NZ Health Strategy Consultation Draft – are the big prevention programmes really in there?

Thursday, December 3rd, 2015 | Kate Sloane | No Comments

Prof Tony Blakely, Prof Nick Wilson

In this blog we comment for a second time this week on the consultation draft of the NZ Health Strategy, focusing this time on preventive interventions that actually would make a meaningful difference to health in Aotearoa NZ. The draft Strategy has many strong aspects, but by having a ‘people centred’ approach it gravitates to IT systems and individual-level actions, and drifts away from population-level prevention activities that would have the biggest health impact (a goal of the strategy), reduce health inequalities (another goal of the strategy) and be best value for money (yet another goal of the strategy). We recommend that the word ‘prevention’ needs to be more than a garnish sprinkled through the document, but rather an actual substantive item on the menu of offerings. We conclude by offering up some interventions for comparison, and note that the population-wide interventions not highlighted in the Strategy can have an impact on health gain and costs (savings) far in excess of those implicitly in the Strategy’s focus.

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Taxing tobacco in NZ: What we know and what could be next

Tuesday, October 27th, 2015 | Kate Sloane | 1 Comment

By members of the BODE3 and ASPIRE 2025 Teams, University of Otago*

death and disease, tobacco taxA series of seven annual tobacco tax increases, typically at the 10% level, will end in January 2016 unless it is extended by the NZ Government. In this blog we take a timely look at what is known about tobacco tax increases in this country, what remains unknown, and what might be needed for the next phase of tobacco taxation related policy and research.

Recent trends

The recent pattern of annual tobacco tax increases in NZ has been associated with a 23% reduction in tobacco consumption per adult (for the period 2010 to 2014) (1). Smoking prevalence has also continued to decline for all major population groups (as per census data for 2013). Youth smoking in particular has continued to decline steeply (see the series of ASH Year 10 Surveys).

Such patterns are consistent with the extensive international literature on the effectiveness of tobacco tax as a tobacco control intervention (2). In particular, it is well established that youth are particularly sensitive to high tobacco prices (3). However, these trends are also likely to be partly due to other non-tax policies such as extensions of smokefree environments, removal of point-of-sale tobacco product displays, mass media campaigns, and enhanced smoking cessation service provision.

The falls in consumption and prevalence have occurred despite the tobacco industry using pricing strategies to blunt the impact of the tax increases by minimising changes in the price of budget brands. For example, the 10% tax increase in January 2014 resulted in only a 2.6% price increase for a budget brand relative to a 8.3% price in a premium brand (based on a NZ survey of 448 retailers (4)). Such pricing strategies provide a means for some smokers to mitigate the impact of the increases by switching to cheaper brands rather than quitting.

Large health gains from tobacco tax increases

NZ research published in 2015 (5) indicates large health gains from ongoing 10% annual tobacco tax rises until 2031, an estimated 260,000 quality-adjusted life-years (QALYs) gained over the remaining lifetime of the 2011 NZ population (see this blog for further details). These health gains do not seem to be threatened by trends in illicit trade in tobacco which is still at very low levels in this country (6). Even modest growth in such trade seems unlikely to have much impact on the success of higher tobacco taxes according to a NZ-specific model (7).

Tobacco tax is good for improving Māori health and reducing health disparities

Although tobacco tax is typically described as being a “regressive tax” overall, actual increases in this tax can be progressive due to the typically greater price sensitivity of low-income populations. Indeed, the two most relevant systematic reviews indicate that tobacco price/tax increases tended to have a positive impact on equity (i.e., in terms of reduction in inequalities in smoking prevalence by socioeconomic status for both adults (8) and youth (9)). A specific recent example is Turkey, where a study (10) found poorer households had enough quitting/reduced consumption to actually result in reduced expenditure on tobacco (albeit with the more wealthier smokers in Turkey paying relatively more). For a graph of this impact in Turkey see this presentation by Prof Frank Chaloupka, an international tobacco tax expert who recently visited NZ.

Furthermore, NZ research indicates that health gains per person from higher tobacco taxes have been estimated to be 3.7 times greater for Māori compared to non-Māori (5). But to still help minimise any financial hardship effects on low-income continuing smokers, it is highly desirable that there is additional targeted smoking cessation support, which could be funded from extra revenue from the tobacco excise increases. The latter is supported by most NZ smokers, of whom 59% favour increased tobacco taxes – “if the extra revenue was used to promote healthy lifestyles and support quitting” (11). There is also an ethical case for such a “dedicated tax” approach (12).

Large cost savings to the NZ health system, but unknown wider impacts to NZ society

The NZ modelling work (5) also indicates large health cost savings from raising tobacco taxes ($3.8 billion saved over the lifetime of the current NZ population). This is even when accounting for the extra health costs from the longer lifespan of ex-smokers. Additional benefits not counted in this analysis arise to the NZ economy from reduced premature death among workers (e.g., from heart attacks and cancer), and from disability (e.g., strokes can prevent people returning to work). Further benefits will come from preventing adverse smoking impacts on infants and children (e.g., from low birth weight and asthma) that may harm long-term educational outcomes and hence employment. But these types of productivity issues remain to be clarified for the NZ setting, along with the implications for extra income tax revenue for the government from healthier workers. Even so, a recent international review provides overall evidence that raising tobacco prices through taxes results in “substantial healthcare cost savings and can generate additional gains from improved productivity in the workplace” (13).

Remaining uncertainties that could benefit from further research

Although it is clear that a comprehensive programme of tax increases is required, there are some remaining uncertainties and hence need for further research and evaluation.

The international research literature is unclear on whether regular increases as per the recent pattern in NZ, or more episodic but larger tax increases would be most effective. Regular annual pre-announced increases have the potential advantages of:

  • Signalling to smokers that the future is one of regular on-going price increases.
  • Normalising the role of tax as an important component of the tobacco control strategy to achieve the 2025 goal and within NZ’s political culture.
  • Possibly being more acceptable to NZ politicians than less frequent but larger increases (via triggering less media and public discourse around each increase).

But less frequent but larger increases have the potential advantages of:

  • Being more effective by being more noticeable to smokers and also being harder for the tobacco industry to smooth out the price increase (e.g., by stock management and providing budget brands).
  • Stimulating more media attention – which may stimulate more interest in quitting.
  • Putting more pressure on policy-makers to do more to help smokers quit (e.g, via funding accompanying mass media campaigns).

A way forward might be to conduct experimental studies with smokers that compare the perceived impact of a sharp 40% increase with two 20% increases over a longer time period or even to implement both approaches nationally over the next 3-4 years and monitor and compare outcomes.

Future tax increases should be accompanied by complementary interventions such as state-of-the-art mass media campaigns that encourage and support quitting. So these also need research to determine optimal design for the NZ setting. Indeed, we need a range of research on effectiveness and cost-effectiveness to determine the best mix of all plausible tobacco control interventions (including further smokefree environment laws, product regulation, and smoking cessation services).

Recommendations for tobacco tax policy to achieve Smokefree 2025

Tobacco tax increases will be an essential component of the comprehensive effort needed in NZ to achieve its goal of becoming Smokefree by 2025. Modelling-level evidence suggests that despite the favourable trends in declining tobacco consumption in NZ, the current business-as-usual approach (even with 10% annual tax increases) is very unlikely to be strong enough to meet the 2025 goal (7, 14). Therefore a series of regular tax increases, preferably at a higher level than the recent series of 10% annual increases, should be implemented up to 2025, accompanied by other enhanced tobacco control policies (ideally all funded with tobacco tax revenue).

Conclusions

Tobacco tax increases are an important means to generate health gain in NZ, reduce health inequalities, and save health costs. Nevertheless, NZ will need additional tobacco control strategies if it is to have a high probability of achieving the Government’s Smokefree 2025 goal. The tax increases should be accompanied by rigorous evaluation and research so that the most effective approaches can be identified to inform subsequent interventions to achieve Smokefree 2025 and to generate knowledge for other countries seeking to reach their own endgame goals.

* Authors: * Associate Professor Nick Wilson, Professor Tony Blakely, Professor Richard Edwards, Dr Nhung Nghiem, Frederieke Sanne van der Deen, Dr Cristina Cleghorn

References

  1. Laugesen M: Analysis of Manufacturers’ Returns on Tobacco. Report to the Ministry of Health for 2014. 2015. https://www.health.govt.nz/system/files/documents/pages/tobacco-returns-2014-analysis-report.pdf.
  2. IARC: Effectiveness of Tax and Price Policies for Tobacco Control. IARC Handbooks of Cancer Prevention in Tobacco Control, Volume 14. Lyon: International Agency for Research on Cancer (IARC); 2011.
  3. Chaloupka FJ, Yurekli A, Fong GT: Tobacco taxes as a tobacco control strategy. Tob Control 2012, 21(2):172-180.
  4. Marsh L, Cameron C, Quigg R, Hoek J, Doscher C, McGee R, Sullivan T: The impact of an increase in excise tax on the retail price of tobacco in New Zealand. Tob Control 2015, (E-publication 2 July).
  5. Blakely T, Cobiac LJ, Cleghorn CL, Pearson AL, van der Deen FS, Kvizhinadze G, Nghiem N, McLeod M, Wilson N: Health, health inequality, and cost impacts of annual increases in tobacco tax: Multistate life table modeling in New Zealand. PLoS Med 2015, 12(7):e1001856.
  6. Ajmal A, U V: Tobacco tax and the illicit trade in tobacco products in New Zealand. Aust N Z J Public Health 2015, 39(2):116-120.
  7. Cobiac LJ, Ikeda T, Nghiem N, Blakely T, Wilson N: Modelling the implications of regular increases in tobacco taxation in the tobacco endgame. Tob Control 2015, 24(e2):e154-160.
  8. Brown T, Platt S, Amos A: Equity impact of population-level interventions and policies to reduce smoking in adults: a systematic review. Drug Alcohol Depend 2014, 138:7-16.
  9. Brown T, Platt S, Amos A: Equity impact of interventions and policies to reduce smoking in youth: systematic review. Tob Control 2014, [E-publication 19 May].
  10. Onder Z, Yurekli AA: Who pays the most cigarette tax in Turkey. Tob Control 2014, (E-publication 16 September).
  11. Wilson N, Weerasekera D, Edwards R, Thomson G, Devlin M, Gifford H: Characteristics of smoker support for increasing a dedicated tobacco tax: national survey data from New Zealand. Nicotine Tob Res 2010, 12(2):168-173.
  12. Wilson N, Thomson G: Tobacco taxation and public health: ethical problems, policy responses. Soc Sci Med 2005, 61(3):649-659.
  13. Contreary KA, Chattopadhyay SK, Hopkins DP, Chaloupka FJ, Forster JL, Grimshaw V, Holmes CB, Goetzel RZ, Fielding JE, Community Preventive Services Task F: Economic Impact of Tobacco Price Increases Through Taxation: A Community Guide Systematic Review. Am J Prev Med 2015, 49(5):800-808.
  14. van der Deen FS, Ikeda T, Cobiac L, Wilson N, Blakely T: Projecting future smoking prevalence to 2025 and beyond in New Zealand using smoking prevalence data from the 2013 Census. N Z Med J 2014, 127(1406):71-79.

A new online calculator for estimating how much a society might spend on life-saving interventions

Wednesday, July 22nd, 2015 | Kate Sloane | No Comments

By the BODE3 Programme Team*

In this blog we describe an online calculator we developed to estimate the maximum investment society might consider spending on life-saving health interventions, while remaining cost-effective. For NZ, the amounts generated by this calculator vary greatly by age: NZ$ 1.2 million for an intervention to save the life of a child, NZ$ 0.7 million for a 50-year-old, and NZ$ 0.2 million for an 80-year-old, assuming we are willing to spend $45,000 per healthy life-years gained and the person is returned to the expected health status of the average NZ citizen. These results are very sensitive to the choice of discount rate and to the selected cost-effectiveness threshold. Policy-makers could use this calculator as a rapid screening tool to determine if more detailed cost-effectiveness analyses of potential life-saving interventions might be worthwhile.

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Reducing salt in food good for health and NZ’s health budget – New research

Monday, May 4th, 2015 | Nick Wilson | No Comments

Associate Professor Nick Wilson, Dr Nhung Nghiem, Dr Cristina Cleghorn, Professor Tony Blakely

Sources of saltIn this blog post we report on a new study from the BODE3 Programme that suggests that strategies to reduce the dietary salt intake of New Zealanders could produce major health gains and major cost savings for the publicly-funded health sector. We also put these results into a wider context of how nutrition could be improved in NZ.


This study was done given the high importance of dietary sodium (salt) as a global disease risk factor – it is the eleventh most important risk factor globally [1], with the same ranking for Australasia. In particular, we aimed to model the health benefits and costs for NZ of reducing salt intakes – given this is a country that still has a high burden of heart attacks and stroke.

Salt is ubiquitous in processed food, and often at levels that vary widely within the same type of food product eg, different breads. The good news, though, is that salt can be readily reduced by food reformulation – and because people’s taste buds adapt, it is possible to lower salt in food by about 10% a year with virtually no one noticing. Indeed, there is even some research suggesting that when people are on lower sodium diets they may actually prefer them, based on research that measured the hedonic value of dietary sodium [2]. Potassium salts, which are beneficial for health [3], can also be used to replace the sodium in processed foods (which has already been happening to some NZ food such as soups).

In our study, published in the journal PLoS One [4], we modelled reducing sodium in the food supply, but also changes in consumer behaviour eg, via the impact of counselling, food labelling and a UK-style mass media campaign on salt.

We found that the largest benefit to health (from reducing heart attacks and strokes) came from the strategy of a “sinking lid” on the amount of food salt released to the national market to achieve an average adult intake of 2300 mg of sodium per day. Such an amount compares to around 3500 mg of sodium per day (around 9 grams of salt – or 1.5 teaspoons of salt) currently for the typical NZ adult – mainly from salt hidden in processed foods. This “sinking lid” strategy generated an extra 211,000 quality-adjusted life-years in the adult NZ population alive in 2011 over the remainder of their lifetimes. For many people this will only save days or weeks of life, but for those at risk of heart attacks and strokes in their 50s – the benefit could be measured in decades of extra life. This “sinking lid” strategy resulted in $1.1 billion in cost savings from fewer heart attacks and strokes – even when considering that people would live longer and cost the health system more in their extra life.

The next highest impact strategy was from a salt tax. It also had the advantage of raising revenue which was estimated at reaching about $450 million per year.

Other effective interventions studied were a mandatory 25% reduction in sodium levels in all processed foods and a package of salt reduction strategies performed in the United Kingdom (including a mass media campaign). We also “gave the tick” to NZ’s own “Tick Programme” which is run by the Heart Foundation and was assessed as being a good investment for reducing salt intakes (it is also good for nutrition in other ways: [5]).

Indeed, seven of the eight salt reduction interventions studied generated both health gain for New Zealanders and saved overall health costs. The exception was dietary counselling by dietitians which was found to be good value for the money invested, but just not to the point of actually saving money overall. See the graph below for the key results of all the 8 interventions studied.

Figure: Impact of different interventions to reduce dietary salt intake in the NZ population – showing large health gains and also large financial savings to the health system Results - PlosNotes: The mandatory 25% reduction is for the sodium level in all processed foods. For “selected” foods, this is just for bread, processed meats and sauces. QALY: quality-adjusted life-years gained from the intervention (by reducing heart attacks and strokes).

When considered alongside the international literature (which we reviewed in our paper [4]), there were no big surprises in our results. Indeed, there is now a quite large body of evidence that interventions to lower salt intakes are good for population health and are cost-effective. What was new in our study was being able to give results for the NZ population using our own disease and cost data. This work was also able to show that the health gain per person will likely be greater for Maori men and women compared to non-Maori – so salt reduction strategies could help reduce the health gaps.

In terms of the feasibility of introducing these interventions we note that two are already in place in NZ (dietary counselling and the Tick Programme). We also suspect that policymakers may be particularly interested in the other potential interventions as these might be achieved with food industry cooperation – as seen with the past success in reducing salt in bread in NZ.

But while salt reduction strategies would help improve health in adults – there is also an urgent need to tackle adult and child obesity eg, following other countries with a tax on sugar-sweetened beverages (see these two relevant systematic reviews [6], [7] and a meta-analysis [8], our previous publications [9] [10], and past blogs on this topic [eg, here]).

We acknowledged in our new paper that the evidence relating to dietary salt and health is still regarded by some people to be controversial (and we have blogged on this topic previously [eg, here]). But there are some recent publications that strengthen the linkage between salt and increased disease risk – not just heart attacks and stroke but also kidney disease and stomach cancer eg, see: this 2015 review [11]; this 2014 systematic review on the DASH diet [12]; this 2015 systematic review on salt and increased cardiovascular disease mortality [13]; this meta-analysis on stomach cancer risk [14]; and this study on renal cancer risk [15]. There is also growing evidence of damage from dietary salt to blood vessel walls which is separate from the impact on raising blood pressure [16].

We plan to soon publish the results of additional modelling work on salt reduction interventions (including substitution with potassium chloride). We have also been using mathematical modelling to design different types of heart healthy bread – which combines both lower sodium levels with the benefit of higher potassium levels, and other improvements such as higher fibre and levels of omega-3 fatty acids. Such “ideal” bread could be used by government-funded institutions (eg, hospitals) or be promoted via providing healthy bread vouchers for those with existing cardiovascular disease.

The health gains (measured in quality-adjusted life-years) and cost savings reported in this study were all discounted at 3% per annum. For example, $1 earned in 10 years time is worth 74 cents at the current value, in 20 years 54 cents, in 40 years 30 cents, and so on. Such discounting is standard practice in economic analyses. But in scenario analyses in the main paper we also considered no discounting and 6% discount rate.

In summary, there are many potential salt reduction interventions available to NZ policymakers if they wish to take the salt reduction path for achieving health gains and to save health sector costs.

 

References

  1. Lim SS, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012, 380(9859):2224-2260.
  2. Blais CA, et al. Effect of dietary sodium restriction on taste responses to sodium chloride: a longitudinal study. Am J Clin Nutr 1986, 44(2):232-243.
  3. Peng YG, et al. Effects of salt substitutes on blood pressure: a meta-analysis of randomized controlled trials. Am J Clin Nutr 2014, 100(6):1448-1454.
  4. Nghiem N, et al. Health and Economic Impacts of Eight Different Dietary Salt Reduction Interventions. PLoS One 2015, 10(4):e0123915.
  5. Wilson N, et al. Possible impact of the Tick Programme in New Zealand on selected nutrient intakes: Tentative estimates and methodological complexities. N Z Med J 2014, 127(1399):85-88.
  6. Thow AM, et al. A systematic review of the effectiveness of food taxes and subsidies to improve diets: understanding the recent evidence. Nutr Rev 2014, 72(9):551-565.
  7. Eyles H, et al. Food pricing strategies, population diets, and non-communicable disease: a systematic review of simulation studies. PLoS Med 2012, 9(12):e1001353.
  8. Cabrera Escobar MA, et al. Evidence that a tax on sugar sweetened beverages reduces the obesity rate: a meta-analysis. BMC Public Health 2013, 13:1072.
  9. Ni Mhurchu C, et al. Twenty percent tax on fizzy drinks could save lives and generate millions in revenue for health programmes in New Zealand. N Z Med J 2014, 127(1389):92-95.
  10. Blakely T, et al. Taxes on sugar-sweetened beverages to curb future obesity and diabetes epidemics. PLoS Med 2014, 11(1):e1001583.
  11. Farquhar WB, et al. Dietary Sodium and Health: More Than Just Blood Pressure. J Am Coll Cardiol 2015, 65(10):1042-1050.
  12. Siervo M, et al. Effects of the Dietary Approach to Stop Hypertension (DASH) diet on cardiovascular risk factors: a systematic review and meta-analysis. Br J Nutr 2014:1-15.
  13. Poggio R, et al. Daily sodium consumption and CVD mortality in the general population: systematic review and meta-analysis of prospective studies. Public Health Nutr 2015, 18(4):695-704.
  14. D’Elia L, et al. Habitual salt intake and risk of gastric cancer: a meta-analysis of prospective studies. Clin Nutr (Edinburgh, Scotland) 2012, 31(4):489-498.
  15. Deckers IA, et al. Long-term dietary sodium, potassium and fluid intake; exploring potential novel risk factors for renal cell cancer in the Netherlands Cohort Study on diet and cancer. Br J Cancer 2014, 110(3):797-801.
  16. Edwards DG, Farquhar WB: Vascular effects of dietary salt. Curr Opin Nephrol Hypertens 2015, 24(1):8-13.