Preventing tobacco use and harm: what is evidence based policy?

The majority of tobacco users commence in early to mid-adolescence. Tobacco smoking can be characterised as a chronic, relapsing disorder. While risk increases with amount smoked, there is no safe level of use (i.e., all use is risky). Duration of use is the most important predictor of premature death with the majority of excess morbidity and mortality avoidable if people quit before middle age. Investment in initiatives that reduce smoking among pregnant women and those at risk of cardiovascular disease provide quickest returns -in reduced health care episodes and expenditure.&nbsp; Measures that successfully reduce smoking among parents probably reduce smoking uptake by children, and high levels of smoking among both children and parents appear to be associated with higher levels of illicit drug use.The evidence base for pharmcotherapies in the treatment of tobacco dependence is very strong. Population-level initiatives such as tax increases, mass media-led campaigns and smoke-free policies are all highly cost-effective in reducing population-smoking levels, including among children and young people.Australian tobacco control initiatives have been based on &quot;social ecology&quot; conceptualisations of the problem, which acknowledge the pivotal role of the media in shaping social values, and public and political opinion.Broad social change, as well as more focused prevention and cessation initiatives, has drawn heavily on research findings from the behavioural sciences. Considerable effort (mainly, in Australian, in the NGO sector) has gone into documenting policy inputs and monitoring impact and outcome measures.This chapter discusses why conceptualising tobacco-related harm from legal, economic and social policy perspectives should also help build support for tobacco control policy among academic and practising economists and lawyers, and in the business, welfare and government sectors.<br /

The potential for tobacco control to reduce PBS costs for smoking-related cardiovaccular disease

Objective: To estimate Pharmaceutical Benefits Scheme (PBS) subsidies for drugs to treat smoking-related cardiovascular disease (CVD) in 2001-02, and over the period of the government\u27s Intergenerational Report (IGR), assuming current smoking prevalence rates and a 5% absolute reduction.Design and setting: An Australian epidemiological study, using prescribing data, aetiological fraction methodology, and IGR trends.Main outcome measures: Estimated smoking-related PBS subsidy costs in 2001-02 and predicted cumulative subsidies until 2041-42, under current and reduced smoking prevalence assumptions.Results: The PBS costs of smoking-related CVD in 2001-02 were $126 million, 9.77$4.5 billion, a 17% reduction. The saving would be $1.14 billion discounting future costs at 5$1 billion, with an internal rate of return of 33%.<br /

Impact of cardiac magnetic resonance imaging on cardiac device and surgical therapy: a prospective study

Cardiac magnetic resonance (CMR) imaging may allow more appropriate selection of patients for cardiac device implantation and/or cardiac surgery. In this prospective observational study we evaluated the impact of CMR imaging on cardiac device and surgical therapy. All CMR examinations performed in a single centre over a 2 year period were prospectively recorded in a dedicated database under 4 clinical pathways [cardiomyopathy, viability, tumour/mass and arrythmogenic right ventricular cardiomyopathy (ARVC)]. Baseline data entered included planned cardiac device implantation and/or cardiac surgical intervention. Patients were contacted 6 months following CMR to evaluate the impact of CMR on planned therapy. Cost savings due to CMR were calculated as the number of surgical or device procedures averted following CMR scanning multiplied by their respective cost weights. Of 732 CMR examinations performed, the clinical pathway was cardiomyopathy in 488 (67 %), ARVC in 118 (16 %), viability in 92 (12 %) and tumour/mass in 34 (5 %). Six month follow-up was available in 666/732 patients. Following CMR, 56/150 (37 %) of patients with an initial plan for device implantation or cardiac surgery, did not undergo the planned intervention (P &lt; 0.001, one-sample exact binomial test). Of 516 patients without an initial device or surgical plan, 33 (6 %) CMR resulted in device implantation or cardiac surgery (P &lt; 0.001, Chi squared). Overall, the estimated saving due to CMR-guided management changes was AUD$737,270. CMR has a significant impact on patient management and offers potential cost savings with respect to selection of device and surgical therapy for cardiac disease

Cost-effectiveness of routine transoesophageal echocardiography during cardiac surgery : a discrete-event simulation study

Background: The aim of this study was to simulate and compare the healthcare and economic outcomes associated with routine use of intraoperative transoesophageal echocardiography (TOE) in patients undergoing cardiac surgery with those associated with a scenario where TOE is not routinely used. Methods: The impact of TOE on surgical decision-making was estimated through a systematic literature review. Individual short-term morbidity and mortality estimates were generated by application of the Society of Thoracic Surgeons risk calculator. Long-term event rates, unit costs, and utility weights were sourced from published literature and expert opinion. A discrete-event simulation model was then constructed to simulate both the in-hospital and post-discharge outcomes for patients undergoing cardiac surgery. Robustness of the base case results was examined through deterministic and probabilistic sensitivity analyses. An incremental cost-effectiveness ratio of V30 000 per quality-adjusted life-year gained was assumed to represent acceptable cost-effectiveness. Results: Routine use of intraoperative TOE was associated with lower costs and higher benefits per patient, which indicates that use of TOE is a dominant strategy. The intervention resulted in the avoidance of 299 cardiac complications, 20 strokes, and 11 all-cause deaths per 10 000 patients. Routine intraoperative TOE was associated with an increased occurrence of bleeding owing to more valvular surgery and subsequent long-term anticoagulation. Conclusions: Routine intraoperative TOE is a cost-effective procedure for patients undergoing cardiac surgery, leading to lower overall costs. It was associated with a decrease in long-term complications including stroke, cardiac complications, and death, although there was a slight increase in extracranial bleeding events

A regeneration proof of the central Llmit theorem for uniformly ergodic Markov chains

Central limit theorems for functionals of general state space Markov chains are of crucial importance in sensible implementation of Markov chain Monte Carlo algorithms as well as of vital theoretical interest. Different approaches to proving this type of results under diverse assumptions led to a large variety of CLT versions. However due to the recent development of the regeneration theory of Markov chains, many classical CLTs can be reproved using this intuitive probabilistic approach, avoiding technicalities of original proofs. In this paper we provide a characterization of CLTs for ergodic Markov chains via regeneration and then use the result to solve the open problem posed in [Roberts & Rosenthal 2005]. We then discuss the difference between one-step and multiple-step small set condition

A progress report on a prospective randomised trial of open and robotic prostatectomy

A randomised trial of robotic and open prostatectomy commenced in October 2010 and is progressing well. Clinical and quality of life outcomes together with economic costs to individuals and the health service are being examined critically to compare outcomes