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Global and regional estimates of the effectiveness and cost-effectiveness of price increases and other tobacco control policies |
Ranson M K, Jha P, Chaloupka F J, Nguyen S N |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology Tobacco control policies were studied. Three different strategies were compared: price increases, nicotine replacement therapy (NRT) and non-price interventions (other than NRT) such as advertising bans, mandatory health warnings and smoking restrictions in work and public places.
Study population The study population comprised current smokers in 1995 based on smoking prevalence data for 139 countries. Using data from the 139 countries, estimates were derived of smoking prevalence by age, region and gender. From the total number of smokers alive in 1995 conservative assumptions about the number of deaths were made.
Setting The setting was the community.
Dates to which data relate Smoking prevalence data from 1995 and rates of smoking-related mortality were derived from studies published between 1994 and 2000.
To examine the effect of price increases, price elasticity values were taken from studies published between 1989 and those in press at the time of publication of this paper. When investigating NRT, effectiveness was established from studies published between 1998 and 2000. Finally, the effectiveness of non-price interventions was drawn from estimates of different strategies published between 1989 and 2000.
For price increases, NRT's administrative and educative cost components and for other non-price interventions, costings were based on estimates from the World Bank in 1997. The cost of drugs used in NRT was based on industry data for 1998 and a study published in 2000. Although not explicitly stated, it appears that the common price year may have been 1997.
Source of effectiveness data The evidence of effectiveness was derived from a review of published studies.
Modelling A simple static model was used to estimate both benefits and costs of price and non-price interventions.
Outcomes assessed in the review The following outcomes were assessed in the literature review: the number of current smokers who ultimately die of a smoking-attributable cause; price elasticity by low-income, middle-income and high-income countries, across genders and by age; the percentage by age who will avoid a tobacco-related death by quitting; the overall effectiveness of NRT and the relevance of age upon the effectiveness of NRT; the effectiveness of other non-price interventions.
Study designs and other criteria for inclusion in the review The review was non-systematic. The author did not describe any inclusion or exclusion criteria for the studies used.
Sources searched to identify primary studies Criteria used to ensure the validity of primary studies No assessment of the validity of the primary studies is reported.
Methods used to judge relevance and validity, and for extracting data Summary statistics from studies were used.
Number of primary studies included Approximately 29 studies were used to establish effectiveness evidence.
Methods of combining primary studies Primary studies were used to formulate ranges over which low-end and high-end estimates were calculated.
Investigation of differences between primary studies Results of the review The price elasticity was estimated as -0.4 to -1.2 in low-income and middle-income countries and -0.2 to -0.8 in high-income countries, and was the same across genders. The price elasticity decreased with increasing age so the total price elasticity for each region was the age-weighted average of the age-specific elasticities.
It was assumed that 95% of 15-29 year olds, 75% of 30-39 year olds, 70% of 40-49 year olds, 50% of 50-59 year olds and 10% of those aged over 60 who stop smoking would avoid a tobacco-related death.
The rate of cessation from the use of NRT was estimated to be 0.5 - 2.5%. NRT was assumed to be 1.5 times more effective in 30-59 year olds than in younger or older age groups.
Other non-price interventions were presumed to reduce smoking prevalence by between 2% and 10%.
Estimates of effectiveness and key assumptions From the literature reviewed, the authors assumed that one-third of current smokers ultimately die of a smoking-attributable cause in all geographical regions.
Measure of benefits used in the economic analysis The primary outcome measure used in the economic analysis was the number of disability-adjusted life years (DALYs) saved. The number of deaths averted was also reported. The benefit measure was discounted at a rate between 3% and 10% per annum.
Direct costs Health services and patient direct costs were included in the analysis. Cost items included the costs incurred by the administrative component of strategies, and the drug cost component of NRT. The cost also assumes cessation rates with NRT. Costs associated with price increase and NRT strategies were not discounted as it was presumed that they would only be incurred in the year of implementation. Other non-price interventions were assumed to recur for 30 years and were discounted by between 3% and 10% per annum. Quantities and costs were not reported separately. Cost estimates were those derived from the literature review. Although not explicitly reported, the common price year appears to have been 1997.
Statistical analysis of costs There was no statistical analysis of costs.
Indirect Costs Indirect costs were not included.
Sensitivity analysis Sensitivity analysis was carried out on price elasticity, NRT effectiveness, effectiveness of other non-price interventions and costs incurred by interventions and discount rate. While the authors chose conservative figures for their estimates, an analysis of the extremes within these assumptions was made.
Estimated benefits used in the economic analysis Neither absolute nor incremental Disability-adjusted Life Years (DALYs) lost figures were reported for the policies compared.
A price increase of 10% was predicted to avert between 5-16 million smoking-attributable deaths globally depending on the degree of elasticity, with low and middle-income countries accounting for 90%. 80% of averted deaths would be male, with the greatest impact among younger age cohorts.
NRT was predicted to prevent between 1.3 and 6.5 million smoking-attributable deaths depending on the assumed effectiveness of the therapy, again with 80% in low and middle-income countries.
Other non-price interventions were predicted to avert between 5 and 25 million smoking-attributable deaths globally conditional on the assumed effectiveness of the strategies with the greatest impact in low and middle-income countries (80%) and among younger ages.
Cost results No absolute or incremental total costs for each policy were reported.
Some specific cost details are as follows. Costs incurred by price increase strategies, the administrative component of the NRT intervention and other non-price strategies were assumed to range between 0.005% and 0.02% of GNP. The drug cost component of the NRT intervention was taken to be $50 in low and middle-income countries and $100 in high-income countries. The cost also assumes a 9% success rate for cessation with NRT.
Synthesis of costs and benefits Estimates of cost-effectiveness were reported in US$ per DALY and were subject to wide ranges.
Costs were only discounted for other non-price strategies with the low-end estimate repeated annually over 30 years and discounted at 3%, while the high-end estimate was repeated annually over 50 years and discounted at 10%.
Most estimates of benefit were distributed over 30 years and discounted at 3% for low-end estimates and 10% for high-end estimates. The one exception was the high-end estimate for other non-price interventions, which was distributed over 50 years.
Price increases were the most cost-effective intervention and could be achieved for $12-$313 per DALY saved worldwide. For NRT this figure was $358-$1917 and for other non-price interventions $145-$2896. The broad range of the estimates reflected the values chosen in the analysis of extremes. All three interventions were most cost-effective in South Asia and sub-Saharan Africa. The cost per healthy year of life gained was greater in high-income countries than elsewhere for all three strategies. Incremental cost-effectiveness ratios were not calculated.
Authors' conclusions The authors concluded that, relative to other health interventions, tobacco control is cost-effective. Tax increases are cost-effective as are non-price measures in many settings.
CRD COMMENTARY - Selection of comparators Although no explicit justification was given for the comparators it would appear to represent current options for tobacco control policies. You, as a user of this database, should decide if the comparators are appropriate for your own setting.
Validity of estimate of measure of effectiveness The authors did not state that a systematic review of the literature had been undertaken. They used data from the available studies selectively and chose conservative estimates of effectiveness, using a range of values from the primary studies. Effectiveness data often came from specific countries such as the USA.
Validity of estimate of measure of benefit The measure of benefit used in the economic analysis was DALYs saved. However, no absolute or incremental benefits were reported for the different policies. It was only used in a cost-utility ratio. The estimate of benefits was modelled. The instrument used to derive a measure of health benefit, a static model, was appropriate.
Validity of estimate of costs All categories of cost relevant to the perspective adopted were included in the analysis. Resource quantities and unit costs were not reported separately. The price year was not clearly reported and neither was the method used to adjust for costs from different years. The discounting was appropriate. Neither the absolute nor the incremental total costs for each policy were reported. This hinders the generalisability of the results to other settings.
Other issues The authors found similar studies only in high-income countries. Comparing their results with previously published work, the authors found their estimates of the cost-effectiveness of all three interventions strategies to be conservative. The authors noted that this study made no attempt to compare the effects of combinations of the policies studied here. Results were not reported selectively. The authors' conclusions appeared to be appropriate given the scope of the analysis.
Implications of the study The authors stated that "individual countries would need to make careful assessments before deciding to provide subsidies for NRT and other cessation intervention for poor smokers". Estimates of cost-effectiveness are prone to considerable variation, especially in costs, so local studies should be undertaken.
Bibliographic details Ranson M K, Jha P, Chaloupka F J, Nguyen S N. Global and regional estimates of the effectiveness and cost-effectiveness of price increases and other tobacco control policies. Nicotine and Tobacco Research 2002; 4(3): 311-319 Other publications of related interest Buck H, Godfrey C, Parrott S & Raw M. Cost Effectiveness of Smoking Interventions. York: Centre for Health Economics, University of York and Health Education Authority, 1997.
Moore M J. Death and Tobacco Taxes. Rand Journal of Economics 1996;27:415-428.
Mudde A N & De Vries. The reach and effectiveness of a national mass-media-led smoking cessation campaign in the Netherlands. American Journal of Public Health 1999;89:346-350.
Indexing Status Subject indexing assigned by NLM MeSH Adult; Africa /epidemiology; Asia /epidemiology; Commerce /economics; Cost-Benefit Analysis; Demography; Europe /epidemiology; Female; Humans; Male; Middle East /epidemiology; Nicotine /economics; Public Health /economics; Tobacco Use Disorder /economics /mortality /prevention & control AccessionNumber 22002006955 Date bibliographic record published 31/01/2004 Date abstract record published 31/01/2004 |
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