Increasing tobacco taxes: A cheap tool to increase public health

Cost-Effectiveness Analysis of Tobacco Control Strategies in Indonesia

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.

Active Health Governance—A Conceptual Framework Based on a Narrative Literature Review

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.

Exploring indigenous perspectives on tobacco tax: how some Māori families are responding in Aotearoa New Zealand

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.

Cost-effectiveness analysis of the 2019 cigarette excise tax reform in the Philippines

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.

A systematic review of economic evaluations of public health interventions targeting alcohol, tobacco, illicit drug use and problematic gambling: Using a case study to assess transferability

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.

Distributional equity as a consideration in economic and modelling evaluations of health taxes: A systematic review

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.

Model-based economic evaluations in smoking cessation and their transferability to new contexts: a systematic review

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, National Health Service (NHS) Economic Evaluation Database (NHS EED), Health Technology Assessment (HTA). The checklist-based quality of the included studies and transferability scores was based on the European Network of Health Economic Evaluation Databases (EURONHEED) criteria. Studies that were not in smoking cessation, not 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, the state-transition Markov model was the most frequently used method (n = 30/64), with quality adjusted life years (QALY) being the most frequently used outcome measure in a life-time horizon. A small number of the included studies (13 of 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). The 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.

Economic Impact of Tobacco Price Increases Through Taxation: A Community Guide Systematic Review

CONTEXT

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.

EVIDENCE ACQUISITION

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.

EVIDENCE SYNTHESIS

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.

CONCLUSIONS

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.

Mathematical Modeling in Tobacco Control Research: Initial Results From a Systematic Review

OBJECTIVES

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Health and economic impacts of eight different dietary salt reduction interventions

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.

Higher Adherence During Reimbursement of Pharmacological Smoking Cessation Treatments

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 behavioral counseling. The aim of this article 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 1000 inhabitants per quarter during 2010. In 2011, the prevalence was on average 0.7, with peaks in the first (0.8 per 1000) and fourth (1.0 per 1000) 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 first quarter. Adherence was 15.4% in 2010 versus 20.1% in 2011 (P = .002). In 2012, adherence was 13.9%, compared with 18.9% in 2013 (P = .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.

The role of cost-effectiveness analysis in developing nutrition policy

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.

Economic evaluation and the postponement of health care costs

The inclusion of medical costs in life years gained in economic evaluations of health care technologies has long been controversial. Arguments in favour of the inclusion of such costs are gaining support, which shifts the question from whether to how to include these costs. This paper elaborates on the issue how to include cost in life years gained in cost effectiveness analysis given the current practice of economic evaluations in which costs of related diseases are included. We combine insights from the theoretical literature on the inclusion of unrelated medical costs in life years gained with insights from the so-called 'red herring' literature. It is argued that for most interventions it would be incorrect to simply add all medical costs in life years gained to an ICER, even when these are corrected for postponement of the expensive last year of life. This is the case since some of the postponement mechanism is already captured in the unadjusted ICER by modelling the costs of related diseases. Using the example of smoking cessation, we illustrate the differences and similarities between different approaches. The paper concludes with a discussion about the proper way to account for medical costs in life years gained in economic evaluations.

Determining responsibility for smoking in society: accountability continuum for Jordanian college students and its implication on FCTC implementation

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.

Recent trends and geographic patterns of the burden of disease attributable to smoking

PURPOSE

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.

METHODS

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).

RESULTS

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.

CONCLUSIONS

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.

The opportunities for and obstacles against prevention: the example of Germany in the areas of tobacco and alcohol

BACKGROUND

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.

DISCUSSION

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.

SUMMARY

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.

Factors associated with differences in mortality and self-reported health across states in the United States

OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Healthcare costs and obesity prevention: drug costs and other sector-specific consequences

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.

Cost-effectiveness of a low-calorie diet and orlistat for obese persons: modeling long-term health gains through prevention of obesity-related chronic diseases

OBJECTIVE

Our study estimated the cost-effectiveness of pharmacologic treatment of obesity in combination with a low-calorie diet in The Netherlands.

METHODS

Costs and effects of a low-calorie diet-only intervention and of a low-calorie diet in combination with 1 year of orlistat were compared to no treatment. The RIVM Chronic Disease Model was used to project the differences in quality adjusted life years (QALYs) and lifetime health-care costs because of the effects of the interventions on body mass index (BMI) status. This was done by linking BMI status to the occurrence of obesity-related diseases and by relating quality of life to disease status. Probabilistic sensitivity analysis was employed to study the effect of uncertainty in the model parameters. In univariate sensitivity analysis, we assessed how sensitive the results were to several key assumptions.

RESULTS

Incremental costs per QALY gained were Euro 17,900 for the low-calorie diet-only intervention compared to no intervention and Euro 58,800 for the low-calorie diet + orlistat compared to the low-calorie diet only. Assuming a direct relation between BMI and quality of life, these ratios decreased to Euro 6000 per QALY gained and Euro 24,100 per QALY gained. Costs per QALY gained were also sensitive to assumptions about long-term weight loss maintenance.

CONCLUSIONS

Cost-effectiveness ratios of interventions aiming at weight reduction depend strongly on assumptions regarding the relation between BMI and quality of life. We recommend that a low-calorie diet should be the first option for policymakers in combating obesity.

The cost-effectiveness of increasing alcohol taxes: a modelling study

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

Focusing on health-care costs and health consequences for drinkers, an alcohol tax increase is a cost-effective policy instrument.

Price effects on the smoking behaviour of adult age groups

OBJECTIVES

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.

STUDY DESIGN

Individual-level data from the Behavioral Risk Factor Surveillance System for 1993-2000 were merged with state-level cigarette price and tax data.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Lifetime medical costs of obesity: prevention no cure for increasing health expenditure

BACKGROUND

Obesity is a major cause of morbidity and mortality and is associated with high medical expenditures. It has been suggested that obesity prevention could result in cost savings. The objective of this study was to estimate the annual and lifetime medical costs attributable to obesity, to compare those to similar costs attributable to smoking, and to discuss the implications for prevention.

METHODS AND FINDINGS

With a simulation model, lifetime health-care costs were estimated for a cohort of obese people aged 20 y at baseline. To assess the impact of obesity, comparisons were made with similar cohorts of smokers and "healthy-living" persons (defined as nonsmokers with a body mass index between 18.5 and 25). Except for relative risk values, all input parameters of the simulation model were based on data from The Netherlands. In sensitivity analyses the effects of epidemiologic parameters and cost definitions were assessed. Until age 56 y, annual health expenditure was highest for obese people. At older ages, smokers incurred higher costs. Because of differences in life expectancy, however, lifetime health expenditure was highest among healthy-living people and lowest for smokers. Obese individuals held an intermediate position. Alternative values of epidemiologic parameters and cost definitions did not alter these conclusions.

CONCLUSIONS

Although effective obesity prevention leads to a decrease in costs of obesity-related diseases, this decrease is offset by cost increases due to diseases unrelated to obesity in life-years gained. Obesity prevention may be an important and cost-effective way of improving public health, but it is not a cure for increasing health expenditures.

The economics of primary prevention of cardiovascular disease - a systematic review of economic evaluations

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.