Melanie Bertram

Assessment of Swedish snus for tobacco harm reduction: an epidemiological modelling study

BACKGROUND Swedish snus is a smokeless tobacco product that has been suggested as a tobacco harm reduction product. Our aim was to assess the potential population health effects of snus. METHODS We assessed the potential population health effects of snus in Australia with multistate life tables to estimate the difference in health-adjusted life expectancy between people who have never been smokers and various trajectories of tobacco use, including switching from smoking to snus use; and the potential for net population-level harm given different rates of snus uptake by current smokers, ex-smokers, and people who have never smoked. FINDINGS There was little difference in health-adjusted life expectancy between smokers who quit all tobacco and smokers who switch to snus (difference of 0.1-0.3 years for men and 0.1-0.4 years for women). For net harm to occur, 14-25 ex-smokers would have to start using snus to offset the health gain from every smoker who switched to snus rather than continuing to smoke. Likewise, 14-25 people who have never smoked would need to start using snus to offset the health gain from every new tobacco user who used snus rather than smoking. INTERPRETATION Current smokers who switch to using snus rather than continuing to smoke can realise substantial health gains. Snus could produce a net benefit to health at the population level if it is adopted in sufficient numbers by inveterate smokers. Relaxing current restrictions on the sale of snus is more likely to produce a net benefit than harm, with the size of the benefit dependent on how many inveterate smokers switch to snus.

Evidence that a tax on sugar sweetened beverages reduces the obesity rate: a meta-analysis

BackgroundExcess intake of sugar sweetened beverages (SSBs) has been shown to result in weight gain. To address the growing epidemic of obesity, one option is to combine programmes that target individual behaviour change with a fiscal policy such as excise tax on SSBs. This study evaluates the literature on SSB taxes or price increases, and their potential impact on consumption levels, obesity, overweight and body mass index (BMI). The possibility of switching to alternative drinks is also considered.MethodsThe following databases were used: Pubmed/Medline, The Cochrane Database of Systematic Reviews, Google Scholar, Econlit, National Bureau of Economics Research (NBER), Research Papers in Economics (RePEc). Articles published between January 2000 and January 2013, which reported changes in diet or BMI, overweight and/or obesity due to a tax on, or price change of, SSBs were included.ResultsNine articles met the criteria for the meta-analysis. Six were from the USA and one each from Mexico, Brazil and France. All showed negative own-price elasticity, which means that higher prices are associated with a lower demand for SSBs. Pooled own price-elasticity was -1.299 (95% CI: -1.089 - -1.509). Four articles reported cross-price elasticities, three from the USA and one from Mexico; higher prices for SSBs were associated with an increased demand for alternative beverages such as fruit juice (0.388, 95% CI: 0.009 – 0.767) and milk (0.129, 95% CI: -0.085 – 0.342), and a reduced demand for diet drinks (-0.423, 95% CI: -0.628 - -1.219). Six articles from the USA showed that a higher price could also lead to a decrease in BMI, and decrease the prevalence of overweight and obesity.ConclusionsTaxing SSBs may reduce obesity. Future research should estimate price elasticities in low- and middle-income countries and identify potential health gains and the wider impact on jobs, monetary savings to the health sector, implementation costs and government revenue. Context-specific cost-effectiveness studies would allow policy makers to weigh these factors.

Cost-effectiveness thresholds: pros and cons.

Abstract Cost–effectiveness analysis is used to compare the costs and outcomes of alternative policy options. Each resulting cost–effectiveness ratio represents the magnitude of additional health gained per additional unit of resources spent. Cost–effectiveness thresholds allow cost–effectiveness ratios that represent good or very good value for money to be identified. In 2001, the World Health Organization’s Commission on Macroeconomics in Health suggested cost–effectiveness thresholds based on multiples of a country’s per-capita gross domestic product (GDP). In some contexts, in choosing which health interventions to fund and which not to fund, these thresholds have been used as decision rules. However, experience with the use of such GDP-based thresholds in decision-making processes at country level shows them to lack country specificity and this – in addition to uncertainty in the modelled cost–effectiveness ratios – can lead to the wrong decision on how to spend health-care resources. Cost–effectiveness information should be used alongside other considerations – e.g. budget impact and feasibility considerations – in a transparent decision-making process, rather than in isolation based on a single threshold value. Although cost–effectiveness ratios are undoubtedly informative in assessing value for money, countries should be encouraged to develop a context-specific process for decision-making that is supported by legislation, has stakeholder buy-in, for example the involvement of civil society organizations and patient groups, and is transparent, consistent and fair.

Epidemiological modelling of routine use of low dose aspirin for the primary prevention of coronary heart disease and stroke in those aged ≥70

Abstract Objective To investigate the routine use of low dose aspirin in people aged ≥ 70 without overt cardiovascular disease. Design Epidemiological modelling in a hypothetical population. Setting Reference populations of men and women in the year 2000 from the state of Victoria, Australia. Subjects 10 000 men and 10 000 women aged 70-74 with no cardiovascular disease. Main outcome measures First ever myocardial infarction or unstable angina, ischaemic or haemorrhagic stroke, and major gastrointestinal haemorrhage. Health adjusted years of life lived. Results The proportional benefit gained from the use of low dose aspirin by the prevention of myocardial infarctions (−389 in men, −321 in women) and ischaemic stroke (−19 in men and −35 in women) is offset by excess gastrointestinal (499 in men, 572 in women) and intracranial (76 in men, 54 in women) bleeding. The results in health adjusted years of life lived (which take into account length and quality of life) are equivocal for aspirin causing net harm or net benefit. Conclusion Epidemiological modelling suggests that any benefits of low dose aspirin on risk of cardiovascular disease in people aged ≥ 70 are offset by adverse events. These findings are tempered by wide confidence intervals, indicating that the overall outcome could be beneficial or adverse.

Assessing the cost-effectiveness of drug and lifestyle intervention following opportunistic screening for pre-diabetes in primary care

Aims/hypothesisThis study aims to evaluate the cost-effectiveness of a screening programme for pre-diabetes, which was followed up by treatment with pharmaceutical interventions (acarbose, metformin, orlistat) or lifestyle interventions (diet, exercise, diet and exercise) in order to prevent or slow the onset of diabetes in those at high risk.MethodsTo approximate the experience of individuals with pre-diabetes in the Australian population, we used a microsimulation approach, following patient progression through diabetes, cardiovascular disease and renal failure. The model compares costs and disability-adjusted life years lived in people identified through an opportunistic screening programme for each intervention compared with a ‘do nothing’ scenario, which is representative of current practice. It is assumed that the effect of a lifestyle change will decay by 10% per year, while the effect of a pharmaceutical intervention remains constant throughout use.ResultsThe most cost-effective intervention options are diet and exercise combined, with a cost-effectiveness ratio of AUD 22,500 per disability-adjusted life year (DALY) averted, and metformin with a cost-effectiveness ratio of AUD 21,500 per DALY averted. The incremental addition of one intervention to the other is not cost-effective.Conclusions/interpretationScreening for pre-diabetes followed by diet and exercise, or metformin treatment is cost-effective and should be considered for incorporation into current practice. The number of dietitians and exercise physiologists needed to deliver such lifestyle change interventions will need to be increased to appropriately support the intervention.

Preventing diabetes blindness : Cost effectiveness of a screening programme using digital non-mydriatic fundus photography for diabetic retinopathy in a primary health care setting in South Africa.

BACKGROUND South Africa like many other developing countries is experiencing an epidemiologic transition with a marked increase in the non-communicable disease (NCD) burden. Diabetic retinopathy is the most common cause of incidental blindness in adults. A screening programme using a mobile fundal camera in a primary care setting has been shown to be effective in the country. Information on affordability and cost is essential for policymakers to consider its adoption. METHODS Economic evaluation is the comparative analysis of competing alternative interventions in terms of costs and consequences. A cost effectiveness analysis was done using actual costs from the primary care screening programme. RESULTS A total of 14,541 patients were screened in three primary healthcare facilities in the Western Cape. Photographs were taken by a trained technician with supervision by an ophthalmic nurse. The photographs were then read by a medical officer with ophthalmic experience. A cost effective ratio of

The national burden of road traffic injuries in Thailand

1206 per blindness case averted was obtained. This included costs for screening and treating an individual. The cost just to screen a patient for retinopathy was

The non-fatal disease burden caused by type 2 diabetes in South Africa, 2009

22. The costs of screening and treating all incident cases of blindness due to diabetes in South Africa would be 168,000,000 ZAR (

Quantifying the duration of pre-diabetes

19,310,344) per annum. CONCLUSION Non mydriatic digital fundoscopy is a cost effective measure in the screening and diagnosis of diabetic retinopathy in a primary care setting in South Africa. The major savings in the long term are a result of avoiding government disability grant for people who suffer loss of vision.

Schizophrenia in Thailand: Prevalence and burden of disease

BackgroundThis study quantifies the burden of road traffic injuries (RTIs) in Thailand in 2004, incorporating new Thai data on mortality and the frequency and severity of long-term disability.MethodsWe quantified the uncertainty around national RTI mortality estimates based on a verbal autopsy study that was conducted to correct for the large proportion of ill-defined deaths in the vital registration system. The number of nonfatal RTI victims was estimated using hospital and survey data. We used the proportion and severity of long-term disabilities from a recent Thai study, instead of the standard Global Burden of Disease assumptions, to calculate the burden due to long-term disability. To evaluate changes over time, we also calculated the burden of RTIs in 2004 using the method and assumptions used in 1999, when standard Global Burden of Disease assumptions were used.ResultsThe total loss of disability-adjusted life years due to RTIs was 673,000 (95% uncertainty interval [UI]: 546,000-881,000). Mortality contributed 88% of this burden. The use of local data led to a significantly higher estimate of the burden of long-term disability due to RTIs (74,000 DALYs [95% UI: 55,400-88,500] vs. 43,000 [UI: 42,700-43,600]) using standard Global Burden of Disease methods. However, this difference constituted only a small proportion of the total burden.ConclusionsThe burden of RTIs in 2004 remained at the same high level as in 1999. The use of local data on the long-term health consequences of RTIs enabled an estimate of this burden and its uncertainty that is likely to be more valid.