The Lifetime Health and Economic Burden of Smokeless Tobacco use in Bangladesh, India, and Pakistan: Results From ASTRAMOD.

INTRODUCTION: Under the current policy landscapes, the lifetime health and economic burden of smokeless tobacco (ST) products, consumed by over 297 million ST users in South Asia, is unknown. The aim of this study was to estimate the lifetime health effects and costs attributable to current and future ST use in Bangladesh, India, and Pakistan where the majority of ST users live. AIMS AND METHODS: We developed a Markov-based state-transition model (ASTRAMOD) to predict the lifetime costs of treatment of four diseases (oral, pharyngeal, esophageal cancers, and stroke) and disability-adjusted life years (DALYs), attributable to the current and future use of ST under existing ST policy scenario. Country-specific Global Adult Tobacco Surveys, life tables, and meta-analyses of South Asian and South East Asian studies were used to populate the model. A probabilistic sensitivity analysis evaluated the uncertainty in model predictions. RESULTS: If there were no change in the current ST policies, the lifetime ST-attributable treatment costs would be over US$19 billion in India, over US$1.5 billion in Bangladesh, and over US$3 billion in Pakistan. For all countries, the attributable costs are higher for younger cohorts with costs declining with increasing age for those over 50. The model predicted that a typical 15-year-old male adoloscent would gain 0.07-0.18 life years, avert 0.07-0.19 DALYs, and generate a cost-savings of US$7-21 on healthcare spending if ST policies were changed to eliminate ST use. CONCLUSIONS: Policy interventions aimed at decreasing the uptake of ST and increasing quitting success have the potential to substantially decrease the economic and health burden of ST. IMPLICATIONS: This study provides the most comprehensive estimates of the lifetime health and economic burden of ST by 5-year age and sex cohorts. This is also the first study that highlights the scale of health and economic burden of ST in Bangladesh, India, and Pakistan if there were no changes in the current ST policies. Policymakers and practitioners can use the reported data to justify their decisions to improve current ST policies and practices in their country. Researchers can use the ASTRAMOD methodology to estimate the impact of future ST policy changes.

The economic burden of multimorbidity: Protocol for a systematic review.

Multimorbidity, also known as multiple long-term conditions, leads to higher healthcare utilisation, including hospitalisation, readmission, and polypharmacy, as well as a financial burden to families, society, and nations. Despite some progress, the economic burden of multimorbidity remains poorly understood. This paper outlines a protocol for a systematic review that aims to identify and synthesise comprehensive evidence on the economic burden of multimorbidity, considering various definitions and measurements of multimorbidity, including their implications for future cost-of-illness analyses. The review will include studies involving people of all ages with multimorbidity without any restriction on location and setting. Cost-of-illness studies or studies that examined economic burden including model-based studies will be included, and economic evaluation studies will be excluded. Databases including Scopus (that includes PubMed/MEDLINE), Web of Science, CINAHL Plus, PsycINFO, NHS EED (including the HTA database), and the Cost-Effectiveness Analysis Registry, will be searched until March 2024. The risk of bias within included studies will be independently assessed by two authors using appropriate checklists. A narrative synthesis of the main characteristics and results, by definitions and measurements of multimorbidity, will be conducted. The total economic burden of multimorbidity will be reported as mean annual costs per patient and disaggregated based on counts of diseases, disease clusters, and weighted indices. The results of this review will provide valuable insights for researchers into the key cost components and areas that require further investigation in order to improve the rigour of future studies on the economic burden of multimorbidity. Additionally, these findings will broaden our understanding of the economic impact of multimorbidity, inform us about the costs of inaction, and guide decision-making regarding resource allocation and cost-effective interventions. The systematic review's results will be submitted to a peer-reviewed journal, presented at conferences, and shared via an online webinar for discussion.

Economic evaluations of interventional opportunities for the management of mental-physical multimorbidity: a systematic review.

OBJECTIVES: Economic evaluations of interventions for people with mental-physical multimorbidity, including a depressive disorder, are sparse. This study examines whether such interventions in adults are cost-effective. DESIGN: A systematic review. DATA SOURCES: MEDLINE, CINAHL Plus, PsycINFO, Cochrane CENTRAL, Scopus, Web of Science and NHS EED databases were searched until 5 March 2022. ELIGIBILITY CRITERIA: We included studies involving people aged ≥18 with two or more chronic conditions (one being a depressive disorder). Economic evaluation studies that compared costs and outcomes of interventions were included, and those that assessed only costs or effects were excluded. DATA EXTRACTION AND SYNTHESIS: Two authors independently assessed risk of bias in included studies using recommended checklists. A narrative analysis of the characteristics and results by type of intervention and levels of healthcare provision was conducted. RESULTS: A total of 19 studies, all undertaken in high-income countries, met inclusion criteria. Four intervention types were reported: collaborative care, self-management, telephone-based and antidepressant treatment. Most (14 of 19) interventions were implemented at the organisational level and were potentially cost-effective, particularly, the collaborative care for people with depressive disorder and diabetes, comorbid major depression and cancer and depression and multiple long-term conditions. Cost-effectiveness ranged from £206 per quality-adjusted life year (QALY) for collaborative care programmes for older adults with diabetes and depression at primary care clinics (USA) to £79 723 per QALY for combining collaborative care with improved opportunistic screening for adults with depressive disorder and diabetes (England). Conclusions on cost-effectiveness were constrained by methodological aspects of the included studies: choice of perspectives, time horizon and costing methods. CONCLUSIONS: Economic evaluations of interventions to manage multimorbidity with a depressive disorder are non-existent in low-income and middle-income countries. The design and reporting of future economic evaluations must improve to provide robust conclusions. PROSPERO REGISTRATION NUMBER: CRD42022302036.

Framework Convention on Tobacco Control 2030-A Program to Accelerate the Implementation of World Health Organization Framework Convention for Tobacco Control in Low- and Middle-Income Countries: A Mixed-Methods Evaluation.

BACKGROUND: Framework Convention on Tobacco Control (FCTC) 2030 Program (2017-2021) was launched to accelerate World Health Organization (WHO) FCTC implementation in 15 low- and middle-income countries (LMICs). We evaluated the Program in six domains: Governance; Smoke-Free Policies; Taxation; Packaging and Health Warnings; Tobacco Advertising, Promotion, and Sponsorship (TAPS) bans; and International and Regional Cooperation. AIMS AND METHODS: Following a mixed-methods design, we surveyed (June-September 2020) FCTC focal persons in 14 of the 15 countries, to understand the Program's financial and technical inputs and progress made in each of the six domains. The data were coded in terms of inputs (financial = 1, technical = 1, or both = 2) and progress (none = 1, some = 2, partial = 3, or strong = 4) and a correlation was computed between the inputs and progress scores for each domain. We conducted semi-structured interviews with key stakeholders in five countries. We triangulated between the survey and interview findings. RESULTS: FCTC 2030 offered substantial financial and technical inputs, responsive to country needs, across all six domains. There was a high positive correlation between technical inputs and progress in five of the six domains, ranging from r = 0.61 for taxation (p < .05) to r = 0.91 and for smoke-free policies (p < .001). The interviews indicated that the Program provided timely and relevant evidence and created opportunities for influencing tobacco control debates. CONCLUSIONS: The FCTC 2030 Program might have led to variable, but significant progress in advancing FCTC implementation in the 15 countries. As expected, much of the progress was in augmenting existing structures and resources for FCTC implementation. The resulting advances are likely to lead to further progress in FCTC policy implementation. IMPLICATIONS: What this study adds: In many LMICs, WHO FCTC policies are not in place; and even when enshrined in law, they are poorly enforced. It is not clear how financial and technical assistance to high tobacco-burden LMICs can most effectively accelerate the implementation of WHO FCTC policies and offer value for money. Bespoke and responsive assistance, both financial and technical, to LMICs aimed at accelerating the implementation of WHO FCTC policies are likely to lead to progress in tobacco control.

Behavioural support and nicotine replacement therapy for smokeless tobacco cessation: protocol for a pilot randomised-controlled multi-country trial.

BACKGROUND: Smokeless tobacco (ST) is consumed globally by more than 350 million people, with approximately 85% of all users based in South and Southeast Asia. In this region, ST products are cheap and easily accessible. Evidence-based interventions to people quit ST use are lacking. This study aims to test the feasibility of conducting a future definitive trial of ST cessation, using a culturally adapted behavioural intervention, and/or nicotine replacement therapy (NRT) in three South Asian countries. METHODS: We will conduct a factorial design, randomised-controlled pilot trial in Bangladesh, India and Pakistan. Daily ST users will be recruited from primary health care settings in Dhaka, Noida and Karachi. Participants will be individually randomised to receive intervention A (4 or 6 mg NRT chewing gum for 8-weeks), intervention B (BISCA: face-to-face behavioural support for ST cessation), a combination of interventions A and B or usual care (Very Brief Advice - VBA). The participants will provide demographic and ST use related data at baseline, and at 6, 12 and 26 weeks of follow-up. Salivary cotinine samples will be collected at baseline and 26 weeks. The analyses will undertake an assessment of the feasibility of recruitment, randomisation, data collection and participant retention, as well as the feasibility of intervention delivery. We will also identify potential cessation outcomes to inform the main trial, understand the implementation, context and mechanisms of impact through a process evaluation and, thirdly, establish health resource use and impact on the quality of life through health economic data. DISCUSSION: The widespread and continued use of ST products in South Asia is consistent with a high rate of associated diseases and negative impact on the quality of life. The identification of feasible, effective and cost-effective interventions for ST is necessary to inform national and regional efforts to reduce ST use at the population level. The findings of this pilot trial will inform the development of larger trials for ST cessation among South Asian users, with relevance to wider regions and populations having high rates of ST use. TRIAL REGISTRATION: ISRCTN identifier 65109397.

Research can be integrated into public health policy-making: global lessons for and from Spanish economic evaluations.

WHO promotes the use of research in policy-making to drive improvements in health, including in achieving Sustainable Development Goals such as tobacco control. The European Union's new €95 billion Horizon Europe research framework programme parallels these aims, and also includes commitments to fund economic evaluations. However, researchers often express frustration at the perceived lack of attention to scientific evidence during policy-making. For example, some researchers claim that evidence regarding the return on investment from optimal implementation of evidence-based policies is frequently overlooked. An increasingly large body of literature acknowledges inevitable barriers to research use, but also analyses facilitators encouraging such use. This opinion piece describes how some research is integrated into policy-making. It highlights two recent reviews. One examines impact assessments of 36 multi-project research programmes and identifies three characteristics of projects more likely to influence policy-making. These include a focus on healthcare system needs, engagement of stakeholders, and research conducted for organizations supported by structures to receive and use evidence. The second review suggests that such characteristics are likely to occur as part of a comprehensive national health research system strategy, especially one integrated into the healthcare system. We also describe two policy-informing economic evaluations conducted in Spain. These examined the most cost-effective package of evidence-based tobacco control interventions and the cost-effectiveness of different strategies to increase screening coverage for cervical cancer. Both projects focused on issues of healthcare concern and involved considerable stakeholder engagement. The Spanish examples reinforce some lessons from the global literature and, therefore, could help demonstrate to authorities in Spain the value of developing comprehensive health research systems, possibly following the interfaces and receptor model. The aim of this would be to integrate needs assessment and stakeholder engagement with structures spanning the research and health systems. In such structures, economic evaluation evidence could be collated, analysed by experts in relation to healthcare needs, and fed into both policy-making as appropriate, and future research calls. The increasingly large local and global evidence base on research utilization could inform detailed implementation of this approach once accepted as politically desirable. Given the COVID-19 pandemic, increasing the cost-effectiveness of healthcare systems and return on investment of public health interventions becomes even more important.

Determinants of Physical Activity and Dietary Habits among Adults in Ghana: A Cross-Sectional Study.

A critical understanding of the interrelationship between two behavioral decisions­participating in physical activity, and eating healthily­is lacking in Ghana. This study aimed to determine which factors affect each of the two behavioral decisions, jointly and separately, among adults aged 18 years or older in three metropolises (Kumasi, Accra, and Tamale) of Ghana. The data from the Ghana Obesity Survey 2021 were used. A bivariate probit model was fitted to estimate nonlinear models that indicate an individual's joint decision to participate in physical activity and consume a healthy diet. A positive correlation (r = 0.085; p < 0.05) was found between these two decisions, indicating a relationship between these two behavioral decisions. The common correlates between these decisions were self-reported good health status, high income, and attitudes toward being overweight. Men were more likely to be physically active but less likely to eat well. Both religion and culture determined participation in physical activity, but not the consumption of a healthy diet. Marital status determined diet, but not physical activity. The new knowledge gained from this analysis around the nature and the extent of the interconnectedness between physical activity and diet is critical to devising targeted interventions for obesity prevention in Ghana.

Determinants of COVID-19-Related Length of Hospital Stays and Long COVID in Ghana: A Cross-Sectional Analysis.

OBJECTIVES: There is paucity of data on determinants of length of COVID-19 admissions and long COVID, an emerging long-term sequel of COVID-19, in Ghana. Therefore, this study identified these determinants and discussed their policy implications. METHOD: Data of 2334 patients seen at the main COVID-19 treatment centre in Ghana were analysed in this study. Their characteristics, such as age, education level and comorbidities, were examined as explanatory variables. The dependent variables were length of COVID-19 hospitalisations and long COVID. Negative binomial and binary logistic regressions were fitted to investigate the determinants. RESULT: The regression analyses showed that, on average, COVID-19 patients with hypertension and diabetes mellitus spent almost 2 days longer in hospital (p = 0.00, 95% CI = 1.42-2.33) and had 4 times the odds of long COVID (95% CI = 1.61-10.85, p = 0.003) compared to those with no comorbidities. In addition, the odds of long COVID decreased with increasing patient's education level (primary OR = 0.73, p = 0.02; secondary/vocational OR = 0.26, p = 0.02; tertiary education OR = 0.23, p = 0.12). CONCLUSION: The presence of hypertension and diabetes mellitus determined both length of hospitalisation and long COVID among patients with COVID-19 in Ghana. COVID-19 prevention and management policies should therefore consider these factors.

Effectiveness of a population-based integrated care model in reducing hospital activity: an interrupted time series analysis.

Objectives: First impact assessment analysis of an integrated care model (ICM) to reduce hospital activity in the London Borough of Hillingdon, UK. Methods: We evaluated a population-based ICM consisting of multiple interventions based on self-management, multidisciplinary teams, case management and discharge management. The sample included 331 330 registered Hillingdon residents (at the time of data extraction) between October 2018 and July 2020. Longitudinal data was extracted from the Whole Systems Integrated Care database. Interrupted time series Poisson and Negative binomial regressions were used to examine changes in non-elective hospital admissions (NEL admissions), accident and emergency visits (A&E) and length of stay (LoS) at the hospital. Multiple imputations were used to replace missing data. Subgroup analysis of various groups with and without long-term conditions (LTC) was also conducted using the same models. Results: In the whole registered population of Hillingdon at the time of data collection, gradual decline over time in NEL admissions (RR 0.91, 95% CI 0.90 to 0.92), A&E visits (RR 0.94, 95% CI 0.93 to 0.95) and LoS (RR 0.93, 95% CI 0.92 to 0.94) following an immediate increase during the first months of implementation in the three outcomes was observed. Subgroup analysis across different groups, including those with and without LTCs, showed similar effects. Sensitivity analysis did not show a notable change compared with the original analysis. Conclusion: The Hillingdon ICM showed effectiveness in reducing NEL admissions, A&E visits and LoS. However, further investigations and analyses could confirm the results of this study and rule out the potential effects of some confounding events, such as the emergence of COVID-19 pandemic.

Effectiveness of integrated care interventions for patients with long-term conditions: a review of systematic reviews.

To examine the effectiveness of integrated care intervention (ICI) models (stand-alone or combination of self-management, discharge management, case management and multidisciplinary teams models) targeting patients with one or more chronic conditions, and to identify outcome measures/indicators of effectiveness, we conducted a systematic review of published systematic reviews and meta-analyses. Included reviews comprise ICIs targeting adult patients with one or more long-term conditions. We searched MEDLINE, CINAHL and the Cochrane Database of Systematic Reviews: 60 reviews were included in the final analysis; 28 reviews evaluated ICIs focused on self-management, 4 on case management, 10 on discharge management and 5 on multidisciplinary teams; 13 reviews assessed multiple interventions that were labelled as complex. Across all reviews, only 19 reviews included intervention with multiple ICIs. Overall, interventions with multiple components, compared with interventions with single components, were more likely to improve hospital use outcomes effectively. Clinical/lifestyle/condition-specific outcomes were more likely to be improved by self-management interventions. Outcome measures identified could be classified into three main categories: organisational, patient-centred and clinical/lifestyle/condition-specific. The findings of this review may provide inputs to future design and evaluation of ICIs.

Cytisine versus varenicline for smoking cessation in New Zealand indigenous Maori: a randomized controlled trial.

AIM: To determine whether cytisine was at least as effective as varenicline in supporting smoking abstinence for ≥ 6 months in New Zealand indigenous Maori or whanau (extended-family) of Maori, given the high smoking prevalence in this population. DESIGN: Pragmatic, open-label, randomized, community-based non-inferiority trial. SETTING: Bay of Plenty, Tokoroa and Lakes District Health Board regions of New Zealand. PARTICIPANTS: Adult daily smokers who identified as Maori or whanau of Maori, were motivated to quit in the next 2 weeks, were aged ≥ 18 years and were eligible for subsidized varenicline. Recruitment used multi-media advertising. INTERVENTIONS: A total of 679 people were randomly assigned (1 : 1) to receive a prescription for 12 weeks of cytisine or varenicline, plus low-intensity cessation behavioural support from the prescribing doctor and community stop-smoking services or a research assistant. Day 5 of treatment was the designated quit date. MEASUREMENTS: The primary outcome was carbon monoxide-verified continuous abstinence at 6 months, analysed as intention-to-treat (with multiple imputation for missing data). Secondary outcomes measured at 1, 3, 6 and 12 months post-quit date included: self-reported continuous abstinence, 7-day point prevalence abstinence, cigarettes per day, time to (re)lapse, adverse events, treatment adherence/compliance and acceptability, nicotine withdrawal/urge to smoke and health-care utilization/health-related quality of life. FINDINGS: Verified continuous abstinence rates at 6 months post-quit date were 12.1% (41 of 337) for cytisine versus 7.9% (27 of 342) for varenicline [risk difference 4.29%, 95% confidence interval (CI) = -0.22 to 8.79; relative risk 1.55; 95% CI = 0.97-2.46]. Sensitivity analyses confirmed that the findings were robust. Self-reported adverse events over 6 months occurred significantly more frequently in the varenicline group (cytisine: 313 events in 111 participants; varenicline: 509 events in 138 participants, incidence rate ratio 0.56, 95% CI = 0.49-0.65, P < 0.001) compared with the cytisine group. Common adverse events were headache, nausea and difficulty sleeping. CONCLUSION: A randomized controlled trial found that cytisine was at least as effective as varenicline at supporting smoking abstinence in New Zealand indigenous Maori or whanau (extended-family) of Maori, with significantly fewer adverse events.

Economics of physical activity in low-income and middle- income countries: a systematic review.

BACKGROUND: Promotion of physical activity (PA) among populations is a global health investment. However, evidence on economic aspects of PA is sparse and scattered in low-income and middle-income countries (LMICs). OBJECTIVE: The objective of this study was to summarise the available evidence on economics of PA in LMICs, identify potential target variables for policy and report gaps in the existing economic evidence alongside research recommendations. DATA SOURCES: A systematic review of the electronic databases (Scopus, Web of Science and SPORTDiscus) and grey literature. STUDY ELIGIBILITY CRITERIA: Cost-of-illness studies, economic evaluations, interventions and descriptive studies on economic factors associated with PA using preset eligibility criteria. STUDY APPRAISAL AND SYNTHESIS OF METHODS: Screening, study selection and quality appraisal based on standard checklists performed by two reviewers with consensus of a third reviewer. Descriptive synthesis of data was performed. RESULTS: The majority of the studies were from upper-middle-income countries (n=16, 88.8%) and mainly from Brazil (n=9, 50%). Only one economic evaluation study was found. The focus of the reviewed literature spanned the economic burden of physical inactivity (n=4, 22%), relationship between PA and costs (n=6, 46%) and socioeconomic determinants of PA (n=7, 39%). The findings showed a considerable economic burden due to insufficient PA, with LMICs accounting for 75% of disability-adjusted life years (DALYs) globally due to insufficient PA. Socioeconomic correlates of PA were identified, and inverse relationship of PA with the cost of chronic diseases was established. Regular PA along with drug treatment as a treatment scheme for chronic diseases showed advantages with a cost-utility ratio of US$3.21/quality-adjusted life year (QALY) compared with the drug treatment-only group (US$3.92/QALY) by the only economic evaluation conducted in the LMIC, Brazil. LIMITATIONS: Meta-analysis was not performed due to heterogeneity of the studies. CONCLUSIONS AND RECOMMENDATIONS: Economic evaluation studies for PA promotion interventions/strategies and local research from low-income countries are grossly inadequate. Setting economic research agenda in LMICs ought to be prioritised in those areas. PROSPERO REGISTRATION NUMBER: CRD42018099856.

How to strengthen a health research system: WHO's review, whose literature and who is providing leadership?

BACKGROUND: Health research is important for the achievement of the Sustainable Development Goals. However, there are many challenges facing health research, including securing sufficient funds, building capacity, producing research findings and using both local and global evidence, and avoiding waste. A WHO initiative addressed these challenges by developing a conceptual framework with four functions to guide the development of national health research systems. Despite some progress, more is needed before health research systems can meet their full potential of improving health systems. The WHO Regional Office for Europe commissioned an evidence synthesis of the systems-level literature. This Opinion piece considers its findings before reflecting on the vast additional literature available on the range of specific health research system functions related to the various challenges. Finally, it considers who should lead research system strengthening. MAIN TEXT: The evidence synthesis identifies two main approaches for strengthening national health research systems, namely implementing comprehensive and coherent strategies and participation in partnerships. The literature describing these approaches at the systems level also provides data on ways to strengthen each of the four functions of governance, securing financing, capacity-building, and production and use of research. Countries effectively implementing strategies include England, Ireland and Rwanda, whereas West Africa experienced effective partnerships. Recommended policy approaches for system strengthening are context specific. The vast literature on each function and the ever-growing evidence-base are illustrated by considering papers in just one key journal, Health Research Policy and Systems, and analysing the contribution of two national studies. A review of the functions of the Iranian system identifies over 200 relevant and mostly national records; an analysis of the creation of the English National Institute for Health Research describes the key leadership role played by the health department. Furthermore, WHO is playing leadership roles in helping coordinate partnerships within and across health research systems that have been attempting to tackle the COVID-19 crisis. CONCLUSIONS: The evidence synthesis provides a firm basis for decision-making by policy-makers and research leaders looking to strengthen national health research systems within their own national context. It identifies five crucial policy approaches - conducting situation analysis, sustaining a comprehensive strategy, engaging stakeholders, evaluating impacts on health systems, and partnership participation. The vast and ever-growing additional literature could provide further perspectives, including on crucial leadership roles for health ministries.

Sports Participation and Health Care Costs in Older Adults Aged 50 Years or Older.

The objective of the study was to analyze the relationship between sports participation and health care costs in older adults. The sample was composed of 556 participants (145 men and 411 women) who were followed from 2010 to 2014. The engagement in sports considered three different components (intensity, volume, and previous time). Health care costs were assessed annually through medical records. Structural equation modeling (longitudinal relationship between sport and costs) and analysis of variance for repeated measures (comparisons over time) were used. Health care costs increased significantly from 2010 to 2014 (analysis of variance; p value = .001). Higher baseline scores for intensity were related to lower health care costs (r = -.223, 95% confidence interval [-.404, -.042]). Similar results were found to volume (r = -.216, 95% confidence interval [-.396, -.036]) and time of engagement (r = -.218, 95% confidence interval [-.402, -.034]). In conclusion, higher sports participation is related to lower health care costs in older adults.

Identification of Policy Priorities to Address the Burden of Smokeless Tobacco in Pakistan: A Multimethod Analysis.

INTRODUCTION: We assessed the magnitude of smokeless tobacco (ST) use in Pakistan and identified policy gaps to help ascertain short-, medium-, and long-term priorities. We then elicited stakeholders' views as to which of these identified priorities are most important. METHODS: In a multimethod study, we: analyzed Global Tobacco Surveillance System data sets to estimate ST consumption and disease burden; conducted a documentary review to identify gaps in policies to control ST in comparison with smoking; elicited stakeholders' views in an interactive workshop to identify a set of policy options available to address ST burden in Pakistan; and ranked policy priorities using a postevent survey. RESULTS: Among all tobacco users in Pakistan (n = 24 million), one-third of men and two-thirds of women consume ST. In 2017, its use led to an estimated 18 711 deaths due to cancer and ischemic heart disease. Compared to smoking, policies to control ST lag behind significantly. Priority areas for ST policies included: banning ST sale to and by minors, advocacy campaigns, introduction of licensing, levying taxes on ST, and standardizing ST packaging. A clear commitment to close cooperation between state actors and stakeholder groups is needed to create a climate of support and information for effective policy making. CONCLUSIONS: Smokeless tobacco control in Pakistan should focus on four key policy instruments: legislation, education, fiscal policies, and quit support. More research into the effectiveness of such policies is also needed. IMPLICATIONS: A number of opportunities to improve ST regulation in Pakistan were identified. Among these, immediate priorities include banning ST sale to and by minors, mobilizing advocacy campaign, introduction of licensing through the 1958 Tobacco Vendors Act, levying taxes on ST, and standardizing ST packaging.

What is the evidence on policies, interventions and tools for establishing and/or strengthening national health research systems and their effectiveness?

High-quality research is important for improving population health and well-being and for achieving the health-related Sustainable Development Goals. The challenges facing individuals, organizations and countries in securing research funding and building research capacity, and then using these resources effectively, have led to renewed interest in adopting a systems approach to national health research systems strengthening. This report found that health research strategies play a key role in combining the diverse interventions to strengthen specific health research system functions into an overall system. Good practices in research systems strengthening were identified as health ministry involvement in and sustained political commitment to the comprehensive research strategy, and, where appropriate, integration of the health research system into the wider health system. Policy considerations include actions to ensure a contextual analysis to inform a comprehensive strategy; stakeholder engagement, including in priority-setting; monitoring and evaluation tools focused on system objectives; and partnerships.

What is the evidence on policies, interventions and tools for establishing and/or strengthening national health research systems and their effectiveness?

High-quality research is important for improving population health and well-being and for achieving the health-related Sustainable Development Goals. The challenges facing individuals, organizations and countries in securing research funding and building research capacity, and then using these resources effectively, have led to renewed interest in adopting a systems approach to national health research systems strengthening. This report found that health research strategies play a key role in combining the diverse interventions to strengthen specific health research system functions into an overall system. Good practices in research systems strengthening were identified as health ministry involvement in and sustained political commitment to the comprehensive research strategy, and, where appropriate, integration of the health research system into the wider health system. Policy considerations include actions to ensure a contextual analysis to inform a comprehensive strategy; stakeholder engagement, including in priority-setting; monitoring and evaluation tools focused on system objectives; and partnerships.

Measuring the effects on quality of life and alcohol consumption of a program to reduce binge drinking in Spanish adolescents.

AIM: To present a comparison between the effects on health due to a reduction in binge drinking (BD) and health-related quality of life (HRQoL), as a result of ALERTA ALCOHOL, an intervention aimed at reducing BD in Spanish adolescents. METHODS: A two-arm cluster randomized controlled trial was conducted with an intervention and a control group, randomized at the school level, following individuals over four months. The study population consisted of Andalusian adolescents aged 15 to 19 years who were enrolled in urban public high schools (n = 1247). Participants were assigned randomly to receive the intervention. The main outcomes studied were the number of occasions of BD in the last 30 days, which was directly obtained from the answers given by the adolescents, and HRQoL measured with the EQ-5D-5 L questionnaire. The model of estimation was the generalized estimating equations (GEE) approach. RESULTS: The program showed a BD reduction at the 4-month follow-up, although it was not shown to significantly increase the HRQoL in adolescents who reduced the number of occasions of BD and had received the intervention. However, it was shown that those who would predictably reduce the number of occasions of BD controlled by several sociodemographic variables perceived a higher HRQoL, as did those who had a greater adherence to the program. CONCLUSIONS: Higher adherence to a web-based computer-tailored intervention to prevent BD in adolescents has a positive effect on decreasing the number of occasions of BD in adolescents as well as on increasing participants' HRQoL, although this second effect is very small, which could be due to the short follow-up time. This fact is quite important and should be assessed extensively to corroborate the results and translate into health policy.

Envisioning and shaping translation of knowledge into action: A comparative case-study of stakeholder engagement in the development of a European tobacco control tool.

Stakeholder engagement in health policy research is often said to increase 'research impact', but the active role of stakeholders in creating impact remains underexplored. We explored how stakeholders shaped the translation of health policy research into action. Our comparative case-study tracked a European research project that aimed to transfer an existing tobacco control return on investment tool. That project also aimed to increase its impact by engaging with stakeholders in further developing the tool. We conducted semi-structured interviews, using an actor-scenario mapping approach. Actor-scenarios can be seen as relational descriptions of a future world. We mapped the scenarios by asking stakeholders to describe who and what would play a role in the tool's utilisation. Our results show that stakeholders envisioned disparate futures for the tool. Some scenarios were specific, whereas most were generic projections of abstract potential users and responsibilities. We show how stakeholders mobilised elements of context, such as legislative support and agricultural practice, that would affect the tool's use. We conclude that stakeholders shape knowledge translation processes by continuously putting forth explicit or implicit scenarios about the future. Mapping actor-scenarios may help in aligning knowledge production with utilisation. Insights into potential roles and responsibilities could be fed back in research projects with the aim of increasing the likelihood that the study results may be used.

The Relationship between Lifestyle and Costs Related to Medicine Use in Adults / Relação entre Estilo de Vida e Custos Relacionados ao Uso de Medicamentos em Adultos

Abstract Background: The unhealthy lifestyle is growing and this can have repercussions on health status demanding actions on the occurrence of diseases and leads to increased expenses. Objective: To examine the interrelationship between the costs of medicine use and lifestyle behaviors. Methods: A cohort study with 118 participants, age around 51.7 ± 7.1 years old. It was collected personal and anthropometric data and information about medicine of continuous use to calculate the costs. Lifestyle variables included habitual physical activity (PA) assessed by pedometer, sedentary behavior by Baecke questionnaire, sleep quality by mini sleep questionnaire and self-report of smoke and alcohol consumption. Statistical analyses were performed by BioEstat (version 5.2) and the significance level set at p-value < 0.05. Results: In 12 months, 62 subjects bought 172 medicines, representing an overall cost of US$ 3,087.01. Expenditures with drugs were negatively related to PA (r = -0.194, p-value = 0.035 and r = -0.281, p-value = 0.002), but positively related with sleep quality (r = 0.299, p-value=0.001 and r = 0.315, p-value = 0.001) and age (r = 0.274, p-value = 0.003). Four multivariate models were executed considering lifestyle behaviors in different moments of cohort and medicine costs, and all these models identify important relationship between lifestyle behaviors with expenditures with drugs. Conclusion: Worse sleep quality seems to increase the costs related to medicine use in adults, while obesity and ageing play a relevant role in this phenomenon and alcohol consumption seems a variable with relevant economic impact.

Resumo Fundamento: O estilo de vida pouco saudável está se expandindo e isso pode ter repercussões no estado de saúde, exigindo ações contra a ocorrência de doenças e levando ao aumento de gastos. Objetivo: Examinar a interrelação entre os custos do uso de medicamentos e comportamentos de estilo de vida. Métodos: Estudo de coorte com 118 participantes com idade de 51,7 ± 7,1 anos. Foram coletados dados pessoais e antropométricos e informações sobre medicamentos de uso contínuo para calcular os custos. As variáveis de estilo de vida incluíram: atividade física (AF) habitual, avaliada por pedômetro; comportamento sedentário, pelo questionário de Baecke; qualidade do sono, através do Mini Questionário do Sono, e autorrelato de tabagismo e consumo de álcool. As análises estatísticas foram realizadas no programa BioEstat (versão 5.2), e o nível de significância estabelecido como p < 0,05. Resultados: Em 12 meses, 62 indivíduos compraram 172 medicamentos, representando um custo total de US$ 3.087,01. Gastos com medicamentos foram negativamente relacionados à AF (r = -0,194, p-valor = 0,035 e r = -0,281, p-valor = 0,002), mas relacionaram-se positivamente com a qualidade do sono (r = 0,299, p-valor=0,001 e r=0,315, p-valor = 0,001) e idade (r = 0,274, p-valor = 0,003). Quatro modelos multivariados foram executados, considerando os comportamentos de estilo de vida em diferentes momentos da coorte e custos dos medicamentos, e todos esses modelos identificam relações importantes entre comportamentos de estilo de vida e gastos com medicamentos. Conclusão: A pior qualidade do sono parece aumentar os custos relacionados ao uso de medicamentos em adultos, enquanto a obesidade e o envelhecimento desempenham um papel relevante nesse fenômeno, e o consumo de álcool parece ser uma variável com impacto econômico significativo.