Anticipatory gaps challenge the public governance of heritable human genome editing.

Considering public moral attitudes is a hallmark of the anticipatory governance of emerging biotechnologies, such as heritable human genome editing. However, such anticipatory governance often overlooks that future morality is open to change and that future generations may perform different moral assessments on the very biotechnologies we are trying to govern in the present. In this article, we identify an 'anticipatory gap' that has not been sufficiently addressed in the discussion on the public governance of heritable genome editing, namely, uncertainty about the moral visions of future generations about the emerging applications that we are currently attempting to govern now. This paper motivates the relevance of this anticipatory gap, identifying the challenges it generates and offering various recommendations so that moral uncertainty does not lead to governance paralysis with regard to human germline genome editing.

Enhancing affordability and profit in a non-cooperative, coordinated, hypothetical pediatric vaccine market via sequential optimization.

This study considers a hypothetical global pediatric vaccine market where multiple coordinating entities make optimal procurement decisions on behalf of countries with different purchasing power. Each entity aims to improve affordability for its countries while maintaining a profitable market for vaccine producers. This study analyzes the effect of several factors on affordability and profitability, including the number of non-cooperative coordinating entities making procuring decisions, the number of market segments in which countries are grouped for tiered pricing purposes, how producers recover fixed production costs, and the procuring order of the coordinating entities. The study relies on a framework where entities negotiate sequentially with vaccine producers using a three-stage optimization process that solves a MIP and two LP problems to determine the optimal procurement plans and prices per dose that maximize savings for the entities' countries and profit for the vaccine producers. The study's results challenge current vaccine market dynamics and contribute novel alternative strategies to orchestrate the interaction of buyers, producers, and coordinating entities for enhancing affordability in a non-cooperative market. Key results show that the order in which the coordinating entities negotiate with vaccine producers and how the latter recuperate their fixed cost investments can significantly affect profitability and affordability. Furthermore, low-income countries can meet their demands more affordably by procuring vaccines through tiered pricing via entities coordinating many market segments. In contrast, upper-middle and high-income countries increase their affordability by procuring through entities with fewer and more extensive market segments. A procurement order that prioritizes entities based on the descending income level of their countries offers higher opportunities to increase affordability and profit when producers offer volume discounts.

Exploring associations of population characteristics and tobacco and vape retailer density and proximity in Australia: a scoping review.

OBJECTIVE: This scoping review synthesises Australian evidence on associations between tobacco and vape retailer density/proximity and various population measures and smoking behaviour to identify research gaps and inform future policy and strategies. DATA SOURCES: Following Joanna Briggs Institute methodology, relevant studies published in English since 2003 were identified via searches of eight databases in March and August 2023. STUDY SELECTION: Two reviewers independently completed screening procedures. Eligible studies were from Australia and described associations between tobacco or vape retailer density/proximity and adult or youth smoking/vaping prevalence or behaviours, neighbourhood socioeconomic status, geographic location, school locations and/or Indigenous status. DATA EXTRACTION: Results are reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. DATA SYNTHESIS: Of 794 publications screened, 12 studies from 6 Australian states were included. Six studies from five states reported statistically significant associations between neighbourhood-level socioeconomic disadvantage and tobacco retailer density, yet only two studies from two states found a significant relationship between retailer density and adult smoking prevalence. Increasing retailer density was consistently significantly associated with increasing geographical remoteness in three states. No studies explored associations with tobacco retailer proximity or vape retailer density/proximity. CONCLUSIONS: Despite a moderate number of studies overall, state-level evidence is limited, and unknown for Australian territories. Evidence from five Australian states reflects the international evidence that increasing retailer density is significantly associated with increasing socioeconomic disadvantage and remoteness, supporting the need for tobacco supply-based policies. Further research is required to understand the impact of retailer density and adult and youth smoking prevalence in Australia.

This year sees an opportunity for long-needed oral health reforms. Cancer patients, in particular, stand to benefit.

The long-standing divide in Australia between medicine and dentistry has left many with inequitable access to dental care. People with oral cancer, in particular, may have few options for dental rehabilitation after cancer treatment, even with private health insurance. However, 2024 could finally see health care reforms that address these inequities, with significant momentum building in Australia. In this Perspective, we argue for a national approach to reforms that incorporate aspects of preventive health, primary health care, Medicare Benefits Schedule item review, and the value of Private Health Insurance rebates for dental care.

Tobacco Taxation in Spain: A tax laggard with a brighter possible future.

INTRODUCTION: In recent years tobacco taxation in Spain has regressed, with its Tobacconomics tax scorecard falling from 3.9 points (out of 5) in 2014, to only 2.625 in 2020. The objective of this research is to provide a detailed analysis of the causes behind this deterioration and identify possible ways forward for reversing this trend. METHODS: A retrospective 2014-2022 analysis of manufactured cigarettes (FM) and roll-your-own tobacco (RYO) markets including tax structure/rates, affordability, retail price gaps across products, and price differentials with bordering countries. A market level simulation model to 2028 studied the impact of various tax policy scenarios on smoking prevalence, premature deaths averted, smoking intensity, product substitution, government revenue, sales, and industry profit. RESULTS: A lack of tax increases in a context of inflation and income growth during the past 8 years means FM and RYO have become 13% more affordable, with a constant differential of €2 between 20 FM and RYO sticks, and the price gap between Spain and neighbouring France increased. Modelling of two realistic reform scenarios that reduce/eliminate the price gap between FM and RYO suggest substantial increases in government revenues and up to 700,000 fewer smokers and 210,000 fewer premature deaths. CONCLUSIONS: Current European Union legislation on tobacco taxes leaves ample room for much needed tobacco tax reform. For the sake of both public health and the economy, Spain should increase its Minimum Excise Tax. This would not only save lives, but also bring much needed revenue for the government. IMPLICATIONS: The stance of Spain on tobacco taxes has deteriorated recently. This study argues that the failure of successive governments to raise minimum taxes in an inflationary context has made tobacco products more affordable, and quantifies the improvements in smoking prevalence and excise revenue that would accrue if the authorities act urgently increasing rates within realistic limits.Spain is representative of European countries where government inaction has rendered minimum tobacco taxes obsolete. Given the postponement of the revision of the European Union Tobacco Tax Directive, this study highlights the need to act unilaterally within the existing legal framework.

Census-Dependent Mortality of Ventilated Patients With COVID-19 in Israel: Noninterventional Observational Cohort Study.

BACKGROUND: The COVID-19 pandemic led to several surges in the mass hospitalization rate. Extreme increases in hospital admissions without adequate medical resources may increase mortality. No study has addressed the impact of daily census of ventilated patients on mortality in the context of the pandemic in a nationwide setting. OBJECTIVE: This study aimed to determine whether daily census of ventilated patients affected COVID-19 mortality rates nationwide in Israel. METHODS: We conducted a cohort study using nationwide, public-domain, population-based COVID-19 data of hospitalized patients from an Israeli database from March 11, 2020, until February 11, 2021. We included all COVID-19 hospital admissions, classified as mild to severe per the Centers for Diseases Control and Prevention classification irrespective of whether they were mechanically ventilated. Outcome measures were daily death rates and death rates expressed as a percentage of ventilated patients. RESULTS: During the study period (338 days from March 11, 2020, to February 11, 2021), 715,743 patients contracted and were clinically confirmed as having COVID-19. Among them, 5577 (0.78%) patients died. In total, 3398 patients were ventilated because of severe COVID-19. Daily mortality correlated with daily census of ventilated patients (R2=0.828, P<.001). The daily percent mortality of ventilated patients also correlated with the daily census of ventilated patients (R2=0.365, P<.001)-backward multiple regression analysis demonstrated that this positive correlation was still highly significant even when correcting for the average age or gender of ventilated patients (R2=0.4328, P<.001) or for the surge in their number. Overall, 40% of the variation in mortality was explained by variations in the daily census of ventilated patients. ANOVA revealed that at less than 50 ventilated patients per day, the daily mortality of ventilated patients was slightly above 5%, and it nearly doubled (10%) with 50-149 patients; moreover, in all categories of ≥200 patients ventilated per day, it more than tripled at ≥15% (P<.001). CONCLUSIONS: Daily mortality rates per ventilated patient increased with an increase in the number of ventilated patients, suggesting the saturation of medical resources. Policy makers should be aware that expanding medical services without adequate resources may increase mortality. Governments should perform similar analyses to provide indicators of system saturation, although further validation of these results might be needed to use this indicator to drive public policy.

Cigarette smoking decline among US young adults from 2000 to 2019, in relation to state-level cigarette price and tobacco control expenditure.

OBJECTIVE: To investigate the association of state-level cigarette price and tobacco control expenditure with the large 2000-2019 decline in cigarette smoking among US 18-24 year-olds. METHODS: Smoking behaviour was assessed in the 24 most populous US states using the 1992-2019 Tobacco Use Supplements to the Current Population Survey; association with price and expenditure was tested using adjusted logistic regression. States were ranked by inflation-adjusted average price and tobacco control expenditure and grouped into tertiles. State-specific time trends were estimated, with slope changes in 2001/2002 and 2010/2011. RESULTS: Between 2000 and 2010, the odds of smoking among US young adults decreased by a third (adjusted OR, AOR 0.68, 95% CI 0.56 to 0.84). By 2019, these odds were one-quarter of their 2000 level (AOR 0.24, 95% CI 0.19 to 0.31). Among states in the lowest tertile of price/expenditure tobacco control activity, initially higher young adult smoking decreased by 13 percentage points from 2010 to 2018-2019, to a prevalence of 5.6% (95% CI 4.5% to 6.8%), equal to that in the highest tobacco-control tertile of states (6.5%, 95% CI 5.2% to 7.8%). Neither state tobacco control spending (AOR 1.0, 95% CI 0.999 to 1.002) nor cigarette price (AOR 0.96, 95% CI: 0.92 to 1.01) were associated with young adult smoking in statistical models. In 2019, seven states had prevalence over 3 SDs higher than the 24-state mean. CONCLUSION: National programmes may have filled a gap in state-level interventions, helping drive down the social acceptability of cigarette smoking among young adults across all states. Additional interventions are needed to assist high-prevalence states to further reduce smoking.

Tracing the refinement of policy tools for disability rights: a content analysis of how the granting process of state-funded personal assistance in Sweden is aligned with the LSS Act.

PURPOSE: According to the Swedish Act concerning Support and Service for Persons with Certain Functional Impairments (The LSS Act), personal assistance (PA) aims to enhance good living conditions for people with disability. The Act is operationalised by a policy tool, an instruction developed and refined by the Swedish Social Insurance Agency (SSIA) to grant PA. The study explores how this instruction is aligned with the LSS rationale and goals. MATERIAL AND METHOD: Qualitative content analysis was applied on the material i.e., a government bill preceding the LSS Act and the policy tool, i.e., the SSIA instruction, versions 1994 and 2019. RESULTS: The result shows that the instruction has deviated from the LSS Act over time, by decreasing users' access to community life, a shift towards health care activities, lack of support for the PA user, increased control and service-granting criteria. CONCLUSION: This paper emphasises that the selection of policy tools goes beyond mere pragmatism, as they are subject to refinement procedures that have significant impacts over time. The deviations observed in fulfilling the objectives of the LSS Act highlights the importance of ongoing adjustments to policy tools to align with the original policy goals in order to promote disability rights.

The study explored how policy tools, which serve as compulsory guidance by outlining the personal assistance granting process for local caseworkers, align with the rationale and policy goals of the Swedish Disability Act and policy goals, aiming to enhance good living conditions for people with disabilities.The designs of policy tools are frequently revised and adjusted and consequently influence policy outcome over time.Since policy tools are important for the implementation of government policy they need to be reviewed and monitored in order to secure original policy goals with the ultimate aim of enhancing good living conditions and advancing disability rights.

Rotation of tobacco health warnings and messages: challenges and recommendations for implementation.

Health warnings and messages-or health warning labels (HWLs)-are integral to tobacco control efforts, but their sustained impact necessitates regular rotation. This paper explores challenges in HWL rotation implementation across six diverse countries: Chile, Guyana, Indonesia, Jamaica, Mexico, and Vietnam. 19 in-depth interviews were conducted with government officials and representatives from civil society organisations and academia. Interviews explored the effectiveness of HWL regulations, the processes involved in their execution, and any challenges encountered along the way. Interviews were analysed thematically, using a combination of deductive and inductive approaches. Interviews revealed critical challenges that fall into two categories: specific and overarching. Government priorities and transitions, political will, time and bureaucracy, legal loopholes, lack of images, evaluation, and economic and human resources constitute HWL-specific challenges. Broad tobacco control challenges included tobacco industry interference and enforcement difficulties. To address HWL rotation challenges, international bodies such as WHO could establish extensive image banks, pre-evaluated for effectiveness and cultural relevance. In addition, countries must institutionalise the rotation process by establishing mechanisms that avoid having to pass complex legal instruments with each new round of warnings, delegating responsibilities to stable government institutions, addressing legal loopholesand planning for multiple rounds within a single legal instrument. Further, partnerships at national and international levels, along with systematic evaluations, are crucial for successful HWL implementation. These recommendations form a comprehensive framework for global collaboration, aiming to strengthen tobacco prevention through impactful HWLs on a sustainable basis.

Other possible perspectives for solving the negative outcome penalty paradox in the application of artificial intelligence in clinical diagnostics.

Artificial intelligence (AI), represented by machine learning, artificial neural networks and deep learning, is impacting all areas of medicine, including translational research (from bench to bedside to health policy), clinical medicine (including diagnosis, treatment, prognosis and healthcare resource allocation) and public health. At a time when almost everyone is focused on how to better realise the promise of AI to transform the entire healthcare system, Dr Appel calls for public attention to the AI in medicine and the negative outcome penalty paradox. Proposing this topic has deepened our thinking about the application of AI in clinical diagnostics, and also prompted us to find more effective ways to integrate AI more effectively into future clinical practice. In addition to Dr Appel's insightful advice, I hope to offer three other possible perspectives, including changing public perceptions, re-engineering clinical practice processes and introducing more stakeholders, to further the discussion on this topic.

No-fault compensation schemes for COVID-19 vaccine injury: a mixed bag for claimants and citizens.

The development of vaccines against SARS-CoV-2 (COVID-19) presented a unique set of challenges. There was a global need for safe, effective vaccines against a new virus. In response to the development of vaccines for COVID-19 (some of which used novel technologies), there was a proliferation of no-fault compensation schemes (NFCS) for COVID-19 vaccine injuries. We identified 28 national vaccine injury NFCS operating in December 2019. Just 2 years later, over 130 countries had some NFCS coverage for COVID-19 vaccines. This rapid expansion was primarily driven by the creation of three multinational schemes. The COVID-19 Vaccines Global Access (COVAX) scheme covers vaccines given under the COVAX framework in 92 low and middle-income countries across the globe. The African Vaccines Acquisition Trust (AVAT) scheme covers vaccines administered under the AVAT framework in 36 African and Caribbean countries. The UNICEF scheme covers vaccines administered by UNICEF in 18 Asian countries.Because of the sudden expansion of no-fault compensation for vaccine injury, especially in developing economies, more research on the foundations, procedures and outcomes of NFCS is needed. In this article, we examine how these NFCS meet the needs of individual claimants and society more widely. To do so, we first review the rationales offered to support the creation of vaccine injury NFCS. We then argue that, in order to achieve their function as compensation mechanisms, NFCS should be accessible and offer substantive and procedural justice to claimants. Finally, we focus on transparency and accountability as necessary requirements to allow scrutiny over existing NFCS and their wider impacts.

Public Support for Tobacco Endgame Policies: A Systematic Review and Meta-analysis.

INTRODUCTIONS: An increasing number of countries are adopting the tobacco endgame goal. High levels of public support can accelerate momentum towards implementing tobacco endgame policies. We aimed to conduct a systematic review of public support for tobacco endgame policies and to examine the geographical distribution of studies, support among key populations (adolescents and young adults, people who smoke), and the association between survey design and support. METHODS: We searched Embase, PubMed, Scopus, Web of Science, and Google Scholar for studies published from 2013 onwards. Google was used to search the grey literature. The reference lists of included articles were hand-searched. Studies were included if they reported the proportions of people supporting one or more endgame policies. Risk of bias was assessed using the JBI checklist for prevalence studies. RESULTS: Forty-seven articles were included. Aotearoa/New Zealand and the United States were the countries with the most studies (n=11, respectively). Three-level meta-analyses showed the highest support for mandating a very low nicotine content in tobacco products (76%, 95% CI 61-87%). Meta-regressions were performed to assess the associations of population subgroup and survey design with support levels. The level of support was lower among people who smoke compared to the general population (ß range: -1.59 to -0.51). Support for some policies was lower when neutral or don't know response options were included. CONCLUSIONS: Public support for most tobacco endgame policies was high. IMPLICATIONS: Assessing public support can assist with progressing tobacco endgame policies. Policies that are widely supported by the public may be more politically feasible to implement. Qualitative studies and trial studies can further inform communication and implementation strategies for tobacco endgame policies.

The effects of an unconditional cash transfer on parents' mental health in the United States.

The provision of unconditional cash transfers may be one effective policy strategy for improving mental health, but causal evidence on their efficacy is rare in high-income countries. This study investigates the mental health consequences of the 2021 child tax credit (CTC) expansion, which temporarily provided unconditional and monthly cash support to most families with children in the United States. Using data from the Behavioral Risk Factor Surveillance System, we exploit differences in CTC benefit levels for households with younger versus older children. More generous CTC transfers are associated with a decrease in the number of bad mental health days reported by the parents. The effect materializes after the third monthly payment and disappears when the benefits are withdrawn. The CTC's improvement of mental health is larger for more credit-constrained individuals, including low-income households, women, and younger respondents.

A global redistributive auction for vaccine allocation.

The global allocation of vaccines during the COVID-19 pandemic is widely perceived as unfair. Priority was given to countries that paid the most with little or no concern for who needed the vaccines the most. No satisfactory institutions have been established to allocate vaccines in a future pandemic. In this paper, we join reformers in proposing a new scheme for vaccine distribution: a global auction for vaccines where profits are distributed fairly to participating countries. Our proposal improves upon previous suggestions morally by taking countries' differing valuations of money and vaccines seriously. Since an auction is in the interest of both vaccine manufacturers and high-income countries, it is also politically feasible. A global redistributive auction for vaccines thus promises to be a robust and morally desirable way to allocate vaccines.

Association between vitamin D insufficiency and depressive symptoms, and functional disability in community-dwelling Brazilian older adults: results from ELSI-Brazil study.

Low serum 25(OH)D levels (< 30 nmol/L) have been associated with increased depressive symptom scores over time, and it is believed that functionality may play a mediating role in the relationship between 25(OH)D and depressive symptoms. To comprehend the association between these factors could have significant implications for public health policy. The aim of this study was to verify the association between simultaneous vitamin D insufficiency and depressive symptoms, and functional disability in community-dwelling older adults. This was a cross-sectional study with data from the Brazilian Longitudinal Study of Aging (ELSI-Brazil), collected between 2015 and 2016. The outcomes were functional disability assessed through basic activities of daily living (ADL) and instrumental activities of daily living (IADL). The exposures were vitamin D insufficiency (< 30 nmol/L) and depressive symptoms (≥ 4 points in 8-item version of the Center for Epidemiological Studies-Depression). Crude and adjusted Poisson regression was performed to estimate associations. A total of 1781 community-dwelling older adults included in this study, 14.6% had disability in ADL and 47.9% in IADL; 59.7% had vitamin D insufficient levels, and 33.2% depressive symptoms. The concomitant presence of vitamin D insufficient and depressive symptoms increased the prevalence of ADL by 2.20 (95% CI: 1.25; 3.86) and IADL by 1.54 (95% CI: 1.24; 1.91), respectively. Therefore, preventive strategies to keep older adults physically and socially active, with a good level of vitamin D, are essential to avoid depression and functional disability.

Tobacco endgame goals and measures in Europe: current status and future directions.

The European Union (EU) aims for a tobacco use prevalence of less than 5% by 2040 with its Tobacco-Free Generation goal, aligning with the tobacco endgame approach. In the Joint Action on Tobacco Control 2 (JATC-2) -project, we examined adopted and planned endgame goals and measures as well as preparedness to counter tobacco industry interference in the process. We surveyed key informants in 24 out of 50 countries in the WHO European Region (19 of the 27 EU Member States, MS). Altogether, eight countries (7 EU MS) had official governmental endgame goals, and an additional six EU MS had similar proposals from government, civil society or research entities. Movement towards tobacco endgame was most evident in retail-oriented and consumer-oriented policies. These include restricting the sales of tobacco and related products and raising the age limit above 18 years. Product standards were used especially to regulate flavours but no measures to substantially reduce addictiveness were reported. Market-oriented measures that tap into industry profits were predominantly missing, and countries often lacked concrete tools to prevent industry interference. Respondents' concerns around tobacco endgame were related to high smoking prevalence in some population groups, non-combustible and new nicotine products, cross-border marketing, political will, challenges with the existing regulations and industry interference. Results indicate both momentum and challenges in adopting and disseminating measures that facilitate achieving tobacco endgame goals. The EU goal can be used to advocate for national endgame goals and measures, and for the strengthened implementation of the WHO Framework Convention on Tobacco Control.

Support for banning sale of smoked tobacco products among adults who smoke: findings from the International Tobacco Control Four Country Smoking and Vaping Surveys (2018-2022).

BACKGROUND: Many people continue to smoke despite strong policies to deter use, thus stronger regulatory measures may be required. In four high-income countries, we examined whether people who smoke would support a total ban on smoked tobacco products under two differing policy scenarios. METHODS: Data were from 14 363 adults (≥18) who smoked cigarettes (≥monthly) and participated in at least one of the 2018, 2020 or 2022 International Tobacco Control Four Country Smoking and Vaping Surveys in Australia, Canada, England and the USA. In 2018, respondents were asked whether they would support a law that totally bans smoked tobacco if the government provides smoking cessation assistance (Cessation Assistance scenario). In 2020 and 2022, respondents were asked a slightly different question as to whether they would support a law that totally bans smoked tobacco if the government encourages people who smoke to use alternative nicotine products like vaping products and nicotine replacement products instead (substitution scenario). Responses (support vs oppose/don't know) were estimated on weighted data. RESULTS: Support was greater for the cessation assistance scenario (2018, 36.6%) than the nicotine substitution scenario (2020, 26.9%; 2022, 26.3%, both p<0.0001). In the longitudinal analysis, there was a significant scenario by country interaction effect with lower support in Canada, the USA and Australia under the substitution scenario than in the cessation scenario, but equivalent levels in England under both scenarios. The strongest correlates of support under both scenarios were planning to quit smoking within 6 months, wanting to quit smoking 'a lot' and recent use of nicotine replacement therapy. CONCLUSIONS: Opposition to banning smoked tobacco predominates among people who smoke, but less with a cessation assistance scenario than one encouraging nicotine substitution. Wanting to quit a lot was the strongest indicator of support.