Ángel López-Nicolás

Unobserved heterogeneity and censoring in the demand for health care

In this paper we estimate a demand for private medical services equation based on the tradition of Grossmans model of demand for health using data for a panel of Spanish households. The econometric specification accounts for the censored nature of the data, which arises from no participation and infrequency of purchases, and the existence of unobserved heterogeneity, which arises from the non-observability of health states. Our evidence suggests that ignoring these features can have a significant impact on the size, sign and significance of the model estimates. The estimates for the participation and consumption processes also suggest that the deduction of expenditures on health care currently applicable in the Spanish tax system are positively associated to income and fertility.

The Spanish tobacco tax loopholes and their consequences

Objectives The Spanish government has strengthened tobacco control policies since 2005, including changes in tobacco taxes. Because these changes have targeted cigarettes mainly, the tobacco industry has marketed cheaper alternative tobacco products, offering smokers the possibility to downtrade. This paper traces the evolution of patterns of demand for cigarettes and other tobacco products in Spain over the period 2005–2011 in order to assess the impact of such tax loopholes. Methods The authors use data on tobacco products prices and sales as well as changes in the structure and levels of tobacco taxes to relate tax changes to price changes and subsequent market share changes. Results Tax reforms have lifted the bottom end of the cigarette price distribution, but the industry has been successful in marketing fine-cut tobacco at cheap prices. There have been partial attempts to correct this asymmetric tax treatment, but these have not avoided a remarkable increase in the market share of fine-cut tobacco. The absence of a minimum tax on quantity for the rest of tobacco products allows the industry to place them as potential future downtrading vehicles. Conclusions In order to address public health objectives, tax policies should aim to equalise the cost of smoking across different tobacco products. Otherwise the tobacco industry can exploit tax loopholes to market cheap alternatives to cigarettes. This requires all tobacco products to bear a minimum tax on quantity, whose levels need to be adjusted in order to reflect the equivalence between different forms of smoking.

Evolución del índice de precios al consumo del tabaco y las bebidas alcohólicas: España, 1992-2001

En el patron de enfermedad y mortalidad de nuestro pais, el impacto del consumo de tabaco y el del abuso de alcohol son notables1. Este viene condicionado por diversos factores, entre los que destaca el precio. Unas politicas de prevencion integrales deben incorporar la fiscalidad como una forma de incrementar el precio y disminuir la demanda, haciendo estos productos menos asequibles, especialmente a los adolescentes que se inician en su consumo y tienen menos dinero disponible para gastar. El Banco Mundial ha documentado la fiscalidad como una de las politicas mas utiles para disminuir el consumo de tabaco2 los incrementos del precio se traducen en menor consumo, a expensas por un lado de menos inicios en los adolescentes, y de menor consumo y mas intentos de cesacion entre los fumadores adultos. La elasticidad es mayor para los adolescentes3 y el resultado es positivo para la salud en todos estos casos. La relacion del consumo de alcohol con su precio es mas compleja: el grueso de los consumidores de alcohol no sufre sindrome de dependencia y los incrementos de precio parecen producir una disminucion del consumo global, pero no a expensas de los grandes bebedores4. Sin embargo, como buena parte de los efectos adversos del alcohol sobre la salud se manifiestan entre consumidores no dependientes (a expensas de lesiones por accidentes), la disminucion del consumo parece traducirse en lesiones y muertes prevenidas5,6.

An Investigation of the Relationship between Job Characteristics and the Gender Wage Gap

This paper re-examines gender wage differences, taking into account not only worker characteristics but also job characteristics. Consideration of a wide set of “job quality” indicators can explain a fraction of the wage gap that would otherwise be attributed to pure wage discrimination. In any case, the fraction of the wage gap that remains associated to differential rewards for identical factors across sexes is still substantial. Our results suggest that in order to avoid overestimation of the fraction of the wage gap attributable to discrimination, it is necessary to control for job characteristics.

Coste-utilidad del consejo médico para dejar de fumar en la Región de Murcia

OBJECTIVE To perform a cost-benefit analysis of brief medical advice to quit smoking in the Region of Murcia. DESIGN A cost-benefit analysis is performed on brief medical advice to quit smoking versus non-intervention. A Markov model is used to estimate the costs (€ in 2014), under the perspective of the National Health System, and health outcomes. These are measured in quality-adjusted life years (QALY). The time horizon of the analysis is 20years, and costs and health outcomes were discounted at 3%. A univariate and multivariate deterministic sensitivity analysis is performed. LOCATION Region of Murcia. PARTICIPANTS Smokers in the Region of Murcia. INTERVENTIONS Brief advice to quit smoking. KEY MEASURES Quality Adjusted Life Years (QALYs). RESULTS With a time horizon of 5years (2018), the incremental cost-effectiveness ratio (ICER) would be €172,400 per QALY gained; at 10years (2023) the ICER was €30,300 per QALY gained; and, for the maximum horizon considered by the model, the ICER was €7,260 per QALY gained. CONCLUSIONS Brief advice intervention is more efficient in the long-term than in the short-term and, depending on the Spanish cost-benefit threshold, public funding for this intervention would be recommended.

Cost-effectiveness of alternative smoking cessation scenarios in Spain: results from the EQUIPTMOD: Cost-effectiveness of smoking cessation in Spain

Abstract Aims To assess the cost‐effectiveness of alternative smoking cessation scenarios from the perspective of the Spanish National Health Service (NHS). Design We used the European study on Quantifying Utility of Investment in Protection from Tobacco model (EQUIPTMOD), a Markov‐based state transition economic model, to estimate the return on investment (ROI) of: (a) the current provision of smoking cessation services (brief physician advice and printed self‐helped material + smoking ban and tobacco duty at current levels); and (b) four alternative scenarios to complement the current provision: coverage of proactive telephone calls; nicotine replacement therapy (mono and combo) [prescription nicotine replacement therapy (Rx NRT)]; varenicline (standard duration); or bupropion. A rate of 3% was used to discount life‐time costs and benefits. Setting Spain. Participants Adult smoking population (16+ years). Measurements Health‐care costs associated with treatment of smoking attributable diseases (lung cancer, coronary heart disease, chronic obstructive pulmonary infection and stroke); intervention costs; quality‐adjusted life years (QALYs). Costs and outcomes were summarized using various ROI estimates. Findings The cost of implementing the current provision of smoking cessation services is approximately €61 million in the current year. This translates to 18 quitters per 1000 smokers and a life‐time benefit–cost ratio of 5, compared with no such provision. All alternative scenarios were dominant (cost‐saving: less expensive to run and generated more QALYs) from the life‐time perspective, compared with the current provision. The life‐time benefit–cost ratios were: 1.87 (proactive telephone calls); 1.17 (Rx NRT); 2.40 (varenicline‐standard duration); and bupropion (2.18). The results remained robust in the sensitivity analysis. Conclusions According to the EQUIPTMOD modelling tool it would be cost‐effective for the Spanish authorities to expand the reach of existing GP brief interventions for smoking cessation, provide pro‐active telephone support, and reimburse smoking cessation medication to smokers trying to stop. Such policies would more than pay for themselves in the long run.

Tax harmonisation and tobacco product prices in the European Union, 2004–2015

Objectives The European Commission has formally opened a process of revision of its tobacco tax directive. The purpose of this study is to analyse the evolution of cigarette and roll-your-own (RYO) tobacco prices in order to identify avenues for the improvement of public health goals. Methods Pooled cross-sectional data on prices and taxes on cigarettes and RYO tobacco in the Member States over 2004–2015 is used to track the distributions of the most popular price category and the weighted average price of these products and to relate them to the underlying tax structure. Results The inflation-adjusted prices for the two products have increased over the period, but the dispersion of prices across Member States has remained constant. Throughout the period, there was a pervasive price gap between cigarettes and RYO tobacco within the Member States. Such features are explained by the underlying tax design. Discussion The current tax stance has been successful at increasing both cigarette and RYO tobacco prices. To further enhance the public health impact of the European Union tax directive, the revision should promote the convergence of prices across Member States and aim at closing the price gap between cigarettes and RYO tobacco. These objectives call for increasing the mandatory minimum levels of excise duty on the two products, preferably linking them to the evolution of a European weighted average price. The pace of increase should be faster for RYO tobacco in order to close the gap with respect to cigarette prices.

Smoking, health-related quality of life and economic evaluation

AbstractBackground and aimsThe economic evaluation of tobacco control policies requires the adoption of assumptions about the impact of changes in smoking status on health-related quality of life (HRQoL). Estimates for such impacts are necessary for different populations. This paper aims to test whether smoking status has an independent effect on HRQoL over and above the effect derived from the increased likelihood of suffering a tobacco related disease, and to calculate utility values for the Spanish population.MethodsUsing data from the Spanish Encuesta Nacional de Salud of 2011–12, we estimate statistical models for HRQoL as measured by the EQ-5D-5L instrument as a function of smoking status. We include a comprehensive set of controls for biological, clinical, lifestyle and socioeconomic characteristics.ResultsSmoking status has an independent, statistically significant effect on HRQoL. However, the size of the effect is small. The typical smoking related diseases, such as lung cancer, are associated with a reduction in HRQoL about 5 times larger than the difference between current smokers and never smokers.ConclusionAttributing substantive HRQoL gains to quitting smoking as well as accounting for the concomitant HRQoL gain derived from a smaller likelihood of contracting tobacco related diseases might lead to an overestimation of the benefits of tobacco control policies. Nonetheless, the relatively large drops in HRQoL associated with being diagnosed with diseases that might be causally linked to tobacco suggest that such diseases should not be omitted from the economic evaluations of tobacco control policies.

Herramienta de retorno de la inversión en control del tabaquismo: ¿qué opinan aquellos que toman decisiones?

INTRODUCTION The European EQUIPT study will co-create a return on investment tool in several countries, aiming to provide decision makers with information and justification on the returns that can be generated by investing in tobacco control. This study aimed to identify the needs of potential users in Spain in order to provide information on the transferability of the tool. METHODS Telephone interviews with stakeholders were conducted including questions about the implementation of the tool, intended use and tobacco control interventions. RESULTS Implementing the tool could provide added value to the information used in decision-making to advocate for cost-effective policies. The main drawback would be the training and time needed to learn how the tool works and for internal calculations. CONCLUSION Knowledge and ideas from potential users collected in this study could inform the EQUIPT Tool adaptation. Thus, stakeholders could have an instrument that assists them on making healthcare decisions.