DODs Report: EQUIPT Final Project Conference

Source: EQUIPT Project

Subject: Counting the benefit of investing in evidence-based tobacco control in Europe

Date:  September 27 2016

On September 27, the EQUIPT project organised its final conference on “Counting the benefit of investing in evidence-based tobacco control in Europe”. Please find a summary of the discussion below.

Opening of the conference:

Karin Kadenbach (S&D, AT) member of the ENVI Committee opened the conference and first insisted on the importance for politicians to have at their disposal reliable and trustworthy information. She also noted the efforts they have to make to combat the methods of the tobacco industry in order to offer people more healthy years in their lifespan. The tobacco industry is a powerful one she continued, thus they have to ensure that the information they are providing is backed by strong evidence.  Science is a resource in order to fill evidence and allow policy makers to do their jobs. However, this is often challenged by the industry. Within this context, the EQUIPT project provides evidence and tools for making decisions on investment. In fact, budgetary constraints faced by governments and authorities often serve as an excuse, while with EQUIPT, it is now possible to show finance and health ministers that investing in the protection from tobacco is cost effective. Indeed, political discussions are usually about numbers and budget lines. Tobacco kills thousands of people every year, she added, but together joining force, we can make a difference, she concluded. Then responding to a question from the EQUIPT project team, about the consideration given by politician to figures and results they produce, she explained that numbers speak when you can realise what they represent, such as the population of a city. Explaining how much it actually costs and what could be done with the money instead helps. This is a valuable instrument.

Dr Subhash Pokhrel: Introduction to the EQUIPT Project, Health Economics Research Group (HERG), Division of health sciences, Brunel University London.

Dr Pokhrel introduced the EQUIPT consortium and explained that today’s presentation is the outcome of a team work and has benefitted from the wider input of stakeholders. He then presented the timeline of the project, since 2010, and the decision to look at how the UK ROI (Return On Investment) model could be extended to other countries.

Public health is trying to achieve benefits from One to Many, to work from clinical efficacy to population health/wider outcomes, he explained. The question is at what costs. Dr Pokhrel explained that there is strong evidence that health policy are cost effective, including in tobacco control. However, the problem is whether this evidence always translates into public health policy. Asking the question of the reasons why evidence is not used, he explained that there is a knowledge-to-action gap in the literature. He further outlined a supply and demand side issue with mismatch between research outputs and needs, and added that decisions are likely to vary with what evidence one uses. In addition, there is also an unbalanced evidence burden relationship, and he posed the question whether national level evidence resonate to local burden. In sum, the use and transferability of evidence is a public health goal in itself.

Dr Pokhrel then went on talking about the three aims of the EQUIPT project.

  • To co create ROI models in four sample EU countries (Germany, Hungary, the Netherlands and Spain) adapting from existing UK ROI Model.
  • To compare the ROI results across sample countries to inform relative cost-effectiveness of tobacco control.
  • To transfer policy recommendations to other EU countries not included in the sample.

Dr Pokhrel explained that the team did a lot of pre-adaptation work, then re-modelling, looked into transferability, with the next steps being to look into policy proposals and dissemination.

The field was full of challenges at all levels, he continued, which translated into the methods. Problems existed in the way they produced and reported on the findings. Thus, they tried to identify and engage with stakeholders while maintaining scientific integrity. This stakeholder engagement aimed at better understanding the decision context, at informal level, formal level, with the objective of collecting data to improve study design, reduce the bias and to improve usability and the chance for evidence-use by policy makers. 

Adam Lester-George LeLan Solutions: Presentation of the ROI tool

Adam Lester-George gave a presentation of the tool the project created.He explained that whilst it has been developed on Microsoft excel it will soon be available for download from the project website. He described the tool as dynamic and interactive. The tool provides data on the smoking population, intentions to quit, ways of doing so, and cessation interventions in details. It also allows to evaluate the cost of interventions and potential benefits. Hence, the tool allows to play with different figures to estimate the expected results of different types of interventions. It is also possible to review the interventions and make changes. Indeed, the impact of increasing the uptake of a particular intervention can also be calculated, showing the investment cost, but also the impact on quitters and values of the investment. The report can be exported to a narrative or a dashboard, he concluded.


Stakeholder engagement in EQUIPT

Professor Silvia Evers, university of Maastricht: Stakeholders’ views to inform development of EQUIPTMOD: methods and key findings.

Professor Silvia Evers first explained the specificity of the project in the way it was developed. The rationale behind the project was the limited use by policy makers of the evidence provided. In fact, health economics and cost effectiveness is about money, and stakeholders generally do not like speaking about money. Among the issues she highlighted, she mentioned the lack of awareness, that some did not feel comfortable with the method, loopholes in the review of evidence and the pressure from the tobacco industry. There are also budget and time constraints, she added. On the research side, she explained that stakeholders deal with a go or not go question, while the results of economic study are expressed in probabilities. There is also uncertainty about the (poor) quality and the (independent) input. This goes with some limited applicability in the daily practice of stakeholders.

Professor Evers then discussed the reasons why stakeholder do not adopt tools, noting the lack of theoretical framework to understand the underlying mechanism towards behavioural change and the importance of analysing perceptions concerning awareness and motivation to adopt ROI tools of tobacco control.

It also appears important to improve the understandings of the mentioned facilitators and barriers to stakeholders usage of ROI tools, to improve the ROI tools and interface and to make it stakeholders friendly. She explained that they look at the theory (I-change) and how they can modify people behaviour, motivation factors, in the way they will use models. They involved stakeholders from scratch and tried to understand the difference between non intenders and intenders.  

Professor Evers then described their methods, which included a stakeholders’ survey, interviews, and a presentation of the ROI tool, which allowed to look at the usability of the tool. Results of the survey showed some willingness to use the tool, while differences exist among the types of stakeholders with regard to risk perception, attitude, social support and self-efficacy. Similarly, differences were raised as regards the types of interventions.

Concluding on her presentation she observed that stakeholder involvement is possible but is time consuming. She thought that EQUIPT is a good marriage between health behaviour change methods (I-change) and HTA economic evaluation and outlined that the intention to use the ROI tool is high.

Professor Annette Boaz on stakeholder engagement for research impact: the SEEIMPADCT study

Professor Annette Boaz presented a study conducted in parallel to the EQUIPT project on the involvement of stakeholders in research. The SEE IMPAC study was funded under the second round of the UK Medical Research Council economic impact call in 2013.

It is not that often that studies take this approach from the start, she explained, as they usually enter late or even at the end, in a project. She began by defining the word “stakeholder” before looking at the notion of stakeholder engagement. She noted the recent pieces of evidence that stakeholder engagement is a way of approaching research and elaborated on three generations of thinking – linear model; relationship model; systems model.

What is interesting with EQUIPT was the engagement of stakeholders early in the process, she said, before elaborating on the design and method of their study, and the prospective approach. Touching upon stakeholder engagement in practice, she noted the tension between inclusion and productivity, and different possible modes of engagement – managed approach, social networking approach. She finally concluded on next steps, with a second round of interviews and event observations. There is an invitation to develop a work package within EQUIPT 2 and to continue this work, she added. 


A discussion with participants followed this first panel presentation.

Exporting this exercise to evaluate the benefit of the prevention of uptake would prove difficult if not impossible said Prof.  Evers . Even if the model is very elaborated, it needs a lot of data input, trustful data. Dr Pokhrel further raised the need to strike a balance between complexity and usability, while the panellist recognised that this is something policy makers would value. One option, said Dr Pokhrel would be to model prevention, but this might require to build a completely different model.

Noting that the context differs among countries, Dr Pokhrel underlined that the main question is how to build an intervention package, how to create policy scenarios.

Questioned on the transferability of the tool and second-hand smoke, Dr. Pokhrel explained that the tool captures some kind of passive smoking and also evaluates the effect of intervention packages on the treatment cost of passive smoking. The same principle will apply to other countries, with one difficulty being that there is no robust data available in most countries and that they would need to build them. Going forward, he added that there are room for improvement, taking into account second-hand smoking.

The crucial question of who to convince, received a twofold answer from Dr Pokhrel . In fact, it is possible to stick to the policy makers or to also speak to the people who will be in a position to draw up and implement policies in the coming years. Both should be done, he thought, and the way they were and are engaging stakeholders throughout the project is promising. Adam Lester-George added that they have to take this reality into account. They can learn lessons from what they have achieved so far and use the policy and tools in other parts of the world.


EQUIPT tool to support decisions

Professor Doug Coyle: EQUIPTMOD: methods and possibilities for the economic model within the EQUIPT ROI tool.

Professor Coyle made a description of the model that is used by the tool. He explained how the existing NICE ROI tool was adapted to the need of the EQUIPT project, described the model which underlies and concluded with examples.

Presenting the NICE ROI features, he discussed the different indicators and the adaptation of the ROI model, with the choice of focusing on four smoking related diseases: coronary heart disease (CHD), stroke, COPD and lung cancer. Smokers were considered falling under two categories, those willing to quit and the others. They considered two alternate package of investment compared to a no investment scenario. He explained that the EQUIPTMOD model simulates what happens to each categories age/sex specific cohort of smokers. In fact, current smokers can each year quit smoking, remain smoking or die. For each smoker you can evaluate to which category they will be going in. Similarly, each year, former smoker can relapse to smoking, remain non-smoker or die. Finally, dead smokers remain dead.

Professor Coyle continued his presentation by talking about the data requirements – related to smokers, smoking status, smoking related disease, and intervention related parameters – which would allow to estimate the outcomes. The model offers possibilities of analysis of different scenarios and the impact and the cost of intervention. EQUIPT could be a tool for decision makers, Prof. Coyle concluded, with a focus that should be on cost effectiveness of policies which will change the uptake of technologies. The ROI tool and the underlying model are highly complex, he continued, insisting on the fact that the tool is reliant on adequate data availability. This tool is powerful but requires decision makers to actively consider policy options open to them. Finally, the tool could be adapted to further geographical settings.

Professor Robert Wess: Effectiveness and reach estimates for modelling return on investment from tobacco cessation interventions

Professor Wess first explained his role in the project, i.e. to help with the parameters to calculate the effect and reach. He explained that accurate forecasting is necessary to tobacco control planning and modelling return on investment. This requires obtaining estimates of impact. The objective was to provide the best possible estimate of the effect size and reach of smoking cessation interventions. 

Professor Wess explained that they focused on interventions for which there were strong evidence of effectiveness and reliable estimates of reach in England, such as increasing quit attempts and increasing quit success. He added that some interventions increasing quit attempts – health warnings, advertising bans, standard packaging and competition – were excluded because not sufficient information to build robust effect size estimates could be found.

Professor  Wess then went on discussing the specification of interventions, the effect size estimation and the reach estimation, before presenting the results. For each intervention tool, he elaborated on the effect size, the percentage point increase, the reach and the population impact on quit attempts.

He further presented the estimates for quit success and concluded by explaining that there is data which provides robust estimates of expected effect size for using in policy planning and return on investment modelling. Similarly, data from Smoking Toolkit Study in England provide robust estimates of reach, allowing population impact of current policies to be estimated and the impact of future policies to be forecasted. Most impact currently derives from measures that raise quit attempt rate because the reach of effective methods aids is low, (except for e-cigarettes).

Dr Marta Trapero-Bertran: Treatment and intervention costs for modelling return on investments from tobacco cessation interventions

Dr Trapero-Bertran spoke about populating a return on investment tool (ROI Tool) to evaluate the efficiency of tobacco control strategies in Europe.

The ROI tool is designed to address the decision problem relating to identifying what is the optimal package, she explained. Dr Trapero-Bertran explained their method which included listing all data requirements provided to country specific modellers and search in administrative databases and published literature to source this data. She then presented how the information was filed and treated. They used a healthcare system perspective and quasi societal perspective, she explained. She also underlined the importance of cost in economic evaluation (ICER: incremental cost/incremental health benefits) and stated that how you are measuring the health benefits is very important.

Smoking related diseases costs can be divided into interventional costs (pharmacological and behavioural interventions), passive and smoking related costs (effect on children and on adults) and productivity costs (days lost per smoker, average hourly wage and percentage of smokers who are employed). With regard to diseases costs, they chose to focus on lung cancer, CHD, COPD and stroke due to the necessity to have robust numbers and data, she explained. She then briefly presented the numbers and findings for the different ones and added that they tried to homogenise the definition of diseases. As for the lessons learnt, she indicated that there is a need of homogenisation of disease definition especially for CVD. Moreover, in the case of Spain, there needs to costing disease further than only including hospital costs. Further research could be on costing diseases along several countries in Europe, she added.

Dr Trapero-Bertran then went on discussing the economic impact, passive smoking costs, productivity losses and intervention costs. On the latter, she noted that pharmaceutical treatments are of different prices in Europe, while an homogeneous description of behavioural intervention related to tobacco is needed, as difficulties are not only linking for country specific costs but on matching definition across countries.

Professor Reiner Leidl: Country application of the EQUIPT model: the case of Germany.

Professor Reiner Leidl thought it is important to have the country perspective of intervention. He mentioned the adaptation steps and use, and which technologies of intervention has to be described per country. From the alternative intervention you can further develop a strategy, he concluded before giving the floor to Maximilian Prager whopresented the case of Germany

Maximilian Prager started with the situation of tobacco control in Germany before going to the sources of parameters, the implementation limitations, interventions, results, and stakeholder intervention. He first compared the situation of Germany with the one of England in terms of smoking prevalence, mortality rate from lung cancer, investment costs and smoking cessation. Presenting the parameters for Germany, and the evaluation of the parameters sources, he explained the limitations of implementing the model in Germany. He then continued by discussing the investment package and scenarios compared from a zero investment situation to the current package and alternative package. He described the interventions uptakes and costs for current investments and scenarios and presented the results. 

MaximilianPrager then continued with a description of the interaction with stakeholders in Germany, highlighting the problems that were identified – tool complexity, information overload and performance issues. He insisted that close collaboration is essential to include stakeholder expertise and foster it. Although there are implementation limitations to be considered, the model adaptation is possible to Germany.

This second panel was followed by a discussion with participants where the question of uncertainties with regard to parameters was evoked. Prof. West replied that the effect size translates into the real world settings. He explained that the effect size parameters are quite generalisable as long as the interventions you are considering are the one that were evaluated in the studies. This is problematic when it comes to behavioural intervention that can vary in intensity. If you want to get the benefit you need to put the input in. On the reach, he mentioned a study that covers a lot of countries and provide a lot of information. Dr Trapero-Bertran added that they can play on several parameters and draw worst case and best case scenarios. It is quite flexible in that sense.


Transferability of EQUIPT to CEE and beyond

Professor Zoltan Kalo: What opportunities can EQUIPT offer to CEE and wider European countries?

Professor Zoltan Kalo explained that low-income countries have low capacities and the health economics have to be trained mainly abroad and indicated that he established a centre in Hungary where a Master programme can be followed. Indeed, the number of house economic research centres is limited. Researchers from lower-income regions have limited representations at major health economic congresses and in health economics and public health research projects funded by the European Commission. Prof. Kalo continued by stating that while Central Eastern European countries have worse health statuses than Western European countries, the pricing of technologies is adjusted to the larger EU market. Less than 5 percent of the Commission’s budget programmes go to Eastern Europe. The geographical representation of the EU should be well-balanced, he said, before calling for a reasonable representation of Central Eastern European countries in consortiums and a separate work package to evaluate the transferability of tools and methods.

He then went on explaining that there were five in-sample countries with a full adaptation and three out-of-sample countries (Bulgaria, Croatia and Romania) in the project. There were two consortia and partners in Croatia and Hungary. They had four steps to have a solution for lower income countries. Hungary is included in the in-sample countries with full implementation of the EQUIPT ROI tool. Prof. Kalo then stated that one can select the most important input variables for the tool implementation in those countries that have limited data. He explained that they conducted a one-way sensitive analysis and compared the data. When the 16 most input variables are selected, then this is sufficient. He added that they held an international workshop where 11 Central Eastern countries were represented by payers, policymakers, HTA doers, patients and healthcare professionals. He said that the Ministry of Health, Finance and health insurance funds can reap the most benefits. He then concluded by stating that they put a lot of emphasis on transferability. The ROI Tool will be a great support for Central and Eastern European Countries to justify policy decisions as they do not have enough health economic capacity and resources to evaluate.

Dr Bertalan Nemeth: Adapting EQUIPT tool to other countries; parameter needs and analysis

Dr Bertalan Nemeth first explained that the local adaption of health economic analysis is advised by many experts. If one wants a complete adaption, then one needs to invest many resources and that is not feasible. The tool requires a lot of data. Therefore only the most important inputs should be collected locally, the others should be gathered from international sources. When conducting a one-way sensitive analysis, they used averages of all input data and thought of the parameters of the country. A list of key input parameters includes population numbers, population 16+, actuarial life tables, smoking rate, smoking status by sex and age etc. It took several years to collect all the data. They had four different interventions. As for the outcomes, the numbers were different when using the zero intervention package. Dr Nemeth then explained that Central Eastern European countries have a high need for HTA analysis, thus they need tools like the EQUIPT ROI tool. He concluded by saying that local adaption of analysis is necessary; collecting only the key input parameters can be a solution.

Andrea Crossfield, CEO Healthier Futures UK: EQUIPT experience for better tobacco control

Andrea Crossfield stated that in terms of combatting the use of tobacco, there are several useful ways: influencing capacity building, stopping promotion, making tobacco less affordable, effective regulation, helping users to quit, reducing exposure to secondary smoke, effective communication for tobacco control and research and monitoring. However, they do not stand alone. She said that there are wide variations within Europe. For instance, 41 percent of men smoke versus 22 percent of women. In the UK, Netherlands, Denmark, Austria and Ireland, male and female prevalence is similar whilst in Sweden and Norway the female prevalence is higher. More girls smoke in Bulgaria, Croatia, Poland and Slovenia. The exposure is greater in young and poor people. She also referred to the 2013 tobacco rank table. Increasing the quit success includes behavioural support and printed self-help materials.

Andrea Crossfield carried on by saying that the potential impact of adding cytidine to stop smoking service would require additional investments. She explained that they face competition but that their marketing strategy continues to deliver great results. They are doing well in terms of the market share. PMI impact initiatives were launched, she said and the strategy of the tobacco industry is to focus on illegal tobacco trade. The tobacco industry may feel one step ahead by bringing out research papers and tools and connect them with the broader commercial sector and governments. In public health, we must embrace change while retaining the power of evidence based interventions to deliver population health outcomes, she stated. Tools like the EQUIPT model are therefore essential.

Professor Zoltan Kalo said that one size fits all does not work. He also pointed out that there are other countries who are interested in the programme.

Subhash Pokhrel, EQUIPT Project Coordinator and WP4 co-chair, said that this can be discussed and in theory it would be possible to extend the programme.

Adam Lester-George, LeLan Solutions , said that they want the tool to be used and it should be promoted as much as they can.



Cornel Radu-Loghin, ENSP General-Secretary, said that he hopes it will be the beginning of a new cooperation. The tool exists now and the work can start, the project has not ended.

A representative of the project said that the project and tool are exciting. Now they have one chance to sell and promote it. He reiterated that it is not the end of the project, it is only the beginning. Now they have to be ambassadors for the tool. The responsibility does not lie on three people or work packages to disseminate it, but everyone has to be an ambassador and take it to the stakeholders. There are long-term gains, he insisted. It is very visual and they have to market it as a nice and easy tool to use. The tool only works if there is face-to-face training and selling techniques. He concluded by saying that he looks forward to having more countries joining as this will be a domino effect. He also announced that a training day will take place in Slovenia on October 20.

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