Background:Alcohol and tobacco are risk factors for non-communicable disease and deaths in England. People using both substances have increased health risks. While increasing tax on each product has been shown to reduce consumption and harm, little research has examined effects of changing both taxes together. Objectives:Work package 1: describe potential tobacco and alcohol tax policies; work package 2: analyse purchasing patterns across population subgroups; work package 3: estimate industry tax-pass-through; consumer response to price changes for 12 products; work package 4: simulate impact of 33 policy options, United Kingdom Government 2021 proposals to restructure alcohol duty and (after project end date) 2023 alcohol duty reform. Design:Work package 1 reviewed literature and interviewed stakeholders to identify policy options. Work package 2 analysed repeat cross-sectional survey data on purchasing. Work package 3 used quantile regression on market research data to estimate tax pass-through and a two-stage Tobit model to estimate consumer responses (own-price and cross-price elasticities) for 12 products (beer, cider, wine, spirits and ready-to-drinks, split off-trade/on-trade; cigarettes, roll-your-own tobacco). Work package 4 developed tax modelling for the Sheffield Tobacco and Alcohol Policy Model (v2.1.0) to analyse work package 1 policy options. Later, version v2.4.2 was used to analyse emerging policy on alcohol duty reforms. Setting:Effects of United Kingdom tax policies in England, covering 2017-50. Participants:Life course simulation of individuals aged 18-89; 2017-50. Interventions:Tax policies changes: (1) specific duty per product, (2) duty escalators for alcohol and tobacco, and Minimum Excise Tax on tobacco, (3) hypothetical strength-based alcohol taxes, (4) United Kingdom Government's 2021 proposals for alcohol duty reform and (5) analysis of United Kingdom Government's implemented Alcohol Duty Reform 2023. Outcome measures:Changes in participation in drinking or smoking, amounts consumed, expenditures, Government tax revenues, retailer revenues, risks of hospitalisation and death from over 60 clinical conditions, National Health Service secondary costs, quality-adjusted life-years, mortality and health inequalities. Results:Work package 1 identified policy options. Work package 2 showed variations in expenditure by subgroup. Work package 3 showed that retailers increased prices of expensive products by more than expected after tax rises, keeping cheap product prices lower. Work package 3 showed statistically significant participation and consumption price responsiveness for all 12 products. Work package 4 compared 33 policies, showing that higher tax increases, especially for cider and hand-rolled tobacco, are effective at reducing smoking rates, drinking and deaths over 20 years. Effects were largest for people living in more deprived areas. Tailored modelling (after project end date) examined United Kingdom Government's 2023 implemented alcohol duty reform, estimating a small reduction in alcohol consumption and deaths. In contrast, a policy to increase cider taxes to be in line with beer could result in a 30 times larger reduction in deaths. Limitations:Uncertainty in estimates remains. Data used were collected pre-coronavirus disease discovered in 2019. Sales data were from legal retailers; illicit tobacco was not examined. Each sub-study has its own data limitations. Conclusions:Combined increases in tax on tobacco and alcohol could potentially be more effective at reducing disease, National Health Service costs, deaths and health inequalities than raising tax on only one product. Potential trade-offs could exist between health benefits and effects of tobacco and alcohol tax increases on financial burden for those who continue consuming both products. Future tobacco or alcohol tax analyses should factor in inter-linkages between both commodities. Future work:We are adapting modelling infrastructure to deliver responsive within-days modelling for new government proposals and budgets. Further work on price elasticities in other countries would be useful. Future analyses will incorporate post-coronavirus disease discovered in 2019 data. We are extending modelling to other United Kingdom countries, and pricing policies beyond tax (e.g. minimum pricing). We are extending analyses to no and low alcohol products and to evaluate observed impacts of the government's alcohol duty reforms. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number 16/105/26.
Background Exposure to particulate matter is linked to increased mortality, respiratory and cardiovascular diseases, including lung cancer, ischaemic heart disease and asthma, among other adverse health outcomes. Emissions of particulate matter from agriculture occur directly from farming activities and from reaction of ammonia with acidic pollutants to form fine particles (PM 2.5 : particles with diameter of 2.5 μm or less). In the United Kingdom, ammonia has slightly increased in recent years, in contrast to other PM 2.5 sources. In addition, NH 3 emissions can contribute to nitrogen deposition, which, in excess of critical thresholds, may result in biodiversity loss. Objectives Our objectives were to assess the effectiveness and cost-effectiveness of inter-related interventions to: (1) assess the annual health impacts of air pollution (PM 2.5 ) from intensive livestock agriculture and farming on the general population; (2) valuate the effectiveness and cost-effectiveness of the specific interventions at the national level; (3) assess impacts on ecosystems; and (4) examine the extent to which rural residents are concerned about agriculture and their health. Design and methods We performed a health impact assessment based on PM 2.5 exposures associated with three levels of agricultural intervention. We also performed an economic analysis, capturing valuation of health and productivity, and costs to the national health service, as well as an assessment of ecosystem impacts based on nitrogen deposition and biodiversity loss. A survey of rural residents’ health was undertaken to investigate links between self-reported health and agriculture. Interventions The three intervention scenarios comprised 19 individual mitigation actions at a farm level, each with differing uptake levels in low, medium and high scenarios. Main outcome measures The health impact assessment and economic analyses included all-cause mortality, and incidence of lung cancer, ischaemic heart disease, cerebrovascular disease, and childhood asthma incidence. The ecosystem analysis examined biodiversity loss, and the rural residents survey addressed respiratory, gastrointestinal, and neurological diseases. Results Modest changes in PM 2.5 concentrations across the United Kingdom associated with the low, medium and high intervention scenarios resulted in relatively small impacts compared to national baseline levels of mortality and morbidity (i.e. −0.01% to −0.05%). Overall, United Kingdom-wide avoided costs ranged from £78.1 to £93.4M, with much lower annual avoided costs to the national health service. All habitats had a relative increase in biodiversity under all scenarios with expected benefits of £3.4–4M. There were 450–500 respondents in each of the 2 waves of the rural resident surveys. No associations were identified between any self-reported disease occurrence and farm-related variables. Limitations Our approach used several different models, requiring important assumptions and uncertainties. Respondents to the residents’ survey tended to be aged over 45 and female and findings are applicable primarily to this demographic. Conclusions Based on the modest modelled changes in PM 2.5 concentrations associated with the intervention scenarios, we estimated small impacts with human health, as well as economic and ecosystem effects. We found no evidence of self-reported health issues in relation to farms or farming practices. Future work Impacts from alternative farming interventions should be assessed to maximise PM 2.5 reductions in the United Kingdom. Funding This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR129449.
Background:Household overcrowding is a growing problem in England. It increases the risk of health outcomes including infections, injuries and poor mental health. For councils to monitor overcrowding at household level, methods are required to identify which homes are overcrowded and how it affects residents. Measures may need to be tailored for families, where overcrowding limits children's ability to play, study and socialise. Study aim:To establish the feasibility of developing a method to identify households with families at high risk of overcrowding affecting their well-being. Objectives:Describe effects of household overcrowding on family well-being through discussions with people with experience of overcrowding. Operationalise a method in one council, by combining publicly available and council-held data, to identify households with families at risk of the health effects of overcrowding. Understand the wider applicability of this method to other councils and its implications for population-level intervention design. Methods:An explanatory sequential mixed-methods design was used with resident and community engagement throughout. First, interviews and focus groups were conducted with parents with lived experience of overcrowding and community representatives and service professionals in two boroughs of London. From discussions with these groups, a description of overcrowding affecting households with families was shared with one London local authority. Informed by this information, this local authority obtained and combined relevant population and housing data to generate two measures of household overcrowding in households with dependent children. The first measure replicated the 'bedroom standard', the most used overcrowding metric. The second measure assessed overcrowding by space available to families. A logistic regression was conducted to examine associations between overcrowding and repairs for damp and mould was undertaken. The methods and illustrative results on overcrowding prevalence from one council were shared with other councils, housing associations and researchers to understand its wider applicability. Results:Analysis of data from 47 parents (n = 25) and staff (n = 22) illustrated how effects of living in overcrowding can be influenced by the space available, and the number of bedrooms in the home, by the condition of the property (particularly damp/mould) and children's age. Using data available to councils, we identified overcrowding in families comparable to national estimates of overcrowding using the 'bedroom standard' and the 'space standard'. While prevalences were similar using space and bedroom standards [34.6% (95% confidence interval: 34.0% to 35.3%) vs. 36.1% (95% confidence interval: 35.4% to 36.8%)], each identified distinct cohorts of households). Using one of the local measures, we found overcrowded council homes had 1.31 times (95% confidence interval: 1.14 to 1.50, p < 0.001) higher risk of needing damp and mould repairs than households not in overcrowding. Stakeholder discussion with 30 participants across six English regions emphasised the importance of local measures for identifying populations at risk and for evaluating impacts of local policies and interventions. Discussion:This project demonstrated the feasibility of generating locally derived measures of overcrowding at household level that are granular enough to: (1) examine variations in overcrowded by household composition and (2) evaluate potential impacts of other policies/services on overcrowded households. Limitations:The project was limited in its geographical transferability; the qualitative research was conducted in two boroughs of London and the quantitative research in only one borough. There were also limitations to data access and quality on population data and housing data which affected the robustness of overcrowding indices. Future work:Household-level identification of overcrowding is needed to develop and evaluate public health interventions to support families living in overcrowding. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR154776.
Background:Inequitable access to health care increases morbidity and mortality among people experiencing homelessness. Peer advocates ('peers') with lived experience may help others to access health care. Objectives:To evaluate the impact and cost-consequence of Groundswell's Homeless Health Peer Advocacy programme on healthcare access, the processes through which it operates and the impact for peer advocates themselves. Ethics and design:A participatory mixed-method design with three components: qualitative study (A), prospective cohort (B), and cost-consequence analysis (C) using cohort and programmatic data. Ethical approval: Dulwich Research Ethics Committee (Integrated Research Application System 271312). Setting:London, United Kingdom (2019-23) coinciding with COVID-19 and disruptions to the National Health Service, Homeless Health Peer Advocacy and housing services. Participants:Homeless Health Peer Advocacy clients and non-clients (A-C); Homeless Health Peer Advocacy staff, volunteers and homelessness-sector stakeholders (A). Intervention:Peer advocates accompany clients to healthcare appointments and provide support to address barriers to access. Main outcome measures:Primary: probability of 'did not attend' at a scheduled outpatient appointment within 12 months of cohort enrolment. Secondary: number of inpatient admissions and accident and emergency visits. Data sources:(A) In-depth interviews and focus groups; (B) Structured questionnaires and National Health Service Hospital Episode Statistics; (C) Groundswell programme data and cohort findings. Results:Qualitative (A): Peer advocacy empowered clients by building cultural health capitals (skills and communication that support healthcare interactions) and strengthening social and economic resources. Advocates themselves gained social, cultural, human and physical resources, though benefits were greatest for those with some pre-existing stability. Cohort (B): Compared with non-clients, Homeless Health Peer Advocacy clients showed no difference in did not attend rates (rate ratio 0.97, 95% confidence interval 0.67 to 1.42) or accident and emergency visits (mean difference 0.86, 95% confidence interval -0.06 to 1.79) for the other pre-specified outcomes. Clients had 1.14 more inpatient admissions (95% confidence interval 0.52 to 1.75). Sensitivity analyses with imputed data suggested higher numbers of outpatient attendances, outpatient 'did not attends', accident and emergency visits and admissions among clients. Secondary analyses suggested differences by levels of anxiety and depression. Cost-consequence (C): Median annual cost per client was £353 (£176 per scheduled engagement). Evidence of National Health Service cost saving was inconclusive. Limitations:The COVID-19 disrupted both Homeless Health Peer Advocacy delivery and National Health Service services. Non-randomised design may have introduced bias. Conclusions:Homeless Health Peer Advocacy enhances clients' cultural health capital and helps peer advocates achieve their goals. We cannot state whether peer advocacy reduces 'did not attends' or demonstrate cost savings, but it was associated with more inpatient admissions and, in sensitivity analyses, more outpatient appointments. Future work:Research should explore how peer advocacy addresses stigma in health care and hostel settings and develop outcome measures that capture wider systemic change. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number 17/44/40.
Background:People leaving prison face significant barriers to reintegration, often resulting in homelessness, which exacerbates health issues and increases recidivism. Critical time interventions aim to support vulnerable individuals during significant life transitions by providing time-limited, emotional and practical support. While effective in other contexts, the impact of housing-led critical time interventions for people leaving prison in the United Kingdom remains unclear. The PHaCT study was a pilot randomised controlled trial of a housing-led critical time intervention for people leaving prison at risk of homelessness. This study aimed to determine whether a full-scale randomised controlled trial of the critical time intervention model in prison leavers at risk of homelessness was feasible. Methods:The pilot was a parallel two-arm, individual-level randomised controlled trial of a pre-existing critical time intervention intervention with an integrated process evaluation and embedded exploratory health economic evaluation. Recruitment occurred in fours male prisons across England and Wales with participants followed up in the communities. Prisons were randomised by site to either receive the critical time intervention or receive usual support, and participants were recruited within 12 weeks of their release. The locations were predetermined by where the intervention was already being delivered by the intervention provider (critical time intervention teams). Critical time intervention included pre-engagement, transition to community, try-out and transfer of care phases, each lasting 3 months. Data collection methods included baseline surveys, follow-up assessments at 3, 6 and 9 months, qualitative interviews, and session observations. Routine data linkage was explored separately to assess feasibility. Progression criteria included recruitment, retention, process evaluation and fidelity. Results:Thirty-four male participants (mean age 38 years) were recruited, with 19 assigned to the intervention and 15 to control. The study achieved a high recruitment rate of 92%, but retention was a significant challenge, with only 18% of participants retained at 9 months follow-up. The process evaluation found critical time intervention was acceptable to staff and participants, but ethical concerns around randomisation and informed consent were raised. Fidelity to the critical time intervention model was generally high, though contextual instability in housing and criminal justice systems posed challenges. Data collection methods for health economics and data linkage were feasible and acceptable. Limitations:The approval to access prisons was lengthy and support provided by Clinical Research Networks was delayed. Contextual instability within the housing and criminal justice systems, including a lack of social housing, high recall rates, the removal of the requirement to have a probation officer and the emergency early release of people in prison, further complicated the trial. Ethical concerns around randomisation and informed consent affected trial acceptability. Conclusions:The trial methodology faced significant challenges. Low retention rates, ethical concerns by intervention delivery staff around randomisation and contextual instability suggest that a full-scale randomised controlled trial is not feasible. Implications/future work:The findings highlight the need for systemic changes within the research support provided to prison-based studies, housing and criminal justice systems to support research in prisons and interventions for people leaving prison. Decision-makers should prioritise policies that increase the availability of affordable housing and provide post-release support. Future research should explore alternative study designs and more intensive recruitment and retention strategies. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR134281.
