Health, economic, and equity consequences of future tobacco control policies in England: a microsimulation study.

BACKGROUND: Smoking still generates a huge, costly, and inequitable burden of disease. The UK tobacco-free generation target to reduce smoking prevalence to below 5% by 2030 will be missed if current trends continue. We aimed to determine whether additional policies could speed progress towards meeting the tobacco-free generation target. METHODS: We developed, calibrated, and validated a microsimulation model, IMPACTHINT simulating English adults aged 30-89 years from 2023 to 2072. The model included a detailed smoking history and quantified policy health outcomes including smoking prevalence and smoking-related diseases, economics, and equity. We simulated five scenarios: (1) baseline trends; (2) increasing the minimum age of access to tobacco to 21 years (MinAge21); (3) a 30% increase in tobacco duty (TaxUP); (4) improved smoking cessation services (ServicesUP); and (5) a combination of TaxUP and ServicesUP. We estimated the smoking prevalence, smoking-related diseases and cumulative cases prevented or postponed, and deaths. We evaluated the scenario cost-effectiveness from the societal perspective. Lastly, we analysed the results by deprivation quintile. We present in our findings cumulative cases prevented or postponed over 50 years. FINDINGS: None of the scenarios would reduce overall smoking prevalence to below 5% by 2030. However, that goal could be reached by 2035 under the TaxUP and the combination of TaxUP and ServicesUP scenarios, by 2037 under the ServicesUP scenario, or by 2038 under the MinAge21 and the baseline scenarios. By 2072, the combined scenario might reduce smoking-related diseases by 160 000 cases (95% CI 140 000-200 000), greatly exceeding the reductions by 140 000 cases (120 000-180 000) with TaxUP, 69 000 cases (53 000-86 000) with MinAge21, or 22 000 cases (14 000-31 000) with ServicesUP. Some 50% of all disease-years reduced by TaxUP would occur in the most deprived quintile. The most affluent quintile could reach the 5% goal sooner than the most deprived quintile (by 2032 for the least deprived vs 2038 for the most deprived), and it could reach the 5% target by 2030 under the combined TaxUP and ServicesUP scenario. Finally, all policies would save costs compared with the baseline trend. INTERPRETATION: Affluent groups will achieve the 5% tobacco-free goal a decade sooner than the most deprived. However, that goal could be achieved in all groups by 2035 through a 30% increase in tax and enhanced smoking cessation services. Our limitations included the uncertainties of any 50-year forecast. However, that long time-horizon can capture the potential policy benefits for younger age groups. FUNDING: Economic and Social Research Council.

Identifying best modelling practices for tobacco control policy simulations: a systematic review and a novel quality assessment framework.

BACKGROUND: Policy simulation models (PSMs) have been used extensively to shape health policies before real-world implementation and evaluate post-implementation impact. This systematic review aimed to examine best practices, identify common pitfalls in tobacco control PSMs and propose a modelling quality assessment framework. METHODS: We searched five databases to identify eligible publications from July 2013 to August 2019. We additionally included papers from Feirman et al for studies before July 2013. Tobacco control PSMs that project tobacco use and tobacco-related outcomes from smoking policies were included. We extracted model inputs, structure and outputs data for models used in two or more included papers. Using our proposed quality assessment framework, we scored these models on population representativeness, policy effectiveness evidence, simulated smoking histories, included smoking-related diseases, exposure-outcome lag time, transparency, sensitivity analysis, validation and equity. FINDINGS: We found 146 eligible papers and 25 distinct models. Most models used population data from public or administrative registries, and all performed sensitivity analysis. However, smoking behaviour was commonly modelled into crude categories of smoking status. Eight models only presented overall changes in mortality rather than explicitly considering smoking-related diseases. Only four models reported impacts on health inequalities, and none offered the source code. Overall, the higher scored models achieved higher citation rates. CONCLUSIONS: While fragments of good practices were widespread across the reviewed PSMs, only a few included a 'critical mass' of the good practices specified in our quality assessment framework. This framework might, therefore, potentially serve as a benchmark and support sharing of good modelling practices.

Putting a price on healthy eating: public perceptions of the need for further food pricing policies in the UK.

BACKGROUND: Understand factors that influence food choice and explore public perceptions of the need for government policies to improve diets in the UK, particularly food pricing interventions. METHODS: A qualitative study design was used with semi-structured interviews. The study was carried out in Greater Manchester, England. In all, 15 participants from a diverse range of backgrounds were recruited. RESULTS: Food price, lack of time, availability, and food knowledge and culture were key factors that led some study participants towards unhealthy food choices. The UK's individual, willpower-focused approach to tackling obesity was deemed ineffective and many participants supported further government intervention. Product reformulation was supported as a less intrusive and less regressive way of improving diets than taxation. There was also support for increasing cooking classes within schools. CONCLUSIONS: Whilst the government ambition to half childhood obesity by 2030 is welcome, population level interventions that enable healthier food choices are needed to achieve this goal. Rising global food prices may make reformulation a more practical policy option than further pricing interventions. Mandatory reformulation of convenience meal and snack products and strengthening education in schools may represent a publicly acceptable and effective package of interventions within a comprehensive strategy to tackle obesity.

The American Heart Association 2030 Impact Goal: A Presidential Advisory From the American Heart Association.

Each decade, the American Heart Association (AHA) develops an Impact Goal to guide its overall strategic direction and investments in its research, quality improvement, advocacy, and public health programs. Guided by the AHA's new Mission Statement, to be a relentless force for a world of longer, healthier lives, the 2030 Impact Goal is anchored in an understanding that to achieve cardiovascular health for all, the AHA must include a broader vision of health and well-being and emphasize health equity. In the next decade, by 2030, the AHA will strive to equitably increase healthy life expectancy beyond current projections, with global and local collaborators, from 66 years of age to at least 68 years of age across the United States and from 64 years of age to at least 67 years of age worldwide. The AHA commits to developing additional targets for equity and well-being to accompany this overarching Impact Goal. To attain the 2030 Impact Goal, we recommend a thoughtful evaluation of interventions available to the public, patients, providers, healthcare delivery systems, communities, policy makers, and legislators. This presidential advisory summarizes the task force's main considerations in determining the 2030 Impact Goal and the metrics to monitor progress. It describes the aspiration that these goals will be achieved by working with a diverse community of volunteers, patients, scientists, healthcare professionals, and partner organizations needed to ensure success.

Estimating the health and economic effects of the voluntary sodium reduction targets in Brazil: microsimulation analysis.

BACKGROUND: Excessive sodium consumption is one of the leading dietary risk factors for non-communicable diseases, including cardiovascular disease (CVD), mediated by high blood pressure. Brazil has implemented voluntary sodium reduction targets with food industries since 2011. This study aimed to analyse the potential health and economic impact of these sodium reduction targets in Brazil from 2013 to 2032. METHODS: We developed a microsimulation of a close-to-reality synthetic population (IMPACTNCD-BR) to evaluate the potential health benefits of setting voluntary upper limits for sodium content as part of the Brazilian government strategy. The model estimates CVD deaths and cases prevented or postponed, and disease treatment costs. Model inputs were informed by the 2013 National Health Survey, the 2008-2009 Household Budget Survey, and high-quality meta-analyses, assuming that all individuals were exposed to the policy proportionally to their sodium intake from processed food. Costs included costs of the National Health System on CVD treatment and informal care costs. The primary outcome measures of the model are cardiovascular disease cases and deaths prevented or postponed over 20 years (2013-2032), stratified by age and sex. RESULTS: The study found that the application of the Brazilian voluntary sodium targets for packaged foods between 2013 and 2032 could prevent or postpone approximately 110,000 CVD cases (95% uncertainty intervals (UI): 28,000 to 260,000) among men and 70,000 cases among women (95% UI: 16,000 to 170,000), and also prevent or postpone approximately 2600 CVD deaths (95% UI: - 1000 to 11,000), 55% in men. The policy could also produce a net cost saving of approximately US$ 220 million (95% UI: US$ 54 to 520 million) in medical costs to the Brazilian National Health System for the treatment of CHD and stroke and save approximately US$ 71 million (95% UI: US$ 17 to170 million) in informal costs. CONCLUSION: Brazilian voluntary sodium targets could generate substantial health and economic impacts. The reduction in sodium intake that was likely achieved from the voluntary targets indicates that sodium reduction in Brazil must go further and faster to achieve the national and World Health Organization goals for sodium intake.

Potential impact of diabetes prevention on mortality and future burden of dementia and disability: a modelling study.

AIMS/HYPOTHESIS: Diabetes is associated with an increased risk of dementia. We estimated the potential impact of trends in diabetes prevalence upon mortality and the future burden of dementia and disability in England and Wales. METHODS: We used a probabilistic multi-state, open cohort Markov model to integrate observed trends in diabetes, cardiovascular disease and dementia to forecast the occurrence of disability and dementia up to the year 2060. Model input data were taken from the English Longitudinal Study of Ageing, Office for National Statistics vital data and published effect estimates for health-state transition probabilities. The baseline scenario corresponded to recent trends in obesity: a 26% increase in the number of people with diabetes by 2060. This scenario was evaluated against three alternative projected trends in diabetes: increases of 49%, 20% and 7%. RESULTS: Our results suggest that changes in the trend in diabetes prevalence will lead to changes in mortality and incidence of dementia and disability, which will become visible after 10-15 years. If the relative prevalence of diabetes increases 49% by 2060, expected additional deaths would be approximately 255,000 (95% uncertainty interval [UI] 236,000-272,200), with 85,900 (71,500-101,600) cumulative additional cases of dementia and 104,900 (85,900-125,400) additional cases of disability. With a smaller relative increase in diabetes prevalence (7% increase by 2060), we estimated 222,200 (205,700-237,300) fewer deaths, and 77,000 (64,300-90,800) and 93,300 (76,700-111,400) fewer additional cases of dementia and disability, respectively, than the baseline case of a 26% increase in diabetes. CONCLUSIONS/INTERPRETATION: Reducing the burden of diabetes could result in substantial reductions in the incidence of dementia and disability over the medium to long term.

Cost-Effectiveness of the US Food and Drug Administration Added Sugar Labeling Policy for Improving Diet and Health.

BACKGROUND: Excess added sugars, particularly from sugar-sweetened beverages, are a major risk factor for cardiometabolic diseases including cardiovascular disease and type 2 diabetes mellitus. In 2016, the US Food and Drug Administration mandated the labeling of added sugar content on all packaged foods and beverages. Yet, the potential health impacts and cost-effectiveness of this policy remain unclear. METHODS: A validated microsimulation model (US IMPACT Food Policy model) was used to estimate cardiovascular disease and type 2 diabetes mellitus cases averted, quality-adjusted life-years, policy costs, health care, informal care, and lost productivity (health-related) savings and cost-effectiveness of 2 policy scenarios: (1) implementation of the US Food and Drug Administration added sugar labeling policy (sugar label), and (2) further accounting for corresponding industry reformulation (sugar label+reformulation). The model used nationally representative demographic and dietary intake data from the National Health and Nutrition Examination Survey, disease data from the Centers for Disease Control and Prevention Wonder Database, policy effects and diet-disease effects from meta-analyses, and policy and health-related costs from established sources. Probabilistic sensitivity analysis accounted for model parameter uncertainties and population heterogeneity. RESULTS: Between 2018 and 2037, the sugar label would prevent 354 400 cardiovascular disease (95% uncertainty interval, 167 000-673 500) and 599 300 (302 400-957 400) diabetes mellitus cases, gain 727 000 (401 300-1 138 000) quality-adjusted life-years, and save $31 billion (15.7-54.5) in net healthcare costs or $61.9 billion (33.1-103.3) societal costs (incorporating reduced lost productivity and informal care costs). For the sugar label+reformulation scenario, corresponding gains were 708 800 (369 200-1 252 000) cardiovascular disease cases, 1.2 million (0.7-1.7) diabetes mellitus cases, 1.3 million (0.8-1.9) quality-adjusted life-years, and $57.6 billion (31.9-92.4) and $113.2 billion (67.3-175.2), respectively. Both scenarios were estimated with >80% probability to be cost saving by 2023. CONCLUSIONS: Implementing the US Food and Drug Administration added sugar labeling policy could generate substantial health gains and cost savings for the US population.

Universal or targeted cardiovascular screening? Modelling study using a sector-specific distributional cost effectiveness analysis.

Distributional cost effectiveness analysis is a new method that can help to redesign prevention programmes by explicitly modelling the distribution of health opportunity costs as well as the distribution of health benefits. Previously we modelled cardiovascular disease (CVD) screening audit data from Liverpool, UK to see if the city could redesign its cardiovascular screening programme to enhance its cost effectiveness and equity. Building on this previous analysis, we explicitly examined the distribution of health opportunity costs and we looked at new redesign options co-designed with stakeholders. We simulated four plausible scenarios: a) no CVD screening, b) 'current' basic universal CVD screening as currently implemented, c) enhanced universal CVD screening with 'increased' population-wide delivery, and d) 'universal plus targeted' with top-up delivery to the most deprived fifth. We also compared assumptions around whether displaced health spend would come from programmes that might benefit the poor more and how much health these programmes would generate. The main outcomes were net health benefit and change in the slope index of inequality (SII) in QALYs per 100,000 person years. 'Universal plus targeted' dominated 'increased' and 'current' and also reduced health inequality by -0.65 QALYs per 100,000 person years. Results are highly sensitive to assumptions about opportunity costs and, in particular, whether funding comes from health care or local government budgets. By analysing who loses as well as who gains from expenditure decisions, distributional cost effectiveness analysis can help decision makers to redesign prevention programmes in ways that improve health and reduce health inequality.

Engaging with stakeholders to inform the development of a decision-support tool for the NHS health check programme: qualitative study.

BACKGROUND: The NHS Health Check Programme is a risk-reduction programme offered to all adults in England aged 40-74 years. Previous studies mainly focused on patient perspectives and programme delivery; however, delivery varies, and costs are substantial. We were therefore working with key stakeholders to develop and co-produce an NHS Health Check Programme modelling tool (workHORSE) for commissioners to quantify local effectiveness, cost-effectiveness, and equity. Here we report on Workshop 1, which specifically aimed to facilitate engagement with stakeholders; develop a shared understanding of current Health Check implementation; identify what is working well, less well, and future hopes; and explore features to include in the tool. METHODS: This qualitative study identified key stakeholders across the UK via networking and snowball techniques. The stakeholders spanned local organisations (NHS commissioners, GPs, and academics), third sector and national organisations (Public Health England and The National Institute for Health and Care Excellence). We used the validated Hovmand "group model building" approach to engage stakeholders in a series of pre-piloted, structured, small group exercises. We then used Framework Analysis to analyse responses. RESULTS: Fifteen stakeholders participated in workshop 1. Stakeholders identified continued financial and political support for the NHS Health Check Programme. However, many stakeholders highlighted issues concerning lack of data on processes and outcomes, variability in quality of delivery, and suboptimal public engagement. Stakeholders' hopes included maximising coverage, uptake, and referrals, and producing additional evidence on population health, equity, and economic impacts. Key model suggestions focused on developing good-practice template scenarios, analysis of broader prevention activities at local level, accessible local data, broader economic perspectives, and fit-for-purpose outputs. CONCLUSIONS: A shared understanding of current implementations of the NHS Health Check Programme was developed. Stakeholders demonstrated their commitment to the NHS Health Check Programme whilst highlighting the perceived requirements for enhancing the service and discussed how the modelling tool could be instrumental in this process. These suggestions for improvement informed subsequent workshops and model development.

Evaluating stakeholder involvement in building a decision support tool for NHS health checks: co-producing the WorkHORSE study.

BACKGROUND: Stakeholder engagement is being increasingly recognised as an important way to achieving impact in public health. The WorkHORSE (Working Health Outcomes Research Simulation Environment) project was designed to continuously engage with stakeholders to inform the development of an open access modelling tool to enable commissioners to quantify the potential cost-effectiveness and equity of the NHS Health Check Programme. An objective of the project was to evaluate the involvement of stakeholders in co-producing the WorkHORSE computer modelling tool and examine how they perceived their involvement in the model building process and ultimately contributed to the strengthening and relevance of the modelling tool. METHODS: We identified stakeholders using our extensive networks and snowballing techniques. Iterative development of the decision support modelling tool was informed through engaging with stakeholders during four workshops. We used detailed scripts facilitating open discussion and opportunities for stakeholders to provide additional feedback subsequently. At the end of each workshop, stakeholders and the research team completed questionnaires to explore their views and experiences throughout the process. RESULTS: 30 stakeholders participated, of which 15 attended two or more workshops. They spanned local (NHS commissioners, GPs, local authorities and academics), third sector and national organisations including Public Health England. Stakeholders felt valued, and commended the involvement of practitioners in the iterative process. Major reasons for attending included: being able to influence development, and having insight and understanding of what the tool could include, and how it would work in practice. Researchers saw the process as an opportunity for developing a common language and trust in the end product, and ensuring the support tool was transparent. The workshops acted as a reality check ensuring model scenarios and outputs were relevant and fit for purpose. CONCLUSIONS: Computational modellers rarely consult with end users when developing tools to inform decision-making. The added value of co-production (continuing collaboration and iteration with stakeholders) enabled modellers to produce a "real-world" operational tool. Likewise, stakeholders had increased confidence in the decision support tool's development and applicability in practice.

Changes in health in the countries of the UK and 150 English Local Authority areas 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016.

BACKGROUND: Previous studies have reported national and regional Global Burden of Disease (GBD) estimates for the UK. Because of substantial variation in health within the UK, action to improve it requires comparable estimates of disease burden and risks at country and local levels. The slowdown in the rate of improvement in life expectancy requires further investigation. We use GBD 2016 data on mortality, causes of death, and disability to analyse the burden of disease in the countries of the UK and within local authorities in England by deprivation quintile. METHODS: We extracted data from the GBD 2016 to estimate years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), and attributable risks from 1990 to 2016 for England, Scotland, Wales, Northern Ireland, the UK, and 150 English Upper-Tier Local Authorities. We estimated the burden of disease by cause of death, condition, year, and sex. We analysed the association between burden of disease and socioeconomic deprivation using the Index of Multiple Deprivation. We present results for all 264 GBD causes of death combined and the leading 20 specific causes, and all 84 GBD risks or risk clusters combined and 17 specific risks or risk clusters. FINDINGS: The leading causes of age-adjusted YLLs in all UK countries in 2016 were ischaemic heart disease, lung cancers, cerebrovascular disease, and chronic obstructive pulmonary disease. Age-standardised rates of YLLs for all causes varied by two times between local areas in England according to levels of socioeconomic deprivation (from 14 274 per 100 000 population [95% uncertainty interval 12 791-15 875] in Blackpool to 6888 [6145-7739] in Wokingham). Some Upper-Tier Local Authorities, particularly those in London, did better than expected for their level of deprivation. Allowing for differences in age structure, more deprived Upper-Tier Local Authorities had higher attributable YLLs for most major risk factors in the GBD. The population attributable fractions for all-cause YLLs for individual major risk factors varied across Upper-Tier Local Authorities. Life expectancy and YLLs have improved more slowly since 2010 in all UK countries compared with 1990-2010. In nine of 150 Upper-Tier Local Authorities, YLLs increased after 2010. For attributable YLLs, the rate of improvement slowed most substantially for cardiovascular disease and breast, colorectal, and lung cancers, and showed little change for Alzheimer's disease and other dementias. Morbidity makes an increasing contribution to overall burden in the UK compared with mortality. The age-standardised UK DALY rate for low back and neck pain (1795 [1258-2356]) was higher than for ischaemic heart disease (1200 [1155-1246]) or lung cancer (660 [642-679]). The leading causes of ill health (measured through YLDs) in the UK in 2016 were low back and neck pain, skin and subcutaneous diseases, migraine, depressive disorders, and sense organ disease. Age-standardised YLD rates varied much less than equivalent YLL rates across the UK, which reflects the relative scarcity of local data on causes of ill health. INTERPRETATION: These estimates at local, regional, and national level will allow policy makers to match resources and priorities to levels of burden and risk factors. Improvement in YLLs and life expectancy slowed notably after 2010, particularly in cardiovascular disease and cancer, and targeted actions are needed if the rate of improvement is to recover. A targeted policy response is also required to address the increasing proportion of burden due to morbidity, such as musculoskeletal problems and depression. Improving the quality and completeness of available data on these causes is an essential component of this response. FUNDING: Bill & Melinda Gates Foundation and Public Health England.

Commercial determinants of health: advertising of alcohol and unhealthy foods during sporting events.

Tobacco, alcohol and foods that are high in fat, salt and sugar generate much of the global burden of noncommunicable diseases. We therefore need a better understanding of how these products are promoted.The promotion of tobacco products through sporting events has largely disappeared over the last two decades, but advertising and sponsorship continues bycompanies selling alcohol, unhealthy food and sugar-sweetened beverage. The sponsorship of sporting events such as the Olympic Games, the men's FIFA World Cup and the men's European Football Championships in 2016, has received some attention in recent years in the public health literature. Meanwhile, British football and the English Premier League have become global events with which transnational companies are keen to be associated, to promote their brands to international markets. Despite its reach, the English Premier League marketing and sponsorship portfolio has received very little scrutiny from public health advocates. We call for policy-makers and the public health community to formulate an approach to the sponsorship of sporting events, one that accounts for public health concerns.

Le tabac, l'alcool et les aliments riches en graisse, en sel et en sucre génèrent la plus large partie de la charge mondiale des maladies non transmissibles. Il est donc nécessaire de mieux comprendre la manière dont ces produits sont promus. La promotion des produits du tabac dans le cadre d'événements sportifs a largement disparu au cours des vingt dernières années, mais la publicité et le sponsoring par des entreprises qui vendent de l'alcool, des produits alimentaires peu sains et des boissons sucrées sont encore d'actualité. Depuis quelques années, la littérature sur la santé publique commence à porter son attention sur le sponsoring d'événements sportifs, tels que les Jeux olympiques, la Coupe du monde masculine de la FIFA ou encore le Championnat d'Europe de football masculin de 2016. Mais dans le même temps, le football britannique et la Premier League anglaise sont devenus des événements mondiaux auxquels les multinationales aiment être associées pour promouvoir leurs marques auprès de marchés internationaux. Malgré leur portée, le marketing et le sponsoring de la Premier League anglaise semblent négligés par les défenseurs de la santé publique. Nous appelons les décideurs politiques et la communauté de santé publique à élaborer une approche pour le sponsoring d'événements sportifs qui réponde aux enjeux de santé publique.

El tabaco, el alcohol y los alimentos que son ricos en grasa, como la sal y el azúcar, generan gran parte de la carga mundial de enfermedades no contagiosas. Por tanto, necesitamos una mejor comprensión de la forma en que se promueven estos productos. La promoción de los productos del tabaco a través de eventos deportivos ha desaparecido en gran medida en las últimas dos décadas, pero la publicidad y el patrocinio continúan por parte de las empresas que venden alcohol, alimentos poco saludables y bebidas azucaradas. El patrocinio de eventos deportivos como los Juegos Olímpicos, la Copa Mundial de la FIFA masculina y el Campeonato de Fútbol Europeo del 2016 ha recibido cierta atención en los últimos años en la bibliografía sobre salud pública. Mientras tanto, el fútbol británico y la Premier League inglesa se han convertido en eventos globales con los que las empresas transnacionales están dispuestas a asociarse, para promocionar sus marcas ante los mercados internacionales. A pesar de su alcance, la cartera de comercialización y patrocinio de la Premier League inglesa apenas han sido objeto de escrutinio por parte de los defensores de la salud pública. Pedimos a los responsables de la formulación de políticas y a la comunidad de la salud pública que formulen un enfoque para el patrocinio de eventos deportivos, que tenga en cuenta estas preocupaciones sobre la salud pública.

FDA Sodium Reduction Targets and the Food Industry: Are There Incentives to Reformulate? Microsimulation Cost-Effectiveness Analysis.

Policy Points The World Health Organization has recommended sodium reduction as a "best buy" to prevent cardiovascular disease (CVD). Despite this, Congress has temporarily blocked the US Food and Drug Administration (FDA) from implementing voluntary industry targets for sodium reduction in processed foods, the implementation of which could cost the industry around $16 billion over 10 years. We modeled the health and economic impact of meeting the two-year and ten-year FDA targets, from the perspective of people working in the food system itself, over 20 years, from 2017 to 2036. Benefits of implementing the FDA voluntary sodium targets extend to food companies and food system workers, and the value of CVD-related health gains and cost savings are together greater than the government and industry costs of reformulation. CONTEXT: The US Food and Drug Administration (FDA) set draft voluntary targets to reduce sodium levels in processed foods. We aimed to determine cost effectiveness of meeting these draft sodium targets, from the perspective of US food system workers. METHODS: We employed a microsimulation cost-effectiveness analysis using the US IMPACT Food Policy model with two scenarios: (1) short term, achieving two-year FDA reformulation targets only, and (2) long term, achieving 10-year FDA reformulation targets. We modeled four close-to-reality populations: food system "ever" workers; food system "current" workers in 2017; and subsets of processed food "ever" and "current" workers. Outcomes included cardiovascular disease cases prevented and postponed as well as incremental cost-effectiveness ratio per quality-adjusted life year (QALY) gained from 2017 to 2036. FINDINGS: Among food system ever workers, achieving long-term sodium reduction targets could produce 20-year health gains of approximately 180,000 QALYs (95% uncertainty interval [UI]: 150,000 to 209,000) and health cost savings of approximately $5.2 billion (95% UI: $3.5 billion to $8.3 billion), with an incremental cost-effectiveness ratio (ICER) of $62,000 (95% UI: $1,000 to $171,000) per QALY gained. For the subset of processed food industry workers, health gains would be approximately 32,000 QALYs (95% UI: 27,000 to 37,000); cost savings, $1.0 billion (95% UI: $0.7bn to $1.6bn); and ICER, $486,000 (95% UI: $148,000 to $1,094,000) per QALY gained. Because many health benefits may occur in individuals older than 65 or the uninsured, these health savings would be shared among individuals, industry, and government. CONCLUSIONS: The benefits of implementing the FDA voluntary sodium targets extend to food companies and food system workers, with the value of health gains and health care cost savings outweighing the costs of reformulation, although not for the processed food industry.

Explaining income-related inequalities in cardiovascular risk factors in Tunisian adults during the last decade: comparison of sensitivity analysis of logistic regression and Wagstaff decomposition analysis.

BACKGROUND: It is important to quantify inequality, explain the contribution of underlying social determinants and to provide evidence to guide health policy. The aim of the study is to explain the income-related inequalities in cardiovascular risk factors in the last decade among Tunisian adults aged between 35 and 70 years old. METHODS: We performed the analysis by applying two approaches and compared the results provided by the two methods. The methods were global sensitivity analysis (GSA) using logistic regression models and the Wagstaff decomposition analysis. RESULTS: Results provided by the two methods found a higher risk of cardiovascular diseases and diabetes in those with high socio-economic status in 2005. Similar results were observed in 2016. In 2016, the GSA showed that education level occupied the first place on the explanatory list of factors explaining 36.1% of the adult social inequality in high cardiovascular risk, followed by the area of residence (26.2%) and income (15.1%). Based on the Wagstaff decomposition analysis, the area of residence occupied the first place and explained 40.3% followed by income and education level explaining 19.2 and 14.0% respectively. Thus, both methods found similar factors explaining inequalities (income, educational level and regional conditions) but with different rankings of importance. CONCLUSIONS: The present study showed substantial income-related inequalities in cardiovascular risk factors and diabetes in Tunisia and provided explanations for this. Results based on two different methods similarly showed that structural disparities on income, educational level and regional conditions should be addressed in order to reduce inequalities.

Following in the footsteps of tobacco and alcohol? Stakeholder discourse in UK newspaper coverage of the Soft Drinks Industry Levy.

OBJECTIVE: In politically contested health debates, stakeholders on both sides present arguments and evidence to influence public opinion and the political agenda. The present study aimed to examine whether stakeholders in the Soft Drinks Industry Levy (SDIL) debate sought to establish or undermine the acceptability of this policy through the news media and how this compared with similar policy debates in relation to tobacco and alcohol industries. DESIGN: Quantitative and qualitative content analysis of newspaper articles discussing sugar-sweetened beverage (SSB) taxation published in eleven UK newspapers between 1 April 2015 and 30 November 2016, identified through the Nexis database. Direct stakeholder citations were entered in NVivo to allow inductive thematic analysis and comparison with an established typology of industry stakeholder arguments used by the alcohol and tobacco industries. SETTING: UK newspapers. PARTICIPANTS: Proponents and opponents of SSB tax/SDIL cited in UK newspapers. RESULTS: Four hundred and ninety-one newspaper articles cited stakeholders' (n 287) arguments in relation to SSB taxation (n 1761: 65 % supportive and 35 % opposing). Stakeholders' positions broadly reflected their vested interests. Inconsistencies arose from: changes in ideological position; insufficient clarity on the nature of the problem to be solved; policy priorities; and consistency with academic rigour. Both opposing and supportive themes were comparable with the alcohol and tobacco industry typology. CONCLUSIONS: Public health advocates were particularly prominent in the UK newspaper debate surrounding the SDIL. Advocates in future policy debates might benefit from seeking a similar level of prominence and avoiding inconsistencies by being clearer about the policy objective and mechanisms.

Future cost-effectiveness and equity of the NHS Health Check cardiovascular disease prevention programme: Microsimulation modelling using data from Liverpool, UK.

BACKGROUND: Aiming to contribute to prevention of cardiovascular disease (CVD), the National Health Service (NHS) Health Check programme has been implemented across England since 2009. The programme involves cardiovascular risk stratification-at 5-year intervals-of all adults between the ages of 40 and 74 years, excluding any with preexisting vascular conditions (including CVD, diabetes mellitus, and hypertension, among others), and offers treatment to those at high risk. However, the cost-effectiveness and equity of population CVD screening is contested. This study aimed to determine whether the NHS Health Check programme is cost-effective and equitable in a city with high levels of deprivation and CVD. METHODS AND FINDINGS: IMPACTNCD is a dynamic stochastic microsimulation policy model, calibrated to Liverpool demographics, risk factor exposure, and CVD epidemiology. Using local and national data, as well as drawing on health and social care disease costs and health-state utilities, we modelled 5 scenarios from 2017 to 2040: Scenario (A): continuing current implementation of NHS Health Check;Scenario (B): implementation 'targeted' toward areas in the most deprived quintile with increased coverage and uptake;Scenario (C): 'optimal' implementation assuming optimal coverage, uptake, treatment, and lifestyle change;Scenario (D): scenario A combined with structural population-wide interventions targeting unhealthy diet and smoking;Scenario (E): scenario B combined with the structural interventions as above. We compared all scenarios with a counterfactual of no-NHS Health Check. Compared with no-NHS Health Check, the model estimated cumulative incremental cost-effectiveness ratio (ICER) (discounted £/quality-adjusted life year [QALY]) to be 11,000 (95% uncertainty interval [UI] -270,000 to 320,000) for scenario A, 1,500 (-91,000 to 100,000) for scenario B, -2,400 (-6,500 to 5,700) for scenario C, -5,100 (-7,400 to -3,200) for scenario D, and -5,000 (-7,400 to -3,100) for scenario E. Overall, scenario A is unlikely to become cost-effective or equitable, and scenario B is likely to become cost-effective by 2040 and equitable by 2039. Scenario C is likely to become cost-effective by 2030 and cost-saving by 2040. Scenarios D and E are likely to be cost-saving by 2021 and 2023, respectively, and equitable by 2025. The main limitation of the analysis is that we explicitly modelled CVD and diabetes mellitus only. CONCLUSIONS: According to our analysis of the situation in Liverpool, current NHS Health Check implementation appears neither equitable nor cost-effective. Optimal implementation is likely to be cost-saving but not equitable, while targeted implementation is likely to be both. Adding structural policies targeting cardiovascular risk factors could substantially improve equity and generate cost savings.

Estimating the health and economic effects of the proposed US Food and Drug Administration voluntary sodium reformulation: Microsimulation cost-effectiveness analysis.

BACKGROUND: Sodium consumption is a modifiable risk factor for higher blood pressure (BP) and cardiovascular disease (CVD). The US Food and Drug Administration (FDA) has proposed voluntary sodium reduction goals targeting processed and commercially prepared foods. We aimed to quantify the potential health and economic impact of this policy. METHODS AND FINDINGS: We used a microsimulation approach of a close-to-reality synthetic population (US IMPACT Food Policy Model) to estimate CVD deaths and cases prevented or postponed, quality-adjusted life years (QALYs), and cost-effectiveness from 2017 to 2036 of 3 scenarios: (1) optimal, 100% compliance with 10-year reformulation targets; (2) modest, 50% compliance with 10-year reformulation targets; and (3) pessimistic, 100% compliance with 2-year reformulation targets, but with no further progress. We used the National Health and Nutrition Examination Survey and high-quality meta-analyses to inform model inputs. Costs included government costs to administer and monitor the policy, industry reformulation costs, and CVD-related healthcare, productivity, and informal care costs. Between 2017 and 2036, the optimal reformulation scenario achieving the FDA sodium reduction targets could prevent approximately 450,000 CVD cases (95% uncertainty interval: 240,000 to 740,000), gain approximately 2.1 million discounted QALYs (1.7 million to 2.4 million), and produce discounted cost savings (health savings minus policy costs) of approximately $41 billion ($14 billion to $81 billion). In the modest and pessimistic scenarios, health gains would be 1.1 million and 0.7 million QALYS, with savings of $19 billion and $12 billion, respectively. All the scenarios were estimated with more than 80% probability to be cost-effective (incremental cost/QALY < $100,000) by 2021 and to become cost-saving by 2031. Limitations include evaluating only diseases mediated through BP, while decreasing sodium consumption could have beneficial effects upon other health burdens such as gastric cancer. Further, the effect estimates in the model are based on interventional and prospective observational studies. They are therefore subject to biases and confounding that may have influenced also our model estimates. CONCLUSIONS: Implementing and achieving the FDA sodium reformulation targets could generate substantial health gains and net cost savings.

The role of the food industry in health: lessons from tobacco?

Introduction: In this review, we highlight poor diet as the biggest risk factor for non-communicable diseases. We examine the denial tactics used by the food industry, how they reflect the tactics previously used by the tobacco industry, and how campaigners can use this knowledge to achieve future public health successes. Sources of data: Data sources are wide ranging, notably publications relating to public health, obesity and processed food, the effectiveness hierarchy and food industry denialism tactics. Areas of agreement: Global burden of disease analyses consistently demonstrate that poor diet produces a bigger burden of non-communicable disease than tobacco, alcohol and inactivity put together. The lessons learnt from the tobacco control experience of successfully fighting the tobacco industry can be applied to other industries including processed food and sugary drinks. Areas of controversy: Tackling obesity and poor diet is a more complex issue than tobacco. Food industries continue to promote weak or ineffective policies such as voluntary reformulation, and resist regulation and taxation. However, the UK food industry now faces increasing pressure from professionals, public and politicians to accept reformulation and taxes, or face more stringent measures. Growing points and areas timely for developing research: The rise in childhood and adult obesity needs to be arrested and then reversed. Unhealthy processed food and sugary drinks are a major contributing factor. There is increasing interest in the tactics being used by the food industry to resist change. Advocacy and activism will be essential to counter these denialism tactics and ensure that scientific evidence is translated into effective regulation and taxation.

Adoption and Design of Emerging Dietary Policies to Improve Cardiometabolic Health in the US.

PURPOSE OF REVIEW: Suboptimal diet is a leading cause of cardiometabolic disease and economic burdens. Evidence-based dietary policies within 5 domains-food prices, reformulation, marketing, labeling, and government food assistance programs-appear promising at improving cardiometabolic health. Yet, the extent of new dietary policy adoption in the US and key elements crucial to define in designing such policies are not well established. We created an inventory of recent US dietary policy cases aiming to improve cardiometabolic health and assessed the extent of their proposal and adoption at federal, state, local, and tribal levels; and categorized and characterized the key elements in their policy design. RECENT FINDINGS: Recent federal dietary policies adopted to improve cardiometabolic health include reformulation (trans-fat elimination), marketing (mass-media campaigns to increase fruits and vegetables), labeling (Nutrition Facts Panel updates, menu calorie labeling), and food assistance programs (financial incentives for fruits and vegetables in the Supplemental Nutrition Assistance Program (SNAP) and Women, Infant and Children (WIC) program). Federal voluntary guidelines have been proposed for sodium reformulation and food marketing to children. Recent state proposals included sugar-sweetened beverage (SSB) taxes, marketing restrictions, and SNAP restrictions, but few were enacted. Local efforts varied significantly, with certain localities consistently leading in the proposal or adoption of relevant policies. Across all jurisdictions, most commonly selected dietary targets included fruits and vegetables, SSBs, trans-fat, added sugar, sodium, and calories; other healthy (e.g., nuts) or unhealthy (e.g., processed meats) factors were largely not addressed. Key policy elements to define in designing these policies included those common across domains (e.g., level of government, target population, dietary target, dietary definition, implementation mechanism), and domain-specific (e.g., media channels for food marketing domain) or policy-specific (e.g., earmarking for taxes) elements. Characteristics of certain elements were similarly defined (e.g., fruit and vegetable definition, warning language used in SSB warning labels), while others varied across cases within a policy (e.g., tax base for SSB taxes). Several key elements were not always sufficiently characterized in government documents, and dietary target selections and definitions did not consistently align with the evidence-base. These findings highlight recent action on dietary policies to improve cardiometabolic health in the US; and key elements necessary to design such policies.

Systems Thinking as a Framework for Analyzing Commercial Determinants of Health.

Policy Points: Worldwide, more than 70% of all deaths are attributable to noncommunicable diseases (NCDs), nearly half of which are premature and apply to individuals of working age. Although such deaths are largely preventable, effective solutions continue to elude the public health community. One reason is the considerable influence of the "commercial determinants of health": NCDs are the product of a system that includes powerful corporate actors, who are often involved in public health policymaking. This article shows how a complex systems perspective may be used to analyze the commercial determinants of NCDs, and it explains how this can help with (1) conceptualizing the problem of NCDs and (2) developing effective policy interventions. CONTEXT: The high burden of noncommunicable diseases (NCDs) is politically salient and eminently preventable. However, effective solutions largely continue to elude the public health community. Two pressing issues heighten this challenge: the first is the public health community's narrow approach to addressing NCDs, and the second is the involvement of corporate actors in policymaking. While NCDs are often conceptualized in terms of individual-level risk factors, we argue that they should be reframed as products of a complex system. This article explores the value of a systems approach to understanding NCDs as an emergent property of a complex system, with a focus on commercial actors. METHODS: Drawing on Donella Meadows's systems thinking framework, this article examines how a systems perspective may be used to analyze the commercial determinants of NCDs and, specifically, how unhealthy commodity industries influence public health policy. FINDINGS: Unhealthy commodity industries actively design and shape the NCD policy system, intervene at different levels of the system to gain agency over policy and politics, and legitimize their presence in public health policy decisions. CONCLUSIONS: It should be possible to apply the principles of systems thinking to other complex public health issues, not just NCDs. Such an approach should be tested and refined for other complex public health challenges.