Bulletin of the World Health Organization

Prioritizing risk factors to identify preventive interventions for economic assessment

Nick Wilson, Tony Blakely, Rachel H Foster, David Hadorn & Theo Vos

Volume 90, Number 2, February 2012, 88-96

Table 2. Highest contributors to disability-adjusted life years (DALYs) in high-income countries of the Western Pacific Region of the World Health Organization (WHO) and evidence of availability of cost-effective interventions to prevent them

Risk factor	Evidence of availability of cost-effective preventive interventions^a	Retain for equity analysis^b
Tobacco use	Examples: tobacco tax raises¹^,⁶; mass media campaigns; expansion of quitline use; provision of nicotine replacement products for quitting smoking. Australian researchers found that a national tobacco campaign would be cost-saving.⁷ There is growing evidence that some tobacco control interventions can promote equity.³	Yes
Alcohol use	Examples: alcohol tax raises; restrictions on alcohol advertising; restriction of the number of sale outlets.¹^,⁸^–¹⁰ Systematic reviews report evidence of many cost-effective regulatory interventions.¹⁰^,¹¹	Yes
High blood pressure^c	Examples: community heart health programmes; reduction of salt in processed foods¹^,¹²^–¹⁵ (voluntary and mandated options); improved access to anti-hypertensives; use of a polypill^d (depending on price and risk groups).¹^,¹⁶	Yes
High blood glucose	ACE-Prevention researchers in Australia found evidence that 5 out of 7 interventions against “pre-diabetes” were cost-effective (i.e. cost < A$ 50 000 [US$ 49 465] per DALY averted), but all at a median cost of ≥ A$ 21 000 (US$ 20 775) per DALY averted.¹	Yes
Overweight and obesity	Examples: a 10% tax on unhealthy foods (high fat/high sugar foods & drinks); reduction of television advertising; traffic light nutrition labelling (colour-coded symbols to indicated healthy vs unhealthy foods); diet and physical activity programmes.¹^,¹⁷ Of the 13 interventions for children and adolescents considered in work in Australia,¹⁷ 6 were found to be cost-saving (however, the evidence was not strong and assumptions around persisting intervention effects may have been unrealistic).	Yes
Physical inactivity	Examples: mass-media-based campaigns; community programmes to encourage use of pedometers; “green prescriptions” from general practitioners; referral by general practitioners to exercise physiologists.¹^,¹⁸ Modelling work suggests that social and environmental changes conducive to increased active transport (walking and cycling) could achieve health gains.¹⁹	Yes
High blood cholesterol^c	Examples: community heart health programmes; promotion of food products with plant sterols; expanded use of statins; use of a polypill^d (depending on price and risk groups).¹ Modelling work suggests that reducing agricultural emissions of greenhouse gases (relevant for New Zealand’s current Emissions Trading Scheme)^e can lead to health benefits.²⁰	Yes
Occupational risks	While occupational programmes can yield substantial health benefits, they are generally occupation-specific and not easily included in a risk-factor-based modelling approach.^f A population-wide SunSmart programme was found to be cost-saving in Australia,²¹ but its applicability to outdoor workers in New Zealand is uncertain.	No
Low fruit & vegetable intake	There is evidence favouring certain types of community-based activities that promote fruit and vegetable consumption (in Australian work: 1 intervention was cost-saving, 3 cost-effective, but 19 were not cost-effective).¹ Some evidence from New Zealand supports healthy food pricing interventions.²²	Yes
Urban outdoor air pollution	Evidence suggests that air pollution can be reduced through regulations on industrial emissions (and, in the United States of America²³ and Europe,²⁴ through emission trading schemes); regulations on domestic fireplaces; regulations on vehicle fuel efficiency and routine vehicle emissions testing. Furthermore, fuel price increases and improved access to public transport have been shown to reduce the use of private vehicles (and therefore probably emissions). A shift from fossil-fuel-powered vehicles to hybrids or electric vehicles would also reduce urban air pollution.	Yes

A$, Australian dollars.

^a Bold typeface indicates that evidence of the intervention being cost-saving also exists.

^b The results of this analysis are shown in Table 3.

^c ACE-Prevention work in Australia combined these topic areas.¹

^d A low-cost polypill that combines three blood-pressure-lowering drugs and one cholesterol-lowering drug¹ (or a similar alternative combination that includes aspirin).¹⁶

^e This is a national system, first established in law in 2008, for putting a price on greenhouse gas emissions. It allows trading of emissions permits (carbon credits) by industries. Forest planting (a “carbon sink”) can be used to earn credits.

^f Smoke-free workplaces are a possible exception, but there is limited scope for expanding this in New Zealand. Improved control of alcohol use may reduce the risk of occupational injury but is more appropriately considered part of alcohol control interventions.