Cost-effectiveness analysis of population-based tobacco control strategies in the prevention of cardiovascular diseases in Tanzania

Application of decision analytic modelling to cardiovascular disease prevention in Sub-Saharan Africa: a systematic review

BACKGROUND

This systematic review sought to examine the application of decision analytic models (DAMs) to evaluate cardiovascular disease (CVD) prevention interventions in sub-Saharan Africa (SSA), a region that has experienced an increasing CVD burden in the last two decades.

METHODS

We searched seven databases and identified model-based economic evaluations of interventions targeting CVD prevention among adult populations in SSA. All articles were screened by two reviewers, data was extracted, and narrative synthesis was performed. Quality assessment was performed using the Philips checklist.

RESULTS

The review included 27 articles from eight SSA countries. The majority of the studies evaluated interventions for primary CVD prevention, with primordial prevention interventions being the least evaluated. Markov models were the most commonly used modelling method. Seven studies incorporated equity dimensions in the modelling, which were assessed mainly through subgroup analysis. The mean quality score of the papers was 68.9% and most studies reported data challenges while only three studies conducted model validation.

CONCLUSIONS

The review finds few studies modelling the impact of interventions targeting primordial prevention and those evaluating equitable strategies for improving access to CVD prevention. There is a need for increased transparency in model building, validation and documentation.

Prevention Lab: a predictive model for estimating the impact of prevention interventions in a simulated Italian cohort

BACKGROUND

A large fraction of the disease burden in the Italian population is due to behavioral risk factors. The objective of this work is to provide a tool to estimate the impact of preventive interventions that reduce the exposure to smoking and sedentary lifestyle of the Italian population, with the goal of selecting optimal interventions.

METHODS

We construct a Markovian model that simulates the state of each subject of the Italian population. The model predicts the distribution of subjects in each health status and risk factor status for every year of the simulation. Based on this distribution, the model provides a rich output summary, such as the number of incident and prevalent cases for each tracing disease and the Disability Adjusted Life Years (DALY), used to assess the impact of preventive interventions, and how this impact is shaped in time.

RESULTS

This paper focuses on the methodological aspects of the model. The proposed model is flexible and can be applied to estimate the impact of complex interventions on the two risk factors and adapted to consider different cohorts. We validate the model by simulating the evolution of the Italian population from 2009 to 2017 and comparing the output with historical data. Furthermore, as a case-study, we simulate a counterfactual scenario where both tobacco and sedentary lifestyle are eradicated from the Italian population in 2019 and estimate the impact of such intervention over the following 20 years.

CONCLUSIONS

We propose a Markovian model to estimate how interventions on smoking and sedentary lifestyle can affect the reduction of the disease burden, and validate the model on historical data. The model is flexible and allows to extend the analysis to consider more risk factors in future research. However, we are aware that, given the ever-increasing availability of data, it is necessary in the future to increase the complexity of the model, to be closer to reality and to provide decision-making support to the policy-makers.

Tobacco Use and Associated Factors Among Men in Tanzania: Further Analysis of the 2022 Tanzania Demographic and Health Survey Data

Background: Tobacco use is a significant public health challenge, contributing to preventable diseases and premature deaths globally. We aimed to determine the prevalence of tobacco use and associated factors among men in Tanzania. Methods: This was a cross-sectional analysis of data from the 2022 Tanzania Demographic and Health Survey and Malaria Indicator Survey. The study population comprised men aged 15-49 years. Weighted logistic regression was performed to identify factors associated with tobacco use. Results: A total of 5763 men with a mean age of 28.6 ± 10 years were included in the analysis. The overall prevalence of tobacco use was 11.1%, with 95% of users consuming smoked products, 17.1% using smokeless products, and 12.1% using both smoked and smokeless products. Older age was associated with increased odds of tobacco use, with odds of tobacco use increasing with each higher age group. Similarly, alcohol consumption was associated with greater odds of tobacco use. On the other hand, having a secondary education or higher, lack of occupation, being the head of the household, and owning a mobile telephone were associated with lower odds of tobacco use. Geographically, men from the Eastern zone and Zanzibar exhibited greater odds of tobacco use, while those from the Southern highlands zone had lower odds. Conclusion: This study revealed a significant prevalence of tobacco use among Tanzanian men and was associated with different individual, interpersonal, and community factors. The findings underscore the need for targeted interventions considering age-specific risk factors and geographical variations.

Estimated health benefits, costs and cost-effectiveness of eliminating dietary industrial trans fatty acids in Kenya: cost-effectiveness analysis

OBJECTIVES

To model the potential health gains and cost-effectiveness of a mandatory limit of industrial trans fatty acids (iTFA) in Kenyan foods.

DESIGN

Multiple cohort proportional multistate life table model, incorporating existing data from the Global Burden of Disease study, pooled analyses of observational studies and peer-reviewed evidence of healthcare and policy implementation costs.

SETTING

Kenya.

PARTICIPANTS

Adults aged ≥20 years at baseline (n=50 million).

INTERVENTION

A mandatory iTFA limit (≤2% of all fats) in the Kenyan food supply compared with a base case scenario of maintaining current trans fat intake.

MAIN OUTCOME MEASURES

Averted ischaemic heart disease (IHD) events and deaths, health-adjusted life years; healthcare costs; policy implementation costs; net costs; and incremental cost-effectiveness ratio.

RESULTS

Over the first 10 years, the intervention was estimated to prevent ~1900 (95% uncertainty interval (UI): 1714; 2148) IHD deaths and ~17 000 (95% UI: 15 475; 19 551) IHD events, and to save ~US$50 million (95% UI: 44; 56). The corresponding estimates over the lifespan of the model population were ~49 000 (95% UI: 43 775; 55 326) IHD deaths prevented, ~113 000 (95% UI: 100 104; 127 969) IHD events prevented and some ~US$300 million (256; 331) saved. Policy implementation costs were estimated as ~US$9 million over the first 10 years and ~US$20 million over the population lifetime. The intervention was estimated to be cost saving regardless of the time horizon. Findings were robust across multiple sensitivity analyses.

CONCLUSIONS

Findings support policy action for a mandatory iTFA limit as a cost-saving strategy to avert IHD events and deaths in Kenya.

Economic evaluations of non-communicable diseases conducted in Sub-Saharan Africa: a critical review of data sources

BACKGROUND

Policymakers in sub-Saharan Africa (SSA) face challenging decisions regarding the allocation of health resources. Economic evaluations can help decision makers to determine which health interventions should be funded and or included in their benefits package. A major problem is whether the evaluations incorporated data from sources that are reliable and relevant to the country of interest. We aimed to review the quality of the data sources used in all published economic evaluations for cardiovascular disease and diabetes in SSA.

METHODS

We systematically searched selected databases for all published economic evaluations for CVD and diabetes in SSA. We modified a hierarchy of data sources and used a reference case to measure the adherence to reporting and methodological characteristics, and descriptively analysed author statements.

RESULTS

From 7,297 articles retrieved from the search, we selected 35 for study inclusion. Most were modelled evaluations and almost all focused on pharmacological interventions. The studies adhered to the reporting standards but were less adherent to the methodological standards. The quality of data sources varied. The quality level of evidence in the data domains of resource use and costs were generally considered of high quality, with studies often sourcing information from reliable databases within the same jurisdiction. The authors of most studies referred to data sources in the discussion section of the publications highlighting the challenges of obtaining good quality and locally relevant data.

CONCLUSIONS

The data sources in some domains are considered high quality but there remains a need to make substantial improvements in the methodological adherence and overall quality of data sources to provide evidence that is sufficiently robust to support decision making in SSA within the context of UHC and health benefits plans. Many SSA governments will need to strengthen and build their capacity to conduct economic evaluations of interventions and health technology assessment for improved priority setting. This capacity building includes enhancing local infrastructures for routine data production and management. If many of the policy makers are using economic evaluations to guide resource allocation, it is imperative that the evidence used is of the feasibly highest quality.

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.

Economic evaluations of tobacco control interventions in low- and middle-income countries: a systematic review

BACKGROUND AND AIMS

Tobacco consumption and its associated adverse outcomes remain major public health issues, particularly in low- and middle-income countries. This systematic review aimed to identify and critically assess full economic evaluations for tobacco control interventions in low- and middle-income countries.

METHODS

Electronic databases, including EMBASE, MEDLINE and PsycINFO and the grey literature, were searched using terms such as 'tobacco', 'economic evaluation' and 'smoking' from 1994 to 2020. Study quality was assessed using the Consensus Health Economic Criteria and the Philips checklist. Studies were included which were full economic evaluations of tobacco control interventions in low- and middle-income settings. Reviews, commentaries, conference proceedings and abstracts were excluded. Study selection and quality assessment were conducted by two reviewers independently. A narrative synthesis was conducted to synthesize the findings of the studies.

RESULTS

This review identified 20 studies for inclusion. The studies evaluated a wide range of interventions, including tax increase, nicotine replacement therapy (nicotine patch/gum) and financial incentives. Overall, 12 interventions were reported to be cost-effective, especially tax increases for tobacco consumption and cessation counselling. There were considerable limitations regarding data sources (e.g. using cost data from other countries or assumptions due to the lack of local data) and the model structure; sensitivity analyses were inadequately described in many studies; and there were issues around the transferability of results to other settings. Additionally, the affordability of the interventions was only discussed in two studies.

CONCLUSIONS

There are few high-quality studies of the cost-effectiveness of tobacco use control interventions in low- and middle-income countries. The methodological limitations of the existing literatures could affect the generalizability of the findings.

Cost-Effectiveness of Population-Based Tobacco Control Interventions on the Health Burden of Cardiovascular Diseases in Vietnam

This study sought to assess the cost-effectiveness of population-based tobacco control interventions, which included health promotion and education, smoke-free models, cessation programs, warning on package, marketing bans, and raising tax. Standardized activity-based costing ingredient approach was applied with the provider perspective to calculate interventions cost from 2013 to 2017. The potential health impacts of the aforementioned interventions were calculated through a Microsoft Excel-based modeling adapted from Higashi et al and Ngalesoni et al. All six population-based tobacco control interventions were highly cost-effective with ranges from 1405 VND (Vietnamese Dong) to 135 560 VND per DALY (disability-adjusted life year) averted. It was identified that raising cigarette taxes and applying health warnings on tobacco packages are the most favorable, cost-effective interventions. The results from this study provide a robust message that calls for increased attention and efforts in developing an appropriate policy agenda, which jointly integrates both political and community-based interventions, to maximize intervention impact on tobacco use.

The battle to increase tobacco taxes: Lessons from Philippines and Ukraine

INTRODUCTION

While increasing taxes on tobacco is one of the most effective tobacco control measures, its adoption has been slow compared to other tobacco control policies. Given this, there is an urgent need to better understand the political and economic dynamics that lead to its adoption despite immense tobacco industry opposition. The primary aim of this study is to explore the process, actors, and determinants that helped lead to the successful passage of the 2012 Sin Tax Reform Law in the Philippines and the 2017 seven-year plan for tobacco tax increases in Ukraine.

METHOD

Under the guidance of the Advocacy Coalition Framework, we used a case study approach gathering data from key informant interviews (n = 37) and documents (n = 56). Subsequently, cross-case analysis was undertaken to identify themes across the two cases.

RESULTS

We found that external events in the Philippines and Ukraine triggered policy subsystem instability and tipped the scale in the favor of tobacco tax proponents. In the Philippines, elections brought forth a new leader in 2010 who was keen to achieve universal health care and improve tax collection efficiency. In Ukraine, the European Union Association Agreement came into force in 2017 and included the Tobacco Products Directive requiring Ukraine to synchronize its excise taxes to that of the European Union. Exploiting these key entry points, tobacco tax proponents formed a multi-sectoral coalition and used a multi-pronged approach. In both countries, respected economic groups and experts who could generate timely evidence were present and used local as well as international data to counter opponents who also used an array of strategies to water down the tax policies.

CONCLUSIONS

Findings are largely consistent with the Advocacy Coalition Framework and suggest the need for tobacco tax proponents to 1) form a multi-sectoral coalition, 2) include respected economic groups and experts who can generate timely evidence, 3) use both local data and international experiences, and 4) undertake a multi-pronged approach.

Proportional multistate lifetable modelling of preventive interventions: concepts, code and worked examples

Burden of Disease studies-such as the Global Burden of Disease (GBD) Study-quantify health loss in disability-adjusted life-years. However, these studies stop short of quantifying the future impact of interventions that shift risk factor distributions, allowing for trends and time lags. This methodology paper explains how proportional multistate lifetable (PMSLT) modelling quantifies intervention impacts, using comparisons between three tobacco control case studies [eradication of tobacco, tobacco-free generation i.e. the age at which tobacco can be legally purchased is lifted by 1 year of age for each calendar year) and tobacco tax]. We also illustrate the importance of epidemiological specification of business-as-usual in the comparator arm that the intervention acts on, by demonstrating variations in simulated health gains when incorrectly: (i) assuming no decreasing trend in tobacco prevalence; and (ii) not including time lags from quitting tobacco to changing disease incidence. In conjunction with increasing availability of baseline and forecast demographic and epidemiological data, PMSLT modelling is well suited to future multiple country comparisons to better inform national, regional and global prioritization of preventive interventions. To facilitate use of PMSLT, we introduce a Python-based modelling framework and associated tools that facilitate the construction, calibration and analysis of PMSLT models.

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.

Simulating future public health benefits of tobacco control interventions: a systematic review of models

BACKGROUND

To prioritise tobacco control interventions, simulating their health impacts is valuable. We undertook a systematic review of tobacco intervention simulation models to assess model structure and input variations that may render model outputs non-comparable.

METHODS

We applied a Medline search with keywords intersecting modelling and tobacco. Papers were limited to those modelling health outputs (eg, mortality, health-adjusted life years), and at least two of cancer, cardiovascular and respiratory diseases. Data were extracted for each simulation model with ≥3 arising papers, including: model type, untimed or with time steps and trends in business-as-usual (BAU) tobacco prevalence and epidemiology.

RESULTS

Of 1911 papers, 186 met the inclusion criteria, including 13 eligible simulation models. The SimSmoke model had the largest number of publications (n=46), followed by Benefits of Smoking Cessation on Outcomes (n=12) and Tobacco Policy Model (n=10). Two of 13 models only estimated deaths averted, 1 had no time steps, 5 had no future trends in BAU tobacco prevalence, 9 had no future trends in BAU disease epidemiology and 7 had no time lags from quitting tobacco to reversal of health harm.

CONCLUSIONS

Considerable heterogeneity exists in simulation models, making outputs substantively non-comparable between models. Ranking of interventions by one model may be valid. However, this may not be true if, for example, interventions that differentially affect age groups (eg, a tobacco-free generation policy vs increased cessation among adults) do not account for plausible future trends. Greater standardisation of model structures and outputs will allow comparison across models and countries, and for comparisons of the impact of tobacco control interventions with other preventive interventions.