Kulchaitanaroaj et al. BMC Health Services Research (2018) 18:115
https://doi.org/10.1186/s12913-018-2923-2
RESEARCH ARTICLE
Open Access
Understanding perceived availability and
importance of tobacco control
interventions to inform European adoption
of a UK economic model: a cross-sectional
study
Puttarin Kulchaitanaroaj1, Zoltán Kaló2,3, Robert West4,5, Kei Long Cheung6,7, Silvia Evers7, Zoltán Vokó2,3,
Mickael Hiligsmann7, Hein de Vries6, Lesley Owen8, Marta Trapero-Bertran9, Reiner Leidl10 and Subhash Pokhrel1*
Abstract
Background: The evidence on the extent to which stakeholders in different European countries agree with availability
and importance of tobacco-control interventions is limited. This study assessed and compared stakeholders’ views from
five European countries and compared the perceived ranking of interventions with evidence-based ranking using costeffectiveness data.
Methods: An interview survey (face-to-face, by phone or Skype) was conducted between April and July 2014 with five
categories of stakeholders - decision makers, service purchasers, service providers, evidence generators and health
promotion advocates - from Germany, Hungary, the Netherlands, Spain, and the United Kingdom. A list of potential
stakeholders drawn from the research team’s contacts and snowballing served as the sampling frame. An email invitation
was sent to all stakeholders in this list and recruitment was based on positive replies. Respondents were asked to rate
availability and importance of 30 tobacco control interventions. Kappa coefficients assessed agreement of stakeholders’
views. A mean importance score for each intervention was used to rank the interventions. This ranking was compared
with the ranking based on cost-effectiveness data from a published review.
Results: Ninety-three stakeholders (55.7% response rate) completed the survey: 18.3% were from Germany, 17.2% from
Hungary, 30.1% from the Netherlands, 19.4% from Spain, and 15.1% from the UK. Of those, 31.2% were
decision makers, 26.9% evidence generators, 19.4% service providers, 15.1% health-promotion advocates, and
7.5% purchasers of services/pharmaceutical products. Smoking restrictions in public areas were rated as the
most important intervention (mean score = 1.89). The agreement on availability of interventions between the
stakeholders was very low (kappa = 0.098; 95% CI = [0.085, 0.111] but the agreement on the importance of the
interventions was fair (kappa = 0.239; 95% CI = [0.208, 0.253]). A correlation was found between availability and
importance rankings for stage-based interventions. The importance ranking was not statistically concordant with the
ranking based on published cost-effectiveness data (Kendall rank correlation coefficient = 0.40; p-value = 0.11;
95% CI = [− 0.09, 0.89]).
(Continued on next page)
* Correspondence: Subhash.Pokhrel@brunel.ac.uk
1
Health Economics Research Group (HERG), Institute of Environment, Health
and Societies, Brunel University London, Uxbridge, UK
Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Kulchaitanaroaj et al. BMC Health Services Research (2018) 18:115
Page 2 of 12
(Continued from previous page)
Conclusions: The intrinsic differences in stakeholder views must be addressed while transferring economic
evidence Europe-wide. Strong engagement with stakeholders, focussing on better communication, has a
potential to mitigate this challenge.
Keywords: Tobacco control, Smoking cessation, Evidence transferability, Economic model
Background
The human and economic costs due to adverse effects
of tobacco use have shown to be enormous– about
700,000 lives claimed [1] and estimated annual economic
burden of at least €100 billion annually in Europe [2].
Even though effort has been made in tobacco control,
smoking is still the largest single cause of death and diseases in Europe [2]. Co-ordinated, high impact and comprehensive approaches are consistently shown to be the
most effective way to reduce smoking initiation, prevalence, and intensity of consumption [3–6]. However,
generation of research evidence on those comprehensive
approaches often occur in certain countries [3, 7]. It is
not clear to what extent that evidence could be transferable to other settings where resources to conduct similar
research are scarce [8–14].
In the United Kingdom (UK), a decision-support tool
(the National Institute for Health and Care Excellence
(NICE) Tobacco Return on Investment (ROI) tool) providing the information about economic and wider
returns from evidence-based tobacco control interventions was developed for policy makers and wider groups
of stakeholders [15]. There was an aim to further develop this tool to be used in other European countries in
a large comparative effectiveness research study, namely
European-study on Quantifying Utility of Investment in
Protection from Tobacco (EQUIPT) [16]. EQUIPT
sought to first understand pre-requisites such as contextual realities in new settings when transferring the
decision-support tool to sample European countries:
Germany, Hungary, the Netherlands, and Spain [16].
The sample countries were selected because they are
from five European Union (EU) member states with significant differences in population health outcomes,
prevalence of smoking, economic status, and health care
spending [2]. This cross-section was deemed to be
broadly representative of the EU countries.
To transfer evidence or an economic model, the need
to understand the contextual realities of a new setting is
highlighted in the literature [17, 18]. This involves appraisal of applicability (i.e. the extent to which the evidence can be used in a new setting) and transferability
(i.e. the extent to which similar outcomes can be
achieved in a new setting) [17, 18]. The appraisal of applicability and transferability should involve stakeholders
such as policy-makers, practitioners, and scientists to
provide opinion on attributes of applicability and transferability [18]. Such attributes may include availability of
essential resources (e.g. whether the intervention is currently available) and political/social acceptability of the
intervention (e.g. whether the intervention is important
to the stakeholders) [19].
In addition to opinion on availability and importance
of tobacco-control interventions, previous research
shows that not all stakeholders in the new context interpret intervention descriptions and evaluation findings in
the same way, even when the same information is presented [20]. This necessitates an enquiry to better understand stakeholders’ views on importance of tobaccocontrol interventions in the new settings relative to their
reported cost-effectiveness.
The specific objectives of this study therefore were as
follows: a) to understand stakeholders’ views about what
tobacco control interventions are available in their countries and how important those interventions are to them,
in five European countries – Germany, Hungary, Spain,
the Netherlands and the UK; and b) to establish the extent of difference in intervention priorities by comparing
perceived importance with the ranking based on published cost-effectiveness data.
Methods
Data
Data for this study were drawn from the following two
sources: (i) the EQUIPT stakeholder interview survey capturing views on availability and importance of tobaccocontrol interventions [21]; and (ii) published data on costeffectiveness of tobacco control interventions [22].
First, a stakeholder interview survey (face-to-face, by
phone or Skype) was conducted between April and July
2014 as part of the EQUIPT project (http://equipt.eu)
[21, 23]. Further information about the interview survey is documented elsewhere [16, 21, 23]. A list of
stakeholders categorized into five groups was drawn by
the EQUIPT team from Germany, Hungary, the
Netherlands, Spain, and the UK based on their previous
knowledge; and then those stakeholders were asked to
provide additional names (snowballing). This list served
as the sampling frame for the interview survey. The five
categories of stakeholders included: decision makers
(e.g. senior officials at the department of health or directors of public health services), purchasers of services
Kulchaitanaroaj et al. BMC Health Services Research (2018) 18:115
or pharmaceutical products (e.g. service commissioners or
top officials at health insurance funds), professionals or
service providers (e.g. leading physicians in smoking cessation, physicians/psychologists, or coordinators of local
health programs), evidence generators (e.g. academic and
researchers with experience in health-technologyassessments, reimbursement procedures, health care costing, general public health and health promotion research,
and specific research to tobacco control and smoking
cessation), and advocates of health promotion (e.g. leaders
of charities, NGO’s or patient organizations).
A researcher from each country interviewed the stakeholders in the local language and filled out the questionnaire, which was developed originally in English and then
translated to each of the local languages. To ensure the
consistency of the survey across countries, a training
workshop was organised in Maastricht in January 2014,
followed by a few online training sessions prior to the
interviews. A pilot study was conducted to improve the
actual interview survey. The interviews were based on
pre-defined questionnaire administered by trained interviewers. Thus, interviewer validity was achieved to a reasonable degree. Interview guide and survey questionnaire
are provided in Additional file 1.
The questionnaire included several questions: stakeholders’ profiles, motivational factors, and stakeholders’
opinion. Perception of availability and importance of
tobacco-control interventions were captured by the following two questions, respectively: (a) “Would you tell me
whether these [show the list] tobacco control measures and
smoking cessation interventions are available in …[name
country]…?” with possible answers being ‘yes’, ‘no’, and
‘don’t know’; and (b) “Could you also indicate on a scale
from 1 to 3 —1 meaning ‘not important’ and 3 meaning
‘important’ – to what extent you think the following interventions are considered important in addressing smoking
behaviour?” Respondents were allowed to state ‘don’t know’
as a response in addition to one of the three numbers (1, 2,
and 3). A total of 30 interventions grouped into five
categories – 3 pharmacological, 11 behavioural, 3 combined pharmacological and behavioural, 7 nonconventional,
and 6 population-level - were shown to stakeholders. The
intervention list was informed by a previous review
conducted as part of the NICE Tobacco ROI project [15].
Secondly, cost-effectiveness data on the selected interventions was sourced from a published study in the UK
by Owen and colleagues who comprehensively reviewed
the economic evidence of key public health interventions
including tobacco-control [22]. This single review study
was selected because it provided summarised costeffectiveness data on most of the tobacco-control interventions listed in the stakeholder survey questionnaire
in a comparable way, and thus allowed a head-to-head
comparison between the two.
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Ethics, consent, and permission
Brunel University Research Ethics Committee (UK)
reviewed this research and gave full ethical clearance.
Respective authorities in other countries - EthikKommission, Bayerische Landesärztekammer (Germany),
Egészségügyi Tudományos Tanács, Tudományosés Kutatásetikai Bizottság (Hungary), Medisch-ethische toetsingscommissie (METC) azM/UM (Netherlands), and Parc de
SalutMAR - Clinical Research Ethics Committee (Spain) also provided clearance. Written consent was obtained
from all respondents.
Statistical analyses
Three separate analyses were carried out. Firstly, descriptive analyses with all possible responses were conducted to explore stakeholders’ perceptions of
availability and importance of tobacco control interventions in each country and between the countries. Kappa
statistics were calculated to evaluate the agreement on
the perceived availability with all three possible responses and importance with all four possible responses
between stakeholders in each country, from two selected
countries, and from all five countries. A kappa statistic
or a kappa coefficient is commonly used to measure the
agreement between multiple observers; it ranges from −
1 to 1, the latter indicating perfect agreement [24]. If it
is less than or equal to 0, there is less or no agreement
between raters other than what would occur by chance.
Kappa values of 0.01–0.20, 0.21–0.40, 0.41–0.60, 0.61–
0.80, and 0.81–0.99 refer to slight agreement, fair agreement, moderate agreement, substantial agreement, and
almost perfect agreement, respectively [24]. A significant
kappa (p-value < 0.05) means that the estimated value of
the kappa coefficient significantly differs from zero. [24].
Confidence intervals around kappa coefficient were calculated by a bootstrap method as the computation involved
more than three raters [25]. Combined kappa coefficients
from all possible responses are reported. Moreover, a
comparison of perceived importance when combining
‘somewhat important’ (response 2 on the questionnaire)
and ‘important’ (response 3) values between the 30 interventions was presented in a visual display. Such comparison was conducted as part of the decision to choose the
interventions for the EQUIPT model.
Secondly, to assess whether stakeholders’ views about
availability of interventions were correlated with their
views about importance of interventions, a descriptive
analysis showing distributions of availability and importance was conducted. This relationship was further analysed using an ordered logistic regression [26]. The
‘don’t know’ responses were excluded from the regression analysis. The model included importance (not important, somewhat important, or important) as the
dependent variable and availability (yes or no), countries
Kulchaitanaroaj et al. BMC Health Services Research (2018) 18:115
(the UK as the reference country), stakeholder roles (evidence generators as the reference role), and gender
(male as the reference group) as covariates.
Thirdly, a perceived importance mean score for each
intervention was computed after excluding the ‘don’tknow’ responses. The 3-point Likert scale response on
the question related to perceived importance of an intervention was recoded from [1, 2 3] to [0, 1, 2] respectively. Then the mean score was calculated as the
arithmetic average of the responses across all stakeholders. This score was finally used to rank the interventions. The other set of ranking involved scrutiny of the
cost-effectiveness data from Owen et al. [22]. To do this,
first the median costs per quality adjusted life years
(QALYs), the only reported measure in that study, were
extracted for the interventions that were in common
with those listed in the EQUIPT stakeholder survey.
Then, interventions were rank ordered using the lowest
median costs per QALY and moving upwards. This ranking was then compared with the ranking based on the
stakeholders’ views to determine where similarities or
differences occurred. Kendall rank (tau) correlation coefficient was estimated to evaluate the difference between
the concordance and the discordance probabilities of the
mean-importance-score ranking and the costeffectiveness-measure ranking. The tau coefficient is
normally used when a distribution of a variable is not assumed and a sample size is small [27]. The coefficient
ranges from − 1 to 1 meaning complete disagreement
and complete agreement between the mean importance
score and the rankings based on cost-effectiveness data,
respectively. The zero value refers to no relationship between the two variables. The null hypothesis states that
the two variables are independent to each other. All analyses were accomplished in Stata version 13.1 by StataCorp LP, Texas, USA.
Results
Respondent characteristics
Of the 167 stakeholders who were invited to participate in
the interview survey, 93 respondents (55.7%) completed
the survey and were included in the analysis—17 from
Germany (18.3%), 16 from Hungary (17.2%), 28 from the
Netherlands (30.1%), 18 from Spain (19.4%), and 14 from
the UK (15.1%). Fifty-eight (62.4%) were males.
Twenty-nine were decision makers (31.2%), 7 were purchasers of services or pharmaceutical products (7.5%), 18
were professionals or service providers (19.4%), 25 were
evidence generators (26.9%), and 14 were advocates of
health promotion (15.1%). The distributions of stakeholder types across the five countries were not largely different except the UK that had a large proportion of
decision makers (approximately 64% compared with the
remaining countries that had around 17–33%). The
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complete compositions of stakeholder types are exhibited
in a Additional file 2: Table S1.
Descriptive statistics of perceived availability and
importance
Perceptions on availability of 11 selected interventions
are shown in Table 1 (data on all interventions shown in
Additional file 2: Table S2). Between the countries, the
perceptions on availability varied considerably for almost
all of the interventions. The interventions that > 70%
stakeholders viewed as ‘available’ in each country were:
advertising restrictions/bans, product labelling and information/health warnings on tobacco products, restrictions on sales to minors, restrictions on smoking in
workplaces and public places, tax increase, self-help
manuals, nicotine replacement therapy, brief physician
advice, and group and counselling with or without pharmacotherapies. Stakeholders did not know about the
availability of some widely-evaluated interventions such
as varenicline (33% of 93 stakeholders), bupropion
(29%), computer tailored programs (20.4%), and community pharmacy-based services (17.2%).
In each country, a number of interventions were
deemed important by > 58% of stakeholders (Table S2).
These included nicotine replacement therapy, brief physician advice, the 5-step protocol advice (i.e. ask, advice,
assess, assist, and arrange), group and individual counselling by specially trained professionals with and without medications (e.g. NRT or bupropion), advertising
restrictions/bans, restrictions on sales to minor, restrictions on smoking in workplaces and public places, and
tax increase. Non-conventional therapies were rated important by stakeholders in Germany and Hungary compared to the remaining countries. Non-conventional
interventions were viewed to be much less important
than the rest of the interventions as only 1.1–6.5% of the
whole sample viewed that they were important. Figure 1
shows perceptions on importance of the 11 interventions
(somewhat important and important responses combined). The pattern of perceptions was similar when
only ‘important’ response was analysed.
Agreement on perceived availability and importance
Generally, stakeholders tended to agree to a lesser extent
on the availability compared with the importance (Table 2).
All combined kappa coefficients were statistically significant with p-values < 0.001. Stakeholders from Germany,
Hungary, and the Netherlands had lower agreement on
the availability of interventions than those from Spain and
the UK. Slight agreement on availability was observed for
every pair of countries except for Spain-UK pair (fair
agreement). In general, stakeholders from all countries
had slight agreement on the intervention availability
Kulchaitanaroaj et al. BMC Health Services Research (2018) 18:115
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Table 1 Perceptions on availability of selected interventions across countries
Intervention
Germany (N = 17)
Group counselling by specially
trained professionals
% Aa
Restrictions on smoking in
workplaces and public places
%A
Tax increase
%A
Hungary (N = 16) The Netherlands (N = 28) Spain (N = 18) UK (N = 14) Total (N = 93)
100 % A
% DKb
100 % A
100 % A
% DK
Nicotine replacement therapy
%A
100 % A
Individual counselling by specially % A
trained professionals
100 % A
Brief advice on smoking cessation % A
given during one GP consultation
100 % A
Telephone counselling
100 % A
%A
% DK
% DK
% DK
Self-help manuals
%A
100 % A
% DK
Mobile phone-based interventions % A
100 % A
% DK
Bupropion
Varenicline
87.5
%A
100
12.5
100
%A
100
%A
72.2
% DK
0
%A
100 % A
% DK
%A
94.4
%A
% DK
0
% DK 7.1
92.9 % A
93.8
%A
89.3
%A
72.2
%A
6.3
% DK
7.1
% DK
0
% DK 7.1
%A
100
%A
96.4
%A
88.9
% DK
3.6
% DK
0
87.5
%A
92.9
%A
72.2
12.5
% DK
7.1
% DK
0
93.8
%A
100
%A
100
0
% DK
92.9 % A
% DK
100 % A
% DK
%A
100 % A
% DK
%A
85.7 % A
% DK 14.3 % DK
68.8
%A
92.9
%A
55.6
%A
31.3
% DK
7.1
% DK
5.6
% DK 14.3 % DK
85.7 % A
93.8
%A
92.9
%A
88.9
%A
6.3
% DK
3.6
% DK
0
% DK 21.4 % DK
71.4 %A
43.8
%A
78.6
%A
22.2
%A
43.8
% DK
17.9
% DK
11.1
% DK 21.4 % DK
64.3 % A
%A
58.8 % A
31.3
%A
64.3
%A
83.3
%A
%DK
41.2 % DK
50.0
% DK
35.7
% DK
5.6
% DK 7.1
92.9 % A
%A
58.8 % A
43.8
%A
57.1
%A
83.3
%A
% DK
41.2 % DK
56.3
% DK
42.9
% DK
11.1
% DK 7.1
% DK
92.9 % A
% DK
92.5
2.2
97.9
1.1
89.3
4.3
96.8
1.1
90.3
4.3
96.8
2.2
81.7
10.8
90.3
5.4
63.4
18.3
65.6
29.0
65.6
33.3
a
A = % of ‘available’
DK = % of ‘don’t know’ and the remaining is % of ‘not available’
b
(combined kappa = 0.0980; 95% confidence interval
= [0.085, 0.111]).
Within country, variations on importance of interventions included slight to fair agreement (Germany,
Hungary, the Netherlands, and Spain) and moderate
agreement (UK) (combined kappa in the UK = 0.4246).
Every pair of the countries showed fair agreement on
importance except Hungary-Spain pair (slight agreement). Stakeholders from all countries had fair agreement on the importance of interventions (combined
kappa = 0.2386; 95% CI = [0.208, 0.253]).
The relationship between availability and importance
Perceived availability of interventions was positively associated with their perceived importance for the following interventions once stakeholder roles, gender and
countries were controlled for (p-values < 0.05): community pharmacy-based services, computer tailored programs,
internet-based
interventions,
stage-based
interventions, and brief advice by a general practitioner
and medication (Table 3). The highest correlation was
observed for stage-based interventions.
Perceived importance score
Table 4 exhibits the scores of all 30 interventions with
their categories. The top three interventions were 1) restrictions on smoking in workplaces and public places
(score: 1.89; N = 92), 2) individual counselling by specially trained professionals with medication (e.g. NRT)
(score: 1.86; N = 90), and 3) advertising restrictions/bans
(score: 1.83; N = 92).
Comparison of importance of intervention
Table 5 puts the stakeholders’ perceived importance
scores into perspective by comparing their rank order
with that by published cost-effectiveness evidence. A
total of 10 interventions were included for this comparison. The top three interventions by the perceived importance score were (1) individual counselling by
professionals with medication (score: 1.86); (2) group
counselling by professionals with medication (score:
1.81); and (3) nicotine replacement therapy (score: 1.74).
These first three interventions would also be most costeffective based on the published review. The large differences in importance of interventions between stakeholder views and cost-effectiveness evidence were
Kulchaitanaroaj et al. BMC Health Services Research (2018) 18:115
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Fig. 1 Percentages of selected interventions viewed as somewhat important or important across countries
apparent for self-help manuals, telephone counselling,
community pharmacy-based services and mass media
campaigns. These interventions ranked lower by importance score than by cost-effectiveness criteria. Brief advice by a general practitioner ranked marginally higher
by importance score than by cost-effectiveness criteria.
Kendall rank correlation coefficient was 0.40 with the pvalue of 0.11, indicating that ranking based on the importance score did not statistically agree with the
ranking based on cost-effectiveness evidence (95% CI
= [− 0.09, 0.89]).
Discussion
To the best of our knowledge, this study is the first of its
kind to improve our understanding of stakeholder views
around availability and importance of interventions with
respect to cross-context transferability of economic evidence on tobacco control. It appears that stakeholders
Combined kappa coefficients*
In the same country
Germany (N = 17)
Hungary (N = 16)
The Netherlands (N = 28)
Spain (N = 18)
The UK (N = 14)
Availability
Importance
Availability
Importance
Agreement level Agreement level Agreement level Agreement level
Availability
Importance
Agreement level Agreement level
Availability
Importance
Agreement level Agreement level
Availability
Importance
Agreement level Agreement level
0.1223
0.2483
0.1826
0.2021
0.1246
0.2711
0.2648
0.2077
0.2293
0.4246
Slight
Fair
Slight
Slight
Slight
Fair
Fair
Fair
Fair
Moderate
0.1318
0.2134
0.1142
0.2509
0.1138
0.2120
0.1021
Slight
Fair
Between the two countries
Germany
Germany
Hungary
Hungary
The Netherlands
Spain
The UK
0.2842
Slight
Fair
Slight
Fair
Slight
Fair
0.1198
0.2317
0.1203
0.1961
0.1131
0.2830
Slight
Fair
Slight
Slight
Slight
Fair
0.1225
0.2377
0.1057
0.2981
Slight
Fair
The
Netherlands
Spain
Slight
Fair
0.2377
0.2739
Fair
Fair
Kulchaitanaroaj et al. BMC Health Services Research (2018) 18:115
Table 2 Agreement on availability and importance of 30 tobacco-control interventions in each country, and between two and five countries
The UK
Total (All settings; Number of raters = 93)
Combined kappa for availabilitya = 0.0980* (Slight agreement); p-value < 0.001; 95% CI = [0.085, 0.111]
Combined kappa for importanceb = 0.2386* (Fair agreement); p-value < 0.001; 95% CI = [0.208, 0.253]).
*All of the combined coefficients were statistically significant with the p-values < 0.001; Kappa and agreement: < 0 = Less than chance agreement, 0.01–0.20 = Slight agreement, 0.21–0.40 = Fair agreement, 0.41–0.60 = Moderate
agreement, 0.61–0.80 = Substantial agreement, 0.81–0.99 = Almost perfect agreement. [24]
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Kulchaitanaroaj et al. BMC Health Services Research (2018) 18:115
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Table 3 Relationship between perceived importance and perceived availability
Descriptive analysis
Interventions
Ordered logistic
regression analysis
Available
Not available
Number saying Number saying Number
Number saying Number saying Number
saying not
important (%) somewhat
saying not
important (%) somewhat
important (%) important (%)
important (%) important (%)
Predicted probability
of saying important
[95% CI]a
Community pharmacybased services (N = 78)
30 (50.0)
19 (31.67)
11 (18.33)
6 (33.33)
4 (22.22)
8 (44.44)
54.28%* [38.64–
69.93%]
Computer tailored
programs (N = 75)
25 (41.67)
27 (45.00)
8 (13.33)
3 (20.00)
7 (46.67)
5 (33.33)
44.71%* [30.35–
59.08%]
Internet-based
interventions (N = 77)
35 (53.03)
23 (34.85)
8 (12.12)
1 (9.09)
7 (63.64)
3 (27.27)
53.41%* [39.54–
67.29%]
Stage-based interventions 34 (59.65)
(N = 70)
16 (28.07)
7 (12.28)
5 (38.46)
3 (23.08)
5 (38.46)
72.90%* [57.89–
87.91%]
49 (59.76)
27 (32.93)
6 (7.32)
2 (22.22)
2 (22.22)
5 (55.56)
62.53%* [51.24–
73.82%]
Brief advice by a general
practitioner and
medication (N = 91)
a
Predicted probability of saying ‘important’ if the intervention is available, when holding other variables at means. It was estimated by ordered logistic regression
model evaluating the effect of availability (yes or no) on importance (not important, somewhat important, or important) controlling for countries, stakeholder
roles, and gender
*The regression models were significant with p-values < 0.05. Availability was a significant variable associated with importance for these interventions in the
models with the p-values of 0.03, 0.004, 0.01, 0.002, and < 0.001, respectively
or end-users of research generally have considerably different opinions on the availability of the interventions
but tend to agree with each other within and across
countries more on the importance of the interventions.
There was positive relationship between availability and
importance of some interventions. The stakeholder perception on the importance of interventions did not necessarily match what existing cost-effectiveness evidence
suggests.
Our findings challenge the commonly-held notion that
widely evaluated tobacco control interventions (e.g. bupropion, varenicline, or community pharmacy based interventions) are already known in the new settings.
Bupropion and varenicline were available in all of the
countries (Germany, Hungary, the Netherlands, Spain,
and the UK) according to WHO [28] but our findings
show that 36–56% of stakeholders in Germany, Hungary,
and the Netherlands and 6–11% in Spain and the UK
did not know that. Therefore, increasing awareness of
these interventions should be recommended. Also, the
assumption that ‘stakeholders know about the interventions’ must be checked prior to facilitating any evidence
transfer to a new context/setting.
The significant positive relationship observed between
what stakeholders viewed as ‘available’ and ‘important’
for some interventions implies that decisions about
implementing a new intervention, or making it available,
may essentially depend on the extent to which those interventions are viewed as important.
Moreover, the difference in rankings by stakeholders’
perceptions on importance and cost-effectiveness data
provides some hints that there may be other factors
behind how interventions are valued in a country.
Burchett et al. (2013) found that one of the factors affecting stakeholders’ perceptions was their previous experiences and beliefs about the interventions [29]. Thus,
recognising this difference prior to any evidence transfer
work is critical as the interventions that are perceived
‘important’ by stakeholders are also the ones that may
be deemed applicable to new settings [17, 18].
Some study limitations should be recognized. First, the
availability question in the survey did not clearly specify
whether availability referred to the product being available on the market in the respective health care system
or available under coverage by social security (i.e., as
part of the National Health Service or statutory sickness
funds, etc.). This might have caused some different interpretations by respondents. If this was the case, this
might have caused larger heterogeneity in the responses
about the availability of, particularly, pharmaceutical
products compared to general-practitioner advice or
public health campaigns.
The second limitation was the sample with the response rate of approximately 56%. Although our sample
had in general similar numbers of respondents in each
country, every country had different stakeholder composition. Majority of the respondents were health advocates in Germany, evidence generators in Hungary and
the Netherlands, and decision makers in Spain and the
UK. This may explain why the agreement on the availability in Spain and the UK were higher than that in
other countries. Decision makers are more likely to be
familiar with intervention availability and may have
more opportunities to discuss this with each other than
Kulchaitanaroaj et al. BMC Health Services Research (2018) 18:115
Page 9 of 12
Table 4 Mean importance score excluding ‘don’t know’ responses
Intervention (Type of the intervention)
b
Mean importance scorea (SD)
N
1
P : Restrictions on smoking in workplaces and public places
1.89 (0.40)
92
2
Cc: Individual counselling by specially trained professionals with medication
(e.g. NRT or bupropion)
1.86 (0.44)
90
3
P: Advertising restrictions/bans
1.83 (0.46)
92
4
C: Group counselling by specially trained professionals with medication
(e.g. NRT or bupropion) (Combined)
1.81 (0.45)
89
5
P: Tax increase
1.80 (0.48)
91
d
6
B : Individual counselling by specially trained professionals
1.79 (0.49)
89
7
B: Group counselling by specially trained professionals
1.77 (0.49)
92
8
P: Restrictions on sales to minors (Population-level)
1.79 (0.53)
91
9
B: Advice on smoking cessation given according to the 5-step protocol
(minimal intervention)
1.76 (0.53)
82
10
Me: Nicotine replacement therapy
1.74 (0.53)
91
11
B: Brief advice on smoking cessation given during one general-practitioner
consultation
1.70 (0.64)
93
12
M: Varenicline
1.59 (0.64)
61
13
P: Mass media campaigns
1.53 (0.69)
89
14
C: Brief advice by a general practitioner and medication
1.44 (0.70)
91
15
P: Product labelling and information/ Health warnings on tobacco products
1.47 (0.75)
91
16
B: Telephone counselling
1.36 (0.67)
85
17
M: Bupropion
1.40 (0.72)
65
18
B: Stage-based interventions
1.39 (0.77)
70
19
B: Internet based interventions
1.32 (0.72)
77
20
B: Computer tailored programs
1.20 (0.72)
75
21
B: Mobile phone-based interventions
1.14 (0.69)
76
22
B: Community pharmacy-based services
1.22 (0.82)
78
23
B: Self-help manuals
1.08 (0.78)
90
24
Nf: Hypnosis-based interventions
0.40 (0.59)
75
25
N: Acupuncture
0.41 (0.63)
81
26
N: Aromatherapy
0.15 (0.40)
72
27
N: Magnetic resonance therapy
0.12 (0.37)
68
28
N: Homeopathy
0.28 (0.53)
78
29
N: Smokeless tobacco
0.30 (0.59)
73
30
N: Herbs
0.22 (0.56)
74
a
The score ranged from 0 to 2 with 0 representing not important and 2 representing important. The ‘don’t know’ response was missing
P = Population-level intervention
C = Combined pharmacological and behavioural intervention
d
B = Behavioural intervention
e
M = Pharmacological intervention
f
N = Non-conventional intervention
b
c
other stakeholder groups. Most non-respondents were
decision makers from the Netherlands but there were
still a good number of them participating (eight while
three to nine from the remaining countries). It is important to realise this caveat before generalising the
study results.
The study results may be helpful to inform the selection of cost-effective tobacco-control interventions that
are transferable. For example, non-conventional interventions which are viewed as less important in every
country compared with other interventions may be excluded from an evidence transfer project. Besides, the interventions which were widely available and considered
valuable such as nicotine replacement therapy,
counselling-related interventions, and population-level
interventions may be included. Being able to transfer
Kulchaitanaroaj et al. BMC Health Services Research (2018) 18:115
Page 10 of 12
Table 5 A head-to-head comparison of selected tobacco-control interventions when ranked by stakeholders’ views and existing
cost-effectiveness evidence
Intervention
Mean importance Rank by mean
Rank by cost- Median cost/ Comparatorb
a
score
importance score effectivenessb QALY (£)b
Rangeb
Individual counselling by
specially trained professionals
with medication (e.g. NRT or
bupropion)
1.86
1
1
Dominatesc
Background quit rate
NA
Group counselling by specially
trained professionals with
medication (e.g. NRT or bupropion)
1.81
2
1
Dominatesc
Background quit rate
NA
Nicotine replacement therapy
1.74
3
1
Dominatesc
Background quit rate
(no intervention)
NA
1.70
Brief advice on smoking cessation
given during one general-practitioner
consultation
4
6
732
Background quit rate
577–1677
Mass media campaigns
1.53
5
2
49
Background quit rate
NA
Brief advice by a general practitioner
and medication
1.44
6
7
2110
Background quit rate
1664–
4833
Stage-based interventions
1.39
7
8
3033
No intervention
(aggregate of controls)
NA
Telephone counselling
1.36
8
4
427
Usual care or intervention
139–1602
but no telephone counselling
Community pharmacy-based services 1.22
9
5
546
Usual care
438–655
Self-help manuals with brief advice
(5 min)
10
3
370b
Background quit rate
292–847
1.08
Kendall rank correlation coefficient evaluating the association between the two rankings = 0.40; p-value = 0.11; 95% CI = [−0.09, 0.89])
a
Calculated using stakeholders’ responses on a 3-point Likert scale, bSourced from Owen et al. (2011), cImplies intervention is less costly with more benefit
economic evidence, instead of fully conducting contextspecific research, will lead to gaining substantial savings in
research resources in other countries. This is important to
countries such as Central and Eastern Europe, where potential to save lives from tobacco control is enormous but
the resources to conduct context-specific economic evaluations of interventions are extremely limited. Therefore,
strong engagement with key stakeholders, focussing on
better communication, has potential to improve evidence
transferability.
Although different from many transferability studies [9]
where the focus appears to gather local input parameters
to the economic model being transferred, this study adds
to transferability pathway by understanding first whether
stakeholders within and across countries have similar
views on the economic evidence being transferred and the
extent of the difference when their views vary. This understanding informed selection of interventions in the European study (EQUIPT) [16] and thus proved to be vital to
improve transferability of evidence.
Conclusions
European stakeholders show low agreement on the availability and fair agreement on the importance of tobaccocontrol interventions within and across countries. These
intrinsic differences in stakeholder views must be
addressed while transferring economic evidence Europewide. Strong engagement with key stakeholders, focussing on better communication, has a potential to mitigate this challenge, and save scarce research resources.
Additional files
Additional file 1: Interview Guide and Questionnaires of the EQUIPT
Stakeholder Survey. (DOCX 86 kb)
Additional file 2: Table S1. Distribution of stakeholders in each
country. Table S2. Perceived availability and importance of tobaccocontrol interventions across countries. (DOC 278 kb)
Abbreviations
EQUIPT: European-study on Quantifying Utility of Investment in Protection
from Tobacco; EU: European Union; METC: Medisch-ethische
toetsingscommissie; NICE: The National Institute for Health and Care
Excellence; QALYs: Quality Adjusted Life Years; ROI: Return on Investment;
UK: United Kingdom
Acknowledgements
We thank all participants whose responses made this study possible. The
inputs from the EQUIPT Working Package 1 team are gratefully acknowledged.
Funding
We have received funding from the European Community’s Seventh
Framework Programme under grant agreement No. 602270 (EQUIPT).
Availability of data and materials
The dataset used in this study is available from the corresponding author on
reasonable request. This may also be available to download freely from the
Kulchaitanaroaj et al. BMC Health Services Research (2018) 18:115
Page 11 of 12
dissemination page of the Project website (http://equipt.eu/deliverables) in
the future.
4.
Authors’ contributions
All authors conceived this study. PK did the analysis and wrote the
manuscript which benefitted significantly from substantive inputs provided
by ZK, LO, RW, SE, ZV, KLC, MH, HDV, MTB, RL and SP at various levels and
stages. This study was a part of the EQUIPT project (http://equipt.eu) of
which SP is the Lead Investigator. All authors have read and approved the
final manuscript.
5.
6.
7.
Ethics approval and consent to participate
Brunel University Research Ethics Committee (UK) reviewed this research and
gave full ethical clearance. Respective authorities in sample countries (EthikKommission, Bayerische Landesärztekammer fromGermany, Egészségügyi
Tudományos Tanács, Tudományosés Kutatásetikai Bizottság from Hungary,
Parc de SalutMAR - Clinical Research Ethics Committee from Spain and
Medisch-ethische toetsingscommissie (METC) azM/UMfrom the Netherlands)
also provided clearance. Prospective participants were approached via an
introductory email requesting their participation in the study. They were
given the information about the project and the confidentiality of their
involvement. Respondents were recruited once they consented to
participate. Written consent forms were obtained from all respondents
included in the study.
8.
9.
10.
11.
Consent for publication
Not applicable.
Competing interests
All authors, except SP and RW, declare that they have no competing
interests. SP is an Associate Editor of this journal. RW undertakes consultancy
and research for and receives travel funds and hospitality from manufacturers
of smoking cessation medications but does not, and will not take funds
from e-cigarette manufacturers or the tobacco industry. RW is an honorary
co-director of the National Centre for Smoking Cessation and Training and
a Trustee of the stop-smoking charity, QUIT. RW’s salary is funded by Cancer
Research UK.
12.
Publisher’s Note
15.
13.
14.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
16.
Author details
1
Health Economics Research Group (HERG), Institute of Environment, Health
and Societies, Brunel University London, Uxbridge, UK. 2Syreon Research
Institute, Budapest, Hungary. 3Department of Health Policy & Health
Economics, Faculty of Social Sciences, Eötvös Loránd University, Budapest,
Hungary. 4Health Behaviour Research Centre, University College London,
London, UK. 5National Centre for Smoking Cessation and Training,
Birmingham, UK. 6Department of Health Promotion, Caphri School of Public
Health, Maastricht University, Maastricht, the Netherlands. 7Department of
Health Services Research, Caphri School of Public Health, Maastricht
University, Maastricht, the Netherlands. 8National Institute for Health and
Care Excellence, London, UK. 9Centre for Research in Economics and Health,
University Pompeu Fabra, Barcelona, Spain. 10Institute of Health Economics
and Healthcare Management, Helmholtz Zentrum München,
Oberschleißheim, Germany.
17.
18.
19.
20.
21.
Received: 3 May 2017 Accepted: 6 February 2018
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