A Cost-Consequence Analysis of Different Screening Procedures in Alzheimer's Disease: Results from the MOPEAD Project.

BACKGROUND: For care planning and support, under-detection and late diagnosis of Alzheimer's disease (AD) is a great challenge. Models of Patient-Engagement for Alzheimer's Disease (MOPEAD) is an EU-funded project aiming at testing different strategies to improve this situation. OBJECTIVE: To make a cost-consequence analysis of MOPEAD. METHODS: Four screening strategies were tested in five countries (Germany, the Netherlands, Slovenia, Spain, and Sweden): 1) a web-approach; 2) Open-House initiative; 3) in primary care; and 4) by diabetes specialists. Persons-at-risk of AD in all strategies were offered referral to a hospital-based specialist. The primary health-economic outcome was the cost per true-positive case (TP) of AD from the screened population. RESULTS: Of 2,847 screened persons, 1,121 screened positive (39%), 402 were evaluated at memory clinics (14%), and 236 got an AD diagnosis (8%). The cost per TP of those screened was €3,115 with the web-approach, €2,722 with the Open-House, €1,530 in primary care, and €1,190 by diabetes specialists. Sensitivity analyses that more likely reflect the real-world situation confirmed the results. The number-needed-to-screen was 30 with the web-approach, 8 with the Open-House and primary care, and 6 with the diabetes specialists.There were country differences in terms of screening rates, referrals to memory clinics, staff-types involved, and costs per TP. CONCLUSION: In primary care and by the diabetes specialist, the costs per TP/screened population were lowest, but the capacity of such settings to identify cases with AD-risk must be discussed. Hence new diagnostic strategies such as web-solutions and Open-House initiatives may be valuable after modifications.

From glass boxes to social media engagement: an audit of tobacco retail marketing in Indonesia.

OBJECTIVE: To assess tobacco promotion intensity, retailer behaviours and tobacco company efforts to link retailer marketing to online channels. METHODS: We completed an audit of tobacco advertisements and promotions at 1000 randomly selected cigarette retailers in Denpasar, Bali, Indonesia that included an observation checklist, digital photos and structured interviews with retailers. We then calculated the tobacco promotion index for each retailer and made comparisons based on store types. Next, we conducted a photo analysis from 100 randomly selected retailers to explore links to online channels and other promotional cues to engage young people. RESULTS: Mini-markets have both the highest total number of promotions and the highest indoor promotion index with a mean score of 5.1 and 3.7, respectively. Kiosks have the highest outdoor promotion index with a mean score of 1.6. Most of the retailers (98.9%) displayed cigarettes, more than half of kiosk retailers (54.8%) and mini-market retailers (56.3%) admitted selling cigarettes to young people, and 74% of kiosk retailers sell single stick cigarettes. We found links to online marketing, including two hashtags and a company website. Promotional materials also included youth-focused content such as English taglines, new products and small packs. CONCLUSION: Tobacco companies in Indonesia have strategically differentiated their advertisements based on retailer type and have bridged conventional retailer marketing to online channels. Reforming Indonesian tobacco laws to include bans on single sticks and small pack sales, point-of-sale advertising, including displays, and enforcement of laws on sales to minors is urgently required.

Tobacco Price Increases and Population Interest in Smoking Cessation in Japan Between 2004 and 2016: A Google Trends Analysis.

INTRODUCTION: Tobacco price increases can generate increased public interest in smoking cessation, but it is not clear how long this interest lasts. Our objective was to evaluate the duration of the impact of cigarette price increase in Japan using Google search data. METHODS: Monthly or daily aggregated Google search volume for smoking cessation in Japan from 2004 to 2016 was collected in terms of relative search volume (RSV) ranging from 0 to 100. Using monthly RSV data, we evaluated possible relationships between the RSVs and tobacco control measures in Japan. Time periods within which the impact of search volume significantly increased were identified by cluster detection test, using daily RSV data. A spike in RSV preceding the enforcement of a cigarette price increase revealed an anticipation effect. RESULTS: Between 2004 and 2016, the three highest monthly RSV spikes were observed in July 2006 (RSV = 66), when cigarette prices increased by 11%, and in September (RSV = 90) and October 2010 (RSV = 100), when cigarette prices increased by 37%. Regarding daily RSV, the detected cluster size around the price increase in 2010 (52 days) was longer than that in 2006 (17 days). In 2010, a cluster period of 25 days before the date of the price increase was observed, suggesting an anticipation effect. After the onset of the price increase, a cluster of 27 days was detected. When the cigarette price increased due to consumption tax in April 2014, almost no anticipation effect was observed. CONCLUSIONS: The population impact of tobacco price increases on smoking cessation may be assessed using Google Trends data. The cluster indicates that a higher cigarette price increase had a higher and longer lasting effect on population interest in cessation, but the impact may continue for a relatively short time. IMPLICATIONS: To examine the duration of the impact of cigarette price increases on population interest in smoking cessation in Japan, Google search data for smoking cessation were analyzed. Between 2004 and 2016, the three highest spikes of monthly RSV were observed in October 2010, when cigarette prices increased by 37%. Analyzing daily RSV data, the detected cluster size around the price increase in 2010 was 52 days, and a cluster period of 25 days before the date of the price increase was observed, suggesting an anticipation effect. The cluster indicates that a higher cigarette price increase had a higher and longer lasting effect, but the population impact continues for a relatively short time. Further increases in the price of cigarettes are necessary.

Youth access to JUUL online: eBay sales of JUUL prior to and following FDA action.

BACKGROUND: The novel e-cigarette product JUUL has experienced rapid market growth. The online auction site eBay has been mentioned as a source of JUUL access for youth, and the US Food and Drug Administration (FDA) notified eBay to remove JUUL listings in April 2018. We sought to characterise the sale of JUUL products on eBay prior to the FDA's request, document the impact of this request and explore ways in which eBay vendors bypassed this effort. METHODS: eBay was searched for JUUL-branded products sold by US vendors in March 2018, yielding a sample of 197 listings for devices and/or pods. Each listing was coded for product, listing and youth access content. Following FDA action, each listing was revisited to determine its status, and each vendor's page was searched for JUUL and other vaping content. Data were analysed using descriptive statistics. RESULTS: Of 197 eBay listings, 189 were for JUUL kits and 13 were for pods. Prices were on average higher than those on the official JUUL store, and language about age restrictions was rare. Following FDA contact, most listings were no longer active. However, 3.4% of these vendors still sold JUUL devices or pods and 15.5% were selling other vaporisers or nicotine products. CONCLUSIONS: Online platforms may lack the will or expertise to effectively monitor content for tobacco products, while vendors quickly adapt to minor changes with simple strategies such as spelling variations. Accurate identification of online e-cigarette vendors is essential to the enforcement of policy and may benefit from cross-sector partnerships.

Investigating the effectiveness and cost-effectiveness of FITNET-NHS (Fatigue In Teenagers on the interNET in the NHS) compared to Activity Management to treat paediatric chronic fatigue syndrome (CFS)/myalgic encephalomyelitis (ME): protocol for a randomised controlled trial.

BACKGROUND: Paediatric chronic fatigue syndrome or myalgic encephalomyelitis (CFS/ME) is a relatively common and disabling condition. The National Institute for Health and Clinical Excellence (NICE) recommends Cognitive Behavioural Therapy (CBT) as a treatment option for paediatric CFS/ME because there is good evidence that it is effective. Despite this, most young people in the UK are unable to access local specialist CBT for CFS/ME. A randomised controlled trial (RCT) showed FITNET was effective in the Netherlands but we do not know if it is effective in the National Health Service (NHS) or if it is cost-effective. This trial will investigate whether FITNET-NHS is clinically effective and cost-effective in the NHS. METHODS: Seven hundred and thirty-four paediatric patients (aged 11-17 years) with CFS/ ME will be randomised (1:1) to receive either FITNET-NHS (online CBT) or Activity Management (delivered via video call). The internal pilot study will use integrated qualitative methods to examine the feasibility of recruitment and the acceptability of treatment. The full trial will assess whether FITNET-NHS is clinically effective and cost-effective. The primary outcome is disability at 6 months, measured using the SF-36-PFS (Physical Function Scale) questionnaire. Cost-effectiveness is measured via cost-utility analysis from an NHS perspective. Secondary subgroup analysis will investigate the effectiveness of FITNET-NHS in those with co-morbid mood disorders. DISCUSSION: If FITNET-NHS is found to be feasible and acceptable (internal pilot) and effective and cost-effective (full trial), its provision by the NHS has the potential to deliver substantial health gains for the large number of young people suffering from CFS/ME but unable to access treatment because there is no local specialist service. This trial will provide further evidence evaluating the delivery of online CBT to young people with chronic conditions. TRIAL REGISTRATION: ISRCTN registry, registration number: ISRCTN18020851 . Registered on 4 August 2016.

Google Searches for "Cheap Cigarettes" Spike at Tax Increases: Evidence from an Algorithm to Detect Spikes in Time Series Data.

Introduction: Online cigarette dealers have lower prices than brick-and-mortar retailers and advertise tax-free status.1-8 Previous studies show smokers search out these online alternatives at the time of a cigarette tax increase.9,10 However, these studies rely upon researchers' decision to consider a specific date and preclude the possibility that researchers focus on the wrong date. The purpose of this study is to introduce an unbiased methodology to the field of observing search patterns and to use this methodology to determine whether smokers search Google for "cheap cigarettes" at cigarette tax increases and, if so, whether the increased level of searches persists. Methods: Publicly available data from Google Trends is used to observe standardized search volumes for the term, "cheap cigarettes". Seasonal Hybrid Extreme Studentized Deviate and E-Divisive with Means tests were performed to observe spikes and mean level shifts in search volume. Results: Of the twelve cigarette tax increases studied, ten showed spikes in searches for "cheap cigarettes" within two weeks of the tax increase. However, the mean level shifts did not occur for any cigarette tax increase. Conclusion: Searches for "cheap cigarettes" spike around the time of a cigarette tax increase, but the mean level of searches does not shift in response to a tax increase. The SHESD and EDM tests are unbiased methodologies that can be used to identify spikes and mean level shifts in time series data without an a priori date to be studied. SHESD and EDM affirm spikes in interest are related to tax increases. Implications: • Applies improved statistical techniques (SHESD and EDM) to Google search data related to cigarettes, reducing bias and increasing power • Contributes to the body of evidence that state and federal tax increases are associated with spikes in searches for cheap cigarettes and may be good dates for increased online health messaging related to tobacco.

Using a Media Campaign to Increase Engagement With a Mobile-Based Youth Smoking Cessation Program.

PURPOSE: To describe the impact of the National Cancer Institute's promotion of its youth smoking cessation program, Smokefree Teen (SFT). DESIGN: We provide a description of campaign strategies and outcomes as a means to engage a teen audience in cessation resources using a cost-effective approach. SETTING: The campaign occurred nationally, using traditional (TV and radio), online, and social media outreach. PARTICIPANTS: Ads targeted adolescent smokers (aged 14-17). The baseline population was 42 586 and increased to 464 357 during the campaign. MEASURES: Metrics used to assess outcomes include (1) visits to SFT website from traditional and online ads, (2) cost to get an online ad clicked (cost-per-click), and (3) SmokefreeTXT program enrollments during the 8-week campaign period. ANALYSIS: We conducted a quantitative performance review of all tactics. RESULTS: The SFT campaign achieved an online ad click-through rate of 0.33%, exceeding industry averages of 0.15%. Overall, web traffic to teen.smokefree.gov increased by 980%, and the online cost-per-click for ads, including social media actions, was approximately $1 as compared with $107 for traditional ads. Additionally, the campaign increased the SmokefreeTXT program teen sign-ups by 1334%. CONCLUSION: The campaign increased engagement with evidence-informed cessation resources for teen smokers. Results show the potential of using multiple, online channels to help increase engagement with core resources.

The Impact of the Internet on Health Consultation Market Concentration: An Econometric Analysis of Secondary Data.

BACKGROUND: Many markets have traditionally been dominated by a few best-selling products, and this is also the case for the health care industry. However, we do not know whether the market will be more or less concentrated when health care services are delivered online (known as E-consultation), nor do we know how to reduce the concentration of the E-consultation market. OBJECTIVE: The aim of this study was to investigate the concentration of the E-consultation market and how to reduce its concentration through information disclosure mechanisms (online reputation and self-representation). METHODS: We employed a secondary data econometric analysis using transaction data obtained from an E-consultation Website (haodf.com) for three diseases (infantile pneumonia, diabetes, and pancreatic cancer) from 2008 to 2015. We included 2439 doctors in the analysis. RESULTS: The E-consultation market largely follows the 20/80 principle, namely that approximately 80% of orders are fulfilled by nearly 20% of doctors. This is much higher than the offline health care market. Meanwhile, the market served by doctors with strong online reputations (beta=0.207, P<.001) or strong online self-representation (beta=0.386, P<.001) is less concentrated. CONCLUSIONS: When health care services are delivered online, the market will be more concentrated (known as the "Superstar" effect), indicating poor service efficiency for society as a whole. To reduce market concentration, E-consultation websites should provide important design elements such as ratings of doctors (user feedback), articles contributed by doctors, and free consultation services (online representation). A possible and important way to reduce the market concentration of the E-consultation market is to accumulate enough highly rated or highly self-represented doctors.

Differences in the design and sale of e-cigarettes by cigarette manufacturers and non-cigarette manufacturers in the USA.

BACKGROUND: Three categories of e-cigarette brands have emerged within the US market: e-cigarette brands developed by cigarette manufacturers, brands acquired by cigarette manufacturers and brands with no cigarette manufacturer affiliation. In the absence of federal regulatory oversight of e-cigarettes, we assessed differences in e-cigarette products and sales practices across these categories. METHODS: Brand websites for top-selling e-cigarette brands from each of these categories were examined in October of 2015 to compare website access restrictions, online sales practices and products sold, including e-cigarette model type (eg, 'cigalike' vs advanced systems) and options available (eg, flavoured, nicotine free). RESULTS: Website access to brands developed by cigarette manufacturers was restricted to users aged 21 years or older, and one website required user registration. In addition, these brands were exclusively reusable/rechargeable 'cigalikes.' Limited flavour options were available for these products, and nicotine-free options were not sold. In contrast, brands acquired by cigarette manufacturers and brands with no cigarette manufacturer affiliation generally required website visitors to be 18, offered a nicotine-free option, and most offered disposable products and an array of flavoured products (eg, fruit/candy flavours). CONCLUSIONS: This exploratory study finds differences in e-cigarette products and sales practices across these three e-cigarette brand categories, with brands developed by cigarette manufacturers adopting a particularly distinctive product and sales strategy. Anticipated regulation of e-cigarettes in the USA may be influencing these product and sales decisions.

[Health Economic Evaluations within the Hamburg Network for Mental Health]. / Gesundheitsökonomische Evaluationen im Rahmen von psychenet.

Within the Hamburg Network for Mental Health, cost-effectiveness analyses of collaborative care models are conducted. After providing an overview of the international literature on the cost-effectiveness of collaborative care for mental disorders, this article describes the rationale, aims and methods of the cost-effectiveness analyses conducted within the Hamburg Network for Mental Health. Proof of cost-effectiveness is expected to promote the transfer of collaborative care models into routine care.

Information gathering and technology use among low-income minority men at risk for prostate cancer.

Health communication researchers, public health workers, and health professionals must learn more about the health information-gathering behavior of low-income minority men at risk for prostate cancer in order to share information effectively with the population. In collaboration with the Milwaukee Health Department Men's Health Referral Network, a total of 90 low-income adult men were recruited to complete a survey gauging information sources, seeking behavior, use of technology, as well as prostate cancer awareness and screening behavior. Results indicated participants primarily relied on health professionals, family, and friends for information about general issues of health as well as prostate cancer. The Internet was the least relied on source of information. A hierarchical regression indicated interpersonal information sources such as family or friends to be the only significant predictor enhancing prostate cancer awareness, controlling for other sources of information. Prostate screening behaviors were predicted by reliance on not only medical professionals but also the Internet. Practical implications of the study are discussed.

Tobacco products sold by Internet vendors following restrictions on flavors and light descriptors.

INTRODUCTION: The 2009 Family Smoking Prevention and Tobacco Control Act bans characterizing flavors (e.g., grape, strawberry) in cigarettes, excluding tobacco and menthol, and prohibits companies from using misleading descriptors (e.g., light, low) that imply reduced health risks without submitting scientific data to support the claim and obtaining a marketing authorization from the U.S. Food and Drug Administration. This observational study examines tobacco products offered by Internet cigarette vendors (ICV) pre- and postimplementation of the ban on characterizing flavors in cigarettes and the restriction on misleading descriptors. METHODS: Cross-sectional samples of the 200 most popular ICVs in 2009, 2010, and 2011 were identified. Data were analyzed in 2012 and 2013. RESULTS: In 2011 the odds for selling cigarettes with banned flavors or misleading descriptors were 0.40 times that for selling the products in 2009 (95% confidence interval [CI] = 0.18, 0.88). However, 89% of vendors continued to sell the products, including 95.8% of international vendors. Following the ban on characterizing flavors, ICVs began selling potential alternative products. In 2010, the odds for selling flavored little cigars were 1.71 (95% CI = 1.09, 2.69) times that for selling the product in 2009 and, for clove cigars, were 5.50 (95% CI = 2.36, 12.80) times that for selling the product in 2009. CONCLUSIONS: Noncompliance with the ban on characterizing flavors and restriction on misleading descriptors has been high, especially among international vendors. Many vendors appear to be circumventing the intent of the flavors ban by selling unbanned flavored cigars, in some cases in lieu of flavored cigarettes.

Low-budget policy tool to empower Israeli insureds to demand their rights in the healthcare system.

Since 1995 universal healthcare coverage has been provided in Israel through National Health Insurance (NHI). Although the country has lower rates of health spending than most OECD countries, the NHI Law stipulates that a broad benefits package will be provided by four competing Health Plans (HPs). These third-party payers manage healthcare utilization and cost through mechanisms that affect both provider and consumer behavior. Cost Containment is one of their main organizational objectives. The Ministry of Health (MoH) supervises HPs to ensure that they provide their members with adequate healthcare of high quality in accordance with the NHI Law and uphold the principles of efficiency and equity. In this paper we report on a policy instrument recently introduced by the MoH which enables it to share some of its responsibility for supervision with the insureds. This policy instrument is a website launched in 2014 that gives access to transparent information about the coverage of the NHI and voluntary health insurance (VHI) benefits packages. The idea is to empower insureds with knowledge and awareness of their rights and eligibility to benefits, so they can demand them from the HPs and/or private insurers; if refused, they can refer the case to the supervisor (the MoH). This policy instrument addresses market failures related to information asymmetry and can potentially improve competition among the HPs and within the VHI market.

Economic evaluation of web-based compared with in-person follow-up after total joint arthroplasty.

BACKGROUND: We previously demonstrated the feasibility and clinical effectiveness of a web-based assessment following total hip or total knee arthroplasty. The purpose of the present study was to conduct an economic evaluation to compare a web-based assessment with in-person follow-up. METHODS: Patients who had undergone total joint arthroplasty at least twelve months previously were randomized to complete a web-based follow-up or visit the clinic for the usual follow-up. We recorded travel costs and time associated with each option. We followed patients for one year after the web-based or in-person follow-up evaluation and documented any resource use related to the joint arthroplasty. We conducted cost analyses from the health-care payer (Ontario Ministry of Health and Long-Term Care) and societal perspectives. All costs are presented in 2012 Canadian dollars. RESULTS: A total of 229 patients (118 in the web-based group, 111 in the usual-care group) completed the study. The mean cost of the assessment from the societal perspective was $98 per patient for the web-based assessment and $162 per patient for the usual method of in-person follow-up. The cost for the web-based assessment was significantly lower from the societal perspective (mean difference, $-64; 95% confidence interval [CI], $-79 to $-48; p < 0.01) and also from the health-care payer perspective (mean difference, $-27; 95% CI, $-29 to $-25; p < 0.01). CONCLUSIONS: The web-based follow-up assessment had a lower cost per patient compared with in-person follow-up from both societal and health-care payer perspectives.

Cost-effectiveness and cost-utility of a Web-based or print-delivered tailored intervention to promote physical activity among adults aged over fifty: an economic evaluation of the Active Plus intervention.

BACKGROUND: The adverse health effects of insufficient physical activity (PA) result in high costs to society. The economic burden of insufficient PA, which increases in our aging population, stresses the urgency for cost-effective interventions to promote PA among older adults. The current study provides insight in the cost-effectiveness and cost-utility of different versions of a tailored PA intervention (Active Plus) among adults aged over fifty. METHODS: The intervention conditions (i.e. print-delivered basic (PB; N = 439), print-delivered environmental (PE; N = 435), Web-based basic (WB; N = 423), Web-based environmental (WE; N = 432)) and a waiting-list control group were studied in a clustered randomized controlled trial. Intervention costs were registered during the trial. Health care costs, participant costs and productivity losses were identified and compared with the intervention effects on PA (in MET-hours per week) and quality-adjusted life years (QALYs) 12 months after the start of the intervention. Cost-effectiveness ratios (ICERs) and cost-utility ratios (ICURs) were calculated per intervention condition. Non-parametric bootstrapping techniques and sensitivity analyses were performed to account for uncertainty. RESULTS: As a whole (i.e. the four intervention conditions together) the Active Plus intervention was found to be cost-effective. The PB-intervention (ICER = €-55/MET-hour), PE-intervention (ICER = €-94/MET-hour) and the WE-intervention (ICER = €-139/MET-hour) all resulted in higher effects on PA and lower societal costs than the control group. With regard to QALYs, the PB-intervention (ICUR = €38,120/QALY), the PE-intervention (ICUR = €405,892/QALY) and the WE-intervention (ICUR = €-47,293/QALY) were found to be cost-effective when considering a willingness-to-pay threshold of €20,000/QALY. In most cases PE had the highest probability to be cost-effective. CONCLUSIONS: The Active Plus intervention was found to be a cost-effective manner to increase PA in a population aged over fifty when compared to no-intervention. The tailored Active Plus intervention delivered through printed material and with additional environmental information (PE) turned out to be the most cost-effective intervention condition as confirmed by the different sensitivity analyses. By increasing PA at relatively low costs, the Active Plus intervention can contribute to a better public health. TRIAL REGISTRATION: Dutch Trial Register: NTR2297.

Preparing adolescents with chronic disease for transition to adult care: a technology program.

BACKGROUND: Adolescents with chronic disease (ACD) must develop independent disease self-management and learn to communicate effectively with their health care team to transition from pediatric to adult-oriented health care systems. Disease-specific interventions have been implemented to aid specific ACD groups through transition. A generic approach might be effective and cost-saving. METHODS: Eighty-one ACD, aged 12 to 20 years, were recruited for a randomized clinical trial evaluating an 8-month transition intervention (MD2Me). MD2Me recipients received a 2-month intensive Web-based and text-delivered disease management and skill-based intervention followed by a 6-month review period. MD2Me recipients also had access to a texting algorithm for disease assessment and health care team contact. The intervention was applicable to adolescents with diverse chronic illnesses. Controls received mailed materials on general health topics. Disease management, health-related self-efficacy, and health assessments were performed at baseline and at 2 and 8 months. Frequency of patient-initiated communications was recorded over the study period. Outcomes were analyzed according to assigned treatment group over time. RESULTS: MD2Me recipients demonstrated significant improvements in performance of disease management tasks, health-related self-efficacy, and patient-initiated communications compared with controls. CONCLUSIONS: Outcomes in ACD improved significantly among recipients of a generic, technology-based intervention. Technology can deliver transition interventions to adolescents with diverse chronic illnesses, and a generic approach offers a cost-effective means of positively influencing transition outcomes. Further research is needed to determine whether improved short-term outcomes translate into an improved transition for ACD.

Economic evaluation of a web-based tailored lifestyle intervention for adults: findings regarding cost-effectiveness and cost-utility from a randomized controlled trial.

BACKGROUND: Different studies have reported the effectiveness of Web-based computer-tailored lifestyle interventions, but economic evaluations of these interventions are scarce. OBJECTIVE: The objective was to assess the cost-effectiveness and cost-utility of a sequential and a simultaneous Web-based computer-tailored lifestyle intervention for adults compared to a control group. METHODS: The economic evaluation, conducted from a societal perspective, was part of a 2-year randomized controlled trial including 3 study groups. All groups received personalized health risk appraisals based on the guidelines for physical activity, fruit intake, vegetable intake, alcohol consumption, and smoking. Additionally, respondents in the sequential condition received personal advice about one lifestyle behavior in the first year and a second behavior in the second year; respondents in the simultaneous condition received personal advice about all unhealthy behaviors in both years. During a period of 24 months, health care use, medication use, absenteeism from work, and quality of life (EQ-5D-3L) were assessed every 3 months using Web-based questionnaires. Demographics were assessed at baseline, and lifestyle behaviors were assessed at both baseline and after 24 months. Cost-effectiveness and cost-utility analyses were performed based on the outcome measures lifestyle factor (the number of guidelines respondents adhered to) and quality of life, respectively. We accounted for uncertainty by using bootstrapping techniques and sensitivity analyses. RESULTS: A total of 1733 respondents were included in the analyses. From a willingness to pay of €4594 per additional guideline met, the sequential intervention (n=552) was likely to be the most cost-effective, whereas from a willingness to pay of €10,850, the simultaneous intervention (n=517) was likely to be most cost-effective. The control condition (n=664) appeared to be preferred with regard to quality of life. CONCLUSIONS: Both the sequential and the simultaneous lifestyle interventions were likely to be cost-effective when it concerned the lifestyle factor, whereas the control condition was when it concerned quality of life. However, there is no accepted cutoff point for the willingness to pay per gain in lifestyle behaviors, making it impossible to draw firm conclusions. Further economic evaluations of lifestyle interventions are needed. TRIAL REGISTRATION: Dutch Trial Register NTR2168; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2168 (Archived by WebCite at http://www.webcitation.org/6MbUqttYB).

Internet cigarette vendor compliance with credit card payment and shipping bans.

INTRODUCTION: Most Internet cigarette sales have violated taxation and youth access laws, leading to landmark 2005 agreements with credit card companies, PayPal, and private shippers (United Parcel Service, Federal Express, DHL) to cease participation in these transactions. Despite their promise at the time, loopholes allowed for check payment and U.S. Postal Service (USPS) shipping. This study assessed actual vendor compliance with the payment and shipping bans using a purchase survey. METHODS: In late 2007 and early 2008, an adult buyer attempted to order cigarettes from the 97 most popular Internet cigarette vendors (ICVs) using banned payment and shipping methods. When banned payment or shipping methods were unavailable, purchases were attempted with alternate methods (e.g., checks, e-checks, USPS). RESULTS: Twenty-seven of 100 orders were placed with (banned) credit cards; 23 were successfully received. Seventy-one orders were placed with checks (60 successfully received). Four orders were delivered using banned shippers; 79 of 83 successfully received orders were delivered by the USPS. CONCLUSIONS: About a quarter of ICVs violated the payment ban, others adapted by accepting checks. Most vendors complied with the shipping ban, perhaps because USPS was an easy substitute shipping option. Better enforcement of the bans is needed; the 2009 Prevent All Cigarette Trafficking Act closed the USPS loophole by making cigarettes nonmailable material; evaluation of enforcement efforts and adaptations by vendors are needed. These sorts of bans are a promising approach to controlling the sale of restricted goods online.