Health Improvement Review
Evidence Sub Group &
Economic Evidence Sub Group
Health Improvement Review
Assessment of No Smoking Day
The following report includes the assessments of the evidence base produced by
the Evidence subgroup (section 1- Evidence of Effectiveness) and the Economic
Evidence sub-group (section 2 – Evidence of Cost effectiveness).
Section 1: Evidence of Effectiveness
1.
Introduction
A core component of the Health Improvement Review (HIR) has been the
assessment of the evidence-base for initiatives included in the HIR. This report
describes the methodology for, and findings of, the assessment of the No
Smoking Day programme.
2.
Methodology
Assessment of the initiative employed a dual approach:


Assessment of the potential effectiveness of the initiative by review of
research on the effectiveness of similar initiatives or of component
interventions (some initiatives involve more than one intervention).
Assessment of the actual effectiveness or impact of the initiative by
review of any available evaluation reports for the initiative in Wales.
2.1
Review of potential effectiveness
The methodology adopted for this review followed systematic review principles
of transparency, a priori setting of the research question, search strategy,
inclusion/exclusion criteria, critical appraisal and standardised data extraction.
2.1.1 A ‘question’ was developed for each initiative following the PICO format1.
For No Smoking Day, the question was: Is 'No smoking Day' effective in
promoting quit attempts on the day and in sustaining non-smoking?
2.1.2 Due to the time constraints of the Health Improvement Review, a ‘best
available evidence’ approach was taken for the reviews of research on potential
effectiveness of initiatives. Key words and search terms were derived from the
question and a pragmatic search strategy designed using specified health
databases and search-engines. For initiatives where recent high quality
secondary analyses of the primary literature were found, searches were
narrower and terminated at an earlier stage. Searches for questions that yielded
little high quality data initially were broadened by date or by search terms in an
attempt to capture related work. The time-constraints did not enable handsearching or contacts with experts in the field (external to Public Health Wales)
to search for missed or unpublished data, however, an iterative process of
1
Population, Intervention, Comparator, Outcomes
Public Health Wales Observatory
Health Improvement Review
Evidence Sub Group &
Economic Evidence Sub Group
related article searches were run on key papers for some questions to try and
capture information that the initial search strategy had not identified. All
reasonable efforts were made to locate the most relevant and highest quality
evidence in the short-time frame allocated.
The search terms used for No Smoking Day Search strategy
“no smoking day”
Databases searched
TRIP Database
NHS Evidence
Campbell Collaboration
EPPI Centre
PubMEd
Google Scholar
Health Evidence Canada
WHO
2.1.3 Retrieved articles were recorded in the ‘Evidence Mapping Table’ for the
initiative (Table 1) and were screened for inclusion by two reviewers
independently (disagreements resolved by discussion), on the basis of direct
relevance to the initiative or component interventions and type of article, thus
single studies were not included if higher level evidence was available:
Primary group of sources: NICE guidance, Single systematic reviews from
Cochrane, Campbell Libraries, the EPPI-Centre
Secondary group (include if no primary group evidence items available):
RCT or evaluation of robust design looking at appropriate outcomes
Other study designs to be included if no primary or secondary sources are
available, the
quality of these to be judged separately/recorded on a case-by-case basis.
2.1.4 Information was extracted from each included article into a standardised
template – the Evidence Mapping Table, for each initiative.
2.1.5 Each included article was assessed in terms of ‘reliability’, strength and
direction, using the following ‘Evidence Grading Scheme’:
++
2
Directly relevant evidence that the intervention evaluated is
beneficial/ useful/ effective - the evidence comes from a reliable
source2 and is guidance based on RCTs, SRs or robust evaluations
of appropriate outcomes or is a well conducted systematic review.
See section 2.1.2
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+
+/0
-not
-
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Health Improvement Review
Evidence Sub Group &
Economic Evidence Sub Group
Directly relevant evidence that the intervention evaluated is
beneficial/ useful/effective -the evidence comes from a reliable
source and is a robust/ large RCT or robust evaluation of
appropriate outcomes.
Conflicting
evidence
(from
reliable
sources)
about
the
usefulness/efficacy of the intervention being evaluated.
Directly relevant evidence on effectiveness of an intervention the
same as, or similar to, the initiative, of acceptable reliability, is
lacking.
Directly relevant evidence that the intervention being evaluated is
beneficial/useful or is ineffective - the evidence comes from a
reliable source and is guidance based on RCTs, SRs or robust
evaluations of appropriate outcomes or is a well conducted
systematic review.
Directly relevant evidence that the intervention evaluated is not
beneficial/useful or is ineffective -the evidence comes from a
reliable source and is a robust/large RCT or robust evaluation of
appropriate outcomes.
Well conducted studies using robust qualitative research methods
which
cast
light
on
how/why
intervention
might
be
effective/ineffective
or
have
important
implications
for
interpretation of findings or other included studies.
The ‘evidence grades’ for each included article were recorded in the Evidence
Mapping Table for the initiative (Table 1).
2.1.6 A subjective judgment of the overall balance of evidence grades given to
included articles was then made by one reviewer, to give a ‘Summary Evidence
Grade’ for the Initiative:
++
+
+/0
--
There is consistent, strong relevant evidence from reliable sources that
the intervention/approach employed in the initiative has the potential to
be effective.
There is some relevant evidence from reliable sources that the
intervention/approach employed in the initiative has the potential to be
effective.
Relevant evidence (from reliable sources) about the likely effectiveness of
the intervention/approach employed in the initiative is conflicting.
Directly relevant evidence (from reliable sources) about the likely
effectiveness of the intervention/approach employed in the initiative is
lacking.
There is consistent, strong relevant evidence from reliable sources that
the intervention/approach employed in the initiative has the potential to
be ineffective.
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There is some relevant evidence from reliable sources that the
intervention/approach employed in the initiative has the potential to be
ineffective.
Checks were made for consistency of application of these ‘Summary Evidence
Grades’ through comparison and discussion amongst the reviewer team.
2.2) Assessment of initiative
An ‘Initiative Assessment Log’ was then completed (Table 2). Information from
any evaluation or other reports about the initiative in Wales was considered for
relevance at this stage and pertinent information summarised into the log along
with the Summary Evidence Grade and other information. A final ‘Initiative
Grade’ was then applied by one reviewer using set criteria (see Annex 1). This
therefore takes into account both the evidence of potential effectiveness and
evidence of actual effectiveness in Wales, where available. This Initiative Grade’
will feed directly into the Programme Budgeting and Marginal Analysis which
forms the decision-making framework for the Health Improvement Review.
Initiative grades were checked for consistency by comparison and discussion
amongst the review team.
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3.
Findings of the assessment
Table 1: Evidence Mapping Table for No Smoking Day
Study
Study
Outcome
Main findings
Details
design
measures
1. Kotz D,
Stapleton JA,
Owen L, West
R.
2011
Interventio
n Reviewed
“No smoking
day”
Target
group
Working Age
Adults
Cross
sectional
surveys Comparison
of reported
quit
attempts in
the month
following
NSD for
three
consecutive
years with
adjacent
months
using
repeated
national
surveys of
quit
attempts.
The number of
additional
smokers who
quit
permanently
in response to
NSD was
estimated
from the
survey
results. The
incremental
costeffectiveness
ratio (ICER)
was calculated
by combining
this estimate
with
established
estimates of
life years
Initiative Evidence Assessment Report NSD Final
NSD emerges as
an extremely
cost-effective
public health
intervention.
Results
The rate of quit attempts
was 2.8 percentage points
higher in the months
following NSD (120/1309)
compared with the
adjacent months
(170/2672; 95% CI
0.99% to 4.62%), leading
to an estimated additional
0.07% of the 8.5 million
smokers in England
quitting permanently in
response to NSD. The cost
of NSD per smoker was £
0.088. The discounted life
years gained per smoker
in the modal age group
35-44 years was 0.00107,
resulting in an ICER of £
82.24 (95% CI 49.7 to
231.6). ICER estimates
for other age groups were
Evidence
Grading
Evidence
Grading +
Include?
Reason for
exclusion
Include
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Study
Details
Study
design
Outcome
measures
Main findings
gained and
the known
costs of NSD.
2. Flack S,
Taylor M &
Trueman P.
2007
Interventio
n Reviewed
“No smoking
day”
A cohort
simulation
model of a
range of
interventions
for NICE –
using data
from Owen
and Youdan
2006 (below)
Quit rate at
three months
If background quit
rate 0%, NSD
highly cost
effective, if not
estimated an
additional 25
quitters needed to
to cost effective
Self reported
awareness
and smoking
Data suggests
that after 22
years No Smoking
Initiative Evidence Assessment Report NSD Final
Evidence
Grading
Include?
Reason for
exclusion
similar.
Target
group –
Whole
population
3. Owen and
Retrospectiv
Youdan, 2006 e cross
sectional
Results
The cost of the campaign
was approximately
£500,000. ‘No Smoking
Day’ is highly costeffective. However, if No
Smoking Day were to
have simply brought
forward the background
quits for the following 9 to
12 months (and had not
resulted in any “new”
quitters), then it would
not have been costeffective. The current
analysis indicates No
Smoking Day would need
to gain 25 new quitters in
order to be cost-effective.
Annual tracking survey
shows reduction from
1986 (89%) to 2004
Evidence
Include
Grading +/More recent
studies
provide
evidence of
increased
quitters
compared
to
background
Evidence
Grading +
Include
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Evidence Sub Group &
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Study
Details
Interventio
n – No
Smoking Day
Target
Group –
Working Age
Adults
4. No Smoking
Day Annual
Report 2010
Study
design
Outcome
measures
Main findings
Results
surveys and
information
collated on
website
activity,
media
coverage
and calls to
smoking
helplines in
2005
behaviour 1wk
and 3 month
post NSD,
volume of
contacts
(78%) in awareness by
smokers, 15% of those
who were aware reported
attempted quit, 1.2%
sustained at 3 months.
Suggests younger
smokers more likely to
participate
0.7% of all smokers were
still not smoking (85,000
quitters) and 1.6%
(160,000) smoking less.
Evaluation
research was
undertaken
after
the
campaign by
GfK NOP.
The results
are based on
interviews
with 4,008
Awareness of
NSD;
participation
in NSD e.g.
making a quit
attempt
Day continues to
be successful in
reaching smokers.
With a budget
insufficient to pay
for advertising
this public
awareness
campaign
supported by local
activities appears
to be effective at
helping smokers
to stop.
NSD continues to
have relatively
high participation
and awareness
Initiative Evidence Assessment Report NSD Final
48% of smokers were
aware of the day (41% in
Wales) up to 70% in
Northern Ireland, of these
18% men and 17%
women partipcated in the
day. The participation
rate is higher among
young smokers aged 16 –
24 (28%).
Evidence
Grading
Include?
Reason for
exclusion
Evidence
Grading –
evaluation
Include
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Health Improvement Review
Evidence Sub Group &
Economic Evidence Sub Group
Public Health Wales Observatory
Study
Details
Study
design
Outcome
measures
Main findings
Results
Evidence
Grading
Include?
Reason for
exclusion
adults
aged 16 and
over. These
interviews
were
conducted in
two omnibus
sessions
during
the two
weeks
immediately
following
No Smoking
Day (11-23
March 2010).
Respondents
were
selected by
quotas of
age, sex and
socioeconomic
classification.
Initiative Evidence Assessment Report NSD Final
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References
1) Kotz D, Stapleton JA, Owen L, West R. How cost-effective is 'No Smoking Day'? Tob Control. 2011 Jul;20(4):302-4. Epub
2010 May 14. PubMed http://www.ncbi.nlm.nih.gov/pubmed/20472574
2) Flack S, Taylor M & Trueman P. Cost-Effectiveness of Interventions for Smoking Cessation. Supplementary Report to
NICE, November 2007. http://www.nice.org.uk/nicemedia/live/11925/43883/43883.pdf
3) Owen, L and Youdan B. 22 years on: the impact and relevance of the UK No Smoking Day. Tobacco Control. 2006; 15
19 – 25
4) No Smoking Day Annual Review 2010. No Smoking Day.
http://www.nosmokingday.org.uk/downloads/annual_report_nsd2010.pdf
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Table 2: INITIATIVE ASSESSMENT LOG
Initiative/Intervention
Priority Area:
Intervention Summary
No Smoking Day
Tobacco Control
Annual event targeted at smokers to encourage a quit attempt, national co-ordination on a
UK/Wales basis with supported local action
Targeted Population
Working Age Adults
Individual behaviour change - indirect
JB
Level of Intervention
Life-course
Outcome Category
ATTRACT/Initiative
Reviewer
Evidence Base
Summary Evidence Grade +
There is some relevant evidence from reliable sources that the intervention/approach employed in the
initiative has the potential to be effective (see evidence table)
Implementation/
Yes
evaluation?
Initiative is a
No
pilot?
Population impact Medium – evidence of population level effect among smokers
Programme
There is good evidence to support the effectiveness of No Smoking Day as a component of an
integrated cessation strategy. There is evidence of particular impact among younger smokers.
Grade: G2
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4.
Limitations of this review
There are a number of limitations to the approach taken for this review which
have arisen due to the time constraints imposed and which should be taken into
account when interpreting the findings:



The review has used higher levels of evidence such as NICE guidance and
systematic reviews from specific sources rather than undertaking an
extensive review of primary research. Other sources and individual studies
have only been included where higher level sources are lacking. It is
possible that relevant, more recent primary research will not have been
included in the guidance or systematic reviews we have consulted.
There may be no published research evidence for innovative technologies
and approaches. We have only considered ‘grey’ literature ie reports on
such initiatives elsewhere, when these have been supplied to us by
subject experts and those involved with implementation of the initiatives
in Wales, we have not systematically searched for grey literature.
NICE guidance has been prioritised, in that if an intervention is
recommended for implementation in the UK, this has influenced the
‘initiative grade’ awarded. It should be noted however, that not all NICE
recommendations are underpinned by directly relevant robust research
evidence. We have highlighted this where it has been found to be the
case.
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Annex 1: Scheme for producing ‘Initiative Grade’
Initiative
GI
G II
AI
A II
A III
RI
R II
R III
R IV
Priority area?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
N
Summary
Evidence
Grade2
++
+
++
+
+/-
+/-
-or- -
-or- -
N.A
or
or
0
0
Yes
No
Yes
No
N.A.
Grade1:
Evaluation3?
Yes
Yes
No
No
1. G=Green, A=Amber, R=Red N.A. = Not applicable
2. Overall grade for evidence-base for initiative
3. If there is no local (Welsh) evaluation or if the evaluation does not provide
information about achievement of appropriate outcomes (effectiveness), then
record ‘No’.
Section 2: Evidence of Cost-effectiveness
1. Grading of Evidence Criteria
Evidence search had a 10 year range 2012-2002 in order to find as much
evidence as possible as the range stated for other sub-groups was considered
too narrow to find sufficient economic evidence.
Databases such as NICE, Pub-Med and the Centre for Reviews and Dissemination
(CRD) Database - which is an economic evidence specific database. These
databases are searched using key terms from each of the 43 Priority area
programmes. Alongside these databases other evidence sub-groups have been
highlighting any economic evidence found in their searches and forwarding our
sub-group the reference for us to appraise.
Abstracts were appraised in the electronic search with the reviewer and for
articles deemed relevant the full article was sourced and then appraised as
follows;
Evidence was defined as;
1. Directly relevant i.e. an economic evaluation of a specific intervention
delivered through the programme/initiative stated in the list of included
programmes
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2. Indirectly relevant (where directly relevant evidence is unavailable) i.e.
evaluation of related intervention similar to the one delivered through the
programme/initiative or as part of the intended aims of the
programme/initiative stated in the list of included programmes by either
method of delivery (school-based smoking cessation) or target population
(pregnant women).
The Drummond et al. (2005) checklist for a sound economic evaluation was used
to appraise evidence found in the electronic searches (Annex 2).
Based upon the appraisal strategy above a subjective judgement of the overall
balance of economic evidence was made by the economic evidence sub-group
using a traffic light system of grading (Annex 3).
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2. Evidence of cost-effectiveness summary
No Smoking
Day
Green II – Small number of good quality economic
evaluations showing cost-effectiveness/cost-savings/
cost-benefits as appraised by Drummond et al’s 2005
Checklist for a sound economic evaluation
In the only initiative specific economic evaluation found (Kotz
et al. 2011) No Smoking Day was found to be cost-effective
for the modal group of adults aged between 35-44 years
group. Using survey data from 3981 respondents of a National
No Smoking Day (NSD) Survey conducted in England. 1309
adults responded in the month following NSD and 2672 adults
responded in the two adjacent months. The annual cost of
NSD was £750, 000 (£0.088 per smoker). The quit attempt
rate was 9.2% for those completing the survey in the month
following NSD compared to 6.4% for the two adjacent months
(incremental difference 2.8%). The measure of benefit in the
study were discounted life years gained (DLYG) per smoker
that can be attributed to NSD. Results were categorised by age
group. Adults < 35 years of age showed a gain of 1.10
discounted life years (DLY), adults between 35-44 years of age
showed a gain of 1.53 DLY, adults between 45-54 years of age
showed a gain of 1.65 DLY and adults between 55-64 years of
age showed a gain of 1.29 DLY. The cost per DLYG was £82.24
for the modal group of adults aged between 35-44 years age
group. The cost per DLYG was £114.29 for the < 35 age
group. The cost per DLYG was £76.19 for the 45-54 age group
and the cost per DLYG was £97.45 for the 55-64 age group.
Reference: Kotz, D., Stapleton, J.A., Owen, L., & West, R.
(2010). How cost-effective is ‘No Smoking Day’? Tobacco
Control, doi:10.1136/tc.2009.034397
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Public Health Wales Observatory
Annex 2:
Health Improvement Review
Evidence Sub Group &
Economic Evidence Sub Group
Drummond Checklist for sound economic evaluation
Drummond, M.F., Sculpher, M.J., Torrance, G.W., O’Brien, B.J., &
Stoddart, G.L. (2005). Methods for the economic evaluation of health
care programmes (3rd Ed.). Oxford University Press: Oxford, U.K).
1. Was a well-defined question posed in answerable form?
1.1. Did the study examine both costs and effects of the service(s) or
programme(s)?
1.2. Did the study involve a comparison of alternatives?
1.3. Was a viewpoint for the analysis stated and was the study placed in any
particular decision-making context?
2. Was a comprehensive description of the competing alternatives
given (i.e. can you tell who did what to whom, where, and how often)?
2.1. Were there any important alternatives omitted?
2.2. Was (should) a do-nothing alternative be considered?
3. Was the effectiveness of the programme or services established?
3.1. Was this done through a randomised, controlled clinical trial? If so, did
the trial protocol reflect what would happen in regular practice?
3.2. Was effectiveness established through an overview of clinical studies?
3.3. Were observational data or assumptions used to establish effectiveness?
If so, what are the potential biases in results?
4. Were all the important and relevant costs and consequences for
each alternative identified?
4.1. Was the range wide enough for the research question at hand?
4.2. Did it cover all relevant viewpoints? (Possible viewpoints include the
community or social viewpoint, and those of patients and third-party payers.
Other viewpoints may also be relevant depending upon the particular analysis.)
4.3. Were the capital costs, as well as operating costs, included?
5. Were costs and consequences measured accurately in appropriate
physical units (e.g. hours of nursing time, number of physician visits,
lost work-days, gained life years)?
5.1. Were any of the identified items omitted from measurement? If so, does
this mean that they carried no weight in the subsequent analysis?
5.2. Were there any special circumstances (e.g., joint use of resources) that
made measurement difficult? Were these circumstances handled appropriately?
6. Were the cost and consequences valued credibly?
6.1. Were the sources of all values clearly identified? (Possible sources include
market values, patient or client preferences and views, policy-makers’ views and
health professionals’ judgements)
6.2. Were market values employed for changes involving resources gained or
depleted?
6.3. Where market values were absent (e.g. volunteer labour), or market
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values did not reflect actual values (such as clinic space donated at a reduced
rate), were adjustments made to approximate market values?
6.4. Was the valuation of consequences appropriate for the question posed
(i.e. has the appropriate type or types of analysis – cost-effectiveness, costbenefit, cost-utility – been selected)?
7. Were costs and consequences adjusted for differential timing?
7.1. Were costs and consequences that occur in the future ‘discounted’ to their
present values?
7.2. Was there any justification given for the discount rate used?
8. Was an incremental analysis of costs and consequences of
alternatives performed?
8.1. Were the additional (incremental) costs generated by one alternative over
another compared to the additional effects, benefits, or utilities generated?
9. Was allowance made for uncertainty in the estimates of costs and
consequences?
9.1. If data on costs and consequences were stochastic (randomly determined
sequence of observations), were appropriate statistical analyses performed?
9.2. If a sensitivity analysis was employed, was justification provided for the
range of values (or for key study parameters)?
9.3. Were the study results sensitive to changes in the values (within the
assumed range for sensitivity analysis, or within the confidence interval around
the ratio of costs to consequences)?
10. Did the presentation and discussion of study results include all
issues of concern to users?
10.1. Were the conclusions of the analysis based on some overall index or
ratio of costs to consequences (e.g. cost-effectiveness ratio)? If so, was the
index interpreted intelligently or in a mechanistic fashion?
10.2. Were the results compared with those of others who have investigated
the same question? If so, were allowances made for potential differences in
study methodology?
10.3. Did the study discuss the generalisability of the results to other settings
and patient/client groups?
10.4. Did the study allude to, or take account of, other important factors in the
choice or decision under consideration (e.g. distribution of costs and
consequences, or relevant ethical issues)?
10.5. Did the study discuss issues of implementation, such as the feasibility of
adopting the ‘preferred’ programme given existing financial or other constraints,
and whether any freed resources could be redeployed to other worthwhile
programmes?
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Annex 3
Evidence of Cost-effectiveness Grading
Based upon the appraisal strategy above a subjective judgement of the overall
balance of economic evidence was made by the economic evidence sub-group
and the following traffic light system of grading was used.
Green I
Large
frequency
of good
quality
economic
evaluation
s showing
costeffectivene
ss/ costsavings/
costbenefits as
appraised
by
Drummond
et al’s
2005
Checklist
for a sound
economic
evaluation
Green II
Small
frequency
of good
quality
economic
evaluation
s showing
costeffectivene
ss/ costsavings/
costbenefits as
appraised
by
Drummond
et al’s
2005
Checklist
for a sound
economic
evaluation
Amber I
Fair quality
economic
evaluation
s showing
costeffectivene
ss/ costsavings/
costbenefits as
appraised
by
Drummond
et al’s
2005
Checklist
for a sound
economic
evaluation
Initiative Evidence Assessment Report NSD Final
Amber II
Fair quality
evidence
however,
showing
mixed
evidence
of costeffectivene
ss/ costsavings/
costbenefits as
appraised
by
Drummond
et al’s
2005
Checklist
for a sound
economic
evaluation
Red I
Poor
quality
evidence
showing
interventio
n was not
costeffectivene
ss/ costsavings/
costbenefits as
appraised
by
Drummond
et al’s
Checklist
for a sound
economic
evaluation
Red II
No
eviden
ce
availa
ble
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