive efforts in Germany, backed up by solid epidemiological and economic research, is hard to deny. -- Die vorliegende Studie ergänzt die gegenwärtige gesundheitspolitische Debatte, die sich vorwiegend auf Kostenaspekte des Gesundheitswesens konzentriert, indem sie den potentiellen ökonomischen Nutzen von Gesundheitsinvestitionen im allgemeinen und (Primär-)Prävention im besonderen hervorhebt. Auch wenn die Sorge um hohe und steigende Kosten des Gesundheitswesens berechtigt ist, bleibt die Notwendigkeit, auch den Nutzen der Gesundheitsausgaben zu erfassen, um somit zu einer ökonomisch vollständigen Einschätzung des sozial optimalen Niveaus der Gesundheitsausgaben zu gelangen. Trotz des Fokus auf Deutschland sind unser Ansatz und die Ergebnisse auch auf andere Mitgliedsländer der EU übertragbar. Wir zeigen anhand neuer und schon bekannter Daten, dass der Spielraum für Gesundheitsverbesserungen, vorwiegend durch Prävention, in Deutschland erheblich ist. Der ökonomische Nutzen - gemessen an der Zahlungsbereitschaft der Bevölkerung - der durch Reduktion eines Teils dieser Krankheitslast mittels Interventionen erzielt werden kann, ist nach unseren Berechnungen beachtlich. Darüber hinaus zeigen mehrere Studien, wie die aktuell gegebene Krankheitslast, ob durch einen Mangel an Prävention oder Versorgung verursacht, eine Reihe relevanter ökonomischer Grössen auf individueller und gesamtwirtschaftlicher Ebene beeinträchtigt. Wie eine parallel durchgeführte Studie der Autoren ergab, existieren auch eine Reihe kosten-effektiver Interventionen im Bereich der primären Prävention. Dennoch bestehen noch Lücken in der ökonomischen Bewertung insbesondere nicht-klinischer Interventionen - ein Ergebnis, das die Rolle des Staates in der Evaluation dieser Interventionen unterstreicht. Aufgrund von Marktversagen in einigen relevanten Bereichen besteht eine ökonomische Rechtfertigung für staatliches Handeln nicht nur im Bereich der Forschung, sondern - überraschend für manche - auch im Bereich der (Primär-)Prävention der nicht-ansteckenden und mit dem individuellen Gesundheitsverhalten verbundenen Krankheiten. Aufgrund des in diesem Papier dokumentierten hohen gesundheitlichen und ökonomischen Nutzens sowie der ökonomischen Rechtfertigung der Rolle des Staates kann das Argument für eine Verstärkung der Prävention in Deutschland nur schwer bestritten werden.
... To estimate QALYs and health care costs for the current practice and intervention scenario, the RIVM Chronic Disease Model (CDM) was used (Hoogenveen et al., in press;van Baal et al., 2006;Hoogenveen et al., 2008). The CDM is a tool to describe the morbidity and mortality effects of risk factors for chronic diseases, including smoking and overweight and has been used for projections of risk factor and disease prevalence and cost effectiveness analysis (van Baal et al., 2006(van Baal et al., , 2007aFeenstra et al., 2001Feenstra et al., , 2005Struijs et al., 2005;Jacobs-van der Bruggen et al., 2007). The model describes the life course of cohorts in terms of changes between risk factor classes and changes between disease states over time. ...
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... For example, knowing that a 10% increase in the real price of cigarettes has been estimated to reduce consumption by nearly 4% would be helpful in examining changes in smoking prevalence geographically as well as for targeted population subgroups after increases in cigarette excise taxes [21]. Increasing tobacco taxes also has been shown to be a cost-effective intervention to reduce the burden of disease contributed by tobacco use [29]. ...
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Quality-adjusted life-years (QALYs) use a single number to provide an assessment of the overall health burden of diseases associated both with mortality and morbidity. This study examined the trend and geographic variation of the burden of smoking by calculating smoking-related QALYs lost from 1993 to 2008 for the US adults and individual states. Population health-related quality of life scores were estimated from the 1993 to 2008 Behavioral Risk Factor Surveillance System. The smoking-related QALYs lost are the sum of QALYs lost due to morbidity and future QALYs lost in expected life years due to premature deaths (mortality). From 1993 to 2008, the percent of US adults who smoked declined from 22.7% to 18.5%, but the smoking-related QALYs lost were relatively stable at 0.0438 QALYs lost per population. Although smoking contributed more QALYs lost for men (0.0535) than for women (0.0339), smoking-related QALYs lost decreased by 2.5% for men but increased by 12.6% for women. Kentucky, Oklahoma, Mississippi, West Virginia, and Tennessee had the most smoking-related QALYs lost wheras Utah, California, Connecticut, Minnesota, and Hawaii had the least QALYs lost. The state tobacco tax rate was strongly and negatively associated with both the percent smoked (r = -0.60) and QALYs lost (r = -0.54), as well as the percentage change in both. This analysis quantified the overall burden of smoking for the nation and individual states from 1993 to 2008. Such data might assist in providing specified quantitative targets for the Healthy People 2020 smoking-related health objectives and for tracking changes on a yearly basis.
... To estimate QALYs and health care costs for the current practice and intervention scenario, the RIVM Chronic Disease Model (CDM) was used (Hoogenveen et al., in press;van Baal et al., 2006;Hoogenveen et al., 2008). The CDM is a tool to describe the morbidity and mortality effects of risk factors for chronic diseases, including smoking and overweight and has been used for projections of risk factor and disease prevalence and cost effectiveness analysis (van Baal et al., 2006(van Baal et al., , 2007aFeenstra et al., 2001Feenstra et al., , 2005Struijs et al., 2005;Jacobs-van der Bruggen et al., 2007). The model describes the life course of cohorts in terms of changes between risk factor classes and changes between disease states over time. ...
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Appropriate decisions based on cost-effectiveness evaluations of health care technologies depend upon the cost-effectiveness threshold and its rate of growth as well as some social rate of time preference for health. The concept of the cost-effectiveness threshold, social rate of time preference for consumption and social opportunity cost of capital are briefly explored before the question of how a social rate of time preference for health might be established is addressed. A more traditional approach to this problem is outlined before a social decision making approach is developed which demonstrates that social time preference for health is revealed through the budget allocations made by a socially legitimate higher authority. The relationship between the social time preference rate for health, the growth rate of the cost-effectiveness threshold and the rate at which the higher authority can borrow or invest is then examined. We establish that the social time preference rate for health is implied by the budget allocation and the health production functions in each period. As such, the social time preference rate for health depends not on the social time preference rate for consumption or growth in the consumption value of health but on growth in the cost-effectiveness threshold and the rate at which the higher authority can save or borrow between periods. The implications for discounting and the policies of bodies such as NICE are then discussed.
... However the excise tax imposed on alcohol and cigarettes has been demonstrated to be successful in reducing consumption of both products through price increases when combined with public health education programs funded from the tax. Also, van Baal et al considered that even if the tax revenues generated by the tobacco tax are not earmarked specifically to the healthcare budget, increasing the tax on tobacco is still a cost-effective intervention for decreasing cigarette smoking (van Baal et al. 2007). This may be true for soft drinks also. ...
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The prevention of overweight and obesity, particularly among children, is a public health priority. A range of initiatives to address this problem have already been developed and implemented in NSW. However, a broader range of additional strategies are needed to effectively address this complex issue. The high consumption of soft drinks, i.e. sugarsweetened carbonated beverages, and other sugary drinks is one of an array of dietary behaviours which has been identified by a number of policy documents as an important, specific behaviour to address in the prevention and management of obesity.
... Raising tobacco taxes is considered perhaps the most effective intervention to reduce tobacco use. [14][15][16] Higher tobacco taxes lead to higher tobacco prices and encourage tobacco users to quit or reduce the amount of tobacco used, and prevent smoking initiation among potential new users, especially youth. A widely accepted estimate is that a 10% increase in cigarette prices will reduce demand for tobacco by as much as 7% among youth and 4% among adults. ...
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The globalization of tobacco began more than 500 years ago, but the public health response to the death, disease, and economic disruption that it has caused is fewer than 50 years old. In this report, the authors briefly trace the history of tobacco use and commerce as it moved from the Americas in the late 15th century and then eastward. They then discuss the wide range of issues that must be addressed, and the equally wide range of expertise that is needed if the global health community is to be successful in reducing, and eventually eliminating, the rising tide of tobacco use, particularly in the low- and middle-income nations that are the target of the multinational tobacco industry.
... The proportion of adult smokers is associated negatively with self-assessed health status, but its effect on mortality and the number of healthy days is statistically insignificant, possibly due to the long-term nature of the consequences of smoking. The statistically significant effect of behavioral factors implies that preventive measures to reduce risky behaviors (e.g., smoking and obesity) are important for improving population-level self-reported health measures3132333435. Although a consensus on policy interventions exists for reducing smoking prevalence [36], prevention programs to address the obesity epidemic have been proposed and implemented only in certain states, including a limited number of states that have undertaken legislative initia- tives [37]. ...
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Recent studies indicate continuing health disparities across geographic units in the US. This paper provides updated estimates of the association between socioeconomic factors and population health using a new state-level dataset and panel econometric methods that account for state-specific effects and autoregressive error structure. Data from multiple sources for the 50 US states and the District of Columbia are merged. The dependent variables are age-adjusted all-cause mortality, self-assessed health status, and number of healthy days. Panel econometric models are used to accommodate state-specific unobserved factors and to incorporate autoregressive random disturbances to provide consistent and robust estimates. A 1-unit increase in the number of physicians per 1000 population is associated with a reduction in mortality by 30/100,000. The effects of physician-to-population ratio on self-reported health measures are mixed. Socioeconomic, demographic, as well as the prevalence of smoking and obesity have varying effects on mortality and self-reported measures of health. The new estimate of the association between physician supply and lower mortality suggests continuing efforts to assess the need for policies and incentives to induce physician labor supply in underserved states. Strategies and policies to reduce health disparities should address social, economic and individual risk factors.
... The relative lack of broader health promotion evidence we report does not imply that there was no economic evidence in its favour, if we take the reviewed studies literally. One relatively strong area of evidence relates to smoking prevention, in particular to smoking cessation and taxation-issues that have deliberately not been analysed in depth here, because they have been addressed elsewhere [11,12]. To quote but one study from our sample in Phase I, Wang et al. [13] demonstrate that a project to prevent tobacco use among school children has proved to be even cost-saving. ...
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In the quest for public and private resources, prevention continues to face a difficult challenge in obtaining tangible public and political support. This may be partly because the economic evidence in favour of prevention is often said to be largely missing. The overall aim of this paper is to examine whether economic evidence in favour of prevention does exist, and if so, what its main characteristics, weaknesses and strengths are. We concentrate on the evidence regarding primary prevention that targets cardiovascular disease event or risk reduction. We conducted a systematic literature review of journal articles published during the period 1995-2005, based on a comprehensive key-word based search in generic and specialized electronic databases, accompanied by manual searches of expert databases. The search strategy consisted of combinations of freetext and keywords related to economic evaluation, cardiovascular diseases, and primary preventive interventions of risk assessment or modification. A total of 195 studies fulfilled all of the relevant inclusion criteria. Overall, a significant amount of relevant economic evidence in favour of prevention does exist, despite important remaining gaps. The majority of studies were cost-effectiveness-analyses, expressing benefits as "life years gained", were conducted in a US or UK setting, assessed clinical prevention, mainly drugs targeted at lowering lipid levels, and referred to subjects aged 35-64 years old with at least one risk factor. First, this review has demonstrated the obvious lack of economic evaluations of broader health promotion interventions, when compared to clinical prevention. Second, the clear role for government to engage more actively in the economic evaluation of prevention has become very obvious, namely, to fill the gap left by private industry in terms of the evaluation of broader public health interventions and regarding clinical prevention, in light of the documented relationship between study funding and reporting of favourable results. Third, the value of greater adherence to established guidelines on economic evaluation cannot be emphasised enough. Finally, there appear to be certain methodological features in the practice of economic evaluations that might bias the choice between prevention and cure in favour of the latter.
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Objectives: In Indonesia, tobacco smoking is a significant public health problem that continues to grow, with a prevalence among the highest worldwide. This study aimed to assess the cost-effectiveness of government-funded varenicline, smoking bans in public places, and an additional 10% tobacco tax in Indonesia. Methods: Markov modeling of Indonesians aged 15 to 84 years was undertaken, with simulated follow-up until age 85 years. Data on demographics, smoking prevalence, and mortality were drawn from the Global Burden of Disease Study 2017. Data regarding the efficacy and costs of the 3 interventions were gathered from published sources. Costs and benefits accrued beyond one year were discounted at 3% per annum. The year value of costing data was 2020. Results: Government-funded varenicline, smoking bans in public places, and an additional 10% tobacco tax were predicted to save 5.5 million, 1.6 million, and 1.7 million years of life, respectively (all discounted). In terms of quality-adjusted life-years, 3 tobacco interventions were predicted to gain 11.9 million, 3.47 million, and 3.78 million in quality-adjusted life-years, respectively. The savings in smoking-related healthcare costs amounted to US $313.8 billion, US $97.5 billion, and US $106 billion, respectively. Hence, from the perspective of the healthcare system, all 3 interventions were cost saving (dominant). Conclusions: In Indonesia, tobacco control measures are likely to be highly cost-effective and even cost saving from the healthcare system's perspective. These cost savings can be balanced against economic losses that would result from the impact on the sizable Indonesian tobacco industry.
Article
Objective High smoking prevalence rates, combined with a steep tax on tobacco and lower household income, mean that 5% of Māori (indigenous) whānau (family unit) expenditure in New Zealand is on tobacco. This paper outlines whānau perceptions of, and behavioural responses to, increasing tobacco tax. Methods This qualitative study was informed by the Kaupapa Māori theory and used a simplified interpretive phenomenological analysis thematic hybrid methodology. A semistructured, open-ended interview guide was designed and used in one-off focus group interviews. Setting and participants Interviews were separately conducted with each of 15 whānau units. A total of 72 participants, most of whom were smokers, took part in the interviews carried out in two geographical regions: one rural/provincial and one urban. Results Whānau were concerned about the rising cost of tobacco. However, this concern had not generally translated into quit attempts. Whānau had instead developed innovative tobacco-related practices. Working collectively within their whānau, they were able to continue to smoke, although in a modified fashion, despite the rising costs of tobacco. Whānau thereby resisted the intended outcome of the government’s tobacco tax which is to reduce rates of smoking prevalence. Conclusion In the face of significant government disinvestment in New Zealand tobacco control over the last 10 years, hypothecated taxes should be used to scale up Māori-specific cessation and uptake prevention programmes, supporting authentic Māori partnerships for endgame solutions including restricting the availability and appeal of tobacco.
Article
Purpose/setting The extent to which distributional equity is incorporated into evaluations of the (potential or observed) impact of health taxes is unclear. This systematic review of economic and modelling evaluations investigating taxation on tobacco, sugar-sweetened-beverages (SSBs), or alcohol aims to assess the proportion that have considered distributional impact by income or socioeconomic group. Secondary aims included summarising the reported distributional impacts, for both costs and health benefits. Findings Of 4656 search results, 69 studies were included. The majority were economic analyses with epidemiological modelling, with studies on SSB taxes being of the highest quality. Tobacco was most commonly investigated tax, with 37 evaluations. Of these, 12 (32%) considered distributional equity, with six (27%) of 22 included SSB evaluations doing the same, and none for alcohol. A tobacco tax favoured lowerincome groups in the distribution of costs in all identified evaluations and for health benefits in nine out of 12 evaluations (75%). For SSBs, four evaluations (67%) found costs to favour low-income groups, with three (50%) for health benefits. Conclusions Despite recommendations, evaluations of health taxes do not routinely consider the distributional impact of both costs and health benefits. Evaluations for alcohol taxation are particularly weak in this regard. Where investigated, the majority of evidence found tobacco taxation to favour low-income groups, whereas the limited evidence for SSBs is mixed.
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EXECUTIVE SUMMARY Health promotion has a critical role to play in improving the health and wellbeing of current and future generations of EU citizens. Based upon a socio-ecological model of health, health promotion has been defined by the WHO (1986) as “the process of enabling people to increase control over, and improve, their health”. Health promotion moves the focus from individuals at risk of developing illness to systems and environments that shape the development of good health at a population level. As such, it is an essential component of modern health systems in order to ensure that all human beings can have healthy lives, can maximise their health potential and that no one is left behind. Cost-effective and feasible health promotion interventions have been shown to make a real difference in improving population health, reducing risks for non-communicable diseases, improving mental health, increasing health literacy, and addressing the social determinants of health and health equity. However, the level of infrastructure and capacity to support health promotion action varies considerably across EU countries. The concept of health promotion is often poorly understood and there is a limited appreciation of the infrastructure, resources, knowledge and skills that are required to translate health promotion into action. As a result, there are significant gaps in implementation in many countries, particularly in terms of mainstreaming health promotion within health services, and there is a lack of investment in developing the necessary health promotion systems for substantive progress to be made. Embracing a health promotion framework requires a significant shift in focus from illness to health and calls for intersectoral action and partnership working as an integral aspect of health promotion practice. Health promotion embraces a new and broader understanding of health and its determinants and calls for a new base of multidisciplinary knowledge, skills and competencies that extend beyond the traditional healthcare approach. While successive EU health policies and strategies have endorsed the need to invest in health promotion, and some countries have made good progress in developing health promotion capacity, political commitment to implementing health promotion is lacking in many countries. Health policies and budgets remain focused primarily on curative interventions. Balancing the prioritization of treating and preventing diseases against the promotion of longer-term health improvement is a difficult trade-off when funding and resources for health systems are under pressure. This Opinion considers what progress has been made in implementing health promotion within the EU region, and considers what mechanisms can be used for strengthening the integration of health promotion within health systems. Current conceptual and policy frameworks for health promotion are outlined, and the rationale for the development of health promotion and its continued relevance within the context of current policy objectives, including the Sustainable Development Goals, is considered. A critical reflection is Options to foster health promoting health systems undertaken of current enablers and barriers to progress including the need for: advocacy and high-level political leadership and support; enabling governance structures and processes for implementation; sustainable funding mechanisms and incentives; organizational and workforce capacity development. Building on this reflection, a number of enabling mechanisms are outlined and practical examples provided including: policy structures and processes for the implementation of a Health in All Policies (HiAP) approach; the integration of health promotion within health services, with a particular focus on strengthening health promotion within primary care; sustainable financing for health promotion; and mobilising wider community participation and engagement. Health promotion is an essential strategy for improving health equity and a key action underpinning the reform of health systems in Europe. Applying the principles of the European Pillar of Social Rights and the competences of the EU treaties for the promotion of wellbeing and protection of health across all EU policies, we recommend that a range of policy measures and financial mechanisms at the European level are applied to support the implementation of transformative health promotion policies and practices in EU Member States. This shift in focus from disease to health can be considered ‘a disruptive innovation’ due to the need to transform existing organisational structures, workforce, and services. More specifically, the following actions are recommended for implementation at the EU level in cooperation with key partners, citizens and national governments in Member States: • Advocate for the importance of health promotion o Develop effective advocacy for health promotion to increase the visibility and relevance of health promotion and ensure that its contribution to human, social and economic development in Europe is recognised across the political spectrum and in communications for public health, especially for vulnerable and underserved population groups. o Advancepoliticalcommitmenttoeffectivehealthpromotionpoliciesandaction plans through the formulation of specific health promotion goals and the development of feasible and evidence-informed policy options for health promotion action in Europe and among high-level policymakers, including those from the non-health sector. • Provide strategic leadership for health promotion at EU level o Provide leadership and coordination at EU level in ensuring the implementation of a HiAP approach in EU Member States and the integration of health promotion as a priority within European and national policies by supporting Members States in developing the required organisational Options to foster health promoting health systems structures and processes for innovative intersectoral health promotion actions and strengthening capacity development in different country contexts. o Promote the integration of health promotion within health services, especially in primary care to ensure universal access to health promotion programmes thereby improving the scope and range of services to health service users, reaching out to the most vulnerable groups in society to ensure better health for all. o Invest in developing a dedicated workforce for health promotion in Europe, through leadership in advancing recognition of the need for a dedicated health promotion workforce with the necessary skills and competencies for quality professional practice and the inclusion of health promotion in the educational curricula of health professionals. • Protect and promote sustainable financing mechanisms for health promotion o Invest in the development of robust health promotion policies and programmes at EU level by ensuring sustained investment for the implementation of comprehensive health promotion strategies in EU Member States. o Apply EU funding and investment mechanisms to ensure that health promotion is included in EU, national and regional programming priorities, thereby protecting funding for capacity development. o ExploretheuseofEUfinancialinstrumentssuchastheESIF,andco-financing mechanisms, to support the re-orientation of health systems to health promotion. o SupportMemberStatesinreviewingcurrenthealthbudgetsandexploringnew ways of balancing spending towards health promotion and developing mechanisms and incentives for ensuring its sustainability. • Develop the capacity to implement health promoting health systems at EU level and in Member States o Apply the EU Semester process and other available policy mechanisms to enable countries to establish the system requirements for health promotion policy and programme development, including high-level leadership and political responsibility at a country level for the implementation of health promotion policies and programmes. o Provide technical guidance on implementing health promotion in practice through the setting of European norms and standards for best practices and Options to foster health promoting health systems evidence-based priority interventions to be delivered at all levels of the health system. o Support the assessment of health promotion capacity in Member States through the development of tools for assessing and benchmarking infrastructure capacity and performance for core health promotion action. • Invest in health promotion research in Europe o Support the development of interdisciplinary and innovative health promotion research through the EU framework programmes for research, development and innovation, with a particular focus on: monitoring of positive indicators of population health and wellbeing status across the social gradient at a country level; the comprehensive evaluation of complex upstream and multilevel health promotion interventions; multi-country implementation trials of evidence-based approaches; economic analyses to determine the cost-benefit and cost-effectiveness of health promotion strategies; health equity impact assessments of policy making across sectors; and the dissemination of feasible evidence-based strategies. o Develop knowledge translation mechanisms for health promotion in the EU region by developing a network of dedicated health promotion knowledge translation centres to promote the timely use of scientific research and knowledge to strengthen health promotion practices and policies. • Strengthen health promotion partnerships at EU level o Support sustained partnerships for health promotion through active collaboration with dedicated health promotion foundations, NGOs such as IUHPE and EuroHealthNet, academic partners and national focal points with a health promotion remit. o Support effective and sustainable multi-level partnerships across diverse sectors in order to progress implementation of HiAP and to meet the targets set by the SDGs. • Support social mobilisation strategies o Invest in improved consultation processes and community engagement strategies to actively engage European citizens in creating a greater demand for health promotion in Europe and advocating for the implementation of policy decisions that impact on population health and wellbeing.
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Article
What we eat and drink can cause obesity, diabetes, hypertension, and other conditions. In response, many governments have enacted or are considering taxes on unhealthy food and drinks. This report evaluates the rationale behind such taxes; reviews evidence on their effects; analyzes different ways of structuring them; draws lessons from taxes on tobacco, alcohol, and carbon emissions; and offers a framework for assessing their benefits and costs. Taxing can influence what people eat and drink, but it is not a silver bullet. Governments must balance potential health gains against taxes’ limits and costs.
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Identifies cigarette smoking as responsible for over 20 percent of all deaths of adult men and 5 percent of deaths of adult women, and about 50 percent of global smoking-related deaths occur in low- and middle-income countries (LMICs). Interventions that rapidly induce cessation focus on aggressive taxation making cigarettes less affordable and the World Health Organization recommends increasing excise tax rates to 70 percent of the retail price. Smoking patterns have changed in response to (1) control policies banning advertising and public area smoking and (2) dissemination of information about health hazards. Cessation programs and counseling, especially with pharmacological treatments, have shown success, and e-cigarettes, used as nicotine replacement, may hold some promise for reduction of tobacco smoking. Controlling cigarette smuggling is effective since 6–11 percent of the 5.9 trillion cigarettes sold globally in 2006 came from this illegal source. Government efforts to target smoking reductions have proven highly cost-effective since the additional tax revenue has a positive budgetary impact and counterbalances the increased expenditure from Social Security as people live longer.
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As smoking has detrimental impacts on the health of smokers and non-smokers, it is important that various restrictive policies are implemented to minimize the prevalence of smoking. Relevant policies have been outlined, such as warning labels on cigarette packages, bans on advertising of tobacco products and the banning of smoking in various places. An increase of the awareness of the public of the detrimental effects of smoking is important; however, the effectiveness of such programmes will depend largely on smokers’ motivation to quit smoking. The more educated people are, the more health conscious they become. As people become more aware of the causes of behavioural diseases, smoking becomes an inferior good so that consequently mortality from smoking declines.
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Cigarette smoking causes a high health burden worldwide. This paper reviews trends in cigarette use, the health and economic consequences of smoking, and the cost-effectiveness of smoking cessation interventions (cost-effectiveness analysis) from a Dutch perspective. The Netherlands are in the third phase of the smoking epidemic, but smoking prevalence is still around 28% in adults. The country ranks in the middle of European countries with respect to the implementation of tobacco control policies. It has been estimated that about 20% of all life years lost, 7% of all disease-year equivalents, 13% of all Disability Adjusted Life Years (DALYs), and 4% of total health care costs in the Dutch population is attributable to smoking. This is far more than the burden attributable to other single risk factors. The overall life expectancy of a male smoker is 7.7 years less than the life expectancy of a male non-smoker. Hence, there is a lot to be gained from the prevention of smoking. Due to the severely reduced life expectancy, lifetime health care costs are lower in smokers than in never smokers. Nevertheless, strong evidence exists that individual smoking cessation interventions consisting of counseling with or without pharmacotherapy are cost-effective. Collective policy measures like tobacco tax increases and mass media campaigns are probably even more efficient. In The Netherlands, structured stop advice by the general practitioner was found to be cost saving, looking at intervention costs net of savings from a reduced incidence of smoking related diseases. When health care costs for diseases not related to smoking that occur during the life years gained by smoking cessation are included, the cost-effectiveness worsens, but the ratios remain below €20,000 per Quality Adjusted Life Year (QALY). Despite this evidence, few smokers receive cessation aid and most try to stop without any professional support. Reimbursement of smoking cessation interventions might stimulate their use and indications were found that reimbursement might be cost-effective. To conclude, smoking prevention will result in large health gains, but not in cost savings. Smoking cessation can realize a substantial health gain, even if quit rates are at most 20% and 75% of quitters relapses. Even when accounting for additional costs in life years gained, many smoking prevention and smoking cessation policy interventions are cost-effective with ratios ranging from a few thousand up to €20,000 per QALY.
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The US Food and Drug Administration has expressed interest in using mathematical models to evaluate potential tobacco policies. The goal of this systematic review was to synthesize data from tobacco control studies that employ mathematical models. We searched five electronic databases on July 1, 2013 to identify published studies that used a mathematical model to project a tobacco-related outcome and developed a data extraction form based on the ISPOR-SMDM Modeling Good Research Practices. We developed an organizational framework to categorize these studies and identify models employed across multiple papers. We synthesized results qualitatively, providing a descriptive synthesis of included studies. The 263 studies in this review were heterogeneous with regard to their methodologies and aims. We used the organizational framework to categorize each study according to its objective and map the objective to a model outcome. We identified two types of study objectives (trend and policy/intervention) and three types of model outcomes (change in tobacco use behavior, change in tobacco-related morbidity or mortality, and economic impact). Eighteen models were used across 118 studies. This paper extends conventional systematic review methods to characterize a body of literature on mathematical modeling in tobacco control. The findings of this synthesis can inform the development of new models and the improvement of existing models, strengthening the ability of researchers to accurately project future tobacco-related trends and evaluate potential tobacco control policies and interventions. These findings can also help decision-makers to identify and become oriented with models relevant to their work. © The Author 2015. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
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Proposition B, which would have raised the tobacco tax in Missouri from 17 cents per pack to 90 cents, narrowly failed in the 2012 general election, leaving Missouri with the lowest tobacco tax in the United States. Despite scientific and economic evidence demonstrating the health and economic benefits of higher tobacco taxes, Missouri remains reluctant to cave into pressure levied by various organizations to raise the rate. There are eight other cigarette tax jurisdictions along Missouri's borders, and three of the states have per-pack taxes of over 1 dollar. This presents an economic opportunity, as Missouri border towns have become a destination for large cigarette purchases. Based on the competitive advantage Missouri cigarette vendors have over similar vendors in adjacent states, we intend to explore the results of the Proposition B vote to examine whether certain border areas were most strongly against the Proposition because it might hurt their local economy.
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Introduction: In The Netherlands, pharmacologic Smoking Cessation Treatments (pSCTs) were reimbursed in 2011. In 2012 the reimbursement was discontinued. As of 2013, pSCTs were again reimbursed, provided they are accompanied by behavioural counselling. The aim of this paper is to assess the impact of changes in reimbursement policy on use of- and adherence to- pSCTs. Methods: A retrospective dispensing database analysis was performed on real-world observational data (2010-2013) from The Netherlands. Data on use and adherence was collected, in patients who were dispensed bupropion or varenicline in community pharmacies for the first time. Using the InterActionDataBase (iadb.nl), adherence per patient that initiated varenicline or bupropion was calculated by adding up all dispenses between initiation of the therapy and the 120 days thereafter. Good adherence was defined as using minimal 80% of the recommended duration and intensity of use. Results: The prevalence of patients initiating pSCTs was stable at 0.4 per 1,000 inhabitants per quarter during 2010. In 2011, the prevalence was on average 0.7, with peaks in the 1st (0.8 per 1,000) and 4th (1.0 per 1,000) quarters of 2011. In 2012, the prevalence was stable again at 0.3. In 2013, prevalence was on average 0.4, with a small peak in the 1st quarter. Adherence was 15.4% in 2010 versus and 20.1% in 2011 (P=0.002). In 2012, adherence was 13.9%, compared with 18.9% in 2013 (P=0.008). Conclusions: Not only the likelihood of initiating pSCTs, but also the extent of adherence to these treatments, although generally low, seems higher during reimbursement.
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This paper examines the impact of statutory policies on the prevalence of smoking in Hong Kong from 1982 to 2010. Different public policy interventions, including tobacco excise duties, bans on tobacco advertising and restrictions of public smoking, are reviewed and their separate and combined effects are empirically measured. The results confirm that increasing the price of tobacco products through taxation is the most effective tool for reducing tobacco consumption. Moreover, the Hong Kong Government's comprehensive ban on tobacco advertising and restrictions on public smoking had a significant and negative impact on smoking prevalence, while the influences of individual policy interventions are less obvious. These results suggest that a comprehensive tobacco control programme is an effective means of reducing tobacco consumption.
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Little is known about the cost-effectiveness of tobacco control policy for different socioeconomic status (SES) groups. We aimed to evaluate SES-specific cost-effectiveness ratios of policies with known favorable effect in low SES groups: A tobacco tax increase and reimbursement of cessation support. A computer model of the adult population specified by smoking behavior (never/current/former smoker), age, gender, and SES simulated policy scenarios reflecting the implementation of a €0.22 tobacco tax increase or full reimbursement of cessation support. These were compared with care as usual. Relating differences in costs to quality-adjusted life years (QALYs) gained generated cost-effectiveness ratios for each SES group. In a cohort of 11 million people, the tobacco tax increase resulted in 27,000 additional quitters after 5 years, proportionally divided over the SES groups. Reimbursement led to 59,000 additional quitters, with relatively more quitters in higher SES groups. The number of QALYs gained were 3,400-6,200 in the various SES groups for the tax increase and 6,300-14,000 for the reimbursement scenario. For both interventions, favorability of the cost-effectiveness ratios increased with SES: Costs per QALY decreased from €6,100 to €4,500 for the tax increase and from €21,000 to €11,000 for reimbursement. The reimbursement policy produced the greatest overall health gain. Surprisingly, neither tax increase nor reimbursement reduced health disparities. Differences in use were too small to compensate for improved health gains per quitter in higher SES groups. Both policies qualified as cost-effective overall, with more favorable cost-effectiveness ratios for high SES than for low SES.
Article
Concern about the overconsumption of unhealthy foods is growing worldwide. With high global rates of noncommunicable diseases related to poor nutrition and projections of more rapid increases of rates in low- and middle-income countries, it is vital to identify effective but low-cost interventions. Cost-effectiveness studies show that individually targeted dietary interventions can be effective and cost-effective, but a growing number of modeling studies suggest that population-wide approaches may bring larger and more sustained benefits for population health at a lower cost to society. Mandatory regulation of salt in processed foods, in particular, is highly recommended. Future research should focus on lacunae in the current evidence base: effectiveness of interventions addressing the marketing, availability, and price of healthy and unhealthy foods; modeling health impacts of complex dietary changes and multi-intervention strategies; and modeling health implications in diverse subpopulations to identify interventions that will most efficiently and effectively reduce health inequalities. Expected final online publication date for the Annual Review of Nutrition Volume 33 is July 17, 2013. Please see http://www.annualreviews.org/catalog/pubdates.aspx for revised estimates.
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Background While Italy has implemented some tobacco control policies over the last few decades, which resulted in a decreased smoking prevalence, there is still considerable scope to strengthen tobacco control policies consistent with the World Health Organization (WHO) policy guidelines. The present study aims to evaluate the effect of past and project the effect of future tobacco control policies on smoking prevalence and associated premature mortality in Italy. Methods To assess, individually and in combination, the effect of seven types of policies, we used the SimSmoke simulation model of tobacco control policy. The model uses population, smoking rates and tobacco control policy data for Italy. Results Significant reductions of smoking prevalence and premature mortality can be achieved through tobacco price increases, high intensity media campaigns, comprehensive cessation treatment program, strong health warnings, stricter smoke-free air regulations and advertising bans, and youth access laws. With a comprehensive approach, the smoking prevalence can be decreased by as much as 12% soon after the policies are in place, increasing to a 30% reduction in the next twenty years and a 34% reduction by 30 years in 2040. Without effective tobacco control policies, a total of almost 300 thousand lives will be prematurely lost due to smoking by the year 2040. Conclusion Besides presenting the benefits of a comprehensive tobacco control strategy, the model helps identify information gaps in surveillance and evaluation schemes that will promote the effectiveness of future tobacco control policy in Italy.
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To evaluate population health benefits and cost-effectiveness of interventions for reducing salt in the diet. Proportional multistate life-table modelling of cardiovascular disease and health sector cost outcomes over the lifetime of the Australian population in 2003. The current Australian programme of incentives to the food industry for moderate reduction of salt in processed foods; a government mandate of moderate salt limits in processed foods; dietary advice for everyone at increased risk of cardiovascular disease and dietary advice for those at high risk. Costs measured in Australian dollars for the year 2003. Health outcomes measured in disability-adjusted life years (DALY) averted over the lifetime. Mandatory and voluntary reductions in the salt content of processed food are cost-saving interventions under all modelled scenarios of discounting, costing and cardiovascular disease risk reversal (dominant cost-effectiveness ratios). Dietary advice targeting individuals is not cost-effective under any of the modelled scenarios, even if directed at those with highest blood pressure risk only (best case median cost-effectiveness A$100 000/DALY; 95% uncertainty interval A$64 000/DALY to A$180 000/DALY). Although the current programme that relies on voluntary action by the food industry is cost-effective, the population health benefits could be 20 times greater with government legislation on moderate salt limits in processed foods. Programmes to encourage the food industry to reduce salt in processed foods are highly recommended for improving population health and reducing health sector spending in the long term, but regulatory action from government may be needed to achieve the potential of significant improvements in population health.
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As one of the first countries to ratify the WHO Framework Convention on Tobacco Control, Jordan has signaled an interest in stronger anti-tobacco restrictions. This study examines whether Jordanian students believe smoking is an individual right or a social issue, and if they would support more stringent policies and enforcement. Undergraduate Jordanian students (n = 1211) from public and private universities completed the survey. Never smokers scored significantly higher on smoking being a social issue that required public policy response (p-value < .001); whereas smokers scored significantly higher with all individual right items. Ample opportunity exists for developing and enforcing stronger tobacco policies both on college campus and generally in the country. However, increasing tobacco taxes may need to be preceded by health communication campaigns that increase knowledge of the effectiveness of the tobacco tax in reducing use and resultant premature deaths.
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Background: Obesity is a major contributor to the overall burden of disease (also reducing life expectancy) and associated with high medical costs due to obesity-related diseases. However, obesity prevention, while reducing obesity-related morbidity and mortality, may not result in overall healthcare cost savings because of additional costs in life-years gained. Sector-specific financial consequences of preventing obesity are less well documented, for pharmaceutical spending as well as for other healthcare segments. Objective: To estimate the effect of obesity prevention on annual and lifetime drug spending as well as other sector-specific expenditures, i.e. the hospital segment, long-term care segment and primary healthcare. Methods: The RIVM (Dutch National Institute for Public Health and the Environment) Chronic Disease Model and Dutch cost of illness data were used to simulate, using a Markov-type model approach, the lifetime expenditures in the pharmaceutical segment and three other healthcare segments for a hypothetical cohort of obese (body mass index [BMI] >or=30 kg/m2), non-smoking people with a starting age of 20 years. In order to assess the sector-specific consequences of obesity prevention, these costs were compared with the costs of two other similar cohorts, i.e. a 'healthy-living' cohort (non-smoking and a BMI >or=18.5 and <25 kg/m2) and a smoking cohort. To assert whether preventing obesity results in cost savings in any of the segments, net present values were estimated using different discount rates. Sensitivity analyses were conducted across key input values and using a broader definition of healthcare. Results: Lifetime drug expenditures are higher for obese people than for 'healthy-living' people, despite shorter life expectancy for the obese. Obesity prevention results in savings on drugs for obesity-related diseases until the age of 74 years, which outweigh additional drug costs for diseases unrelated to obesity in life-years gained. Furthermore, obesity prevention will increase long-term care expenditures substantially, while savings in the other healthcare segments are small or non-existent. Discounting costs more heavily or using lower relative mortality risks for obesity would make obesity prevention a relatively more attractive strategy in terms of healthcare costs, especially for the long-term care segment. Application of a broader definition of healthcare costs has the opposite effect. Conclusions: Obesity prevention will likely result in savings in the pharmaceutical segment, but substantial additional costs for long-term care. These are important considerations for policy makers concerned with the future sustainability of the healthcare system.
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Prevention of unhealthy lifestyles has sometimes been promoted as simultaneously reducing costs and improving public health but this will unlikely prove to be true. Additional medical costs in life years gained due to treatment of unrelated diseases may offset possible savings in related diseases, but are often ignored both in health promotion policies and in economic evaluations of life-prolonging interventions. Many national guidelines explicitly recommend excluding these costs from economic evaluations or leave inclusion up to the discretion of the analyst. This may result in too favorable estimations of cost-effectiveness, feeding the unjustified optimism among policymakers regarding lifestyle interventions as a cost-saving option. However, prevention may still be a cost-effective way to improve public health, even when it does not result in cost savings, but this should be judged taking all future costs into account and be based on the true value for money provided by lifestyle interventions.
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To provide a cigarette price elasticity reference for adult age groups, and to estimate the smoking behaviour changes in US adults in light of unprecedented state excise tax increases on cigarettes during the 1990s. Individual-level data from the Behavioral Risk Factor Surveillance System for 1993-2000 were merged with state-level cigarette price and tax data. Data were analysed for different age groups using a weighted least squares regression framework. The outcome variables measured were whether an individual was a smoker, whether he/she had tried to quit smoking during the previous year, and how many cigarettes were smoked per day among the total population and among active smokers. This study confirmed previous results that younger individuals are more responsive to price changes than older individuals. Although older age groups are less sensitive to price changes, their smoking behaviour changes are still statistically significant. This study found that while older individuals are less responsive to price changes than younger individuals, their behavioural changes due to cigarette price increases should not be ignored.
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In an era of limited resources, cost-effectiveness analysis and cost-benefit analysis (CEA/CBA) can be significant policy-making aids. Because the often stated belief that prevention is cost-effective has not been systematically examined, we surveyed about 250 CEA/CBA articles concerning prevention. We found that few authors have followed generally accepted methodological standards, which raised questions concerning the validity of their findings and conclusions. In addition, prevention itself is a problem in CEA/CBA because of such factors as the long intervals between interventions and outcomes, problems which have rarely been considered in the CEA/CBA prevention literature. At the same time, a number of high quality studies concerning prevention indicates that United States policy makers have not aggressively pursued significant opportunities to improve health through prevention, for example by immunizing the elderly and by screening for and treating hypertension. We recommend that analysts follow general methodological principles in CEA/CBA prevention studies to assure both valid and credible results.
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Cytochrome P-450 (CYP) is involved in the activation and metabolism of polycyclic aromatic hydrocarbons in tobacco products. The authors evaluated the association of two polymorphisms in the CYP1A1 gene--the noncoding Msp I polymorphism in the 3'-untranslated region and the Ile462Val polymorphism in exon 7--with colon and rectal cancer. The authors used data from two incident case-control studies of colon cancer (1,026 cases and 1,185 controls) and rectal cancer (820 cases and 1,036 controls) conducted in California and Utah (1991-2002). CYP1A1 genotype was not associated with colon or rectal cancer. Having GSTM1 present, a CYP1A1 variant allele, and the rapid-acetylator NAT2 imputed phenotype was associated with increased risk of colon cancer (odds ratio = 1.7, 95% confidence interval: 1.2, 2.3). Among men, the greatest colon cancer risk was observed for having any CYP1A1 variant allele and currently smoking (odds ratio = 2.5, 95% confidence interval: 1.3, 4.8; Wald chi(2)test: p < 0.01). Assessment of GSTM1 and CYP1A1 and rectal cancer in men showed a twofold elevation in risk for more than 20 pack-years of smoking, except among those with GSTM1 present who had a variant CYP1A1 allele. These data support the association between smoking and colon and rectal cancer. Smoking may have a greater impact on colorectal cancer risk based on CYP1A1 genotype; this might further be modified by GSTM1 for rectal cancer risk.
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Using the simulation model context we checked the consistency of incidence, prevalence and mortality data for specific types of cancer so as to construct an appropriate data set for chronic disease modelling. The data sources used were IKZ for regional cancer prevalence rates and survival proportions, NKR for national incidence rates, and CBS for national registered cause-specific mortality rates. Consistency checks were made for lung, rectal, colon, stomach, oesophagus, breast and prostate cancer. Using national incidence rates and regional survival proportions and a two-state transition model, we calculated prevalence and population mortality rates. We compared the calculated rates to empirical ones. For most types of cancer the calculated prevalence rates fitted well to the empirical ones, except for lung cancer (females), breast and prostate cancer. We found several possible explanations for these differences. The first one was double counts in case of multiple tumours. Based on data we corrected for double counts for breast cancer. The second explanation was differences between regional and national morbidity figures. This was confirmed for lung cancer (females) and prostate cancer. The third explanation was past trends in disease incidence. Correcting for these trends resulted in smaller differences for lung cancer (females), breast and prostate cancer. The calculated mortality rates fitted well to the empirical ones for the lethal types of cancer, but less well for those types of cancer with better prognosis, namely rectal, breast and prostate cancer. These differences could be explained by competing death risks. Several studies have confirmed this explanation. Om te komen tot consistente verzamelingen van invoergegevens voor dynamische modellen van verschillende belangrijke vormen van kanker, hebben we de consistentie geanalyseerd van gegevens over incidentie, prevalentie en sterfte. Het gebruikte model betreft een zogenaamd 'two-state' transitiemodel. Dit model beschrijft de prevalentie en ziekte-specifieke sterfte van een cohort over de tijd als functie van de incidentie en ziekte-gerelateerde 'excess' sterfte. Regionale prevalentie- en overlevingsgegevens waren afkomstig van IKZ, landelijke incidentiegegevens van NKR, en landelijke geregistreerde sterftecijfers van CBS. We hebben de analyses uitgevoerd voor long-, endeldarm-, dikke darm, maag-, slokdarm-, borst- en prostaatkanker. De berekende en empirische prevalentiecijfers kwamen telkens goed overeen, behalve voor longkanker (vrouwen), borst- en prostaat-kanker. We hebben verschillende mogelijke verklaringen voor deze verschillen gevonden. Deze verklaringen waren: dubbeltellingen in geval van multipele tumoren, verschillen tussen regionale en landelijke ziektecijfers, en trends over de tijd in de incidentie. Correctie hiervoor leidde inderdaad tot kleinere verschillen voor de genoemde kankervormen.Ook de berekende en empirische sterftecijfers kwamen telkens goed overeen. Uitzonderingen hierop waren de minder letale vormen van kanker, i.e. endeldarm- en borstkanker. Hier werd de empirische sterfte overschat. Naast de drie eerdergenoemde mogelijke verklaringen kunnen hier ook concurrerende doodsoorzaken een rol spelen. Deze verklaring is voor de twee genoemde kankervormen ook in de literatuur teruggevonden.
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Using the simulation model context we analysed data the consistency of data on incidence, prevalence and mortality for specific chronic diseases so as to construct an appropriate data set for chronic disease models. These simulation models integrate data from different sources and are used to estimate the public health effects of trends in and interventions on disease risk factors. Disease incidence and prevalence data are derived from disease registration in general practice, epidemiological surveys and health-care registration. Disease-specific mortality data are collected from national statistics, while remission and case fatality rates are taken from the scientific literature. The successive steps followed in the consistency analyses were: (visual) comparison of data from different sources, calculation of remission and mortality rates from given disease incidence and prevalence rates and comparison of results with remission and mortality data from other sources. Data was evaluated on lung cancer, asthma and COPD, coronary heart diseases and congestive heartfailure, diabetes mellitus, and dementia and stroke. From the results it can be concluded that differences between data from several sources can often be explained by differences in registration coding rules. For most diseases, calculated excess mortality rates are much greater than the mortality where the disease is the primary cause of death, registered in national statistics. In general, the estimated mortality parameters are in agreement with data from the literature, with the estimation of age-specific rates being complicated by time-trends. Om te komen tot consistente verzamelingen van invoergegevens voor dynamische modellen van chronische ziekten hebben we de consistentie binnen de modelcontext geanalyseerd van gegevens over incidentie, prevalentie en sterfte voor specifieke ziekten. Dergelijke modellen integreren gegevens uit verschillende bronnen en worden gebruikt om de volksgezondheids-effecten van trends in en interventies op risicofactoren door te rekenen. Incidentie- en prevalentie-gegevens komen uit huisartsenregistraties, epidemiologische onderzoeken en registraties in de gezondheidszorg, gegevens over overleving uit de wetenschappelijke literatuur, terwijl ziekte-specifieke sterftecijfers uit de CBS-statistieken komen. De opeenvolgende analysestappen zijn: 1) een vergelijking van de gegevens uit verschillende bronnen, 2) de berekening van remissie- en sterfterates uit gegeven incidentie- en prevalentierates, vervolgens 3) een vergelijking met data uit de literatuur. We hebben data ge6valueerd met betrekking tot longkanker, astma en COPD, coronaire hartziekten en hartfalen, diabetes mellitus, dementie, en beroerte. Verschillende algemene conclusies kunnen getrokken worden: de gevonden verschillen tussen de bronnen zijn meestal terug te vertalen naar verschillen in registratiekarakteristieken; voor veel aandoeningen is de berekende 'excess' sterfte veel groter dan de sterfte met de ziekte als de primaire doodsoorzaak in de CBS-statistieken; de geschatte sterfteparameters komen in de meeste gevallen goed overeen met die uit de literatuur; de aanwezigheid van trends in de tijd maakt het schatten van leeftijd-specifieke cijfers lastig.
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Zorg voor gezondheid, de vierde Volksgezondheid Toekomst Verkenning (VTV) brengt opnieuw een grote hoeveelheid actuele informatie samen over gezondheid, preventie en zorg in Nederland. De Nederlander is weer wat gezonder geworden, maar het kan nog beter. Zo zijn ongezond gedrag en overgewicht, vooral bij de jeugd, een bron van zorg voor de gezondheid in de toekomst. Ook worden binnen Nederland grote verschillen in gezondheid en gezondheidsrisico's aangetroffen tussen regio's of buurten. Gezondheidsachterstanden hangen vaak samen met sociaal-economische achterstanden en andere ongunstige kenmerken van de leefomgeving. Preventie zal zich daarom niet alleen op het individu moeten richten, maar evenzeer op de sociale en ruimtelijke aspecten van de omgeving. Ook andere sectoren zoals onderwijs, ruimtelijke ordening en sociaal-economisch beleid moeten waar mogelijk betrokken worden bij het gezonder maken van Nederland en zijn inwoners. De uitgaven voor zorg zijn de afgelopen jaren flink gestegen, maar de gezondheidszorg heeft in de achterliggende decennia ook veel bijgedragen aan een langer leven in goede gezondheid. En die betere gezondheid betekent ook meer zelfredzaamheid, meer deelname aan de samenleving en uiteindelijk minder beroep op langdurige zorg. Toch is nog winst te boeken op het terrein van patientveiligheid, ketenzorg en vooral ook effectieve preventie en zorg. De informatie in de VTV is van belang voor de beleidsontwikkeling bij VWS, maar is ook waardevol voor andere ministeries, lagere overheden, partijen in het zorgveld en instellingen voor onderwijs en wetenschap. As in the past a large amount of information on health, prevention and health care in the Netherlands has been collected for this edition of the VTV public health forecast. Public health in the Netherlands is improving, but can still be better. Overweight and unhealthy behaviour, especially among young people, are becoming a source of concern for public health in the future. Furthermore, there are many differences in health and health risks cited among regions and neighbourhoods. Backlogs in public health are often associated with socio-economic backlogs and other unfavourable aspects in the living environment. Prevention should not only focus on the individual but just as much on the social and spatial factors in the environment. Other sectors too, such as education, spatial planning and socio-economic policy, should as far as possible, be included in the health improvement initiatives for a healthier population.True, the amounts spent on health care have risen considerably, but the health care offered in the past decennia has also contributed to longer lives in good health. Better health means more control over one's own life, more participation in society and ultimately less need for long-term care. However, great gains can still be made in patient safety, integral chain care, and especially in effective prevention and care. The information offered in this public health forecast is not only important for policy development at the Ministry of Public Health, Welfare and Sport, but is also valuable for other ministries, local and regional authorities, health care , and educational and scientific institutions. Zorg voor gezondheid, de vierde Volksgezondheid Toekomst Verkenning (VTV) brengt opnieuw een grote hoeveelheid actuele informatie samen over gezondheid, preventie en zorg in Nederland. De Nederlander is weer wat gezonder geworden, maar het kan nog beter. Zo zijn ongezond gedrag en overgewicht, vooral bij de jeugd, een bron van zorg voor de gezondheid in de toekomst. Ook worden binnen Nederland grote verschillen in gezondheid en gezondheidsrisico's aangetroffen tussen regio's of buurten. Gezondheidsachterstanden hangen vaak samen met sociaal-economische achterstanden en andere ongunstige kenmerken van de leefomgeving. Preventie zal zich daarom niet alleen op het individu moeten richten, maar evenzeer op de sociale en ruimtelijke aspecten van de omgeving. Ook andere sectoren zoals onderwijs, ruimtelijke ordening en sociaal-economisch beleid moeten waar mogelijk betrokken worden bij het gezonder maken van Nederland en zijn inwoners. De uitgaven voor zorg zijn de afgelopen jaren flink gestegen, maar de gezondheidszorg heeft in de achterliggende decennia ook veel bijgedragen aan een langer leven in goede gezondheid. En die betere gezondheid betekent ook meer zelfredzaamheid, meer deelname aan de samenleving en uiteindelijk minder beroep op langdurige zorg. Toch is nog winst te boeken op het terrein van patientveiligheid, ketenzorg en vooral ook effectieve preventie en zorg. De informatie in de VTV is van belang voor de beleidsontwikkeling bij VWS, maar is ook waardevol voor andere ministeries, lagere overheden, partijen in het zorgveld en instellingen voor onderwijs en wetenschap.
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Support of decision makers in health care priority setting is one of the objectives of cost effectiveness analysis. Cost effectiveness analysis presents the costs and effects of an intervention compared to an alternative in cost effectiveness ratios. The denominator of the ratio measures the health gain from the intervention and the numerator measures the costs of obtaining that health gain. The objective was to develop a methodology to be used with economic evaluations conducted with the RIVM Chronic Disease Model (CDM). Using the CDM to compute health effects and costs ensures that the same model is used for all different economic evaluations, which improves their comparability. The current report describes how cost effectiveness ratios are computed with the CDM. Special attention is paid to the selection and estimation of the costs and effects to be included during years of life gained. A cost effectiveness module was written to be attached to the RIVM Chronic Disease Model (CDM). To decide what costs and effects to include, a distinction was made between diseases causally related and diseases indirectly related to the intervention. Given this distinction the approach from Nyman (Health Economics 2004) was followed: all costs that directly produce the utility measured in the denominator have to be included in the numerator of the cost effectiveness ratio. To estimate the impact of indirectly related diseases on quality of life we use data from the Dutch Burden of Disease study. Data from the Costs of Illness study in the Netherlands were used to estimate the impact of an intervention on total health care costs. We argue that for comparison of different interventions with the RIVM CDM, one should include the costs and effects of both causally related and indirectly related diseases, since it seems impossible to isolate the precise effects of an intervention. De medische kosten van alle ziekten die kunnen optreden in gewonnen levensjaren dienen te worden meegenomen in kosten effectiviteit analyses als ook de effecten van de medische zorg voor alle ziekten in gewonnen levensjaren worden meegenomen. In kosten effectiviteit analyses van primaire preventie worden vaak alleen de medische kosten van direct gerelateerde ziekten meegenomen. Bij kosten effectiviteit analyses van stoppen met roken interventies worden bijvoorbeeld wel de besparingen dankzij de vermeden kosten van longkanker meegenomen maar niet de medische kosten van een heupfractuur die iemand kan oplopen in zijn extra levensjaren. Dit is niet consistent als de winst in levensjaren dankzij de behandeling van de heupfractuur wel wordt meegenomen in de kosten effectiviteit analyse. Een van de toepassingen van het RIVM Chronische Ziekten Model (CZM) is het schatten van de kosten effectiviteit van interventies gericht op het verbeteren van de volksgezondheid in Nederland. De centrale vraagstelling van dit rapport is hoe we in kosten effectiviteit analyses met het CZM omgaan met de medische kosten en gezondheidseffecten van ziekten die zijn opgelopen in extra levensjaren. Met het CZM is het mogelijk om de medische kosten in gewonnen levensjaren in kosten effectiviteit analyses mee te nemen. Op basis van inzichten uit de recente economische literatuur concluderen wij dat de medische kosten van alle ziekten die kunnen optreden in extra levensjaren dienen te worden meegenomen als de effecten van de medische zorg in gewonnen levensjaren niet zijn te scheiden van de effecten van de interventie.
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To examine whether elimination of fatal diseases will increase healthcare costs. Mortality data from vital statistics combined with healthcare spending in a cause elimination life table. Costs were allocated to specific diseases through the various healthcare registers. The population of the Netherlands, 1988. Healthcare costs of a synthetic life table cohort, expressed as life time expected costs. The life time expected healthcare costs for 1988 in the Netherlands were 56,600 Pounds for men and 80,900 Pounds for women. Elimination of fatal diseases--such as coronary heart disease, cancer, or chronic obstructive lung disease--increases healthcare costs. Major savings will be achieved only by elimination of non-fatal disease--such as musculoskeletal diseases and mental disorders. The aim of prevention is to spare people from avoidable misery and death not to save money on the healthcare system. In countries with low mortality, elimination of fatal diseases by successful prevention increases healthcare spending because of the medical expenses during added life years.
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We studied the impact of several smoking cessation-based scenarios on future pancreatic cancer incidence in the European Union by means of computer simulation. Among other data, published data on pancreatic cancer incidence rate and smoking prevalence in ten member states of the European Union, and on the relative risk of smoking were entered into a simulation model. Four different scenarios were simulated: one reference scenario, one based on theoretically maximal smoking reduction and two feasible scenarios based on WHO's Health for All targets. In each scenario, pancreatic cancer incidence was computed from 1994 up to the year 2020. Results were extrapolated to the European Union as a whole. When the percentage of smokers remains unchanged, 627,000 and 588,000 newly diagnosed pancreatic cancer cases among males and females respectively will arise in the European Union up to 2020. Theoretically, if all smokers would give up smoking instantly, this number can be reduced by 133,000 cases among men and 43,000 cases among women. In more feasible scenarios up to 35,500 male and 32,500 female pancreatic cancer cases can be prevented. Giving up smoking substantially reduces future burden of pancreatic cancer up to almost 68,000 patients in the European Union up to the year 2020.
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This study estimated the burden of disease due to 48 major causes in the Netherlands in 1994 in disability-adjusted life-years (DALYs), using national epidemiologic data and disability weights, and explored associated problems and uncertainties. We combined data from Dutch vital statistics, registrations, and surveys with Dutch disability weights to calculate disease-specific health loss in DALYs, which are the sum of years of life lost (YLLs) and years lived with disability (YLDs) weighted for severity. YLLs were primarily lost by cardiovascular diseases and cancers, while YLDs were mostly lost by mental disorders and a range of chronic somatic disorders (such as chronic nonspecific lung disease and diabetes). These 4 diagnostic groups caused approximately equal numbers of DALYs. Sensitivity analysis calls for improving the accuracy of the epidemiologic data in connection with disability weights, especially for mild and frequent diseases. The DALY approach appeared to be feasible at a national Western European level and produced interpretable results, comparable to results from the Global Burden of Disease Study for the Established Market Economies. Suggestions for improving the methodology and its applicability are presented.
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Net costs of smoking in a lifetime perspective and, hence, the economic interests in antismoking policies have been questioned. It has been proposed that the health-related costs of smoking are balanced by smaller expenditure due to shorter life expectancy. A dynamic (life cycle) method taking differences in life expectancy into account. Main outcome measures were direct and indirect lifetime health costs for ever-smokers and never-smokers, and cost ratios (ever-smokers to never-smokers). The estimations were based on annual disease rates of use of the healthcare services, smoking relative risks, smoking prevalences, and costs. Annual direct and indirect costs of ever-smokers were higher than for never-smokers in all age groups of both genders. The direct and indirect cost ratios were highest at age 45 for women, and at age 35 and 40 for men, respectively. Taking life expectancy differences into account, direct and indirect lifetime health costs for men aged 35, discounted by 5% per year were 66% and 83% higher in ever-smokers than in never-smokers. Corresponding results for women were 74% and 79%, respectively. The results are insensitive to a broad range of relative risk-estimates and discount rates including no discounting. Excess costs of ever-smokers disappear if the inclusion of smoking-related diseases is narrowed to that of previous studies. Smoking imposes costs to society even when taking life expectancy into consideration--both in direct and indirect costs.
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Smoking cessation has major immediate and long-term health benefits. However, ex-smokers' total lifetime health costs and continuing smokers' costs remain uncompared, and hence the economic savings of smoking cessation to society have not been determined. The economic effects of smoking cessation in a lifetime perspective have been examined by comparing the health costs of continuing smokers and ex-smokers by quantity of daily tobacco consumption, age, gender and disease group, while taking differences in life expectancy and the reductions in relative risks after cessation into account. The total lifetime health cost savings of smoking cessation are highest at the younger ages. Although the economic savings vary with age at quitting, gender and quantity of daily tobacco consumption, all ex-smoking men and women who quit smoking at the age of 35 to 55 years generate sizeable total lifetime cost savings. At older ages, the total lifetime health cost savings of smoking cessation are of little economic consequence to the society. The total, direct and productivity lifetime cost savings of smoking cessation in moderate smokers who quit smoking at the age of 35 years are 24,800 euros, 7600 euros, and 17,200 euros in men, and 34,100 euros, 12,200 euros, and 21,800 euros in women, respectively. Lifetime health cost savings of smoking cessation to society are substantial at younger ages, in terms of both direct and productivity costs.
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Comorbidity complicates estimations of health-adjusted life expectancy (HALE) using disease prevalences and disability weights from Burden of Disease studies. Usually, the exact amount of comorbidity is unknown and no disability weights are defined for comorbidity. Using data of the Dutch national burden of disease study, the effects of different methods to adjust for comorbidity on HALE calculations are estimated. The default multiplicative adjustment method to define disability weights for comorbidity is compared to HALE estimates without adjustment for comorbidity and to HALE estimates in which the amount of disability in patients with multiple diseases is solely determined by the disease that leads to most disability (the maximum adjustment method). To estimate the amount of comorbidity, independence between diseases is assumed. Compared to the multiplicative adjustment method, the maximum adjustment method lowers HALE estimates by 1.2 years for males and 1.9 years for females. Compared to no adjustment, a multiplicative adjustment lowers HALE estimates by 1.0 years for males and 1.4 years for females. The differences in HALE caused by the different adjustment methods demonstrate that adjusting for comorbidity in HALE calculations is an important topic that needs more attention. More empirical research is needed to develop a more general theory as to how comorbidity influences disability.
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Although narrative reviews have concluded that there is strong support for an association between cigarette smoking and urinary tract cancer, the association has never been quantified systematically in reviews. The purpose of this systematic review was to summarize and quantify the impact of different smoking characteristics (status, amount, duration, cessation, and age at first exposure) both unadjusted and adjusted for age and gender.
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Below we reprint the excecutive summary of an important new report published by the World Bank. This report has its origins in the converging efforts of several partners to address a shared problem: the relative neglect of economic contributions to the debate on tobacco control. In 1997, at the tenth world conference on tobacco in Beijing, China, the World Bank organised a consultation session on the economics of tobacco control. The meeting was part of an ongoing review of the Bank's own control policies. There was clear recognition at this meeting that insufficient global attention was being paid to the economics of smoking-related deaths. The meeting's participants also agreed that the discipline of economics was not being applied to tobacco control in many countries, and that even where economic approaches were being used, their methodology was of variable quality. At the same rime that the World Bank began reviewing its policies, economists at the University, of Cape Town, South Africa, had begun a project on the economics of tobacco control for southern Africa. These initiatives were brought together, in partnership with economists at the University, of lausanne, Switzerland, and others, to form a wider review The work ei culminated in a conference range in Cape Town in February, 1998. The proceedings of the conference have been published separately. (1) The collaboration led to a broader analysis of the economics of tobacco control, involving economists and others from, a wide range of countries and institutions;; This report summarises the findings of those studies as they, are relevant to policy-makers.
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The authors explored two methodological issues in the estimation of smoking-attributable mortality for the United States. First, age-specific and age-adjusted relative risk, attributable fraction, and smoking-attributable mortality estimates obtained using data from the American Cancer Society's second Cancer Prevention Study (CPS II), a cohort study of 1.2 million participants (1982-1988), were compared with those obtained using a combination of data from the National Mortality Follow-back Survey (NMFS), a representative sample of US decedents in which information was collected from informants (1986), and the National Health Interview Survey (NHIS), a nationally representative household survey (1987). Second, the potential for residual confounding of the disease-specific age-adjusted smoking-attributable mortality estimates was addressed with a model-based approach. The estimated smoking-attributable mortality based on the CPS II for the four most common smoking-related diseases-lung cancer, chronic obstructive pulmonary disease, coronary heart disease, and cerebrovascular disease-was 19% larger than the estimated smoking-attributable mortality based on the NMFS/NHIS, yet the two data sources yielded essentially the same smoking-attributable mortality estimate for lung cancer alone. Further adjustment of smoking-attributable mortality for disease-appropriate confounding factors (education, alcohol intake, hypertension status, and diabetes status) indicated little residual confounding once age was taken into account.
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Background: Over one fourth of the California population was Latino in 1999, and by 2015 Latinos are expected to be the single largest ethnic group in California. Patterns of smoking and nicotine dependence among Latino smokers may be quite different from those of smokers in other ethnic groups. In addition, Latino smokers may be more sensitive to cigarette prices. Therefore, the effect of an increase in cigarette excise taxes on Latino smoking prevalence may be quite large, and consequently the impact on Latino health may be proportionately greater than on population health in general.Methods: We simulated changes in Latino smoking, morbidity, mortality, and quality-adjusted life years (QALYs) that would result from a range of actual and proposed cigarette excise-tax increases using a range of cigarette price-elasticity estimates specific to Latino smokers. Monte Carlo simulation was used to generate confidence intervals.Results: Assuming a Latino price elasticity of demand for cigarettes of −1.0, reductions in Latino smoking resulting from an additional $0.50/pack tax would produce nearly 3000 Latino QALYs in California in 1999. Greater benefits would accrue each year, until a steady state relative to population size is reached 75 years after the program is initiated.Conclusions: If Latino smokers are more responsive to changes in cigarette prices than other smokers, Latino smokers also stand to gain a disproportionate share of the health benefit from an excise tax increase.
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BACKGROUND Although narrative reviews have concluded that there is strong support for an association between cigarette smoking and urinary tract cancer, the association has never been quantified systematically in reviews. The purpose of this systematic review was to summarize and quantify the impact of different smoking characteristics (status, amount, duration, cessation, and age at first exposure) both unadjusted and adjusted for age and gender.METHODS The authors included 43 epidemiologic studies (8 cohort and 35 case–control) and calculated summary odds ratios (SORs) by meta-regression analyses for different smoking characteristics. They also evaluated changes in summary estimates according to differences in study methodology.RESULTSSmoking status and increased amount and duration of smoking were associated with a strong increased risk of urinary tract cancer. Smoking cessation and age at first exposure were negatively associated with the risk of urinary tract cancer. The age- and gender-adjusted SORs for current and former cigarette smokers compared with those for nonsmokers were 3.33 (95% confidence interval [CI], 2.63–4.21) and 1.98 (CI, 1.72–2.29), respectively. Even though the component studies differed in methodology, the results were rather consistent.CONCLUSIONS The results suggest a substantial increase in risk of cancer of the urinary tract for cigarette smokers. Based on the results of this study and previous literature, the authors conclude that current cigarette smokers have an approximately threefold higher risk of urinary tract cancer than nonsmokers. In Europe, approximately half of urinary tract cancer cases among males and one-third of cases among females might be attributable to cigarette smoking. Cancer 2000;89:630–9. © 2000 American Cancer Society.
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The annual 5% increase in tobacco taxes in real terms proposed in the recent White Paper on smoking has reaffirmed the commitment of successive UK Governments to above-inflation increases in tobacco taxation to encourage people to stop smoking. This paper presents evidence on the determinants of starting and quitting smoking by using data from the British Health and Lifestyle Survey and is the first to identify tax elasticities for starting and quitting smoking using British data. Self-reported individual smoking histories are coupled with a long time series for the tax rate on cigarettes to construct a longitudinal data set. Estimates are obtained for the effect of above-inflation tax rises on the age of starting smoking and the number of years of smoking. The estimates of the tax elasticity of the age of starting smoking are 0.16 for men and 0.08 for women. The estimates of the tax elasticity of quitting are −0.60 for men and −0.46 for women. These are robust to different specifications.
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This paper analyses the effect of tobacco prices on the propensity to start and quit smoking using a pool of the 1993, 1995 and 1997 editions of the Spanish National Health Surveys. The estimates for several parametric models of the hazard rate for starting and quitting suggest that i) The public health measures applied as of 1992 have had a significative effect on both reducing the hazard of starting and increasing the hazard of quitting, ii) Prices have a very weak effect on the hazard of starting in the male population and no significant effect in the female population, iii) The price floor of cigarrettes, proxied by the average price of a pack of black cigarrettes, has a significant effect on the quitting hazard which is robust across specifications and applies to both men and women. The implied price elasticity of the time up to quitting is situated around -1.4.
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A mathematical model structure is described that can be used to simulate the changes of the Dutch public health state over time. The model is based on the concept of demographic and epidemiologic processes (events) and is mathematically based on the lifetable method. The population is divided over several states, risk factor classes and disease stadia. State transitions over time are possible due to birth, aging, migration, mortality, transitions between risk factor classes, disease incidence, progression and remission. The main model parameters are initial population numbers, initial risk factor class and disease stadium prevalence rates, one-year transition rates between the risk factor classes and disease stadia, and risk factor-cause-specific relative risks. The model is used to describe the public health effects of possible intervention programs. These effects can be defined in terms of classic epidemiologic morbidity and mortality figures, but also in terms of life and health expectancy. Several examples of model applications are described: comparing trend extrapolations and model predictions on cause-specific mortality, and comparing the effects of different intervention programs on population smoking and physical activity levels. Een wiskundige modelstructuur wordt beschreven waarmee veranderingen van de gezondheidstoestand van de Nederlandse bevolking gesimuleerd kunnen worden. Het model is gebaseerd op het concept van demografische en epidemiologische processen (gebeurtenissen) en is afgeleid van de overlevingstafel. De bevolking wordt verdeeld over verschillende mogelijke toestanden, namelijk voor onderscheiden risicofactoren in verschillende klassen en voor onderscheiden ziekten in een of meer stadia. Toestandsveranderingen zijn mogelijk ten gevolge van geboorte, veroudering, migratie, sterfte, verandering van risicofactor-klasse, incidentie, voortschrijding van de ziekte en remissie. De belangrijkste modelparameters zijn initiele bevolkingsaantallen, initiele risicofactor en ziekte-prevalentiefracties, eenjaars overgangskansen tussen de risicofactor-klassen en ziektestadia, en risicofactor-oorzaak-specifieke relatieve risico's. Het model wordt gebruikt om de gezondheidseffecten door te rekenen van mogelijke beleidsmaatregelen, interventies etc. Enkele voorbeelden worden beschreven van verschillende modeltoepassingen: een vergelijking van trendextrapolaties en modelmatige vooruit-berekeningen voor oorzaak-specifieke sterfte, en een vergelijking van de effectiviteit van verschillende mogelijke anti-roken en meer-bewegen campagnes.
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It is known that cigarette smoking is associated with increased risk of both thrombotic and hemorrhagic stroke among men. To test for such an association among women, we examined the incidence of stroke in relation to cigarette smoking in a prospective cohort study of 118,539 women 30 to 55 years of age and free from coronary heart disease, stroke, and cancer in 1976. During eight years of follow-up (908,447 person-years), we identified 274 strokes, comprising 71 subarachnoid hemorrhages, 26 intracerebral hemorrhages, 122 thromboembolic strokes, and 55 strokes about which information was insufficient to permit classification. The number of cigarettes smoked per day was associated positively with the risk of stroke. Compared with the women who had never smoked, those who smoked 1 to 14 cigarettes per day had an age-adjusted relative risk of 2.2 (95 percent confidence interval, 1.5 to 3.3), whereas those who smoked 25 or more cigarettes per day had a relative risk of 3.7 (95 percent confidence interval, 2.7 to 5.1). For women in this latter group, the relative risk of subarachnoid hemorrhage was 9.8 (95 percent confidence interval, 5.3 to 17.9), as compared with those who had never smoked. Adjustment for the effects of relative weight, hypertension, diabetes, history of high cholesterol, previous use of oral contraceptives, postmenopausal estrogen therapy, and alcohol intake did not appreciably alter the association between cigarette use and incidence of stroke. These prospective data support a strong causal relation between cigarette smoking and stroke among young and middle-aged women.
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To examine the association between cigarette smoking and the risk for stroke in men. Prospective cohort study. Participants in the Physicians' Health Study, a randomized trial of aspirin and beta-carotene among U.S. male physicians. 22,071 men, 40 to 84 years of age at entry, free from self-reported myocardial infarction, stroke, and transient ischemic attack; followed for an average of 9.7 years; and classified as never-smokers, current smokers, and former smokers based on self-report. Incidence rates of total, ischemic, and hemorrhagic stroke. With never-smokers as the reference group (relative risk, 1.00), relative risks (adjusted for age and treatment assignment) for total nonfatal stroke (n = 312) were as follows: former smoking, 1.20 (95% CI, 0.94 to 1.53); currently smoking fewer than 20 cigarettes daily, 2.02 (CI, 1.23 to 3.31); and currently smoking 20 or more cigarettes daily, 2.52 (CI, 1.75 to 3.61) (P for trend, < 0.0001). For participants who had total fatal stroke (n = 28), the risk for stroke was not increased with smoking (P > 0.2). In proportional-hazards models that controlled simultaneously for other risk factors, these associations were not materially altered. Current but not former cigarette smoking was significantly associated with an increased risk for stroke in men. Smoking may account for a substantial amount of stroke-associated morbidity and mortality.
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A total of 44,290 men and 24,535 women aged 35-49 have been followed with respect to different causes of death during 13.3 years on average. A detailed history of smoking, together with other important risk factors, were recorded in a standardized way. Compared with the classical American and British studies, the excess mortality for the smokers was largely the same for the majority of causes. The exceptions were cerebrovascular mortality and suicides and accidents, which were more strongly related to smoking in this study. Furthermore, men who smoked only pipe, had nearly the same coronary heart disease mortality as men who smoked only cigarettes. The same applies to lung cancer mortality. Among men who had quit cigarette smoking, the coronary heart disease mortality decreased with time since quitting to almost the level of the never cigarette smokers after 5 years or more.
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Although smoking cessation is desirable from a public health perspective, its consequences with respect to health care costs are still debated. Smokers have more disease than nonsmokers, but nonsmokers live longer and can incur more health costs at advanced ages. We analyzed health care costs for smokers and nonsmokers and estimated the economic consequences of smoking cessation. We used three life tables to examine the effect of smoking on health care costs - one for a mixed population of smokers and nonsmokers, one for a population of smokers, and one for a population of nonsmokers. We also used a dynamic method to estimate the effects of smoking cessation on health care costs over time. Health care costs for smokers at a given age are as much as 40 percent higher than those for nonsmokers, but in a population in which no one smoked the costs would be 7 percent higher among men and 4 percent higher among women than the costs in the current mixed population of smokers and nonsmokers. If all smokers quit, health care costs would be lower at first, but after 15 years they would become higher than at present. In the long term, complete smoking cessation would produce a net increase in health care costs, but it could still be seen as economically favorable under reasonable assumptions of discount rate and evaluation period. If people stopped smoking, there would be a savings in health care costs, but only in the short term. Eventually, smoking cessation would lead to increased health care costs.
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Cigarette smuggling, now on the increase, is so widespread and well organised that it poses a serious threat to public health. This threat comes from two principal directions. First, smuggling makes cigarettes available cheaply, thereby increasing consumption. A third of annual global exports go to the contraband market, representing an enormous impact on consumption, and thus causing an increase in the burden of disease, especially in poorer countries. It is also costing government treasuries thousands of millions of dollars in lost tax revenue. Second, the tobacco industry uses smuggling politically, lobbying governments to lower tax, arguing that smuggling is caused by price differences. This paper shows that the claimed correlation between high prices and high levels of smuggling does not exist in western Europe. In fact, countries such as Norway and Sweden, with expensive cigarettes, do not have a large smuggling problem, whereas countries in the south of Europe do. Cigarette smuggling is not caused principally by "market forces". It is mainly caused by fraud, by the illegal evasion of import duty. The cigarettes involved are not the cheap brands from southern European countries, for which there is no international market. It is the well-known international brands such as Marlboro and Winston. We propose much tighter regulation of cigarette trade, including an international transport convention, and a total ban on transit trade-sale by the manufacturers to dealers, who sell on to smugglers.
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Most medical cost-effectiveness analyses include future costs only for related illnesses, but this approach is controversial. This paper demonstrates that cost-effectiveness analysis is consistent with lifetime utility maximization only if it includes all future medical and non-medical expenditures. Estimates of the magnitude of these future costs suggest that they may substantially alter both the absolute and relative cost-effectiveness of medical interventions, particularly when an intervention increases length of life more than quality of life. In older populations, current methods overstate the cost-effectiveness of interventions which extend life compared to interventions which improve the quality of life.
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The aim of this study was to develop a simulation model to predict the effects of taxes on the smoking rate and smoking-attributable deaths. The model projects the number of smokers and smoking-related deaths from a baseline year forward. The effects of taxes of different sizes, indexed and unindexed, and temporary vs sustained are modeled. The model predicts that sustained tax increases have the potential to substantially reduce the number of smokers and the number of premature deaths, with the effects growing over time. Indexing taxes to inflation stems erosion of the tax effect. Tax hikes have the ability to substantially affect smoking rates in the near term. These effects grow over time and lead to substantial savings in lives and health care costs.
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There are still many ongoing debates about several aspects of the methodology of economic evaluations of health care interventions. Some of the disparities in recommendations on methodological issues may be traced back to different viewpoints on cost-effectiveness analysis (CEA) in general. Two important views are the welfarist approach, which aims at embedding CEA into traditional welfare economics, and the decision maker's approach, which takes a broader and more pragmatic view on CEA. The focus in welfarism may be on utility while that of the decision maker's approach may be considered to be on health. In this paper it is examined how these two views differ and how these differences may subsequently lead to debates in methodological areas. It is indicated that embedding the practical operationalization of CEA in welfare economics seems impossible. In a strict welfarist approach it is necessary to view QALYs as being utilities, although one may question whether such an approach to QALYs is appropriate. Also, equity considerations may play an important role in cost-effectiveness analysis and these should preferably be taken into account in a way that reflects societal attitudes towards an equitable distribution of health care. These equity considerations may not always be directly related to utility or efficiency. Furthermore, both camps may prefer different methods for cost measurement in areas such as productivity costs and informal care. A better recognition of the contents and origins of controversies and disputes may enhance the clarity of discussions.