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1.  Health, Health Inequality, and Cost Impacts of Annual Increases in Tobacco Tax: Multistate Life Table Modeling in New Zealand 
PLoS Medicine  2015;12(7):e1001856.
Countries are increasingly considering how to reduce or even end tobacco consumption, and raising tobacco taxes is a potential strategy to achieve these goals. We estimated the impacts on health, health inequalities, and health system costs of ongoing tobacco tax increases (10% annually from 2011 to 2031, compared to no tax increases from 2011 [“business as usual,” BAU]), in a country (New Zealand) with large ethnic inequalities in smoking-related and noncommunicable disease (NCD) burden.
Methods and Findings
We modeled 16 tobacco-related diseases in parallel, using rich national data by sex, age, and ethnicity, to estimate undiscounted quality-adjusted life-years (QALYs) gained and net health system costs over the remaining life of the 2011 population (n = 4.4 million). A total of 260,000 (95% uncertainty interval [UI]: 155,000–419,000) QALYs were gained among the 2011 cohort exposed to annual tobacco tax increases, compared to BAU, and cost savings were US$2,550 million (95% UI: US$1,480 to US$4,000). QALY gains and cost savings took 50 y to peak, owing to such factors as the price sensitivity of youth and young adult smokers. The QALY gains per capita were 3.7 times greater for Māori (indigenous population) compared to non-Māori because of higher background smoking prevalence and price sensitivity in Māori. Health inequalities measured by differences in 45+ y-old standardized mortality rates between Māori and non-Māori were projected to be 2.31% (95% UI: 1.49% to 3.41%) less in 2041 with ongoing tax rises, compared to BAU. Percentage reductions in inequalities in 2041 were maximal for 45–64-y-old women (3.01%). As with all such modeling, there were limitations pertaining to the model structure and input parameters.
Ongoing tobacco tax increases deliver sizeable health gains and health sector cost savings and are likely to reduce health inequalities. However, if policy makers are to achieve more rapid reductions in the NCD burden and health inequalities, they will also need to complement tobacco tax increases with additional tobacco control interventions focused on cessation.
Using a multistate life table modeling approach, Frederieke van der Deen and colleagues estimate the potential impact of annual increases in tobacco tax on health and health inequalities in New Zealand.
Editors' Summary
Worldwide, approximately 21% of the population aged 15 and above smoke cigarettes and other tobacco products. However, tobacco is a killer. Half of all tobacco users die because of cancer, lung disease, heart disease, or another tobacco-related disease. Tobacco caused 100 million deaths in the 20th century; if current trends continue, it could cause a many more deaths in the 21st century. In response to this global tobacco epidemic, individual countries are considering how to reduce or even end tobacco consumption (the “tobacco endgame”), and international bodies have drawn up various tobacco control directives. The World Health Organization, for example, has developed an international instrument for tobacco control called the Framework Convention on Tobacco Control (FCTC). Countries that are party to the FCTC agree to implement a wide range of measures designed to reduce tobacco use. For example, they agree to implement bans on tobacco advertising, promotion, and sponsorship and to protect people from tobacco smoke exposure in public spaces and indoor workplaces.
Why Was This Study Done?
An important tobacco control measure is the implementation of taxation policies aimed at reducing tobacco consumption, promoting cessation, and preventing young people from taking up smoking. But less is known about the impact on population health, health inequality (higher rates of illness and death in specific parts of the population), and health system costs of annual tobacco tax increases, a strategy that is being used or considered by many countries. Here, the researchers estimate the impact of annual tobacco tax increases compared with no tax increases in New Zealand using a mathematical approach called multistate life table modeling. In New Zealand, a country that collects data on disease incidence and mortality by sociodemographic status and has implemented annual tobacco taxation increases since 2010, there are marked health inequalities between indigenous Māori (15% of the population) and non-Māori residents. Smoking is a major cause of these existing health inequalities (as in many other countries)—33% of Māori smoke compared to 14% of New Zealand Europeans. A life table shows, for each age, the probability that a person of that age will die before his or her next birthday.
What Did the Researchers Do and Find?
The researchers estimated quality-adjusted life-years (QALYs; a measure of disease burden that includes both the quantity and quality of life lived) gained and net health system costs over the remaining life of New Zealand’s 2011 population exposed to annual 10% tobacco tax increases or to no tax increases by modeling 16 tobacco-related diseases in parallel using national data on all-cause mortality and morbidity (illness). Compared to the 2011 population exposed to no tax increases, 260,000 QALYs were gained among the population exposed to annual tax increases from 2011 to 2031 and followed up for the remainder of their lives. The net health system cost savings associated with this intervention were estimated at US$2,550 million over the remainder of the 2011 population’s life. Both the health gains and cost savings began to accrue immediately but took five decades to peak. The QALY gains per capita associated with annual tobacco tax increases were 3.7-fold higher for Māori than for non-Māori because of higher smoking levels and price sensitivity among Māori (the tobacco purchasing behavior of Māori is affected more by the price of tobacco than non-Māori because they have less disposable income). Finally, projected health inequalities measured by the difference in mortality rates among Māori and non-Māori aged 45+ y were 2.3% lower in 2041 with ongoing tax rises than with no tax rises.
What Do These Findings Mean?
These findings suggest that in New Zealand (and probably in other similar populations), ongoing tobacco tax increases should deliver sizeable health gains and health system cost savings and should modestly reduce health inequalities. Notably, the health gains and cost savings will not peak for several decades because smoking is more common among younger age groups and the tobacco tax effect is greater among young people (who have limited disposable income) but young people do not benefit maximally from reduced rates of tobacco-related diseases for many decades. As with all modeling studies, the accuracy of these findings depends on the assumptions built into the model and the data fed into it. Overall, however, these findings support the use of annual increases of tobacco tax as a way to improve population health, save health system costs, and reduce health inequalities but suggest that policy makers will need to introduce other tobacco control interventions focused on smoking cessation among middle-age to older smokers if they want to achieve more rapid reductions in tobacco-related diseases and health inequalities.
Additional Information
This list of resources contains links that can be accessed when viewing the PDF on a device or via the online version of the article at
The World Health Organization provides information about the dangers of tobacco (in several languages), about FCTC, and about tobacco control economics; its 2013 report on the global tobacco epidemic is available
The United States Centers for Disease Control and Prevention provides detailed information about all aspects of smoking and tobacco use
The United Kingdom National Health Services website provides information about the health risks associated with smoking
The UK campaigning public health not-for profit organization Action on Smoking and Health (ASH) provides detailed information on tobacco taxation
Information about tobacco control in New Zealand is available
SmokeFree, a website provided by the UK National Health Service, offers advice on quitting smoking and includes personal stories from people who have stopped smoking, from the US National Cancer Institute, offers online tools and resources to help people quit smoking
PMCID: PMC4517929  PMID: 26218517
2.  How much might a society spend on life-saving interventions at different ages while remaining cost-effective? A case study in a country with detailed data 
We aimed to estimate the maximum intervention cost (EMIC) a society could invest in a life-saving intervention at different ages while remaining cost-effective according to a user-specified cost-effectiveness threshold.
New Zealand (NZ) was used as a case study, and a health system perspective was taken. Data from NZ life tables and morbidity data from a burden of disease study were used to estimate health-adjusted life-years (HALYs) gained by a life-saving intervention. Health system costs were estimated from a national database of all publicly funded health events (hospitalizations, outpatient events, pharmaceuticals, etc.). For illustrative purposes we followed the WHO-CHOICE approach and used a cost-effectiveness threshold of the gross domestic product (GDP) per capita (NZ$45,000 or US$30,000 per HALY). We then calculated EMICs for an “ideal” life-saving intervention that fully returned survivors to the same average morbidity, mortality, and cost trajectories as the rest of their cohort.
The EMIC of the “ideal” life-saving intervention varied markedly by age: NZ$1.3 million (US$880,000) for an intervention to save the life of a child, NZ$0.8 million (US$540,000) for a 50-year-old, and NZ$0.235 million (US$158,000) for an 80-year-old. These results were predictably very sensitive to the choice of discount rate and to the selected cost-effectiveness threshold. Using WHO data, we produced an online calculator to allow the performance of similar calculations for all other countries.
We present an approach to estimating maximal cost-effective investment in life-saving health interventions, under various assumptions. Our online calculator allows this approach to be applied in other countries. Policymakers could use these estimates as a rapid screening tool to determine if more detailed cost-effectiveness analyses of potential life-saving interventions might be worthwhile or which proposed life-saving interventions are very unlikely to benefit from such additional research.
Electronic supplementary material
The online version of this article (doi:10.1186/s12963-015-0052-2) contains supplementary material, which is available to authorized users.
PMCID: PMC4493819  PMID: 26155199
Health-adjusted life-years (HALYs); Health-adjusted life expectancy (HALE); Cost-effective; Cost-effectiveness threshold; Age; Quality-adjusted life-years (QALYs); Morbidity; Health system costs
3.  Prediction of novel alloy phases of Al with Sc or Ta 
Scientific Reports  2015;5:9909.
Using the evolutionary optimization algorithm, as implemented in the USPEX crystal predictor program, and first principles total energy calculations, the compositional phase diagrams for Al-Sc and Al-Ta alloy systems at zero temperature and pressure have been calculated. In addition to the known binary intermetallic phases, new potentially stable alloys, AlSc3 and AlTa7, have been identified in the Al-poor region of the phase diagram. The dynamic and thermal stability of their lattices has been confirmed from the calculated vibrational normal mode spectra in the harmonic approximation.
PMCID: PMC4423498  PMID: 25950915
4.  Health and Economic Impacts of Eight Different Dietary Salt Reduction Interventions 
PLoS ONE  2015;10(4):e0123915.
Given the high importance of dietary sodium (salt) as a global disease risk factor, our objective was to compare the impact of eight sodium reduction interventions, including feasible and more theoretical ones, to assist prioritisation.
Epidemiological modelling and cost-utility analysis were performed using a Markov macro-simulation model. The setting was New Zealand (NZ) (2.3 million citizens, aged 35+ years) which has detailed individual-level administrative cost data.
Of the most feasible interventions, the largest health gains were from (in descending order): (i) mandatory 25% reduction in sodium levels in all processed foods; (ii) the package of interventions performed in the United Kingdom (UK); (iii) mandatory 25% reduction in sodium levels in bread, processed meats and sauces; (iv) media campaign (as per a previous UK one); (v) voluntary food labelling as currently used in NZ; (vi) dietary counselling as currently used in NZ. Even larger health gains came from the more theoretical options of a “sinking lid” on the amount of food salt released to the national market to achieve an average adult intake of 2300 mg sodium/day (211,000 QALYs gained, 95% uncertainty interval: 170,000 – 255,000), and from a salt tax. All the interventions produced net cost savings (except counselling – albeit still cost-effective). Cost savings were especially large with the sinking lid (NZ$ 1.1 billion, US$ 0.7 billion). Also the salt tax would raise revenue (up to NZ$ 452 million/year). Health gain per person was greater for Māori (indigenous population) men and women compared to non-Māori.
This study substantially expands on the range of previously modelled salt reduction interventions and suggests that some of these might achieve major health gains and major cost savings (particularly the regulatory interventions). They could also reduce ethnic inequalities in health.
PMCID: PMC4409110  PMID: 25910259
5.  How reaction to cigarette packet health warnings influence quitting: Findings from the ITC Four Country survey 
Addiction (Abingdon, England)  2009;104(4):669-675.
To examine prospectively the impact of health warnings on quitting activity.
Five waves (2002–2006) of a cohort survey where reactions to health warnings at one survey wave are used to predict cessation activity at the next wave, controlling for country (proxy for warning differences) and other factors. These analyses were replicated on four wave-to-wave transitions.
Setting and participants
Smokers from Australia, Canada, the UK and USA. Samples were Waves 1–2: n=6525; Waves 2–3: n=5257; Waves 3–4:n=4439; and Waves 4–5: n=3993.
Warning salience, cognitive responses (thoughts of harm and of quitting), forgoing of cigarettes and avoidance of warnings were examined as predictors of quit attempts, and of quitting success among those who tried (1 month sustained abstinence), replicated across four wave-to-wave transitions.
All four responses to warnings were independently predictive of quitting activity in bivariate analyses. In multivariate analyses, forgoing cigarettes and cognitive responses to the warnings both prospectively predicted making quit attempts in all replications. However, avoiding warnings did not consistently add predictive value, and there was no consistent pattern for warning salience. There were no interactions by country. Some, but not all, of the effects were mediated by quitting intentions. There were no consistent effects on quit success.
This study adds to the evidence that forgoing cigarettes as a result of noticing warnings and quit-related cognitive reactions to warnings are consistent prospective predictors of making quit attempts. This work strengthens the evidence base for governments to go beyond the FCTC to mandate health warnings on tobacco products that stimulate the highest possible levels of these reactions.
PMCID: PMC4394051  PMID: 19215595
Health warnings; graphic warnings; tobacco product labelling; consumer information; tobacco health information
6.  Patterns of Cancer Care Costs in a Country With Detailed Individual Data 
Medical Care  2015;53(4):302-309.
Supplemental Digital Content is available in the text.
To determine health system expenditure on cancers by time since diagnosis using data for an entire country.
New Zealand cancer registry data was linked to hospitalization, pharmaceutical, outpatient, general practice, laboratory, and other datasets, with costs ascribed to each event occurring in 2006–2011. “Excess” cancer costs were estimated by subtracting “expected costs” for citizens without cancer from the “total cost” for cancer patients ($2011 inflation-adjusted). Gamma regressions were used to estimate costs per person-month.
For first adult cancer diagnosed that the excess cost per person was between US$3400 and US$4300 in the first month postdiagnosis (varied by sex and age), fell to US$50–US$150 per month at 2 or more years postdiagnosis (excluding those within a year of death), but increased again if dying from their cancer (US$3800–US$8300 in the last month of life). Such patterns varied by cancer, for example, in the first month postdiagnosis for 65 year olds it varied 20-fold from US$800 for prostate to US$15,900 for brain cancer.
Per diagnosed case, total excess costs varied from US$8000 (melanoma) to US$98,000 (bone and connective tissue).
Excess cancer costs made up 6.5% of total Vote:Health expenditure in 2010–2011, with colorectal (14.7%), breast (14.4%) being the top 2 contributors, and prostate, non-Hodgkin lymphoma, leukemia, and lung each contributing about 6%.
Costs vary substantially by time since diagnosis and cancer type. The results and regression equations reported in this paper can be used in modeling requiring cancer costs by time since diagnosis and proximity to death.
PMCID: PMC4379114  PMID: 25749656
cancer; health system; costs
8.  Is expanding HPV vaccination programs to include school-aged boys likely to be value-for-money: a cost-utility analysis in a country with an existing school-girl program 
BMC Infectious Diseases  2014;14:351.
Similar to many developed countries, vaccination against human papillomavirus (HPV) is provided only to girls in New Zealand and coverage is relatively low (47% in school-aged girls for dose 3). Some jurisdictions have already extended HPV vaccination to school-aged boys. Thus, exploration of the cost-utility of adding boys’ vaccination is relevant. We modeled the incremental health gain and costs for extending the current girls-only program to boys, intensifying the current girls-only program to achieve 73% coverage, and extension of the intensive program to boys.
A Markov macro-simulation model, which accounted for herd immunity, was developed for an annual cohort of 12-year-olds in 2011 and included the future health states of: cervical cancer, pre-cancer (CIN I to III), genital warts, and three other HPV-related cancers. In each state, health sector costs, including additional health costs from extra life, and quality-adjusted life-years (QALYs) were accumulated. The model included New Zealand data on cancer incidence and survival, and other cause mortality (all by sex, age, ethnicity and deprivation).
At an assumed local willingness-to-pay threshold of US$29,600, vaccination of 12-year-old boys to achieve the current coverage for girls would not be cost-effective, at US$61,400/QALY gained (95% UI $29,700 to $112,000; OECD purchasing power parities) compared to the current girls-only program, with an assumed vaccine cost of US$59 (NZ$113). This was dominated though by the intensified girls-only program; US$17,400/QALY gained (95% UI: dominant to $46,100). Adding boys to this intensified program was also not cost-effective; US$128,000/QALY gained, 95% UI: $61,900 to $247,000).
Vaccination of boys was not found to be cost-effective, even for additional scenarios with very low vaccine or program administration costs – only when combined vaccine and administration costs were NZ$125 or lower per dose was vaccination of boys cost-effective.
These results suggest that adding boys to the girls-only HPV vaccination program in New Zealand is highly unlikely to be cost-effective. In order for vaccination of males to become cost-effective in New Zealand, vaccine would need to be supplied at very low prices and administration costs would need to be minimised.
PMCID: PMC4082618  PMID: 24965837
9.  Violent deaths of media workers associated with conflict in Iraq, 2003–2012 
PeerJ  2014;2:e390.
Background. The violent deaths of media workers is a critical issue worldwide, especially in areas of political and social instability. Such deaths can be a particular concern as they may undermine the development and functioning of an open and democratic society.
Method. Data on the violent deaths of media workers in Iraq for ten years (2003–2012) were systematically collated from five international databases. Analyses included time trends, weapons involved, nationality of the deceased, outcome for perpetrators and location of death.
Results. During this ten-year period, there were 199 violent deaths of media workers in Iraq. The annual number increased substantially after the invasion in 2003 (peaking at n = 47 in 2007) and then declined (n = 5 in 2012). The peak years (2006–2007) for these deaths matched the peak years for estimated violent deaths among civilians. Most of the media worker deaths (85%) were Iraqi nationals. Some were killed whilst on assignment in the field (39%) and 28% involved a preceding threat. Common perpetrators of the violence were: political groups (45%), and coalition forces (9%), but the source of the violence was often unknown (29%). None of the perpetrators have subsequently been prosecuted (as of April 2014). For each violent death of a media worker, an average of 3.1 other people were also killed in the same attack (range 0–100 other deaths).
Discussion. This analysis highlights the high number of homicides of media workers in Iraq in this conflict period, in addition to the apparently total level of impunity. One of the potential solutions may be establishing a functioning legal system that apprehends offenders and puts them on trial. The relatively high quality of data on violent deaths in this occupational group, suggests that it could act as one sentinel population within a broader surveillance system of societal violence in conflict zones.
PMCID: PMC4034609  PMID: 24883251
Media worker; Iraq; Epidemiology; Surveillance; Violent death
10.  Risk factors for death from pandemic influenza in 1918–1919: a case–control study 
Despite the persisting threat from future influenza pandemics, much is still unknown about the risk factors for death from such events, and especially for the 1918–1919 influenza pandemic.
A case–control study was performed to explore possible risk factors for death from pandemic influenza among New Zealand military personnel in the Northern Hemisphere in 1918–1919 (n = 218 cases, n = 221 controls). Data were compiled from a Roll-of-Honour dataset, a dataset of nearly all military personnel involved in the war and archived individual records.
In the fully adjusted multivariable model, the following were significantly associated with increased risk of death from pandemic influenza: age (25–29 years), pre-pandemic hospitalisations for a chronic condition (e.g. tuberculosis), relatively early year of military deployment, a relatively short time from enlistment to foreign service, and having a larger chest size (e.g. adjusted odds ratio for 90–99 cm versus <90 cm was 2·45; 95% CI=1·47–4·10). There were no significant associations in the fully adjusted model with military rank, occupational class at enlistment, and rurality at enlistment.
This is one of the first published case–control studies of mortality risk factors for the 1918–1919 influenza pandemic. Some of the findings are consistent with previous research on risk factors (such as chronic conditions and age groups), but others appear more novel (e.g., larger chest size). As all such historical analyses have limitations, there is a need for additional studies in other settings as archival World War One records become digitalised.
PMCID: PMC4181481  PMID: 24490663
1918–1919 Influenza pandemic; infectious disease; influenza; military; pandemic
11.  Obtaining Fruit and Vegetables for the Lowest Prices: Pricing Survey of Different Outlets and Geographical Analysis of Competition Effects 
PLoS ONE  2014;9(3):e89775.
Inadequate fruit and vegetable (F&V) consumption is an important dietary risk factor for disease internationally. High F&V prices can be a barrier to dietary intake and so to improve understanding of this topic we surveyed prices and potential competition between F&V outlet types.
Over a three week early autumn period in 2013, prices were collected bi-weekly for 18 commonly purchased F&Vs from farmers' markets (FM) selling local produce (n = 3), other F&V markets (OFVM) (n = 5), supermarkets that neighbored markets (n = 8), and more distant supermarkets (n = 8), (in urban Wellington and Christchurch areas of New Zealand). Prices from an online supermarket were also collected.
A total of 3120 prices were collected. Most F&Vs (13/18) were significantly cheaper at OFVMs than supermarkets. Over half of the F&Vs (10/18) were significantly cheaper at nearby compared to distant supermarkets, providing evidence of a moderate ‘halo effect’ in price reductions in supermarkets that neighbored markets. Weekend (vs midweek) prices were also significantly cheaper at nearby (vs distant) supermarkets, supporting evidence for a ‘halo effect’.
Ideal weekly ‘food basket’ prices for a two adult, two child family were: OFVMs (NZ$76), online supermarket ($113), nearby supermarkets ($124), distant supermarkets ($127), and FMs ($138). This represents a savings of $49 per week (US$26) by using OFVMs relative to (non-online) supermarkets. Similarly, a shift from non-online supermarkets to the online supermarket would generate a $13 saving.
In these locations general markets appear to be providing some substantially lower prices for fruit and vegetables than supermarkets. They also appear to be depressing prices in neighboring supermarkets. These results, when supplemented by other needed research, may help inform the case for interventions to improve access to fruit and vegetables, particularly for low-income populations.
PMCID: PMC3961225  PMID: 24651475
12.  Smoking close to others and butt littering at bus stops: pilot observational study 
PeerJ  2014;2:e272.
Background. Transportation settings such as bus stops and train station platforms are increasingly the target for new smokefree legislation. Relevant issues include secondhand smoke exposure, nuisance, litter, fire risks and the normalization of smoking. We therefore aimed to pilot study aspects of smoking behavior and butt disposal at bus stops.
Methods. Systematic observation of smoking and butt disposal by smokers at bus stops. The selection of 11 sites was a mix of convenience and purposeful (bus stops on main routes) in two New Zealand cities.
Results. During 27 h of observation, a total of 112 lit cigarettes were observed being smoked. Smoking occurred in the presence of: just adults (46%), both young people and adults (44%), just young people (6%) and alone (5%). An average of 6.3 adults and 3.8 young people were present at the bus stops while smoking occurred, at average minimum distances of 1.7 and 2.2 m respectively. In bus stops that included an enclosed shelter, 33% of the cigarettes were smoked inside the shelter with others present. Littering was the major form of cigarette disposal with 84% of cigarettes smoked being littered (95% CI; 77%–90%). Also, 4% of disposals were into vegetation, which may pose a fire risk.
Conclusions. This pilot study is limited by its small size and various methodological aspects but it appears to be a first attempt to provide observational evidence around smoking at bus stops. The issues described could be considered by policy makers who are investigating national smokefree laws or by-laws covering transportation settings.
PMCID: PMC3940480  PMID: 24688851
Smoking; Tobacco control; Transportation; Observational study
13.  Taxes on Sugar-Sweetened Beverages to Curb Future Obesity and Diabetes Epidemics 
PLoS Medicine  2014;11(1):e1001583.
In a linked Perspective, Tony Blakely and colleagues discuss the real-world implications of this type of modeling study.
Please see later in the article for the Editors' Summary
PMCID: PMC3883634  PMID: 24409103
14.  Optimising locational access of deprived populations to farmers’ markets at a national scale: one route to improved fruit and vegetable consumption? 
PeerJ  2013;1:e94.
Background. Evidence suggests that improved locational access to farmers’ markets increases fruit and vegetable (FV) consumption, particularly for low-income groups. Therefore, we modelled potential alternative distributions of farmers’ markets in one country (New Zealand) to explore the potential impact for deprived populations and an indigenous population (Māori).
Methods. Data were collected on current farmers’ markets (n = 48), population distributions, area deprivation, and roads. Geographic analyses were performed to optimize market locations for the most deprived populations.
Results. We found that, currently, farmers’ markets provided fairly poor access for the total population: 7% within 12.5 km (15 min driving time); 5% within 5 km; and 3% within 2 km. Modelling the optimal distribution of the 48 markets substantially improved access for the most deprived groups: 9% (vs 2% currently) within 12.5 km; 5% (vs 1%) within 5 km; and 3% (vs 1%) within 2 km. Access for Māori also improved: 22% (vs 7%) within 12.5 km; 12% (vs 4%) within 5 km; and 6% (vs 2%) within 2 km. Smaller pro-equity results arose from optimising the locations of the 18 least pro-equity markets or adding 10 new markets.
Conclusion. These results highlight the potential for improving farmers’ market locations to increase accessibility for groups with low FV consumption. Given that such markets are easily established and relocated, local governments could consider these results to inform decisions, including subsidies for using government land and facilities. Such results can also inform central governments planning around voucher schemes for such markets and exempting them from taxes (e.g., VAT/GST).
PMCID: PMC3709110  PMID: 23862107
Farmers’ market; Fruit and vegetable intake; Geography; Equity
15.  Foods and Dietary Patterns That Are Healthy, Low-Cost, and Environmentally Sustainable: A Case Study of Optimization Modeling for New Zealand 
PLoS ONE  2013;8(3):e59648.
Global health challenges include non-communicable disease burdens, ensuring food security in the context of rising food prices, and environmental constraints around food production, e.g., greenhouse gas [GHG] emissions. We therefore aimed to consider optimized solutions to the mix of food items in daily diets for a developed country population: New Zealand (NZ).
We conducted scenario development and linear programming to model 16 diets (some with uncertainty). Data inputs included nutrients in foods, food prices, food wastage and food-specific GHG emissions.
This study identified daily dietary patterns that met key nutrient requirements for as little as a median of NZ$ 3.17 per day (US$ 2.41/d) (95% simulation interval [SI] = NZ$ 2.86 to 3.50/d). Diets that included “more familiar meals” for New Zealanders, increased the cost. The optimized diets also had low GHG emission profiles compared with the estimate for the ‘typical NZ diet’ e.g., 1.62 kg CO2e/d for one scenario (95%SI = 1.39 to 1.85 kg CO2e) compared with 10.1 kg CO2e/d, respectively. All of the optimized low-cost and low-GHG dietary patterns had likely health advantages over the current NZ dietary pattern, i.e., lower cardiovascular disease and cancer risk.
We identified optimal foods and dietary patterns that would lower the risk of non-communicable diseases at low cost and with low greenhouse gas emission profiles. These results could help guide central and local government decisions around which foods to focus policies on. That is which foods are most suitable for: food taxes (additions and exemptions); healthy food vouchers and subsidies; and for increased use by public institutions involved in food preparation.
PMCID: PMC3609827  PMID: 23544082
16.  The Feasibility of Achieving Low-Sodium Intake in Diets That Are Also Nutritious, Low-Cost, and Have Familiar Meal Components 
PLoS ONE  2013;8(3):e58539.
Given the importance of high sodium diets as a risk factor for disease burden (ranked 11th in importance in the Global Burden of Disease Study 2010), we aimed to determine the feasibility of low-sodium diets that were also low-cost, nutritious and (for some scenarios) included familiar meals.
The mathematical technique of “linear programming” was used to model eight optimized daily diets (some with uncertainty), including some diets that contained “familiar meals” for New Zealanders or were Mediterranean-, Asian- and Pacific-style diets. Data inputs included nutrients in foods, food prices and food wastage.
Using nutrient recommendations for men and a cost constraint of
These results provide some reassurance for the feasibility of substantially reducing population sodium intake given currently available low-cost foods and while maintaining some level of familiar meals. Policy makers could consider ways to promote such optimized diets and foods, including regulations on maximum salt levels in processed foods, and taxes on alternative foods that are high in salt, sugar and saturated fat.
PMCID: PMC3591307  PMID: 23505532
Addiction (Abingdon, England)  2012;107(1):197-205.
To describe some of the variability across the world in levels of quit smoking attempts and use of various forms of cessation support.
Use of the International Tobacco Control Policy Evaluation Project surveys of smokers, using the 2007 survey wave (or later, where necessary).
Australia, Canada, China, France, Germany, Ireland, Malaysia, Mexico, Netherlands, New Zealand, South Korea, Thailand, UK, Uruguay and USA.
Self-report on use of cessation aids and on visits to health professionals and provision of cessation advice during the visits.
Prevalence of quit attempts in the last year varied from under 20% to over 50% across countries. Similarly, smokers varied greatly in reporting of visiting health professionals in the last year (< 20% to over 70%), and among those who did, provision of advice to quit also varied greatly. There was also marked variability in the levels and types of help reported. Use of medication was generally more common than use of behavioural support, except where medications are not readily available.
There is wide variation across countries in rates of attempts to stop smoking and use of assistance with higher overall use of medication than behavioural support. There is also wide variation in the provision of brief advice to stop by health professionals.
PMCID: PMC3237953  PMID: 21883605
BMC Public Health  2012;12:782.
There is increasing interest in ending the tobacco epidemic and in applying ‘endgame’ solutions to achieve that goal at national levels. We explored the understanding of, and reactions to, a tobacco-free vision and an endgame approach to tobacco control among New Zealand smokers and non-smokers.
We recruited participants in four focus groups held in June 2009: Māori (indigenous people) smokers (n=7); non-Māori smokers (n=6); Māori non-smokers (n=7); and non-Māori non-smokers (n=4). Participants were from the city of Whanganui, New Zealand. We introduced to them the vision of a tobacco-free New Zealand and the concept of a semi-autonomous agency (Tobacco-Free Commission [TFC]) that would control the tobacco market as part of an endgame approach.
There was mostly strong support for the tobacco-free New Zealand vision among all groups of participants. The reason most commonly given for supporting the vision was to protect children from tobacco. Most participants stated that they understood the TFC concept and reacted positively to it. Nevertheless, rather than focusing on organisational or structural arrangements, participants tended to focus on supporting the specific measures which a future TFC might facilitate such as plain packaging of tobacco products. Various concerns were also raised around the TFC, particularly around the feasibility of its establishment.
We were able to successfully communicate a complex and novel supply-side focused tobacco control policy intervention to smokers and non-smokers. The findings add to the evidence from national surveys that there is public support, including from smokers, for achieving a tobacco-free vision and using regulatory and policy measures to achieve it. Support for such measures may be enhanced if they are clearly communicated and explained with a rationale which stresses protecting children and future generations from tobacco smoking.
PMCID: PMC3505727  PMID: 22974338
Objective. To establish the trends in prevalence, and correlates, of roll-your-own (RYO) use in Canada, USA, UK and Australia, 2002–2008. Methods. Participants were 19,456 cigarette smokers interviewed during the longitudinal International Tobacco Control (ITC) Four-Country Survey in Canada, USA, UK, and Australia. Results. “Predominant” RYO use (i.e., >50% of cigarettes smoked) increased significantly in the UK and USA as a proportion of all cigarette use (both P < .001) and in all countries as a proportion of any RYO use (all P < .010). Younger, financially stressed smokers are disproportionately contributing to “some” use (i.e., ≤50% of cigarettes smoked). Relative cost was the major reason given for using RYO, and predominant RYO use is consistently and significantly associated with low income. Conclusions. RYO market trends reflect the price advantages accruing to RYO (a product of favourable taxation regimes in some jurisdictions reinforced by the enhanced control over the amount of tobacco used), especially following the impact of the Global Financial Crisis; the availability of competing low-cost alternatives to RYO; accessibility of duty-free RYO tobacco; and tobacco industry niche marketing strategies. If policy makers want to ensure that the RYO option does not inhibit the fight to end the tobacco epidemic, especially amongst the disadvantaged, they need to reduce the price advantage, target additional health messages at (young) RYO users, and challenge niche marketing of RYO by the industry.
PMCID: PMC3361236  PMID: 22666277
Emerging Infectious Diseases  2012;18(2):226-233.
Food safety measures that lower incidence of campylobacteriosis might also prevent Guillain-Barré syndrome.
PMCID: PMC3310455  PMID: 22304786
Guillain-Barré syndrome; Campylobacter infection; camplyobacteriosis; food safety; poultry; government regulations; public health surveillance; epidemiology; New Zealand
Emerging Infectious Diseases  2012;18(1):71-77.
The persistent excess in adverse outcomes by ethnicity highlights the need for improved public health responses.
Evidence suggests that indigenous populations have suffered disproportionately from past influenza pandemics. To examine any such patterns for Māori in New Zealand, we searched the literature and performed new analyses by using additional datasets. The Māori death rate in the 1918 pandemic (4,230/100,000 population) was 7.3× the European rate. In the 1957 pandemic, the Māori death rate (40/100,000) was 6.2× the European rate. In the 2009 pandemic, the Māori rate was higher than the European rate (rate ratio 2.6, 95% confidence interval 1.3–5.3). These findings suggest some decline in pandemic-related ethnic inequalities in death rates over the past century. Nevertheless, the persistent excess in adverse outcomes for Māori, and for Pacific persons residing in New Zealand, highlights the need for improved public health responses.
PMCID: PMC3310086  PMID: 22257434
influenza pandemic; virus; historical; Maori; Pacific
Nicotine & Tobacco Research  2010;12(Suppl 1):S78-S84.
We aimed to describe use of a national quitline service and the variation in its use by smoker characteristics (particularly ethnicity and deprivation). The setting was New Zealand (NZ), which takes proactive measures to attract disadvantaged smokers to this service.
The NZ arm of the International Tobacco Control Policy Evaluation Survey (ITC Project) utilizes the New Zealand Health Survey (a national sample) from which we surveyed adult smokers in two waves (N = 1,376 and N = 923) 1 year apart.
Quitline use in the last 12 months rose from 8.1% (95% CI = 6.3%–9.8%) in Wave 1 to 11.2% (95% CI = 8.4%–14.0%) at Wave 2. Māori (the indigenous people of NZ) were significantly more likely to call the Quitline than were European/other smokers. Relatively higher call rates also occurred among those reporting higher deprivation, financial stress, a past mental health disorder, a past drug-related disorder, and higher psychological distress (Kessler 10-item index). Independent associations in the multivariate analyses of Quitline use were being Māori, reporting financial stress, and ever having been diagnosed with a mental health disorder.
This national Quitline service is successfully stimulating disproportionately more calls by Māori smokers and those with some measures of disadvantage. It may therefore be contributing to reducing health inequalities. It appears possible to target quitlines to reach those smokers in greatest need.
PMCID: PMC2981469  PMID: 20889485
BMC Public Health  2011;11:598.
Although the association between smoking status and poorer mental health has been well documented, the association between quit status and psychological distress is less clear. The aim of the present study is to investigate the association of smoking status and quit status with psychological distress.
Data for this study is from a single year of the Survey of Families, Income and Employment (SoFIE) conducted in New Zealand (2004/05) (n = 18,525 respondents). Smoking status and quit status were treated as exposure variables, and psychological distress (Kessler-10) was treated as the outcome variable. Logistic regression analyses were performed to determine the association of smoking with psychological distress in the whole adult population and quit status with psychological distress in the ex- and current-smoking population.
Current smokers had higher rates of high and very high psychological distress compared to never smokers (adjusted odds ratio (aOR) = 1.45; 95% CI: 1.24-1.69). Unsuccessful quitters had much higher levels of high to very high levels of psychological distress (16%) than any other group. Moreover, compared to long-term ex-smokers, unsuccessful quitters had a much higher odds of high to very high levels of psychological distress (aOR = 1.73; 95% CI: 1.36-2.21).
These findings suggest that the significant association between smoking and psychological distress might be partly explained by increased levels of psychological distress among current smokers who made a quit attempt in the last year. This issue needs further study as it has implications for optimising the design of quitting support.
PMCID: PMC3160992  PMID: 21798059
smoking status; quit status; psychological distress; socioeconomic status
BMC Public Health  2011;11:580.
Tobacco control strategies have mainly targeted reducing demand. Supply-side focused measures, though less familiar, deserve consideration, particularly to achieve 'endgame' tobacco control aims (e.g. achieving close to zero smoking prevalence). We explored attitudes towards supply-side focused 'endgame' tobacco control approaches and how they can be best communicated with senior policymakers, journalists, and public health practitioners.
We identified five supply-side focused approaches which could potentially lead to the tobacco endgame: two structural models and three discrete actions. The structural models were: (i) a Nicotine Authority to coordinate tobacco control activities and regulate the nicotine/tobacco market for public health aims; and (ii) a Tobacco Supply Agency acting as a monopoly purchaser of tobacco products and controlling the tobacco supply for public health aims. The actions were: (a) allocating progressively reducing tobacco product import quotas (the 'sinking lid') until importation and commercial sale of tobacco products ceased; (b) making tobacco companies responsible for reducing smoking prevalence with stringent financial penalties if targets were missed; and (c) new laws to facilitate litigation against tobacco companies. These approaches were presented as means to achieve a tobacco free New Zealand by 2020 to 19 senior policymakers, journalists, and public health physicians in two focus groups and eight interviews, and their reactions sought.
The tobacco-free vision was widely supported. Participants engaged fully with the proposed tobacco control approaches, which were viewed as interesting or even intriguing. Most supported increasing the focus on supply-side measures. Views differed greatly about the desirability, feasibility and likely effectiveness of each approach. Participants identified a range of potential barriers to implementation and challenges to successfully advocating and communicating these approaches. The current framing of tobacco as a risky but legal commodity was noted as an important potential barrier to implementing endgame approaches.
Endgame tobacco control approaches were considered to be viable policy options. Further policy analysis, research and public discussion are needed to develop endgame approaches. A significant change in the public framing of tobacco may be a prerequisite for implementing endgame solutions.
PMCID: PMC3160990  PMID: 21774829
Emerging Infectious Diseases  2011;17(6):1007-1015.
A population-level food safety response successfully reduced disease incidence.
Beginning in the 1980s, New Zealand experienced rising annual rates of campylobacteriosis that peaked in 2006. We analyzed notification, hospitalization, and other data to explore the 2007–2008 drop in campylobacteriosis incidence. Source attribution techniques based on genotyping of Campylobacter jejuni isolates from patients and environmental sources were also used to examine the decline. In 2008, the annual campylobacteriosis notification rate was 161.5/100,000 population, representing a 54% decline compared with the average annual rate of 353.8/100,000 for 2002–2006. A similar decline was seen for hospitalizations. Source attribution findings demonstrated a 74% (95% credible interval 49%–94%) reduction in the number of cases attributed to poultry. These reductions coincided with the introduction of a range of voluntary and regulatory interventions to reduce Campylobacter spp. contamination of poultry. The apparent success of these interventions may inform approaches other countries could consider to help control foodborne campylobacteriosis.
PMCID: PMC3358198  PMID: 21749761
bacteria; foodborne infections; Campylobacter; epidemiology; surveillance; poultry; food supply; bacterial typing; research; New Zealand

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