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Collins LG, Lindsay D, Lal A, Doan T, Schüz J, Jongenelis M, Scollo M. A systematic review of the modelling and economic evaluation studies assessing regulatory options for e-cigarette use. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 129:104476. [PMID: 38851141 DOI: 10.1016/j.drugpo.2024.104476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 05/30/2024] [Accepted: 06/02/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND Governments around the world are considering regulating access to nicotine e-cigarettes to prevent uptake among youth however people that smoke tobacco may use them to assist with smoking cessation. The health and cost implications of regulating e-cigarette use among populations are unknown but have been explored in modelling studies. We reviewed health economic evaluation and simulation modelling studies that assessed long-term consequences and interpret their potential usefulness for decision-makers. METHODS A systematic review with a narrative synthesis was undertaken. Six databases were searched for modelling studies evaluating population-level e-cigarette control policies or interventions restricting e-cigarette use versus more liberalized use. Studies were required to report the outcomes of life years, quality-adjusted life years (QALYs) and/or healthcare costs. The quality of the studies was assessed using two quality assessment tools. RESULTS In total, 15 studies were included with nine for the United States and one each for the United Kingdom, Italy, Australia, Singapore, Canada, and New Zealand. Three studies included cost-utility analyses. Most studies involved health state transition (or Markov) closed cohort models. Many studies had limitations with their model structures, data input quality and transparency, and insufficient analyses handling model uncertainty. Findings were mixed with 11 studies concluding that policies permitting e-cigarette use lead to net benefits and 4 studies concluding net losses in life-years or QALYs and/or healthcare costs.Five studies had industry conflicts of interest. CONCLUSIONS While authors did conclude net benefit than net harm in more of the studies so far conducted, the significant limitations that we identified with many of the studies in this review, make it uncertain whether or not countries can expect net population harms or benefits of restrictive versus unrestrictive e-cigarette policies. The generalizability of the findings is limited for decision-makers. In light of the deep uncertainty around the health and economic outcomes of e-cigarettes, simulation modelling methods and uncertainty analyses should be strengthened.
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Affiliation(s)
- Louisa G Collins
- QIMR Berghofer Medical Research Institute, Population Health Program, Brisbane, Queensland, Australia; Queensland University of Technology (QUT), School of Nursing, Brisbane, Queensland, Australia; The University of Queensland, School of Public Health, Brisbane, Queensland, Australia.
| | - Daniel Lindsay
- QIMR Berghofer Medical Research Institute, Population Health Program, Brisbane, Queensland, Australia
| | - Anita Lal
- Deakin Health Economics, Deakin University
| | - Tan Doan
- Queensland Ambulance Service, Department of Health, Brisbane, Australia
| | - Joachim Schüz
- International Agency for Research in Cancer, World Health Organization, Lyon, France
| | - Michelle Jongenelis
- The University of Melbourne, Melbourne School of Psychological Sciences, Melbourne, Victoria
| | - Michelle Scollo
- Cancer Council Victoria, Centre for Behavioural Research in Cancer, Melbourne, Victoria, Australia
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Gordon LG, Preston P. Healthcare costs attributable to e-cigarette use and subsequent uptake of cigarette smoking by Australians who have never smoked. AUST HEALTH REV 2024; 48:52-57. [PMID: 38127822 DOI: 10.1071/ah23178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 12/01/2023] [Indexed: 12/23/2023]
Abstract
Objective New legislation to curb the rapid increase in e-cigarette use among youth is underway. We estimated the future healthcare costs for chronic diseases from e-cigarette use among never smokers who transition to tobacco smoking. Methods Using population-attributable fractions, we estimated the health expenditure attributable to e-cigarettes based on the prevalence of e-cigarette use, uptake of tobacco smoking, and risk of smoking on developing chronic disease. Data for men and women were derived from published reports on e-cigarette use prevalence, risk of smoking-related disease and addiction, and health expenditure for 25 diseases. Sensitivity analyses were undertaken to address data input variation. Results Future healthcare costs attributed to new e-cigarette-initiated smokers were conservatively estimated to be (in Australian dollars) $179.6 million annually. Collectively, the estimated costs were highest for respiratory diseases ($102.2 million; 57% of total costs), malignant cancers ($49.6 million; 28%), and cardiovascular disease ($27.7 million; 15%). The uptake rate of e-cigarettes was more important in driving healthcare costs than the proportion moving from e-cigarettes to cigarette smoking. Conclusion High avoidable health system costs are predicted for the treatment of chronic conditions created by e-cigarette-initiated smoking. These costs exclude the immediate and direct healthcare harms of e-cigarette-related poisoning, lung injury, and respiratory problems, and costs associated with the unknown health harms of e-cigarette use alone. The proposed regulations to curb recreational e-cigarette use in Australia are set to prevent expensive health care arising sometime in the future from new cigarette smokers.
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Affiliation(s)
- Louisa G Gordon
- QIMR Berghofer Medical Research Institute, Population Health Program, Brisbane, Qld, Australia; and School of Nursing, Queensland University of Technology (QUT), Brisbane, Qld, Australia; and School of Public Health, The University of Queensland, Brisbane, Qld, Australia
| | - Paige Preston
- School of Public Health, The University of Queensland, Brisbane, Qld, Australia; and Lung Foundation Australia, Level 2/11 Finchley Street, Milton, Qld 4064, Australia
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Stubbs T, White V, Yong HH, Toumbourou JW. Implications of nicotine vaping products for tobacco control in ASEAN low-income and middle-income countries: in-depth interviews with experts from the region. BMJ Open 2023; 13:e073106. [PMID: 37730408 PMCID: PMC10510874 DOI: 10.1136/bmjopen-2023-073106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 08/25/2023] [Indexed: 09/22/2023] Open
Abstract
OBJECTIVES The use of nicotine vaping products (NVPs) has increased in low-income and middle-income countries (LMICs) in the Association of Southeast Asian Nations (ASEAN) region; however, it is uncertain what implications the presence and use of NVPs have for tobacco control. DESIGN In-depth interviews were conducted to explore ASEAN tobacco control experts' (n=11) views on the rise of NVP use in ASEAN LMICs, current NVP policies, the potential harm reduction and smoking cessation utilities of these devices, and what implications they may have for tobacco control. Data were analysed using inductive, reflexive thematic analysis. RESULTS Five themes emerged: (1) NVPs threaten tobacco control in ASEAN LMICs; (2) commercial factors influence youth appeal and access: product attributes, marketing, supply chains; (3) opposition to the smoking cessation and harm reduction utilities of NVPs; (4) policies are inconsistent and fragmented in the region; and (5) tobacco industry power and tactics have been used to capture NVP markets. CONCLUSIONS ASEAN tobacco control experts believe that NVPs pose a threat to youth and non-smokers in LMICs in the region, largely because of tobacco industry NVP marketing activities. They do not support the use of NVPs for smoking cessation or harm reduction and call for more restrictions and consistent policy enforcement across the region to protect young people, while also cautiously recognising that use of NVPs may have some benefits for smokers.
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Affiliation(s)
- Thomas Stubbs
- Faculty of Health, School of Psychology, Deakin University, Burwood, Victoria, Australia
| | - Victoria White
- Faculty of Health, School of Psychology, Deakin University, Burwood, Victoria, Australia
| | - Hua-Hie Yong
- Faculty of Health, School of Psychology, Deakin University, Burwood, Victoria, Australia
| | - John W Toumbourou
- Centre for Drug Use, Addictive and Anti-social Behaviour Research, School of Psychology, Deakin University, Burwood, Victoria, Australia
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Mason A, Riordan BC, Winter T, Conner TS, Sibley CG, Scarf D. Effects of vaping on uptake and cessation of smoking: Longitudinal analysis in Aotearoa New Zealand adults. Drug Alcohol Rev 2023; 42:1587-1594. [PMID: 37368846 DOI: 10.1111/dar.13702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 05/04/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023]
Abstract
INTRODUCTION Globally, the use of vapes, or e-cigarettes, is increasing. While vaping is less harmful than smoking and may help smokers to quit, there is also the possibility that vaping may lead to smoking. The current study aimed to determine the prevalence of vaping and smoking in Aotearoa New Zealand and explore longitudinal pathways between smoking status and vape use. METHOD Data related to smoking and vaping status was analysed from Times 10, 11 and 12 across 2018-2020 of the New Zealand Attitudes and Values study, a large, representative, multi-wave study of adults living in New Zealand. Weighted descriptive analyses were used to determine prevalence rates of vaping and smoking and a generalised linear modelling approach was used to examine the likelihood of changing to, or taking up, the other behaviour in the transition between time points. RESULTS Broadly, the prevalence of smoking was found to be decreasing over time while the prevalence of vaping was increasing. Despite these general trends, no differences were observed in the likelihood of transitioning from smoking to vaping or from vaping to smoking, indicating that either pathway was equally as likely. DISCUSSION AND CONCLUSIONS The current findings demonstrate that vaping appeared to be just as likely to have a gateway effect to smoking as it was to have a cessation effect. This highlights the need for greater consideration regarding vaping-related policies and restrictions.
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Affiliation(s)
- Andre Mason
- Department of Psychology, University of Otago, Dunedin, New Zealand
| | - Benjamin C Riordan
- Centre for Alcohol Policy Research, La Trobe University, Melbourne, Australia
| | - Taylor Winter
- School of Mathematics and Statistics, University of Canterbury, Christchurch, New Zealand
| | - Tamlin S Conner
- Department of Psychology, University of Otago, Dunedin, New Zealand
| | - Chris G Sibley
- School of Psychology, University of Auckland, Auckland, New Zealand
| | - Damian Scarf
- Department of Psychology, University of Otago, Dunedin, New Zealand
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Gordon LG. Diverse e-cigarette regulations in the Asia Pacific: A health economic perspective. Respirology 2023. [PMID: 37315946 DOI: 10.1111/resp.14535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 06/06/2023] [Indexed: 06/16/2023]
Affiliation(s)
- Louisa G Gordon
- QIMR Berghofer Medical Research Institute, Population Health Program, Brisbane, Queensland, Australia
- School of Nursing, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
- School of Public Health, The University of Queensland, Brisbane, Queensland, Australia
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Vu GT, Stjepanović D, Sun T, Leung J, Chung J, Connor J, Thai PK, Gartner CE, Tran BX, Hall WD, Chan G. Predicting the long-term effects of electronic cigarette use on population health: a systematic review of modelling studies. Tob Control 2023:tc-2022-057748. [PMID: 37295941 DOI: 10.1136/tc-2022-057748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 05/29/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To systematically review and synthesise the findings of modelling studies on the population impacts of e-cigarette use and to identify potential gaps requiring future investigation. DATA SOURCE AND STUDY SELECTION Four databases were searched for modelling studies of e-cigarette use on population health published between 2010 and 2023. A total of 32 studies were included. DATA EXTRACTION Data on study characteristics, model attributes and estimates of population impacts including health outcomes and smoking prevalence were extracted from each article. The findings were synthesised narratively. DATA SYNTHESIS The introduction of e-cigarettes was predicted to lead to decreased smoking-related mortality, increased quality-adjusted life-years and reduced health system costs in 29 studies. Seventeen studies predicted a lower prevalence of cigarette smoking. Models that predicted negative population impacts assumed very high e-cigarette initiation rates among non-smokers and that e-cigarette use would discourage smoking cessation by a large margin. The majority of the studies were based on US population data and few studies included factors other than smoking status, such as jurisdictional tobacco control policies or social influence. CONCLUSIONS A population increase in e-cigarette use may result in lower smoking prevalence and reduced burden of disease in the long run, especially if their use can be restricted to assisting smoking cessation. Given the assumption-dependent nature of modelling outcomes, future modelling studies should consider incorporating different policy options in their projection exercises, using shorter time horizons and expanding their modelling to low-income and middle-income countries where smoking rates remain relatively high.
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Affiliation(s)
- Giang T Vu
- National Centre for Youth Substance Use Research, The University of Queensland, Brisbane, Queensland, Australia
- School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
| | - Daniel Stjepanović
- National Centre for Youth Substance Use Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Tianze Sun
- National Centre for Youth Substance Use Research, The University of Queensland, Brisbane, Queensland, Australia
- School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
| | - Janni Leung
- National Centre for Youth Substance Use Research, The University of Queensland, Brisbane, Queensland, Australia
- School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
| | - Jack Chung
- National Centre for Youth Substance Use Research, The University of Queensland, Brisbane, Queensland, Australia
- School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
| | - Jason Connor
- National Centre for Youth Substance Use Research, The University of Queensland, Brisbane, Queensland, Australia
- School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
- Discipline of Psychiatry, The University of Queensland, Brisbane, Queensland, Australia
| | - Phong K Thai
- Queensland Alliance for Environmental Health Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Coral E Gartner
- NHMRC Centre of Research Excellence on Achieving the Tobacco Endgame, School of Public Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Bach Xuan Tran
- Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Viet Nam
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Wayne D Hall
- National Centre for Youth Substance Use Research, The University of Queensland, Brisbane, Queensland, Australia
- Queensland Alliance for Environmental Health Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Gary Chan
- National Centre for Youth Substance Use Research, The University of Queensland, Brisbane, Queensland, Australia
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Mendelsohn CP, Hall W, Borland R, Wodak A, Beaglehole R, Benowitz NL, Britton J, Bullen C, Etter JF, McNeill A, Rigotti NA. A critique of the Australian National Health and Medical Research Council CEO statement on electronic cigarettes. Addiction 2023; 118:1184-1192. [PMID: 36808672 DOI: 10.1111/add.16143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/13/2023] [Indexed: 02/23/2023]
Abstract
This paper critically analyses a statement by Australia's National Health and Medical Research Council (NHMRC) on e-cigarettes in May 2022 that will be used to guide national policy. We reviewed the evidence and the conclusions drawn in the NHMRC Statement. In our view, the Statement is not a balanced reflection of the benefits and risks of vaping because it exaggerates the risks of vaping and fails to compare them to the far greater risks of smoking; it uncritically accepts evidence of harms from e-cigarettes while adopting a highly sceptical attitude towards evidence of their benefits; it incorrectly claims that the association between adolescent vaping and subsequent smoking is causal; and it understates the evidence of the benefits of e-cigarettes in assisting smokers to quit. The Statement dismisses the evidence that vaping is probably already having a positive net public health effect and misapplies the precautionary principle. Several sources of evidence supporting our assessment were published after the NHMRC Statement's publication and are also referenced. The NHMRC Statement on e-cigarettes does not present a balanced assessment of the available scientific literature and fails to meet the standard expected of a leading national scientific body.
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Affiliation(s)
| | - Wayne Hall
- National Centre for Youth Substance Use Research, The University of Queensland, St Lucia, Queensland, Australia
| | - Ron Borland
- Melbourne Centre for Behaviour Change, School of Psychological Sciences, The University of Melbourne, Victoria, Australia
| | - Alex Wodak
- Emeritus Consultant, Alcohol and Drug Service, St Vincents' Hospital, Sydney, Australia
| | | | - Neal L Benowitz
- Department of Medicine, University of California San Francisco, California, USA
| | - John Britton
- University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Chris Bullen
- School of Population Health, The University of Auckland, Auckland, New Zealand
| | - Jean-François Etter
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Ann McNeill
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - Nancy A Rigotti
- Harvard Medical School, Director, Tobacco Research and Treatment Center, Massachusetts General Hospital, Massachusetts, Boston, USA
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Wilson N, Cleghorn C, Nghiem N, Blakely T. Prioritization of intervention domains to prevent cardiovascular disease: a country-level case study using global burden of disease and local data. Popul Health Metr 2023; 21:1. [PMID: 36703150 PMCID: PMC9878487 DOI: 10.1186/s12963-023-00301-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 01/20/2023] [Indexed: 01/27/2023] Open
Abstract
AIM We aimed to combine Global Burden of Disease (GBD) Study data and local data to identify the highest priority intervention domains for preventing cardiovascular disease (CVD) in the case study country of Aotearoa New Zealand (NZ). METHODS Risk factor data for CVD in NZ were extracted from the GBD using the "GBD Results Tool." We prioritized risk factor domains based on consideration of the size of the health burden (disability-adjusted life years [DALYs]) and then by the domain-specific interventions that delivered the highest health gains and cost-savings. RESULTS Based on the size of the CVD health burden in DALYs, the five top prioritized risk factor domains were: high systolic blood pressure (84,800 DALYs; 5400 deaths in 2019), then dietary risk factors, then high LDL cholesterol, then high BMI and then tobacco (30,400 DALYs; 1400 deaths). But if policy-makers aimed to maximize health gain and cost-savings from specific interventions that have been studied, then they would favor the dietary risk domain (e.g., a combined fruit and vegetable subsidy plus a sugar tax produced estimated lifetime savings of 894,000 health-adjusted life years and health system cost-savings of US$11.0 billion; both 3% discount rate). Other potential considerations for prioritization included the potential for total health gain that includes non-CVD health loss and potential for achieving relatively greater per capita health gain for Māori (Indigenous) to reduce health inequities. CONCLUSIONS We were able to show how CVD risk factor domains could be systematically prioritized using a mix of GBD and country-level data. Addressing high systolic blood pressure would be the top ranked domain if policy-makers focused just on the size of the health loss. But if policy-makers wished to maximize health gain and cost-savings using evaluated interventions, dietary interventions would be prioritized, e.g., food taxes and subsidies.
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Affiliation(s)
- Nick Wilson
- Department of Public Health, University of Otago, Wellington, New Zealand.
| | - Christine Cleghorn
- grid.29980.3a0000 0004 1936 7830Department of Public Health, University of Otago, Wellington, New Zealand
| | - Nhung Nghiem
- grid.29980.3a0000 0004 1936 7830Department of Public Health, University of Otago, Wellington, New Zealand
| | - Tony Blakely
- grid.1008.90000 0001 2179 088XSchool of Population and Global Health, The University of Melbourne, Parkville, VIC Australia
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Mendelsohn CP, Wodak A, Hall W, Borland R. A critical analysis of 'Electronic cigarettes and health outcomes: Systematic review of global evidence'. Drug Alcohol Rev 2022; 41:1493-1498. [PMID: 35862283 DOI: 10.1111/dar.13515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/19/2022] [Accepted: 06/25/2022] [Indexed: 11/26/2022]
Affiliation(s)
| | - Alex Wodak
- St Vincent's Hospital Sydney, Alcohol and Drug Service, Sydney, Australia
| | - Wayne Hall
- University of Queensland, Centre for Youth Substance Abuse Research, Brisbane, Australia
| | - Ron Borland
- School of Psychological Sciences, The University of Melbourne, Melbourne, Australia
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Wilson N, Summers JA, Ait Ouakrim D, Hoek J, Edwards R, Blakely T. Improving on estimates of the potential relative harm to health from using modern ENDS (vaping) compared to tobacco smoking. BMC Public Health 2021; 21:2038. [PMID: 34749706 PMCID: PMC8577029 DOI: 10.1186/s12889-021-12103-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 10/19/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Although the harm to health from electronic nicotine delivery systems (ENDS) compared to smoked tobacco remains highly uncertain, society and governments still need to know the likely range of the relative harm to inform regulatory policies for ENDS and smoking. METHODS We identified biomarkers with specificity of association with different disease groupings e.g., volatile organic compound (VOCs) for chronic obstructive pulmonary disease; and tobacco-specific N´-nitrosamines (TSNAs) and polycyclic aromatic hydrocarbons (PAHs) for all cancers. We conducted a review of recent studies (post January 2017) that compared these biomarkers between people exclusively using ENDS and those exclusively smoking tobacco. The percentage differences in these biomarkers, weighted by study size and adjusted for acrolein from other sources, were used as a proxy for the assumed percentage difference in disease harm between ENDS and smoking. These relative differences were applied to previously modelled estimates of smoking-related health loss (in health-adjusted life-years; HALYs). RESULTS The respective relative biomarker levels (ENDS vs smoking) were: 28% for respiratory diseases (five results, three studies); 42% for cancers (five results, four studies); and 35% for cardiovascular (seven results, four studies). When integrated with the HALY impacts by disease, the overall harm to health from ENDS was estimated to be 33% that of smoking. CONCLUSIONS This analysis, suggests that the use of modern ENDS devices (vaping) could be a third as harmful to health as smoking in a high-income country setting. But this estimate is based on a limited number of biomarker studies and is best be considered a likely upper level of ENDS risk given potential biases in our method (i.e., the biomarkers used being correlated with more unaccounted for toxicants in smoking compared to with using ENDS).
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Affiliation(s)
- Nick Wilson
- University of Otago, Wellington, New Zealand.
| | | | - Driss Ait Ouakrim
- Population Interventions, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Janet Hoek
- University of Otago, Wellington, New Zealand
| | | | - Tony Blakely
- Population Interventions, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
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