Health gains from achieving optimal body mass index in Australia: a simulation study.

Background: We estimated the health gains and health inequality impacts for the Australian population alive in 2021 (n = 25.0 million) in the next 20 years and over their remaining lifespan, from shifting everyone above a BMI of 25 kg/m2 to 25 kg/m2 compared to the BMI distribution in 2021 persisting into the future. Methods: National Health Survey 2017-2018 was used to estimate BMI distributions by sex, age and, socio-economic status (Socio-Economic Indexes for Areas; SEIFA). A proportional multistate life table linking BMI to 19 associated diseases and allowing for time lags and competing morbidity and mortality, was used to estimate the future stream of health adjusted life years (HALYs) gained from eradicating high BMI. Findings: Undiscounted health gains in the first 20 years and lifetime of the population were, respectively, 2.00 million (95% uncertainty interval 1.70-2.32) and 20.4 million (17.0-24.2) (at a 3% annual discount rate, HALY gains were 1.37 and 5.77 million, respectively). Reductions in the incidence of cardio metabolic diseases contributed 61% (95% UI: 54%-68%) of the undiscounted health gains in the first 20 years, musculoskeletal diseases contributed 26% (20%-32%) and cancer 5% (3%-8%). HALY gains in the first 20 years and lifetime, per person alive in 2021, were 2.5 (2.4-2.5) and 1.9 (1.9-2.0) times higher for the most compared to the least deprived SEIFA quintile. Interpretation: The total theoretical envelope of health gains, and health inequality reductions, through eradication of BMI is substantial. Our modeling infrastructure can be used to estimate the health impacts and cost effectiveness of many actual interventions. Funding: No funding was received for the study.

Economic effects for citizens and the government of a country-level tobacco endgame strategy: a modelling study.

BACKGROUND: Aotearoa-New Zealand (A/NZ) was the first country to pass a comprehensive commercial tobacco endgame strategy into law. Key components include the denicotinisation of smoked tobacco products and a major reduction in tobacco retail outlets. Understanding the potential long-term economic impacts of such measures is important for government planning. DESIGN: A tobacco policy simulation model that evaluated the health impacts of the A/NZ Smokefree Action Plan was extended to evaluate the economic effects from both government and citizen perspectives. Estimates were presented in 2021 US$, discounted at 3% per annum. RESULTS: The modelled endgame policy package generates considerable growth in income for the A/NZ population with a total cumulative gain of US$31 billion by 2050. From a government perspective, increased superannuation payments and reduced tobacco excise tax revenue result in a negative net financial position and a cumulative shortfall of US$11.5 billion by 2050. In a sensitivity analysis considering future labour force changes, the government's cumulative net position remained negative by 2050, but only by US$1.9 billion. CONCLUSIONS: A policy such as the A/NZ Smokefree Action Plan is likely to produce substantial economic benefits for citizens, and modest impacts on government finances related to reduced tobacco tax and increases in aged pensions due to increased life expectancy. Such costs can be anticipated and planned for and might be largely offset by future increases in the size of the labour force and the proportion of people 65+ years old working in the formal economy.

Fifty-year forecasts of daily smoking prevalence: can Australia reach 5% by 2030?

OBJECTIVE: To compare 50-year forecasts of Australian tobacco smoking rates in relation to trends in smoking initiation and cessation and in relation to a national target of ≤5% adult daily prevalence by 2030. METHODS: A compartmental model of Australian population daily smoking, calibrated to the observed smoking status of 229 523 participants aged 20-99 years in 26 surveys (1962-2016) by age, sex and birth year (1910-1996), estimated smoking prevalence to 2066 using Australian Bureau of Statistics 50-year population predictions. Prevalence forecasts were compared across scenarios in which smoking initiation and cessation trends from 2017 were continued, kept constant or reversed. RESULTS: At the end of the observation period in 2016, model-estimated daily smoking prevalence was 13.7% (90% equal-tailed interval (EI) 13.4%-14.0%). When smoking initiation and cessation rates were held constant, daily smoking prevalence reached 5.2% (90% EI 4.9%-5.5%) after 50 years, in 2066. When initiation and cessation rates continued their trajectory downwards and upwards, respectively, daily smoking prevalence reached 5% by 2039 (90% EI 2037-2041). The greatest progress towards the 5% goal came from eliminating initiation among younger cohorts, with the target met by 2037 (90% EI 2036-2038) in the most optimistic scenario. Conversely, if initiation and cessation rates reversed to 2007 levels, estimated prevalence was 9.1% (90% EI 8.8%-9.4%) in 2066. CONCLUSION: A 5% adult daily smoking prevalence target cannot be achieved by the year 2030 based on current trends. Urgent investment in concerted strategies that prevent smoking initiation and facilitate cessation is necessary to achieve 5% prevalence by 2030.

Prioritization of intervention domains to prevent cardiovascular disease: a country-level case study using global burden of disease and local data.

AIM: We aimed to combine Global Burden of Disease (GBD) Study data and local data to identify the highest priority intervention domains for preventing cardiovascular disease (CVD) in the case study country of Aotearoa New Zealand (NZ). METHODS: Risk factor data for CVD in NZ were extracted from the GBD using the "GBD Results Tool." We prioritized risk factor domains based on consideration of the size of the health burden (disability-adjusted life years [DALYs]) and then by the domain-specific interventions that delivered the highest health gains and cost-savings. RESULTS: Based on the size of the CVD health burden in DALYs, the five top prioritized risk factor domains were: high systolic blood pressure (84,800 DALYs; 5400 deaths in 2019), then dietary risk factors, then high LDL cholesterol, then high BMI and then tobacco (30,400 DALYs; 1400 deaths). But if policy-makers aimed to maximize health gain and cost-savings from specific interventions that have been studied, then they would favor the dietary risk domain (e.g., a combined fruit and vegetable subsidy plus a sugar tax produced estimated lifetime savings of 894,000 health-adjusted life years and health system cost-savings of US$11.0 billion; both 3% discount rate). Other potential considerations for prioritization included the potential for total health gain that includes non-CVD health loss and potential for achieving relatively greater per capita health gain for Maori (Indigenous) to reduce health inequities. CONCLUSIONS: We were able to show how CVD risk factor domains could be systematically prioritized using a mix of GBD and country-level data. Addressing high systolic blood pressure would be the top ranked domain if policy-makers focused just on the size of the health loss. But if policy-makers wished to maximize health gain and cost-savings using evaluated interventions, dietary interventions would be prioritized, e.g., food taxes and subsidies.

Tobacco endgame intervention impacts on health gains and Maori:non-Maori health inequity: a simulation study of the Aotearoa/New Zealand Tobacco Action Plan.

BACKGROUND: The Aotearoa/New Zealand Government is aiming to end the tobacco epidemic and markedly reduce Maori:non-Maori health inequalities by legislating: (1) denicotinisation of retail tobacco, (2) 95% reduction in retail outlets and (c) a tobacco free-generation whereby people born after 2005 are unable to legally purchase tobacco. This paper estimates future smoking prevalence, mortality inequality and health-adjusted life year (HALY) impacts of these strategies. METHODS: We used a Markov model to estimate future yearly smoking and vaping prevalence, linked to a proportional multistate life table model to estimate future mortality and HALYs. RESULTS: The combined package of strategies (plus media promotion) reduced adult smoking prevalence from 31.8% in 2022 to 7.3% in 2025 for Maori, and 11.8% to 2.7% for non-Maori. The 5% smoking prevalence target was forecast to be achieved in 2026 and 2027 for Maori males and females, respectively.The HALY gains for the combined package over the population's remaining lifespan were estimated to be 594 000 (95% uncertainty interval (UI): 443 000 to 738 000; 3% discount rate). Denicotinisation alone achieved 97% of these HALYs, the retail strategy 19% and tobacco-free generation 12%.By 2040, the combined package was forcat to reduce the gap in Maori:non-Maori all-cause mortality rates for people 45+ years old by 22.9% (95% UI: 19.9% to 26.2%) for females and 9.6% (8.4% to 11.0%) for males. CONCLUSION: A tobacco endgame strategy, especially denicotinisation, could deliver large health benefits and dramatically reduce health inequities between Maori and non-Maori in Aotearoa/New Zealand.

Potential effect of real-world junk food and sugar-sweetened beverage taxes on population health, health system costs and greenhouse gas emissions in New Zealand: a modelling study.

Poor diet is a major risk factor for excess weight gain and obesity-related diseases, including cardiovascular diseases, type 2 diabetes mellitus, osteoarthritis and several cancers. This paper aims to assess the potential impacts of real-world food and beverage taxes on change in dietary risk factors, health gains (in quality-adjusted life years (QALYs)), health system costs and greenhouse gas (GHG) emissions as if they had all been implemented in New Zealand (NZ). Ten taxes or tax packages were modelled. A proportional multistate life table model was used to predict resultant QALYs and costs over the remaining lifespan of the NZ population alive in 2011, as well as GHG emissions. QALYs ranged from 12.5 (95% uncertainty interval (UI) 10.2 to 15.0; 3% discount rate) per 1000 population for the import tax on sugar-sweetened beverages (SSB) in Palau to 143 (95% UI 118 to 171) per 1000 population for the excise duties on saturated fat, chocolate and sweets in Denmark, while health expenditure savings ranged from 2011 NZ$245 (95% UI 188 to 310; 2020 US$185) per capita to NZ$2770 (95% UI 2140 to 3480; US$2100) per capita, respectively. The modelled taxes resulted in decreases in GHG emissions from baseline diets, ranging from -0.2% for the tax on SSB in Barbados to -2.8% for Denmark's tax package. There is strong evidence for the implementation of food and beverage tax packages in NZ or similar high-income settings.

Comparing health gains, costs and cost-effectiveness of 100s of interventions in Australia and New Zealand: an online interactive league table.

BACKGROUND: This study compares the health gains, costs, and cost-effectiveness of hundreds of Australian and New Zealand (NZ) health interventions conducted with comparable methods in an online interactive league table designed to inform policy. METHODS: A literature review was conducted to identify peer-reviewed evaluations (2010 to 2018) arising from the Australia Cost-Effectiveness research and NZ Burden of Disease Epidemiology, Equity and Cost-Effectiveness Programmes, or using similar methodology, with: health gains quantified as health-adjusted life years (HALYs); net health system costs and/or incremental cost-effectiveness ratio; time horizon of at least 10 years; and 3% to 5% discount rates. RESULTS: We identified 384 evaluations that met the inclusion criteria, covering 14 intervention domains: alcohol; cancer; cannabis; communicable disease; cardiovascular disease; diabetes; diet; injury; mental illness; other non-communicable diseases; overweight and obesity; physical inactivity; salt; and tobacco. There were large variations in health gain across evaluations: 33.9% gained less than 0.1 HALYs per 1000 people in the total population over the remainder of their lifespan, through to 13.0% gaining > 10 HALYs per 1000 people. Over a third (38.8%) of evaluations were cost-saving. CONCLUSIONS: League tables of comparably conducted evaluations illustrate the large health gain (and cost) variations per capita between interventions, in addition to cost-effectiveness. Further work can test the utility of this league table with policy-makers and researchers.

Can a Greenhouse Gas Emissions Tax on Food also Be Healthy and Equitable? A Systemised Review and Modelling Study from Aotearoa New Zealand.

Policies to mitigate climate change are essential. The objective of this paper was to estimate the impact of greenhouse gas (GHG) food taxes and assess whether such a tax could also have health benefits in Aotearoa NZ. We undertook a systemised review on GHG food taxes to inform four tax scenarios, including one combined with a subsidy. These scenarios were modelled to estimate lifetime impacts on quality-adjusted health years (QALY), health inequities by ethnicity, GHG emissions, health system costs and food costs to the individual. Twenty-eight modelling studies on food tax policies were identified. Taxes resulted in decreased consumption of the targeted foods (e.g., -15.4% in beef/ruminant consumption, N = 12 studies) and an average decrease of 8.3% in GHG emissions (N = 19 studies). The "GHG weighted tax on all foods" scenario had the largest health gains and costs savings (455,800 QALYs and NZD 8.8 billion), followed by the tax-fruit and vegetable subsidy scenario (410,400 QALYs and NZD 6.4 billion). All scenarios were associated with reduced GHG emissions and higher age standardised per capita QALYs for Maori. Applying taxes that target foods with high GHG emissions has the potential to be effective for reducing GHG emissions and to result in co-benefits for population health.

Closing the gaps in tobacco endgame evidence: a scoping review.

OBJECTIVE: Tobacco endgame policies aim to rapidly and permanently reduce smoking to minimal levels. We reviewed evidence syntheses for: (1) endgame policies, (2) evidence gaps, and (3) future research priorities. DATA SOURCES: Guided by JBI scoping review methodology, we searched five databases (PubMed, CINAHL, Scopus, Embase and Web of Science) for evidence syntheses published in English since 1990 on 12 policies, and Google for publications from key national and international organisations. Reference lists of included publications were hand searched. STUDY SELECTION: Two reviewers independently screened titles and abstracts. Inclusion criteria were broad to capture policy impacts (including unintended), feasibility, public and stakeholder acceptability and other aspects of policy implementation. DATA EXTRACTION: We report the results according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. DATA SYNTHESIS: Eight policies have progressed to evidence synthesis stage (49 publications): mandatory very low nicotine content (VLNC) standard (n=26); product standards to substantially reduce consumer appeal or remove the most toxic products from the market (n=1); moving consumers to reduced risk products (n=8); tobacco-free generation (n=4); ending sales (n=2); sinking lid (n=2); tax increases (n=7); and restrictions on tobacco retailers (n=10). Based on published evidence syntheses, the evidence base was most developed for a VLNC standard, with a wide range of evidence synthesised. CONCLUSIONS: VLNC cigarettes have attracted the most attention, in terms of synthesised evidence. Additional focus on policies that reduce the availability of tobacco is warranted given these measures are being implemented in some jurisdictions.

Updated Health and Cost Impacts of Electronic Nicotine Delivery Systems, Using Recent Estimates of Relative Harm for Vaping Compared to Smoking.

BACKGROUND: Measuring population health and costs effects of liberalizing access to electronic nicotine delivery systems (ENDS) is an evolving field with high persisting uncertainty. A critical area of uncertainty for policy-makers are estimates of net harms from ENDS relative to cigarettes, therefore, we model these harms using updated estimates incorporating disease specificity. METHODS: We use updated estimates of relative harm of vaping vs smoking, based upon relevant biomarker studies to model the impact of liberalizing access to ENDS in New Zealand (NZ), relative to a ban (where ENDS are not legally available), in an existing proportional multi-state life-table model of 16 tobacco-related diseases. RESULTS: This modeling suggests that ENDS liberalization results in an expected gain of 195 000 quality-adjusted life-years (QALYs) over the remainder of the NZ population's lifespan. There was wide uncertainty in QALYs gained (95% uncertainty interval [UI] = -8000 to 406 000) with a 3.2% probability of net health loss (based upon the number of simulation runs returning positive QALY gains). The average per capita health gain was 0.044 QALYs (equivalent to an extra 16 days of healthy life). Health system cost-savings were expected to be NZ$2.8 billion (US$2.1 billion in 2020 US$; 95%UI: -0.3 to 6.2 billion [2011 NZ$]), with an estimated 3% chance of a net increase in per capita cost. CONCLUSIONS: This updated modeling around liberalizing ENDs in NZ, still suggests likely net health and cost-saving benefits-but of lesser magnitude than previous work and with a small possibility of net harm to population health. IMPLICATIONS: This study found evidence using updated biomarker studies that ENDS liberalization could result in QALY gains across the New Zealand population lifespan that are also cost-saving to the health system. Governments should include the information from these types of modeling studies in their decision-making around potentially improving access to ENDS for existing smokers, while at the same further reducing access to tobacco.

Ten-year prediction model for post-bronchodilator airflow obstruction and early detection of COPD: development and validation in two middle-aged population-based cohorts.

BACKGROUND: Classifying individuals at high chronic obstructive pulmonary disease (COPD)-risk creates opportunities for early COPD detection and active intervention. OBJECTIVE: To develop and validate a statistical model to predict 10-year probabilities of COPD defined by post-bronchodilator airflow obstruction (post-BD-AO; forced expiratory volume in 1 s/forced vital capacity<5th percentile). SETTING: General Caucasian populations from Australia and Europe, 10 and 27 centres, respectively. PARTICIPANTS: For the development cohort, questionnaire data on respiratory symptoms, smoking, asthma, occupation and participant sex were from the Tasmanian Longitudinal Health Study (TAHS) participants at age 41-45 years (n=5729) who did not have self-reported COPD/emphysema at baseline but had post-BD spirometry and smoking status at age 51-55 years (n=2407). The validation cohort comprised participants from the European Community Respiratory Health Survey (ECRHS) II and III (n=5970), restricted to those of age 40-49 and 50-59 with complete questionnaire and spirometry/smoking data, respectively (n=1407). STATISTICAL METHOD: Risk-prediction models were developed using randomForest then externally validated. RESULTS: Area under the receiver operating characteristic curve (AUCROC) of the final model was 80.8% (95% CI 80.0% to 81.6%), sensitivity 80.3% (77.7% to 82.9%), specificity 69.1% (68.7% to 69.5%), positive predictive value (PPV) 11.1% (10.3% to 11.9%) and negative predictive value (NPV) 98.7% (98.5% to 98.9%). The external validation was fair (AUCROC 75.6%), with the PPV increasing to 17.9% and NPV still 97.5% for adults aged 40-49 years with ≥1 respiratory symptom. To illustrate the model output using hypothetical case scenarios, a 43-year-old female unskilled worker who smoked 20 cigarettes/day for 30 years had a 27% predicted probability for post-BD-AO at age 53 if she continued to smoke. The predicted risk was 42% if she had coexistent active asthma, but only 4.5% if she had quit after age 43. CONCLUSION: This novel and validated risk-prediction model could identify adults aged in their 40s at high 10-year COPD-risk in the general population with potential to facilitate active monitoring/intervention in predicted 'COPD cases' at a much earlier age.

Disease-related income and economic productivity loss in New Zealand: A longitudinal analysis of linked individual-level data.

BACKGROUND: Reducing disease can maintain personal individual income and improve societal economic productivity. However, estimates of income loss for multiple diseases simultaneously with thorough adjustment for confounding are lacking, to our knowledge. We estimate individual-level income loss for 40 conditions simultaneously by phase of diagnosis, and the total income loss at the population level (a function of how common the disease is and the individual-level income loss if one has the disease). METHODS AND FINDINGS: We used linked health tax data for New Zealand as a high-income country case study, from 2006 to 2007 to 2015 to 2016 for 25- to 64-year-olds (22.5 million person-years). Fixed effects regression was used to estimate within-individual income loss by disease, and cause-deletion methods to estimate economic productivity loss at the population level. Income loss in the year of diagnosis was highest for dementia for both men (US$8,882; 95% CI $6,709 to $11,056) and women ($7,103; $5,499 to $8,707). Mental illness also had high income losses in the year of diagnosis (average of about $5,300 per year for males and $4,100 per year for females, for 4 subcategories of: depression and anxiety; alcohol related; schizophrenia; and other). Similar patterns were evident for prevalent years of diagnosis. For the last year of life, cancers tended to have the highest income losses, (e.g., colorectal cancer males: $17,786, 95% CI $15,555 to $20,018; females: $14,192, $12,357 to $16,026). The combined annual income loss from all diseases among 25- to 64-year-olds was US$2.72 billion or 4.3% of total income. Diseases contributing more than 4% of total disease-related income loss were mental illness (30.0%), cardiovascular disease (15.6%), musculoskeletal (13.7%), endocrine (8.9%), gastrointestinal (7.4%), neurological (6.5%), and cancer (4.5%). The limitations of this study include residual biases that may overestimate the effect of disease on income loss, such as unmeasured time-varying confounding (e.g., divorce leading to both depression and income loss) and reverse causation (e.g., income loss leading to depression). Conversely, there may also be offsetting underestimation biases, such as income loss in the prodromal phase before diagnosis that is misclassified to "healthy" person time. CONCLUSIONS: In this longitudinal study, we found that income loss varies considerably by disease. Nevertheless, mental illness, cardiovascular, and musculoskeletal diseases stand out as likely major causes of economic productivity loss, suggesting that they should be prioritised in prevention programmes.

Improving on estimates of the potential relative harm to health from using modern ENDS (vaping) compared to tobacco smoking.

BACKGROUND: Although the harm to health from electronic nicotine delivery systems (ENDS) compared to smoked tobacco remains highly uncertain, society and governments still need to know the likely range of the relative harm to inform regulatory policies for ENDS and smoking. METHODS: We identified biomarkers with specificity of association with different disease groupings e.g., volatile organic compound (VOCs) for chronic obstructive pulmonary disease; and tobacco-specific N´-nitrosamines (TSNAs) and polycyclic aromatic hydrocarbons (PAHs) for all cancers. We conducted a review of recent studies (post January 2017) that compared these biomarkers between people exclusively using ENDS and those exclusively smoking tobacco. The percentage differences in these biomarkers, weighted by study size and adjusted for acrolein from other sources, were used as a proxy for the assumed percentage difference in disease harm between ENDS and smoking. These relative differences were applied to previously modelled estimates of smoking-related health loss (in health-adjusted life-years; HALYs). RESULTS: The respective relative biomarker levels (ENDS vs smoking) were: 28% for respiratory diseases (five results, three studies); 42% for cancers (five results, four studies); and 35% for cardiovascular (seven results, four studies). When integrated with the HALY impacts by disease, the overall harm to health from ENDS was estimated to be 33% that of smoking. CONCLUSIONS: This analysis, suggests that the use of modern ENDS devices (vaping) could be a third as harmful to health as smoking in a high-income country setting. But this estimate is based on a limited number of biomarker studies and is best be considered a likely upper level of ENDS risk given potential biases in our method (i.e., the biomarkers used being correlated with more unaccounted for toxicants in smoking compared to with using ENDS).

Factors Explaining Socio-Economic Inequalities in Survival from Colon Cancer: A Causal Mediation Analysis.

BACKGROUND: Socio-economic inequalities in colon cancer survival exist in high-income countries, but the reasons are unclear. We assessed the mediating effects of stage at diagnosis, comorbidities, and treatment (surgery and intravenous chemotherapy) on survival from colon cancer. METHODS: We identified 2,203 people aged 15 to 79 years with first primary colon cancer diagnosed in Victoria, Australia, between 2008 and 2011. Colon cancer cases were identified through the Victorian Cancer Registry (VCR), and clinical information was obtained from hospital records. Deaths till December 31, 2016 (n = 807), were identified from Victorian and national death registries. Socio-economic disadvantage was based on residential address at diagnosis. For stage III disease, we decomposed its total effect into direct and indirect effects using interventional mediation analysis. RESULTS: Socio-economic inequalities in colon cancer survival were not explained by stage and were greater for men than women. For men with stage III disease, there were 161 [95% confidence interval (CI), 67-256] additional deaths per 1,000 cases in the 5 years following diagnosis for the most disadvantaged compared with the least disadvantaged. The indirect effects through comorbidities and intravenous chemotherapy explained 6 (95% CI, -10-21) and 15 (95% CI, -14-44) per 1,000 of these additional deaths, respectively. Surgery did not explain the observed gap in survival. CONCLUSIONS: Disadvantaged men have lower survival from stage III colon cancer that is only modestly explained by having comorbidities or not receiving chemotherapy after surgery. IMPACT: Future studies should investigate the potential mediating role of factors occurring beyond the first year following diagnosis, such as compliance with surveillance for recurrence and supportive care services.

Should prioritising health interventions be informed by modelling studies? The case of cancer control in Aotearoa New Zealand.

In this viewpoint, we suggest that policymakers should prioritise health interventions by using evidence around health gain, impact on equity, health-system costs and cost-effectiveness. We take the example of the new cancer control agency in New Zealand, Te Aho o Te Kahu, and argue that its decision-making can now be informed by many methodologically compatible epidemiological and health economic analyses. These analyses span primary prevention of cancer (eg, tobacco control, dietary and physical activity interventions and HPV vaccination), cancer screening, cancer treatment and palliative care. The largest health gain and cost-savings from the available modelling work for New Zealand are seen in nutrition and tobacco control interventions in particular. Many of these interventions have potentially greater per capita health gain for Maori than non-Maori and are also found to be cost saving for the health sector. In summary, appropriate prioritisation of interventions can potentially both maximise health benefits as well as making best use of government funding of the health system.

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.

Changing social inequalities in smoking, obesity and cause-specific mortality: Cross-national comparisons using compass typology.

BACKGROUND: In many countries smoking rates have declined and obesity rates have increased, and social inequalities in each have varied over time. At the same time, mortality has declined in most high-income countries, but gaps by educational qualification persist-at least partially due to differential smoking and obesity distributions. This study uses a compass typology to simultaneously examine the magnitude and trends in educational inequalities across multiple countries in: a) smoking and obesity; b) smoking-related mortality and c) cause-specific mortality. METHODS: Smoking prevalence, obesity prevalence and cause-specific mortality rates (35-79 year olds by sex) in nine European countries and New Zealand were sourced from between 1980 and 2010. We calculated relative and absolute inequalities in prevalence and mortality (relative and slope indices of inequality, respectively RII, SII) by highest educational qualification. Countries were then plotted on a compass typology which simultaneously examines trends in the population average rates or odds on the x-axis, RII on the Y-axis, and contour lines depicting SII. FINDINGS: Smoking and obesity. Smoking prevalence in men decreased over time but relative inequalities increased. For women there were fewer declines in smoking prevalence and relative inequalities tended to increase. Obesity prevalence in men and women increased over time with a mixed picture of increasing absolute and sometimes relative inequalities. Absolute inequalities in obesity increased for men and women in Czech Republic, France, New Zealand, Norway, for women in Austria and Lithuania, and for men in Finland. Cause-specific mortality. Average rates of smoking-related mortality were generally stable or increasing for women, accompanied by increasing relative inequalities. For men, average rates were stable or decreasing, but relative inequalities increased over time. Cardiovascular disease, cancer, and external injury rates generally decreased over time, and relative inequalities increased. In Eastern European countries mortality started declining later compared to other countries, however it remained at higher levels; and absolute inequalities in mortality increased whereas they were more stable elsewhere. CONCLUSIONS: Tobacco control remains vital for addressing social inequalities in health by education, and focus on the least educated is required to address increasing relative inequalities. Increasing obesity in all countries and increasing absolute obesity inequalities in several countries is concerning for future potential health impacts. Obesity prevention may be increasingly important for addressing health inequalities in some settings. The compass typology was useful to compare trends in inequalities because it simultaneously tracks changes in rates/odds, and absolute and relative inequality measures.

Fuelling walking and cycling: human powered locomotion is associated with non-negligible greenhouse gas emissions.

Reducing motorized transport and increasing active transport (i.e. transport by walking, cycling and other active modes) may reduce greenhouse gas (GHG) emissions and improve health. But, active modes of transport are not zero emitters. We aimed to quantify GHG emissions from food production required to fuel extra physical activity for walking and cycling. We estimate the emissions (in kgCO2e) per kilometre travelled for walking and cycling from energy intake required to compensate for increased energy expenditure, and data on food-related GHG emissions. We assume that persons who shift from passive modes of transport (e.g. driving) have increased energy expenditure that may be compensated with increased food consumption. The GHG emissions associated with food intake required to fuel a kilometre of walking range between 0.05 kgCO2e/km in the least economically developed countries to 0.26 kgCO2e/km in the most economically developed countries. Emissions for cycling are approximately half those of walking. Emissions from food required for walking and cycling are not negligible in economically developed countries which have high dietary-related emissions. There is high uncertainty about the actual emissions associated with walking and cycling, and high variability based on country economic development. Our study highlights the need to consider emissions from other sectors when estimating net-emissions impacts from transport interventions.