The Lancet Public Health

Background: The UK Government aims to reduce smoking rates by implementing new, and investing in existing, tobacco control strategies including increased funding for Stop Smoking Services (SSS) in England. This study examined whether the additional funding starting in April 2024 was associated with a detectable increase in quit attempts supported by SSS and whether it was cost-effective. Methods: We used data from the Smoking Toolkit Study, a repeat cross-sectional survey conducted in 2021 to 2025. Adults aged [≥]18 years who smoked cigarettes and had made a quit attempt in the past year were included (weighted n=5,076). The outcome was monthly prevalence of past-year quit attempts supported by SSS. We fitted general additive models with a step change in April 2024 to represent the start of the increased funding. We adjusted for tobacco tax increases, the Swap-to-Stop scheme, age, gender, and a measure of socioeconomic position. In an unplanned analysis, we extended the time series back to 2006. For the cost-effectiveness, we estimated incremental cost-effectiveness ratios for the total population and age groups, accounting for future lifetime cessation. Results: In the primary model, the April 2024 step change was not statistically significant (adjusted odds ratio: 1.13; 95% CI: 0.52, 2.49). The cost-effectiveness analysis ranged from cost-effective to extremely ineffective (incremental cost-effectiveness ratio (ICER): GBP 104,126, 95% CI: 939,398 to 8,293). When using the extended time series, the adjusted odds ratio for the step change was 2.70 (95% CI: 2.03, 3.60) and the intervention was cost-effective (ICER: GBP 13,857; 21,393 to 9,620). Conclusions: Compared with the long-term trend, increased funding to SSS in England in 2024 appeared to lead to an increase in quit attempts supported by SSS at the population level. This result is somewhat uncertain because our primary pre-planned analyses assessing the impact relative to a more recent trend were insensitive.

Objectives To compare hospital claims and costs for major tobacco associated diseases with ICD 10 F17 tobacco dependence coding in Indonesian national health insurance claims and to assess whether the insurer records tobacco addiction or mainly pays for its complications. Design Retrospective claims based observational study using routinely collected administrative claims reported according to STROBE and the RECORD extension. Setting Indonesian national health insurance scheme Jaminan Kesehatan Nasional including referral hospital and primary care claims from 2015 to 2023. Participants A national mental health claims sample of 54820 members with at least one ICD 10 mental or behavioral F code diagnosis weighted to 1032022 members and 2074277 referral hospital visits. Primary and secondary outcome measures The primary outcome was verified claim costs in USD for hospital visits with a primary diagnosis of chronic obstructive pulmonary disease J44 or tracheal bronchial or lung cancer C33 to C34 or ischemic heart disease I20 to I25 or stroke I60 to I69. Secondary outcomes were counts of ICD 10 F17 tobacco dependence coding and the disease to F17 coding ratio. Results The four tobacco associated disease groups accounted for 13946 visits among 5223 patients and USD 4.20 million in verified costs representing 6.0 percent of hospital spending in the sample. Weighted costs were USD 74.7 million of which cardiovascular and cerebrovascular disease accounted for 95 percent. F17 appeared in only 51 referral hospital encounters and 26 primary care encounters. Only 2 of 5223 patients with these tobacco associated diseases or 0.04 percent were ever coded with F17. Conclusions The Indonesian national insurer paid substantially for tobacco associated morbidity while tobacco dependence was almost never coded. Smoking related diseases were reimbursed but tobacco dependence treatment was not captured as a financed care target. Embedding brief cessation care reimbursable pharmacotherapy and routine F17 coding into primary care could help shift tobacco related expenditure from downstream complications toward addiction care. Keywords tobacco dependence smoking cessation F17 coding health expenditure administrative claims Indonesia

ObjectivesTo assess the impact of Tier 3 covid-19 restrictions implemented in December 2020 in England on covid-19 hospital admissions compared to Tier 2 restrictions, and its potential variations by neighbourhood deprivation levels and the prevalence of the Alpha variant (B.1.1.7). DesignObservational study utilising a synthetic control approach. Comparison of changes in weekly hospitalisation rates in Tier 3 areas to a synthetic control group derived from Tier 2 areas. SettingEngland between 4th October 2020 and 21st February 2021. Participants23 million people under Tier 3 restrictions, compared to a synthetic control group derived from 29 million people under Tier 2 restrictions. InterventionsImplementation of Tier 3 covid-19 restrictions in designated areas on 7th December 2020, with additional constraints on indoor and outdoor meetings and the hospitality sector compared to less stringent Tier 2 restrictions. Main Outcome MeasuresWeekly covid-19 related hospital admissions for neighbourhoods in England over a 12-week period following the interventions. ResultsThe introduction of Tier 3 restrictions was associated with a 17% average reduction in hospital admissions compared to Tier 2 areas (95% CI 13% to 21%; 8158 (6286 to 9981) in total)). The effects were similar across different levels of neighbourhood deprivation and prevalence of the Alpha variant (B.1.1.7). ConclusionsRegionally targeted Tier 3 restrictions in England had a moderate but significant effect on reducing hospitalisations. The impact did not exacerbate socioeconomic inequalities during the pandemic. Our findings suggest that regionally targeted restrictions can be effective in managing infectious diseases. SUMMARY BOXESO_ST_ABSWhat is already known on this topicC_ST_ABS-- Previous studies of localised non-pharmaceutical interventions (NPIs) found that they could be effective in reducing covid-19 transmissions. -- covid-19 hospitalisation was a key indicator of healthcare resource dynamics, encompassing supply, demand, burden, and allocation, during the pandemic. -- There is a need for a detailed examination of the impact of specific localised restrictions in the UK, such as Tier 3 measures, on hospital admissions to inform targeted public health strategies. What this study adds-- This study found that additional localised restrictions on outdoor gatherings and in the hospitality sector were effective in mitigating hospital admissions during the pandemic. How this study might affect research, practice or policy-- This study provides evidence for future public health policies and preparedness strategies supporting the use of differential regional restrictions during pandemics.

PurposeHealthcare workers (HCWs) play a critical role in responding to the COVID-19 pandemic. Early in the pandemic, urban centres were hit hardest globally; rural areas gradually became more impacted. We compared COVID-19 infection and vaccine uptake in HCWs living in urban versus rural locations within, and between, two health authorities in British Columbia (BC), Canada. We also analyzed the impact of a vaccine mandate for HCWs. MethodsWe tracked laboratory-confirmed SARS-CoV-2 infections, positivity rates, and vaccine uptake in 29,021 HCWs in Interior Health (IH) and 24,634 HCWs in Vancouver Coastal Health (VCH), by occupation, age, and home location, comparing to the general population in that region. We then evaluated the impact of infection rates as well as the mandate on vaccination uptake. ResultsBy October 27, 2021, the date that unvaccinated HCWs were prohibited from providing healthcare, only 1.6% in VCH yet 6.5% in IH remained unvaccinated. Rural workers in both areas had significantly higher unvaccinated rates compared with urban dwellers. Over 1,800 workers, comprising 6.4% of rural HCWs and 3.3% of urban HCWs, remained unvaccinated and set to be terminated from their employment. While the mandate prompted a significant increase in second doses, the impact on the unvaccinated was less clear. ConclusionsAs rural areas often suffer from under-staffing, loss of HCWs could have serious impacts on healthcare provision as well as on the livelihoods of unvaccinated HCWs. Greater efforts are needed to understand how to better address the drivers of rural-related vaccine hesitancy as the pandemic continues.

Aims: To assess whether recent declines in U.S. rolling 12-month-ending drug overdose death counts are projected to continue, compare the retrospective performance of short-term forecasting models, and estimate national and regional 12-month changes. Design: Comparative time-series forecasting study with a retrospective March 2025-February 2026 forecast evaluation and subsequent 12-month-ahead projections through February 2027. Setting: United States and four U.S. Census regions: Northeast, Midwest, South, and West. Cases: Aggregate drug overdose deaths reported in the National Center for Health Statistics Vital Statistics Rapid Release system (VSRR) and identified using ICD-10 underlying cause-of-death codes X40-X44, X60-X64, X85, and Y10-Y14. Measurements: The primary outcome was the monthly series of rolling 12-month-ending overdose deaths. Candidate models included ARIMA, generalized additive models, Prophet, and AICc-ranked n-sub-epidemic models. Models were calibrated using January 2020-February 2025 data and evaluated against March 2025-February 2026 observations using mean absolute error, mean squared error, empirical 95% prediction interval coverage, and weighted interval score (WIS). Individual models were ranked by retrospective WIS, and normalized inverse-WIS weights were used to construct ensembles from the top-ranked models. Final forecasts were generated for March 2026-February 2027 after recalibrating models using January 2020-February 2026 data. Results: Retrospective WIS performance differed geographically: GAM performed best nationally and in the Midwest and West, the leading n-sub-epidemic model in the Northeast, and ARIMA in the South. Median forecasts from all individual models and ensembles projected declines from February 2026 to February 2027 nationally and in each region, although prediction intervals varied substantially. Individual national median projections ranged from declines of 12.8% to 25.8%, while weighted-ensemble median projections indicated declines of 20.5% to 21.7%. Projected weighted-ensemble declines were larger in the Northeast (25.4%-30.0%) and Midwest (24.3%-26.3%) than in the South (16.6%-19.5%) and West (18.0%-21.8%). Summary: Ensemble forecasts of the reported provisional VSRR series were consistent with continued declines in rolling annual overdose death counts nationally and across U.S. Census regions. The projected magnitude of decline differed by region and model specification. Because the forecasts used provisional rolling 12-month-ending counts, they should be interpreted as surveillance projections rather than exact monthly mortality predictions.

ObjectivesTo assess variation in vaccination uptake across occupational groups as a potential explanation for variation in risk of SARS-CoV-2 infection. DesignWe analysed data from the UK Office of National Statistics COVID-19 Infection Survey linked to vaccination data from the National Immunisation Management System in England from December 1st 2020 to 11th May 2022. We analysed vaccination uptake and SARS-CoV-2 infection risk by occupational group and assessed whether adjustment for vaccination reduced the variation in risk between occupational groups. Setting ResultsEstimated rates of triple-vaccination were high across all occupational groups (80% or above), but were lowest for food processing (80%), personal care (82%), hospitality (83%), manual occupations (84%), and retail (85%). High rates were observed for individuals working in health (95% for office-based, 92% for those in patient-facing roles) and education (91%) and office-based workers not included in other categories (90%). The impact of adjusting for vaccination when estimating relative risks of infection was generally modest (ratio of hazard ratios reduced from 1.38 to 1.32), but was consistent with the hypothesis that low vaccination rates contribute to elevated risk in some groups. Conversely, estimated relative risk for some occupational groups, such as people working in education, remained high despite high vaccine coverage. ConclusionsVariation in vaccination coverage might account for a modest proportion of occupational differences in infection risk. Vaccination rates were uniformly very high in this cohort, which may suggest that the participants are not representative of the general population. Accordingly, these results should be considered tentative pending the accumulation of additional evidence.

BackgroundMandatory COVID-19 certification was introduced at different times in the four countries of the UK. We aimed to study the effect of this intervention on the incidence of cases and hospital admissions. MethodsThe main outcome was the weekly averaged incidence of COVID-19 confirmed cases and hospital admissions. We performed Negative Binomial Segmented Regression (NBSR) and Autoregressive Integrated Moving Average (ARIMA) analyses for the four countries (England, Northern Ireland, Scotland and Wales), and fitted Difference-in-Differences (DiD) models to compare the latter three to England, where COVID-19 certification was imposed the latest. FindingsNBSR methods suggested COVID-19 certification led to a decrease in the incidence of cases in Northern Ireland, but not in hospitalizations. In Wales, they also caused a decrease in the incidence of cases but not in hospital admissions. In Scotland, we observed a decrease in both cases and admissions. ARIMA models confirmed these results. The DiD model showed that the intervention decreased the incidence of COVID compared to England in all countries except Wales, in October. Then, the incidence rate of cases already had a decreasing tendency, as well as in England, hence a particular impact of Covid Passport was less obvious. In Wales, the model coefficients were 2.2 (95% CI -6.24,10.70) for cases and -0.144 (95% CI -0.248, -0.039) for admissions in October and -7.75 (95% CI -13.1, -2.46) for cases and -0.169 (95% CI-0.308, -0.031) for admissions in November. In Northern Ireland, -10.1 (95% CI -18.4, -1.79) for cases and -0.269 (95% CI -0.385, -0.153) for admissions. In Scotland they were 7.91 (95% CI 4.46,11.4) for cases and -0.097 (95% CI - 0.219,0.024) for admissions. InterpretationThe introduction of mandatory certificates decreased cases in all countries except in England. Differences on concomitant measures, on vaccination uptake or Omicron variant prevalence could explain this discrepancy.

BackgroundIncreasing hospital use in the past decade has placed considerable strain on children and young peoples (CYP) health services in England. Greater integration of healthcare may reduce these increases. We projected CYP healthcare activity out to 2040 and examined the potential impact of integrated care systems on projected activity. MethodsWe used routine administrative data (Hospital Episode Statistics (HES)) on emergency department (ED) attendances, emergency admissions and outpatient (OP) attendances for England by age-group for 0-24 year olds from 2007 to 2017. Bayesian projections of future activity used projected population and ethnicity and future child poverty rates. Cause data were used to identify ambulatory-care-sensitive-conditions (ACSC). FindingsED attendances, emergency admissions and OP attendances increased in all age groups from 2007 to 2017. ED and OP attendances increased 60-80% amongst children under 10 years. ACSC and neonatal causes drove the majority of increases in emergency admissions. Activity was projected to increase by 2040 by 50-145% for ED attendances, 20-125% for OP attendances and 4-58% for total admissions. Scenarios of increasing or decreasing child poverty resulted in small changes to forecast activity. Scenarios in which 50% of ACSC were seen outside hospital in integrated care reduced estimated activity in 2040 by 21.2-25.9% for admissions and 23.5-30.1% for ED attendances across poverty scenarios amongst infants. InterpretationThe rapid increases in CYP healthcare activity seen in the past decade may continue for the next decade given projected changes in population and child poverty, unless some of the drivers of increased activity are addressed. Contrary to these pessimistic scenarios, our findings suggest that development of integrated care for CYP at scale in England has the potential to dramatically reduce or even reverse these forecast increases FundingNil funding obtained. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSThere has been marked increases in hospital use (inpatient, outpatient and emergency department (ED)) by children and young people (CYP). Search of the PubMed database using the search terms: ((((("child"[MeSH Major Topic]) OR ("adolescent"[MeSH Major Topic])) OR ("infant"[MeSH Major Topic]))) AND ((healthcare use[Text Word])) OR (emergency admission[Text Word])) AND (united kingdom[Text Word]). Drivers of increased activity include population growth and sociodemographic factors, help-seeking behaviour, growth in medical knowledge and capability, and by factors within the health system. Additional factors in child health include increased survival of premature neonates and those with congenital conditions and rising parental expectations of modern medicine. Previous studies have shown that ambulatory-care-sensitive-conditions (ACSC) are responsible for much of the increase in CYP emergency activity in England and Scotland. Added value of this studyThis is the first study to use existing data to project possible future scenarios for CYP healthcare activity out to 2030 and 2040 in any country. Our future scenarios are based upon authoritative projections for population, ethnic diversity and child poverty in England and allow us to estimate the potential impact of integrated care scenarios in which ACSC are treated outside hospital. We show that future projected CYP activity is very high if mitigations such as integrated care are not instituted in England. Implications of all the available evidenceHealthcare activity has grown dramatically over the last decade in CYP, largely due to ACSC and the consequences of premature delivery. Projections to 2040 suggest that similar increases are likely over the next 2 decades without action to reduce child poverty and implementation of integrated care at scale in the NHS.

ImportanceInternationally, there are gaps in data to monitor both early childhood development (ECD) and progress in closing the inequality gap. The unequal impact of the COVID-19 pandemic, and any differential impact on ECD domains is also not poorly understood. ObjectiveTo examine time trends and area-level socioeconomic inequalities in ECD at 2 2.5 years in England between 2019 and 2024 DesignCross-sectional and longitudinal ecological analysis Setting149 local authorities in England Participants143 local authorities (662 annual observations, publishable quality data and at least 75% coverage of eligible children) ExposureYear of assessment, area-level socioeconomic conditions (Index of Multiple Deprivation 2019, Income Deprivation Affecting Children Index (IDACI)) assessed as the Slope Index of Inequality (SII) and Relative Index of Inequality (RII)) Main outcomesAges and Stages Questionnaire 3, rate per 100 not developmentally on track (Five domains of development: Communication, Gross Motor, Fine Motor, Personal Social, or Problem Solving; and any domain) ResultsRate per 100 children not developmentally on track in any domain increased progressively from 2019 (16[95%CI: 14.2; 16.9]), and was highest in 2023 (20.6[18.9; 22.4]) and 2024 (19.8[18.2; 21.4]). Compared to 2019 rates, the largest absolute increase was in 2023 (4.9[3.6; 6.3]), largest for Communication (4.3[3.5; 5.2], followed by similar increases for Personal Social (3.3[2.5; 4]) and Problem Solving (2.9[2.2; 3.5]), and smaller increases for Fine Motor (1.4[0.6; 2]) and Gross Motor (0.9[0.2; 1.6]). All rates except Gross Motor remained elevated in 2024. On average, 21.3[19.5; 23.0] per 100 children were not on track in any domain for the most income-deprived quintile compared to 16.2[14.7;17.8] for the least income-deprived (SII: 2.9[1.8; 3.9]; RII: 23%[14%; 32%]). Inequalities were largest in Communication (SII: 2.8[2.0; 3.6]; RII: 36%[25%; 49%]). Year by area-level socioeconomic conditions interaction effects were not statistically significant. Conclusions and RelevanceIn England, ECD worsened during the pandemic, more so for children exposed for longer, or from a younger age. Children born after the pandemic continue to be affected. Area-level inequalities were striking but did not worsen during this period. Pandemic-recovery efforts need to consider the potentially enormous economic and societal cost of disruption to ECD. Key pointsO_ST_ABSQuestionC_ST_ABSWhat are the time trends and area-level socioeconomic inequalities in early childhood development at 2 to 2.5 years in England around the time of the COVID-19 pandemic? FindingsEarly childhood development at 2 to 2.5 years in England worsened in the wake of the COVID-19 pandemic. Stark socioeconomic inequalities were observed throughout the period of 2019 to 2024. MeaningPolicy makers need to prioritise early years and children services in pandemic recovery efforts to improve early developmental outcomes, especially for children from socioeconomically deprived backgrounds.

IntroductionIn China, standard smoking cessation practices are rarely used by healthcare service providers (HSPs). WeChat, a popular social media app, has been widely used in China. MethodsIn this single-blind, randomized trial, undertaken in China with 8-week interventions and follow-up to 52 weeks, about 2,200 providers from different health care settings will be randomly selected to the intervention or control group. This trial will be conducted in China between June 2018 to October 2019. The intervention group will receive regular smoking cessation training program messages by the professional team to 8 weeks and follow to 52 weeks. A hard copy of the manual will be sent to each provider from the intervention group by mail after randomization. The Control group will only communicate by themselves and receive thanks messages for 8 weeks, and follow-up to 52 weeks. The trial will be carried out in two phases. The first phase is the pilot study (n=200, 8-week intervention and follow-up to 16 weeks) and the second is the main study (n=2000, 8-week intervention and follow-up to 52 weeks). The primary outcome measure will be the utilization rate of behavioural and pharmacotherapy interventions for smoking patients from 8 to 52 weeks. This trial is registered at ClinicalTrials.gov (number NCT03556774). ConclusionsThis program will be the first evidence-based educational program in smoking cessation designed specifically for the improvement of Chinese HSPs utilization of behavioural and pharmacotherapy interventions for cigarette smoking cessation in health care settings by the WeChat WeQuit program. ImplicationsThis protocol may show that WeChat WeQuit training program will be effective in increasing the provision of effective tobacco cessation interventions by Chinese-speaking HSPs, especially therapists, to patients with cigarette smoking, which will provide valuable insights into bridging the gap between need and services for smoking cessation in China. Overall, we believe this program will be likely to have very substantial public health benefits if it would provide a widely accessible and efficacious smoking cessation information for Chinese HSPs.

Non-pharmaceutical interventions (NPIs) are essential for controlling infectious diseases during pre-vaccine periods, yet their success hinges on sustained public adherence. This study investigates adherence dynamics to tiered restriction systems implemented during COVID-19 in six geographical regions across Europe, North America, Africa, and South America. Using daily mobility data and linear-mixed models, we assessed three types of fatigue: overall fatigue (linked to cumulative time under restrictions), tier fatigue (linked to time spent under a specific tier), and iteration fatigue (linked to repeated implementation of the same tier). Tier fatigue caused the most rapid adherence loss, producing effects within days that overall fatigue required months of restrictions to achieve. Iterative application of shorter NPIs, interspersed with temporary relaxation, helped reset adherence, mitigating fatigue and sometimes even improving compliance. Psychological relief and a sense of regained autonomy during relaxation periods may renew public willingness to comply when restrictions are reintroduced. These findings emphasize the dual benefits of short, strategic NPIs for epidemic control and public resilience, offering actionable insights for designing more sustainable pandemic interventions.

Hospital artificial intelligence (AI) and robotics are spreading unevenly across the United States, yet national evidence on how these technologies are associated with hospital performance and population health remains limited. This observational study linked the 2024 American Hospital Association Annual Survey, capturing calendar-year 2023 adoption across 6,166 hospitals, to CMS, CDC, and County Health Rankings outcomes for 3,143 U.S. counties. Conditioning on 2019 baseline performance, hospitals using AI for staff scheduling had roughly 4% higher adherence to the SEP-1 sepsis bundle, and hospitals using AI for routine-task automation had approximately 5.1% lower 30-day pneumonia mortality. At the county level, the clearest timing-aligned outcome was contemporaneous hospital-setting mortality (2023): any access to workflow AI hospitals was associated with 25.5 fewer hospital deaths per 100,000 residents under cross-fitted doubly robust estimation (9.9% lower; non-cross-fitted estimate: 16.9 fewer per 100,000). A historical county benchmark (County Health Rankings premature mortality, 2020-2022) showed a concordant pattern, with the cross-fitted estimate corresponding to 975.8 fewer years of potential life lost per 100,000 before age 75 (p < 0.001), though this outcome predates the 2023 adoption measurement and should be interpreted as a lagged benchmark rather than a contemporaneous association. Workflow AI access was also associated with about 206 fewer preventable hospital stays per 100,000 residents (7.2% lower). Robotics showed narrower and more mixed associations. Yet access reflected a substantial digital divide: only 65.8% of Americans lived within 30 minutes of AI-enabled care, leaving about 114.6 million people outside that catchment (AI access Gini = 0.740), and despite a 56% increase in AI-enabled hospitals between 2022 and 2024, distributional inequality persisted. Overall, the evidence is consistent with adjusted associations between workflow AI access and better rescue outcomes where adoption occurs. Significance StatementIn this study of 6,166 hospitals and 3,143 U.S. counties, hospitals using AI for staff scheduling had roughly 4% higher adherence to the recommended sepsis care bundle, and cross-fitted doubly robust estimation associated workflow AI with 25.5 fewer contemporaneous hospital deaths per 100,000 residents (9.9% lower than comparable unexposed counties; non-cross-fitted baseline: 16.9 fewer per 100,000). A concordant historical benchmark (premature mortality, 2020-2022) and a 7.2% reduction in preventable hospital stays reinforce the pattern. Yet about 114.6 million Americans live beyond a 30-minute drive of any hospital using AI. Only 65.8% of Americans lived within 30 minutes of AI-enabled care (AI access Gini = 0.740), and despite a 56% increase in AI-enabled hospitals between 2022 and 2024, distributional inequality did not improve. The contribution is not a blanket claim that AI saves lives; it is a national estimate of health disparities created when hospital technologies diffuse unevenly, suggesting that extending AI-enabled care to underserved areas may represent a high-return intervention.

Structured AbstractO_ST_ABSObjectiveC_ST_ABSTo track uptake of workplace SARS-CoV-2 testing programs using publicly-available data (e.g., press releases), supplementing findings from employer surveys. MethodsWe tracked testing programs reported by 1,159 Canadian and 1,081 international employers across sectors from March 1, 2020 to March 31, 2021. We analyzed trends in uptake of testing programs, including over time and by workplace setting. Results9.5% (n=110) of Canadian employers and 24.6% (n=266) of international employers tracked reported testing. The prevalence of reported testing programs was less than 20% in some settings associated with high risk of transmission including retail and customer-facing environments, and indoor and mixed blue collar workplaces. ConclusionsPublicly-available data suggest that fewer employers are testing than indicated by surveys. Workplace safety in high-risk workplaces could be further improved by implementing testing strategies that deploy both screening and diagnostic tests.

1.ObjectivesIn a global context of increasing telework, this study explores its health effects, to determine if there is an optimal teleworking frequency during an epidemic. We aim to quantify the relationship between teleworking frequency and both infectious disease (ID) transmission and non-communicable disease (NCD) risk. MethodsWe developed a mathematical model simulating ID transmission and NCD acquisition in a medium-sized company, analysing how different teleworking levels impact workers health. We conducted a rapid literature review to identify potential exposure-response relationships between teleworking and NCD risk and inform this model. We then simulated infection dynamics over a three-month epidemic wave to contrast ID and NCD risks in relation to the extent of telework engagement. ResultsEvidence from the literature showed varying patterns of NCD risk across different teleworking frequencies. Depending on these relationships, we observed that risk may peak at low, intermediate, or high teleworking levels. We demonstrated the existence of a benefit-risk balance between reducing ID transmission and potentially increasing NCD burden. ConclusionsOur study highlights that the definition of an "optimal" teleworking frequency to maximise health benefits is inconsistent, and depends on the NCD considered. Effective teleworking strategies must consider both ID prevention and the risk of NCDs, and weigh these health impacts accordingly to optimise societal health outcomes.

ImportanceCigarette smoking during pregnancy increases the risks of miscarriage, ectopic pregnancy, placental complications, hypertensive disorders of pregnancy, and infant mortality. Reducing smoking in pregnancy remains a pressing public health priority. ObjectiveTo project the impact of a proposed nicotine product standard on maternal complications and infant mortality using the Smoking, E-cigarette use, and Pregnancy (SEP) microsimulation model. Design, Settings, and ParticipantsIndividual-level, annual-cycle microsimulation of U.S. females of reproductive age that tracks smoking, vaping, pregnancy, and pregnancy outcomes was constructed. Model inputs were drawn from national surveillance and vital statistics, including National Health Interview Survey (NHIS) for general population, Behavioral Risk Factor Surveillance System (BRFSS) (2016-2023) for smoking/vaping among pregnant women and NVSS Natality/Linked Birth-Infant Death files for late-pregnancy morbidities and infant mortality. Policy effects on tobacco and e-cig usage transitions are based on FDAs expert-elicitation and used to simulate outcomes under status quo vs. the new policy from 2027-2100. ExposureSmoking and vaping. Main Outcome(s)Maternal outcomes during pregnancy (ectopic pregnancy, miscarriage, placenta previa, placental abruption, hypertensive disorders of pregnancy/pre-eclampsia, eclampsia), infant mortality, pregnancy-related costs, and maternal Quality Adjusted Life Years (QALYs). ResultsUnder the nicotine product standard (policy start 2027), smoking in pregnancy falls sharply from 6.0% in 2027 to 1.2% by 2040. These behavioral shifts translate into large perinatal gains through 2100: approximately 167,000 ectopic pregnancies, 950,000 miscarriages, 15,000 placenta previa, 62,000 placental abruptions, 167,000 hypertensive disorders of pregnancy/pre-eclampsia, 9,000 eclampsia cases, and 64,000 infant deaths are averted cumulatively. Maternal health improves as well, with 103,000 pregnancy QALYs gained. Health system spending falls despite conservative costing, with $4.9 billion in pregnancy-related medical costs avoided. Across uncertainty bounds, direction and magnitude of benefit remain favorable for all maternal morbidities and infant deaths, indicating that new policy yields substantial and durable health gains alongside meaningful cost offsets. ConclusionsA proposed nicotine product standard is projected to improve maternal and infant outcomes and yield sizable pregnancy-related health gains and cost offsets. The SEP model complements prior tobacco policy evaluation frameworks while focusing on maternal and infant health.

BackgroundPeople living in social housing in Australia have higher prevalence of daily smoking and greater exposure to second-hand smoke (SHS), particularly in multi-unit housing where smoke can drift between dwellings. The health impact of this exposure has not been quantified for this population. MethodsWe developed a Monte-Carlo matrix model of household SHS exposure, including smoke drift between dwellings in multi-unit housing, and linked it to the SHINE Tobacco simulation platform. The model projected health outcomes for the population living in social housing in the state of Victoria, Australia, over 20 years, comparing scenarios that eradicated SHS exposure and/or smoking with a business-as-usual (BAU) scenario of constant smoking prevalence. Outcomes were health-adjusted life years (HALYs) gained, and premature deaths averted across 31 smoking-attributable and eight SHS-attributable diseases. FindingsEradicating SHS exposure within the social housing population of Victoria in 2025 could result in 5,350 HALYs (95% uncertainty interval [UI] 4,670-6,120) gained, and 600 premature deaths (95% UI 500-700) averted over 20 years. In multi-unit housing, about half of the SHS-related health gain was attributable to eliminating smoke drift between units. Overall, SHS eradication accounted for approximately 27% of the total health gain achievable if tobacco smoking were fully eradicated in this setting. InterpretationReducing SHS exposure in social housing would deliver substantial health benefits, with a large share resulting from preventing smoke drift in multi-unit housing. Better data on population dynamics and smoke infiltration would strengthen estimates and support policy design. FundingThis research was funded by a seed funding grant awarded by the NHMRC Centre of Research Excellence on Achieving the Tobacco Endgame (NHMRC, GNT1198301)

BackgroundIn addition to national policies and interventions, certain regions in England (particularly in the North) coordinate regional tobacco control programmes. This study examined trends in tobacco smoking prevalence and socioeconomic inequalities in smoking across regions. MethodsData were obtained from monthly household surveys of adults ([&ge;]16y) in England, conducted between November 2006 and July 2024 (total n=368,057). We used logistic regression to estimate time trends in current smoking by region, and tested interactions with occupational social grade to explore differences between more and less advantaged groups. ResultsSmoking prevalence declined most in the North (28.8% to 15.8%; -12.9 percentage points [95%CI -14.4; -11.5]), similar to the national average in the Midlands (25.2% to 16.0%; -9.2 [-10.6; -7.9]), and least in the South (22.7% to 17.3%; -5.3 [-6.5; -4.0]), reducing regional disparities such that prevalence was similar across regions in 2024. Socioeconomic inequalities in smoking prevalence between more and less advantaged social grades fell most in Yorkshire and the Humber (from 17.9 percentage points [14.1; 21.8] to 3.7 [0.4; 7.0]) and the West Midlands (from 16.1 [12.8; 19.6] to 3.0 [-0.03; 6.0]). Regions with sustained regional tobacco control activity saw greater declines in smoking prevalence (-18.1 [-21.4; - 14.7]) than regions with none (-12.8 [-13.9; -11.6]). ConclusionsBetween 2006 and 2024, smoking rates in the North of England fell faster than the national average, aligning with other regions. Regional tobacco control programmes appeared to contribute to this progress.

ObjectiveTo evaluate the impact of equity-focused community-engagement initiatives on the uptake of five routine childhood vaccinations. DesignQuasi-experimental study within a synthetic control analysis framework. SettingPrimary care in England between April 2019 and March 2025. Childhood vaccination data were obtained from the Cover of Vaccination Evaluated Rapidly (COVER) programme. InterventionThe Health Equity Liverpool Project (HELP) is a community-engagement vaccination initiative implemented between October 2023 and June 2024 across nine sites in central and north Liverpool. Activities were co-developed with local partners and delivered in neighbourhoods with persistently low childhood vaccine coverage. Intervention practices were defined as those located within 1 km of HELP delivery sites (n=19). A weighted combination of non-intervention practices across England (n=5826) was used to construct a synthetic control group. Main outcomesQuarterly counts of vaccinated children following intervention implementation for first doses of the measles, mumps and rubella vaccine (MMR1 at 24 months and at 5 years), second dose of MMR (MMR2 at 5 years), pneumococcal conjugate vaccine (PCV at 24 months), the 6-in-1 vaccine, covering diphtheria, tetanus, pertussis, polio, haemophilus influenzae type b, and hepatitis B (at 12 months), and the rotavirus vaccine (at 12 months). ResultsFollowing HELP, rotavirus vaccine uptake increased by 10.03% (95% CI 0.37% to 24.63%), corresponding to 120 (95% CI 4 to 295) additional infants vaccinated in the intervention group compared to the synthetic control. Similarly, 6-in-1 vaccine uptake rose by 11.56% (95% CI 2.37% to 25.56% [~]143 95% CI 29 to 317 additional children vaccinated. No statistically significant changes were observed for MMR1, MMR2, or PCV. Improvements were short-lived, with uptakes returning to pre-intervention levels after approximately nine months. ConclusionsCommunity-engagement vaccination interventions may produce a modest short-term improvement in uptake of selected early life vaccines but show limited evidence of benefit for MMR uptake. Our findings suggest that such approaches are unlikely to have a sustained impact without long-term investment, integration into existing immunisation systems and addressing the wider social determinants of health. What is already known on this topic?O_LIChildhood vaccination rates in England have declined over the last decade and inequalities in uptake are persistent andwidening. C_LIO_LIChildren in socioeconomically deprived areas are less likely to receive routine vaccinations, reflecting both structural barriers and vaccine hesitancy driven by misinformation and lack of trust. C_LIO_LIInnovative community engagement interventions are recommended to address these inequalities, yet evidence of their effectiveness remains limited. C_LI What this study adds?O_LIOur study shows that hyperlocal community engagement interventions can increase uptake of early-life infant vaccines (rotavirus and 6-in-1) by around 10-12% but provides limited evidence of similar improvements for the MMR vaccine. C_LIO_LIThe observed improvements in infant vaccines were transient, returning to baseline levels after approximately nine months, suggesting that one-off initiatives may not produce sustained public health gains without tackling wider social determinants of health. C_LI

ObjectivesTo estimate the potential impacts of unmitigated and mitigated cost of living increases on real household income, mortality, and mortality inequalities in Scotland. DesignModelling study. SettingScotland, 2022/23. ParticipantsA representative sample of 5,602 Scottish individuals (within 2,704 households) in the 2015/16 Family Resources Survey. We estimated changes in real household income associated with differential price inflation (based on proportion of household spending on different goods and services, by income group), both with and without mitigating UK Government policies, and scaled these to the Scottish population. We estimated mortality effects using a cross-sectional relationship between household income and mortality data, by deprivation group. InterventionsBaseline was Scotland in 2022/23 with the average wage and price inflation of preceding years. The comparison scenarios were unmitigated cost of living increases, and mitigation by the UK Governments Energy Price Guarantee (EPG) and Cost of Living Support payments. Main outcome measuresPremature mortality rate and life expectancy at birth by Scottish Index of Multiple Deprivation (SIMD) group, and inequalities in both. ResultsUnmitigated price inflation was 14.9% for the highest income group and 22.9% for the lowest. UK Government policies partially mitigated impacts of the rising cost of living on real incomes, although households in the most deprived areas of Scotland would still be {pound}1,400 per year worse off than at baseline. With the mitigating measures in place, premature mortality was estimated to increase by up to 6.4%, and life expectancy to decrease by up to 0.9%. Effects would be greater in more deprived areas, and inequalities would increase as a result. ConclusionsLarge and inequitable impacts on mortality in Scotland are predicted if real-terms income reductions are sustained. Progressive Cost of Living Support payments are not sufficient to offset the mortality impacts of the greater real income reductions in deprived areas. What is already known on this topicO_LIOver the last decade, life expectancy in Scotland has stalled and inequalities have increased. C_LIO_LIIncome reductions have been related to increased mortality risk, hence the economy matters for public health. C_LIO_LIThe impacts of the rising cost of living and mitigating policies on mortality and inequalities require estimation to inform policymaking. C_LI What this study addsO_LIThe mortality impacts of inflation and real-terms income reduction are likely to be large and negative, with marked inequalities in how these are experienced. C_LIO_LICurrent public policy responses are not sufficient to protect health and prevent widening inequalities. C_LIO_LIBolder and more progressive policy responses are required if health is to improve and health inequalities are to narrow. C_LI

BackgroundAotearoa-New Zealand (A/NZ) is the first country to pass a comprehensive commercial tobacco endgame strategy into law. Key components include the denicotinisation of smoked tobacco products and a major reduction in tobacco retail outlets. Understanding the potential long-term economic impacts of these measures is important for government planning. MethodsA tobacco policy simulation model that evaluated the health impacts of the A/NZ Smokefree Action Plan was extended to evaluate the economic effect of the new measures from both Government and citizen perspectives. Estimates were discounted at 3% per annum and presented in 2021 purchasing power parities US$. FindingsThe modelled endgame policy package generates considerable growth in income for the A/NZ population with a total cumulative gain by 2050 amounting to US$31 billion. From a government perspective, the policy results in foregone tobacco excise tax revenue with a negative net financial position estimated at US$11.5 billion by 2050. In a sensitivity analysis considering future changes to labour workforce, the governments cumulative net position remained negative by 2050, but only by US$1.9 billion. InterpretationOur modelling suggests the Smokefree Aotearoa 2025 Action Plan is likely to produce substantial economic benefits for the A/NZ population, and modest impacts on government revenue and expenditure related to the reduction in tobacco tax and increases in aged pensions due to increased life expectancy. Such costs can be anticipated and planned for and might be largely offset by future increases in labour force and the proportion of 65+ year olds working in the formal economy. FundingThis study was funded by a grant from the Australian National Health and Medical Research Council (GNT1198301) Research in ContextO_ST_ABSEvidence before this studyC_ST_ABSMultiple countries have set targets to achieve a commercial tobacco endgame. Most simulation modelling studies have evaluated traditional tobacco control interventions (e.g., tobacco excise tax increases, indoor smoking bans, smoking cessation health services). Very few have modelled the economic effects of endgame strategies. We searched PubMed with no language restrictions for articles published from 1 January 2000 to 8 February 2023 using the following search terms: (smoking[TW] OR tobacco[TW]) AND (endgame[TW] OR eliminat*[TW] OR "phasing out"[TW] OR "phase out"[TW] OR aboli*[TW] OR prohibit*[TW] OR ban[TW] OR "smoke free"[TW] OR "smoke-free"[TW]) AND (model*[TW] OR simulat*[TW]) AND (cost[TW] OR economic[TW]). We identified six economic evaluations of commercial tobacco endgame strategies, including different interventions and cost perspectives. Five studies modelled interventions in the Aotearoa/New Zealand (A/NZ) context and one in the UK. Four studies were conducted from a healthcare system perspective, estimating the costs to the health system associated with tobacco-related diseases. One of these studies additionally estimated non-health social costs, as the productivity loss resulting from smoking-associated morbidity and mortality. Another study estimated the cost to consumers resulting from a policy in which retail outlets selling tobacco were significantly reduced, considering both the actual cost of a pack of cigarettes and the cost of increased travel to retailers, and the last estimated excise tax revenue to the government resulting from increases to tobacco taxation (compared to no increases to current tobacco tax levels). Of the identified literature, none evaluated the effect of endgame strategies on citizen income nor the fiscal impacts to government revenue and expenditure. Added value of this studyThis study evaluates the economic impacts of a recently introduced commercial tobacco endgame legislation in A/NZ. We modelled the economic impacts by 2050 of a policy package that includes the four key measures in the new legislation (i.e., denicotinisation of smoked tobacco products, enhanced antismoking mass media campaigns, 90% reduction in the number of tobacco retail outlets, and a smoke-free generation law that bans sale of tobacco to anyone born after 2008). The analysis presents both a government and citizen perspective. The government fiscal impacts extend beyond health system expenditure to also include differences between business as usual (BAU) - i.e., no endgame strategy - and endgame scenarios in excise tax revenue, goods and services tax (GST) revenue, income tax revenue, and superannuation expenditure. A net government position is also calculated. The citizen perspective estimates the impact of the policy on population income and savings that may result from reduced tobacco consumption. Our model projects large economic gains for consumers from the tobacco endgame package resulting from a sharp reduction in smoking prevalence, morbidity and mortality. For the A/NZ Government, the policy is projected to result in reduced healthcare costs, and increased income tax and GST revenue. These gains are offset by increased superannuation payments resulting from a greater number of individuals living past the age at which superannuation is provided to all citizens (65 years in A/NZ and described in this article as "retirement age" for simplicity), as well as large reductions in excise tax revenue. Implication of all the available evidenceOur findings support previous evidence indicating that ambitious tobacco control policies can produce large heath and economic benefits. Our model suggests that a commercial tobacco endgame strategy is likely to result in a large revenue transfer to the benefit of the A/NZ population. An endgame approach moves beyond the BAU model of incremental policy change to a deliberate strategy to permanently reduce tobacco smoking to minimal levels within a short timeframe. A logical result of such a strategy is a significant decrease in excise tax revenue for governments. Under the endgame scenario, the net position of the A/NZ Government is likely to be negative due mainly to the foregone excise tax revenue. In a sensitivity analysis of the endgame scenario that takes into account recent projections from Stats NZ of a future larger and older labour force in A/NZ, our model suggests that the net government position might become positive as early as 2036 - less than 15 years after the introduction of the endgame policy.