International treaties have mostly failed to produce their intended effects.

There are over 250,000 international treaties that aim to foster global cooperation. But are treaties actually helpful for addressing global challenges? This systematic field-wide evidence synthesis of 224 primary studies and meta-analysis of the higher-quality 82 studies finds treaties have mostly failed to produce their intended effects. The only exceptions are treaties governing international trade and finance, which consistently produced intended effects. We also found evidence that impactful treaties achieve their effects through socialization and normative processes rather than longer-term legal processes and that enforcement mechanisms are the only modifiable treaty design choice with the potential to improve the effectiveness of treaties governing environmental, human rights, humanitarian, maritime, and security policy domains. This evidence synthesis raises doubts about the value of international treaties that neither regulate trade or finance nor contain enforcement mechanisms.

Is the UN Convention on the Rights of Persons with Disabilities Impacting Mental Health Laws and Policies in High-Income Countries? A Case Study of Implementation in Canada.

BACKGROUND: Persons with psychosocial disabilities face disparate access to healthcare and social services worldwide, along with systemic discrimination, structural inequalities, and widespread human rights abuses. Accordingly, many people have looked to international human rights law to help address mental health challenges. On December 13, 2006, the United Nations formally adopted the Convention on the Rights of Persons with Disabilities (CRPD) - the first human rights treaty of the 21st century and the fastest ever negotiated. METHODS: This study assesses the CRPD's potential impact on mental health systems and presents a legal and public policy analysis of its implementation in one high-income country: Canada. As part of this analysis, a critical review was undertaken of the CRPD's implementation in Canadian legislation, public policy, and jurisprudence related to mental health. RESULTS: While the Convention is clearly an important step forward, there remains a divide, even in Canada, between the Convention's goals and the experiences of Canadians with disabilities. Its implementation is perhaps hindered most by Canada's reservations to Article 12 of the CRPD on legal capacity for persons with psychosocial disabilities. The overseeing CRPD Committee has stated that Article 12 only permits "supported decision-making" regimes, yet most Canadian jurisdictions maintain their "substitute decision-making" regimes. This means that many Canadians with mental health challenges continue to be denied legal capacity to make decisions related to their healthcare, housing, and finances. But changes are afoot: new legislation has been introduced in different jurisdictions across the country, and recent court decisions have started to push policymakers in this direction. CONCLUSION: Despite the lack of explicit implementation, the CRPD has helped to facilitate a larger shift in social and cultural paradigms of mental health and disability in Canada. But ratification and passive implementation are not enough. Further efforts are needed to implement the CRPD's provisions and promote the equal enjoyment of human rights by all Canadian citizens - and presumably for all other people too, from the poorest to the wealthiest countries.

Health technology assessment and judicial deference to priority-setting decisions in healthcare: Quasi-experimental analysis of right-to-health litigation in Brazil.

The constitutional right to health in Brazil has entitled patients to litigate against the government-funded national health system (SUS), claiming access to various health treatments including those excluded from the health system's benefits package. Courts have tended to rely on a single medical prescription to judge these cases in favor of individual patients and against the health system. The large volume of cases has had a substantial financial impact on the government's health budget and has created unfairness in accessing healthcare. To change courts' behavior, a new health technology assessment (HTA) body - CONITEC - was created in 2011. Its creation was accompanied by an administrative procedure that made decisions about the health system's benefits package more transparent, accountable, participative and evidence-informed. It was expected that this HTA system would bring more legitimacy to the government's priority-setting decisions and promote deference from the courts. This study tests whether Brazil's new HTA system succeeded in encouraging judicial deference by analyzing a stratified random sample of 13,263 court decisions for whether the existence of a CONITEC report resulted in less frequent court orders to provide treatment for individual litigants. The results show that the creation of CONITEC did not change courts' behavior; courts still decide in favor of patients in most cases. Indeed, even when there was a CONITEC report recommending against government funding for a particular healthcare treatment, the vast majority of the relatively few patients who were unsuccessful in obtaining a health benefit at their first court hearing later obtained a favorable decision after appealing to a higher court. This finding was confirmed through an interrupted time-series analysis that did not find an impact of having a CONITEC report on courts' willingness to override a government priority-setting decision. In fact, CONITEC was rarely cited in court decisions, even when litigants mentioned the existence of a CONITEC report.

Impact of the WHO Framework Convention on Tobacco Control on global cigarette consumption: quasi-experimental evaluations using interrupted time series analysis and in-sample forecast event modelling.

OBJECTIVE: To evaluate the impact of the WHO Framework Convention on Tobacco Control (FCTC) on global cigarette consumption. DESIGN: Two quasi-experimental impact evaluations, using interrupted time series analysis (ITS) and in-sample forecast event modelling. SETTING AND POPULATION: 71 countries for which verified national estimates of cigarette consumption from 1970 to 2015 were available, representing over 95% of the world's cigarette consumption and 85% of the world's population. MAIN OUTCOME MEASURES: The FCTC is an international treaty adopted in 2003 that aims to reduce harmful tobacco consumption and is legally binding on the 181 countries that have ratified it. Main outcomes were annual national estimates of cigarette consumption per adult from 71 countries since 1970, allowing global, regional, and country comparisons of consumption levels and trends before and after 2003, with counterfactual control groups modelled using pre-intervention linear time trends (for ITS) and in-sample forecasts (for event modelling). RESULTS: No significant change was found in the rate at which global cigarette consumption had been decreasing after the FCTC's adoption in 2003, using either ITS or event modelling. Results were robust after realigning data to the year FCTC negotiations commenced (1999), or to the year when the FCTC first became legally binding in each country. By contrast to global consumption, high income and European countries showed a decrease in annual consumption by over 1000 cigarettes per adult after 2003, whereas low and middle income and Asian countries showed an increased annual consumption by over 500 cigarettes per adult when compared with a counterfactual event model. CONCLUSIONS: This study finds no evidence to indicate that global progress in reducing cigarette consumption has been accelerated by the FCTC treaty mechanism. This null finding, combined with regional differences, should caution against complacency in the global tobacco control community, motivate greater implementation of proven tobacco control policies, encourage assertive responses to tobacco industry activities, and inform the design of more effective health treaties.

Cigarette consumption estimates for 71 countries from 1970 to 2015: systematic collection of comparable data to facilitate quasi-experimental evaluations of national and global tobacco control interventions.

OBJECTIVES: To collect, appraise, select, and report the best available national estimates of cigarette consumption since 1970. DESIGN: Systematic collection of comparable data. SETTING AND POPULATION: 71 of 214 countries for which searches for national cigarette consumption data were conducted, representing over 95% of global cigarette consumption and 85% of the world's population. MAIN OUTCOME MEASURES: Validated cigarette consumption data covering 1970-2015 were identified for 71 countries. Data quality appraisal was conducted by two research team members in duplicate, with greatest weight given to official government sources. All data were standardised into units of cigarettes consumed per year in each country, a detailed accounting of data quality and sourcing was prepared, and all collected data and metadata were made freely available in an open access dataset. RESULTS: Cigarette consumption fell in most countries over the past three decades but trends in country specific consumption were highly variable. For example, China consumed 2.5 million metric tonnes (MMT) of cigarettes in 2013, more than Russia (0.36 MMT), the United States (0.28 MMT), Indonesia (0.28 MMT), Japan (0.20 MMT), and the next 35 highest consuming countries combined. The US and Japan achieved reductions of more than 0.1 MMT from a decade earlier, whereas Russian consumption plateaued, and Chinese and Indonesian consumption increased by 0.75 MMT and 0.1 MMT, respectively. These data generally concord with modelled country level data from the Institute for Health Metrics and Evaluation and have the additional advantage of not smoothing year-over-year discontinuities that are necessary for robust quasi-experimental impact evaluations. CONCLUSIONS: Before this study, publicly available data on cigarette consumption have been limited; they have been inappropriate for quasi-experimental impact evaluations (modelled data), held privately by companies (proprietary data), or widely dispersed across many national statistical agencies and research organisations (disaggregated data). This new dataset confirms that cigarette consumption has decreased in most countries over the past three decades, but that secular country specific consumption trends are highly variable. The findings underscore the need for more robust processes in data reporting, ideally built into international legal instruments or other mandated processes. To monitor the impact of the WHO Framework Convention on Tobacco Control and other tobacco control interventions, data on national tobacco production, trade, and sales should be routinely collected and openly reported.

An Overview of Systematic Reviews to Inform the Institutional Design of Scientific Advisory Committees.

The current lack of synthesized evidence for informing the design of scientific advisory committees (SACs) is surprising in light of the widespread use of SACs throughout decision-making processes. While existing research points to the importance of quality, relevance, and legitimacy for SACs' effectiveness, those planning SACs would benefit from efforts to systematically pinpoint optimal designs of these committees for maximal effectiveness. Search strategies are developed for seven electronic databases. Of the 1895 systematic reviews identified, six reviews meet the inclusion criteria: they report the results of systematic reviews that followed a clearly identified systematic methodology, examine factors related to the design of SACs, and involve processes in the natural or social sciences. These reviews collectively summarize 444 primary studies. Three of the six reviews look at the impacts of SAC size, two evaluate the influence of the committee's diversity, and half mention the importance of properly on-boarding new members. The goal is to identify recurring themes to understand the specific institutional features that optimize the usefulness of SACs. In turn, this overview of systematic reviews aims to contribute to a growing body of literature on how SACs should be designed to maximize their effectiveness and helpfulness for decision-making.

Celebrities' impact on health-related knowledge, attitudes, behaviors, and status outcomes: protocol for a systematic review, meta-analysis, and meta-regression analysis.

BACKGROUND: Celebrities are highly influential people whose actions and decisions are watched and often emulated by wide audiences. Many celebrities have used their prominent social standing to offer medical advice or endorse health products, a trend that is expected to increase. However, the extent of the impact that celebrities have in shaping the public's health-related knowledge, attitudes, behaviors, and status is unclear. This systematic review seeks to answer the following questions: (1) Which health-related outcomes are influenced by celebrities? (2) How large of an impact do celebrities actually have on these health-related outcomes? (3) Under what circumstances do celebrities produce either beneficial or harmful impacts? METHODS: Ten databases were searched, including MEDLINE, EMBASE, PsycINFO, PubMed, CINAHL, Communication Complete, Sociological Abstracts, Social Sciences Citation Index, Journals @ Scholars Portal, and ProQuest Dissertations & Theses A&I. Two reviewers conducted title and abstract screening and full-text screening to identify primary studies that employed empirical methods (either quantitative or qualitative) to examine celebrities' impact on health-related knowledge, attitudes, behaviors, or status outcomes. DISCUSSION: The results of this review will contribute to our understanding of celebrity influences and how to design positive evidence-based celebrity health promotion activities. In addition, these findings can help inform the development of media reporting guidelines pertaining to celebrity health news and provide guidance to public health authorities on whether and how to respond to or work with celebrities. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015019268.

International law's effects on health and its social determinants: protocol for a systematic review, meta-analysis, and meta-regression analysis.

BACKGROUND: In recent years, there have been numerous calls for global institutions to develop and enforce new international laws. International laws are, however, often blunt instruments with many uncertain benefits, costs, risks of harm, and trade-offs. Thus, they are probably not always appropriate solutions to global health challenges. Given these uncertainties and international law's potential importance for improving global health, the paucity of synthesized evidence addressing whether international laws achieve their intended effects or whether they are superior in comparison to other approaches is problematic. METHODS: Ten electronic bibliographic databases were searched using predefined search strategies, including MEDLINE, Global Health, CINAHL, Applied Social Sciences Index and Abstracts, Dissertations and Theses, International Bibliography of Social Sciences, International Political Science Abstracts, Social Sciences Abstracts, Social Sciences Citation Index, PAIS International, and Worldwide Political Science Abstracts. Two reviewers will independently screen titles and abstracts using predefined inclusion criteria. Pairs of reviewers will then independently screen the full-text of articles for inclusion using predefined inclusion criteria and then independently extract data and assess risk of bias for included studies. Where feasible, results will be pooled through subgroup analyses, meta-analyses, and meta-regression techniques. DISCUSSION: The findings of this review will contribute to a better understanding of the expected benefits and possible harms of using international law to address different kinds of problems, thereby providing important evidence-informed guidance on when and how it can be effectively introduced and implemented by countries and global institutions. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015019830.