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This article covers recent National Institute for Health and Care Excellence guidance and standards relevant to public health with a focus on behaviour change. The article summarizes recommendations for local commissioners and providers to help them tackle a range of behaviours including smoking, poor eating patterns, lack of physical activity and alcohol misuse., (© The Author(s) 2019. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The need to make best use of limited resources in the English National Health Service is now greater than ever. This paper contributes to this endeavour by synthesizing data from cost-effectiveness evidence produced to support the development of public health guidance at the National Institute of Health and Clinical Excellence (NICE). No comprehensive list of cost-effectiveness estimates for public health interventions has previously been published in England., Methods: Cost-effectiveness estimates using English cost data were collected and analysed from 21 (of 26) economic analyses underpinning public health guidance published by NICE between 2006 and 2010., Results: Two hundred base-case cost-effectiveness estimates were analysed, 15% were cost saving (i.e. the intervention was more effective and cheaper than comparator). Eighty-five per cent were cost-effective at a threshold of £20,000 per quality-adjusted life year and 89% at the higher threshold of £30,000. A further 5.5% were above £30,000 and 5.5% of the interventions were dominated (i.e. the intervention was more costly and less effective than comparator)., Conclusions: The majority of public health interventions assessed are highly cost-effective. The next challenge is to provide commissioners with a framework that allows information from economic analyses to be combined with other criteria that supports making better investment decisions at a local level.

Background: Legislation is one of the most powerful weapons for improving population health and is often used by policy and decision makers. Little research exists to guide them as to whether legislation is feasible and/or will succeed. We aimed to produce a coherent and transferable evidence based framework of threats to legislative interventions to assist the decision making process and to test this through the 'case study' of legislation to ban smoking in cars carrying children., Methods: We conceptualised legislative interventions as a complex social interventions and so used the realist synthesis method to systematically review the literature for evidence. 99 articles were found through searches on five electronic databases (MEDLINE, HMIC, EMBASE, PsychINFO, Social Policy and Practice) and iterative purposive searching. Our initial searches sought any studies that contained information on smoking in vehicles carrying children. Throughout the review we continued where needed to search for additional studies of any type that would conceptually contribute to helping build and/or test our framework., Results: Our framework identified a series of transferable threats to public health legislation. When applied to smoking bans in vehicles; problem misidentification; public support; opposition; and enforcement issues were particularly prominent threats. Our framework enabled us to understand and explain the nature of each threat and to infer the most likely outcome if such legislation were to be proposed in a jurisdiction where no such ban existed. Specifically, the micro-environment of a vehicle can contain highly hazardous levels of second hand smoke. Public support for such legislation is high amongst smokers and non-smokers and their underlying motivations were very similar - wanting to practice the Millian principle of protecting children from harm. Evidence indicated that the tobacco industry was not likely to oppose legislation and arguments that such a law would be 'unenforceable' were unfounded., Conclusion: It is possible to develop a coherent and transferable evidence based framework of the ideas and assumptions behind the threats to legislative intervention that may assist policy and decision makers to analyse and judge if legislation is feasible and/or likely to succeed.

This article examines the timorous courtship between public health law and evidence-based policy. Legislation, in the form of direct prescriptions or proscriptions on behaviour, is perhaps the most powerful tool available to the public health policymaker. Increasingly, the same policymakers have striven to ensure that interventions are based soundly on a secure evidence base. The modern mantra is that the policies to follow are the ones that have been demonstrated to work. Legislative interventions, involving trade-offs between public benefit and private interests, present formidable challenges for the evaluator. Systematic reviews of their overall efficacy, the main tool of evidence-based policy, are in their infancy. The article presents a design for such reviews using the example of a forthcoming synthesis on the effectiveness of banning smoking in cars carrying children.

The authors present a case study examining the potential for policies to be "evidence-based." To what extent is it possible to say that a decision to implement a complex social intervention is warranted on the basis of available empirical data? The case chosen is whether there is sufficient evidence to justify banning smoking in cars carrying children. The numerous assumptions underpinning such legislation are elicited, the weight and validity of evidence for each is appraised, and a mixed picture emerges. Certain propositions seem well supported; others are not yet proven and possibly unknowable. The authors argue that this is the standard predicament of evidence-based policy. Evidence does not come in finite chunks offering certainty and security to policy decisions. Rather, evidence-based policy is an accumulative process in which the data pursue but never quite capture unfolding policy problems. The whole point is the steady conversion of "unknowns" to "knowns." (Contains 2 boxes, 1 table and 1 figure.)

Introduction. We describe a simplified distributional cost-effectiveness analysis based on aggregate data to estimate the health inequality impact of public health interventions. Methods. We extracted data on costs, health outcomes expressed as quality-adjusted life years (QALYs), and target populations for interventions within National Institute for Health and Care Excellence (NICE) public health guidance published up to October 2016. Evidence on variation by age, gender, and index of multiple deprivation informed socioeconomic distributions of incremental QALYs, health opportunity costs, and the baseline distribution of health. Total population QALYs, summary measures of inequality, and a health equity impact plane show results by intervention and by guideline. A value for inequality aversion from a general population survey in England let us combine impacts on health inequality and total health into a single measure of intervention value. Results. Our estimates suggest that of 134 interventions considered by NICE, 70 (52%) reduce inequality and increase health, 21 (16%) involve a tradeoff between improving health and improving health inequality, and 43 (32%) reduce health and increase health inequality. Fully implemented, the potential impact of all recommendations was 23,336,181 additional QALYs for the population of England and Wales and a reduction of the gap in quality-adjusted life expectancy between the healthiest and least healthy from 13.78 to 13.34 QALYs. The combined value of the additional health and reduction in inequality was 28,723,776 QALYs. Discussion. Our analysis takes account of the fact that existing public health spending likely benefits the most disadvantaged. This simple method applied separately to economic evaluation produces evidence of intervention impacts on the distribution of health that is vital in determining value for money when health inequality reduction is a policy goal. [ABSTRACT FROM AUTHOR]

Background A review of economic evaluations of public health interventions assessed by NICE between 2005 and 2010 found 85% were cost-effective. Owen et al. (The cost-effectiveness of public health interventions. J Public Health 2012; 34 (1):37–45). With significant pressure on budgets the role of economics in securing funding remains important. This study updates the earlier analysis. Methods Economic evaluations carried out between 2011 and 2016 were categorized: cost-utility analysis (CUA), cost-effectiveness analysis (CEA), cost-benefit analysis (CBA) and cost-consequences analysis (CCA). Cost-effectiveness estimates were analysed and compared with Owen et al. (The cost-effectiveness of public health interventions. J Public Health 2012; 34 (1):37–45). Results Of 43 guidelines examined, 23 used CUA for specific interventions yielding 138 base-case incremental cost-effectiveness ratio (ICER) estimates, 11 used CUA for a threshold or 'what if' analysis, 1 used CEA, 3 used CCA, 1 used CBA and CUA and 1 used CEA and CUA, 5 did not require economic modelling. Compared with the earlier period, the median ICER for the 138 estimates was substantially higher (£7843 versus £1053) and there was greater variability (a higher proportion in the later period was cost-saving, but a higher proportion was also over £20 000 per quality adjusted life year). Conclusions Nearly two-thirds (63%) of public health interventions assessed were cost-effective. However, increased variability in estimates highlights the importance of assessing cost-effectiveness to ensure good use of scarce resources. [ABSTRACT FROM AUTHOR]

Abstract: Background and aims: Increasing the reach of smoking cessation services and/or including new but effective medications to the current provision may provide significant health and economic benefits; the scale of such benefits is currently unknown. The aim of this study was to estimate the cost‐effectiveness from a health‐care perspective of viable national level changes in smoking cessation provision in the Netherlands and England. Methods: A Markov‐based state transition model [European study on Quantifying Utility of Investment in Protection from Tobacco model (EQUIPTMOD)] was used to estimate costs and benefits [expressed in quality‐adjusted life years (QALY)] of changing the current provision of smoking cessation programmes in the Netherlands and England. The changes included: (a) increasing the reach of top‐level services to increase potential quitters (e.g. brief physician advice); (b) increasing the reach of behavioural support (group‐based therapy and SMS text‐messaging support) to increase the success rates; (c) including a new but effective medication (cytisine); and (d) all changes implemented together (combined change). The costs and QALYs generated by those changes over 2, 5, 10 years and a life‐time were compared with that of the current practice in each country. Results were expressed as incremental net benefit (INB) and incremental cost‐effectiveness ratio (ICER). A sequential analysis from a life‐time perspective was conducted to identify the optimal change. Results: The combined change was dominant (cost‐saving) over all alternative changes and over the current practice, in both countries. The combined change would generate an incremental net benefit of €11.47 (2 years) to €56.16 (life‐time) per smoker in the Netherlands and €9.96 (2 years) to €60.72 (life‐time) per smoker in England. The current practice was dominated by all alternative changes. Conclusion: Current provision of smoking cessation services in the Netherlands and England can benefit economically from the inclusion of cytisine and increasing the reach of brief physician advice, text‐messaging support and group‐based therapy. [ABSTRACT FROM AUTHOR]

This article covers recent NICE guidance relevant to public health and has a focus on healthy ageing. The article contextualizes NICE guidance on increasing personal capacity, creating supportive environments and developing longer term strategies to reduce chronic disease and disability through primary prevention. [ABSTRACT FROM AUTHOR]

Prescribing nicotine replacement therapy (NRT) or bupropion for smoking cessation is of considerable importance to public health but little is known about prescribing practices. This paper examines general practitioners’ (GPs’) prescribing patterns in Britain where these drugs are reimbursed. The results have implications for other health-care systems considering introducing reimbursement.Postal survey conducted in 2002 of a random sample of 1088 GPs in England and Wales, of whom 642 (59%) responded.Number of requests GPs reported having received from patients for NRT and bupropion over the past month, the number of prescriptions they reported issuing and ratings of attitudes to these medications.GPs reported receiving an average of 4.3 requests for NRT and 1.9 for bupropion in the previous month. They reported issuing 3.5 prescriptions for NRT and 1.2 for bupropion. Almost all GPs accepted that NRT (95%) and bupropion (97%) should be reimbursable on National Health Service (NHS) prescription. However, a significant minority of those who received requests for prescriptions did not issue any (8% for NRT and 26% for bupropion). This was related to whether they thought these products should be available on NHS prescription for both NRT and bupropion (OR = 0.66,P < 0.05), which in turn was related to beliefs about whether smokers should have to pay for treatment themselves, the cost-effectiveness of NRT/bupropion and the low priority they would give NRT/bupropion in the drug budget. For bupropion, concern about side-effects independently predicted not prescribing[odds ratio (OR) = 1.46,P < 0.03].In the British health-care system, which has a well-established system for technology assessment and professionally endorsed guidelines, a significant minority of GPs decline all patient requests for stop-smoking medicines. [ABSTRACT FROM AUTHOR]

A correction is presented to the article "NICE public health guidance update" in which references 7-31 were in the incorrect order, published in 2020 issue of the periodical.

Reduction of health inequality is a goal in health policy, but commissioners lack information on how policies change health inequality. This study illustrates how decision models can be readily extended to produce information on health inequality impacts as well as for population health, using the example of smoking cessation therapies. We retrospectively adapt a model developed for public health guidance to undertake distributional cost effectiveness analysis. We identify and incorporate evidence on how inputs vary by area-level deprivation. Therapies are evaluated in terms of total population health, extent of inequality, and a summary measure of equally distributed equivalent health based on a societal value for inequality aversion. Last, we examine how accounting for social variation in different sets of parameters affects our results. All interventions increase population health and increase the slope index ofinequality. At estimated levels of health inequality aversion for England, our resultsindicate that the increases in inequality are compensated by the health gains. The inequality impacts are driven by higher benefits of quitting and higher intervention uptake amongst advantaged groups, despite the greater proportion of smokers in disadvantaged groups. Failure to account for differential effects between groups leadsto different conclusions about health inequality impact but does not alter conclusionsabout value for money. • We modify a smoking cessation decision model to include health inequality impacts. • The model includes differences in prevalence, uptake, mortality and morbidity. • All interventions improve population health and reduce health inequality. • Including uptake differences has the largest effect on inequality impacts. [ABSTRACT FROM AUTHOR]