Taxation options for nicotine and tobacco products in Switzerland - a review of tax policies

Alternative nicotine products such as electronic nicotine delivery systems (ENDS) and tobacco heating systems have gained worldwide popularity. Findings suggest ENDS to be probably less harmful than combustible cigarettes, but evidence on long-term health effects is still lacking. The potential risk reduction by using tobacco heating systems instead of combustible cigarettes has largely been studied by tobacco industry-sponsored research. Evidence on the extent of risk reduction is key for risk-adapted taxation policies, which will be discussed soon in the Swiss parliament. Evidence on the effects of tax policies in the USA shows that the level of taxation of ENDS, tobacco heating systems and combustible cigarettes has an effect on switches between these products. Therefore, excise taxes influencing one another need to be considered. In Switzerland, tobacco heating systems are currently taxed at a level of 12%, whereas ENDS are not subject to tobacco excise taxation as yet, because they do not meet the legal definition of a tobacco product. This article analyses approaches for imposing taxes on tobacco and nicotine products and possible outcomes, depending on the intended public health goals. At least three tax models can be considered. Tax model A would apply a very small tax on ENDS and a higher tax for tobacco products, which could increase incentives for smokers to switch to vaping but comes with risks of increased vaping initiation among the youth and subsequent switch to or dual use of tobacco products. In contrast, model B would levy a moderate tax on ENDS and an increased tax on tobacco products, which could limit initiation among youth, incentivise to switch from smoking to vaping and discourage dual use. In model C, a comparable tax level for ENDS, tobacco heating systems and combustible cigarettes is levied. This could have overall positive effects in reducing tobacco- and nicotine-associated burden of disease by discouraging initiation in youth, overall consumption and dual use, but could discourage switching to less harmful products. When applying these tax models to current sales prices of these products we found that no public health goal, such as protecting youth and reducing tobacco-associated morbidity and mortality can be achieved. The price of tobacco products is too low to achieve any price differentiation that reflects the different risks associated with ENDS and tobacco products. In order to achieve any public health goal with one of these tax models, prices for tobacco products need to be increased substantially

Perception of surgical complications among patients, nurses and physicians: a prospective cross-sectional survey

BACKGROUND: Several scores grade the severity of post-operative complications but it is unclear whether such scores truly reflect the perception of patients and practicing nurses and physicians. Study design: 227 patients, 143 nurses and 245 physicians independently rated the severity of 30 common post-operative complications on a numerical analogue scale from 0 (not severe at all) to 100 (extremely severe) while being blinded towards the Clavien-Dindo classification. We considered a difference in ratings of >10 to be clinically important in distinguishing between grades of severity and groups. We evaluated the level of reproducibility of responses by calculating intraclass correlation coefficients (ICC) and compared scores across severity grades and between groups using the generalized estimating equations. RESULTS: Reproducibility of the ratings was good for all three groups (ICCpatients 0.71 (95%-CI 0.64-0.76), ICCnurses 0.83 (0.78-0.87) and ICCphysicians 0.87 (0.83-0.90)). The participants' perceptions of the severity of complications reflected the Clavien-Dindo classification (median of grade I: 20 (IQR 10-30), grade II: 40 (31.3-52.5), grade IIIa: 50 (40-60), grade IIIb: 70 (60-75), grade IVa: 85 (80-90) and grade IVB: 95 (90-100)). Although patients' perception differed significantly from those of physicians (average difference -8.7 (95%-CI -10.4 to -6.9, p<0.001) and nurses (difference -2.8 (-4.8 to -0.8, p=0.007) they did not reach our thresholds for clinical importance. CONCLUSION: The severity of post-operative complications is perceived similarly by patients, nurses and physicians and reflects the Clavien-Dindo classification well. Our results support the use of Clavien-Dindo classification system as part of the shared or informed decision making process

Interventions to improve children's access to mental health care: a systematic review and meta-analysis

AimsMental disorders in children are a significant and growing cause of morbidity worldwide. Although interventions to help overcome barriers along the pathway to accessing health care for children with mental disorders exist, there is no overview of randomised controlled trials (RCTs) on these interventions as yet. This study aimed to systematically identify RCTs of interventions to improve access to mental health care for children and synthesise them using a conceptual framework of access to health care.MethodsThis systematic review was performed following a predefined protocol registered with PROSPERO (ID: CRD42018081714). We searched the databases MEDLINE, EMBASE, PsycINFO and CENTRAL for RCTs up to 15 May 2019 using terms related to the concepts ‘young people,’ ‘mental disorders’ and ‘help-seeking interventions’ and scanned reference lists from relevant studies. Two reviewers independently screened all identified articles in a two-stage process, extracted results on outcomes of interest (knowledge, attitudes, intentions, help-seeking, accessing care, mental health outcomes and satisfaction), assessed the risk of bias and conducted meta-analyses where deemed appropriate.ResultsAfter screening 5641 identified articles, 34 RCTs were eligible for inclusion. Eighty per cent of universal school-based interventions measuring knowledge (n = 5) and 67% measuring attitudes (n = 6) reported significantly better results compared with controls on those outcomes, whereas 20% measuring access to care (n = 5) and none measuring mental health outcomes (n = 7) did. In contrast, 71% of interventions targeting at-risk individuals (n = 21) reported better access to care compared with controls, while just 33% (n = 6) did for mental health outcomes. For satisfaction with care, this proportion was 80% (n = 5). Meta-analyses of interventions measuring initial appointment attendance yielded combined odds ratios of 3.11 (2.07–4.67) for appointment reminder interventions and 3.51 (2.02–6.11) for treatment engagement interventions. The outcomes for universal school-based interventions were heterogeneous and could not be summarised quantitatively through meta-analysis.ConclusionsTo have a population-level effect on improving children's access to mental health care, two-stage interventions that identify those in need and then engage them in the health-care system may be necessary. We need more evidence on interventions to target contextual factors such as affordability and infrastructural barriers.</jats:sec

Physical activity and risk of comorbidities in patients with chronic obstructive pulmonary disease: a cohort study

Multi-morbidity is common in patients with chronic obstructive pulmonary disease and low levels of physical activity are hypothesized to be an important risk factor. The current study aimed to assess the longitudinal association between physical activity and risk of seven categories of comorbidity in chronic obstructive pulmonary disease patients. The study included 409 patients from primary care practice in the Netherlands and Switzerland. We assessed physical activity using the Longitudinal Ageing Study Amsterdam Physical Activity Questionnaire at baseline and followed patients for up to 5 years. During follow-up, patients reported their comorbidities (cardiovascular, neurological, endocrine, musculoskeletal, malignant, and infectious diseases) and completed the Hospital Anxiety and Depression Scale questionnaire for mental health assessment. We implemented multinomial logistic regression (an approximation to discrete time survival model using death as a competing risk) for our analysis. Study results did not suggest a statistically significant association of baseline physical activity with the development of seven categories of comorbidity. However, when we focused on depression and anxiety symptoms, we found that higher levels of physical activity at baseline were associated with a lower risk for depression (adjusted hazard ratio, 0.85; 0.75-0.95; p = 0.005) and anxiety (adjusted hazard ratio, 0.89; 0.79-1.00; p = 0.045). In chronic obstructive pulmonary disease patients, those with high physical activity are less likely to develop depression or anxiety symptoms over time. Increasing physical activity in chronic obstructive pulmonary disease patients may be an approach for testing to lower the burden from incident depression and anxiet

The minimal important difference of the hospital anxiety and depression scale in patients with chronic obstructive pulmonary disease

BACKGROUND: Interpretation of the Hospital Anxiety and Depression Scale (HADS), commonly used to assess anxiety and depression in COPD patients, is unclear. Since its minimal important difference has never been established, our aim was to determine it using several approaches. METHODS: 88 COPD patients with FEV1 /= 0.5 we performed linear regression analyses to predict the minimal important difference from the anchors. As distribution-based approach we used the Effect Size approach. RESULTS: Based on CRQ emotional function and mastery domain as well as on total scores, the minimal important difference was 1.41 (95% CI 1.18-1.63) and 1.57 (1.37-1.76) for the HADS anxiety score and 1.68 (1.48-1.87) and 1.60 (1.38-1.82) for the HADS total score. Correlations of the HADS depression score and CRQ domain and Feeling Thermometer scores were < 0.5. Based on the Effect Size approach the MID of the HADS anxiety and depression score was 1.32 and 1.40, respectively. CONCLUSION: The minimal important difference of the HADS is around 1.5 in COPD patients corresponding to a change from baseline of around 20%. It can be used for the planning and interpretation of trials

Patient Preference Studies for Advanced Prostate Cancer Treatment Along the Medical Product Life Cycle: Systematic Literature Review

Background: Patient preference studies can inform decision-making across all stages of the medical product life cycle (MPLC). The treatment landscape for advanced prostate cancer (APC) treatment has substantially changed in recent years. However, the most patient-relevant aspects of APC treatment remain unclear. This systematic review of patient preference studies in APC aimed to summarize the evidence on patient preferences and patient-relevant aspects of APC treatments, and to evaluate the potential contribution of existing studies to decision-making within the respective stages of the MPLC. Methods: We searched MEDLINE and EMBASE for studies evaluating patient preferences related to APC treatment up to October 2020. Two reviewers independently performed screening, data extraction and quality assessment in duplicate. We descriptively summarized the findings and analyzed the studies regarding their contribution within the MPLC using an analytical framework. Results: Seven quantitative preference studies were included. One study each was conducted in the marketing approval and the health technology assessment (HTA) and reimbursement stage, and five were conducted in the post-marketing stage of the MPLC. While almost all stated to inform clinical practice, the specific contributions to clinical decision-making remained unclear for almost all studies. Evaluated attributes related to benefits, harms, and other treatment-related aspects and their relative importance varied relevantly between studies. All studies were judged of high quality overall, but some methodological issues regarding sample selection and the definition of patient-relevant treatment attributes were identified. Conclusion: The most patient-relevant aspects regarding the benefits and harms of APC treatment are not yet established, and it remains unclear which APC treatments are preferred by patients. Findings from this study highlight the importance of transparent reporting and discussion of study findings according to their aims and with respect to their stage within the MPLC. Future research may benefit from using the MPLC framework for analyzing or determining the aims and design of patient preference studies. Keywords: benefit-harm assessment; medical product life cycle; patient preferences; patient-centered care; preference research; prostate cancer; systematic revie

Fingolimod versus interferon beta 1-a: Benefit-harm assessment approach based on TRANSFORMS individual patient data

BACKGROUND Fingolimod is a disease-modifying drug approved for multiple sclerosis but its benefit-harm balance has never been assessed compared to other active treatments. OBJECTIVES Our aim was to compare the benefits and harms of fingolimod with interferon beta-1a using individual patient data from TRial Assessing injectable interferon versus FTY720 Oral in RRMS trial. METHODS We modelled the health status of patients over time including Expanded Disability Status Scale measurements, relapses and any adverse events. We assessed the mean health status between arms and the proportion of patients whose health deteriorated or improved relatively to baseline, using a prespecified minimal important difference of 4.6. We performed sensitivity analyses to test our assumptions. RESULTS Main and sensitivity analyses favoured fingolimod 0.5 mg over interferon beta-1a. The average health status difference was 1.01 (95% CI 0.93-1.08). Patients on fingolimod 0.5 mg were 0.47 (95% CI: 0.35-0.63, p < 0.001) times less likely to experience a relevant decline in health status compared to interferon beta-1a patients, with a number needed to treat of 7.10 [5.18, 11.23]. CONCLUSIONS Fingolimod's net benefit over interferon beta-1a did not reach the clinical relevance over 1 year, but the decreased risk for health status deterioration may be more pronounced more long term and patients may prefer less treatment burden associated with fingolimod