WEB APPENDIX
Background information on ten areas of health policy
Below we present a summary of the evidence on the effectiveness of interventions and policies in each of the ten areas of health policy contributed by the authors of individual
chapters in our forthcoming edited book (1).
Tobacco
There is a wide range of interventions and policies which help reduce smoking in the
population (2). Implementation of smoke-free legislation is associated with reductions in exposure to second-hand tobacco smoke by up to 40% in the general population (3).
Pharmacotherapy, e.g. nicotine replacement therapies, increases the odds of successful
smoking cessation (4). Mass media campaigns, as part of comprehensive tobacco control programmes, are associated with reductions in smoking rates (5). Comprehensive bans on tobacco advertising, promotion and sponsorship are highly effective in reducing smoking (6).
Increasing tobacco prices through increased taxation reduces overall consumption and
prevalence of tobacco use (7).
Alcohol
There is extensive evidence on the effectiveness of a range of alcohol control policies (8).
The three best buys for alcohol policy are price increase, limits on availability, and bans on
advertising (9). When alcohol becomes cheaper, more is consumed and more harm ensues
(10). When alcohol is more difficult to get, less is consumed and less harm results (11).
Commercial communications, particularly through social media and electronic communication outlets, encourage non-drinkers to start drinking and existing drinkers to
drink more (12).
Food and nutrition
Although the effectiveness of food and nutrition policies is less well established than that of tobacco and alcohol control policies, there is evidence for effectiveness in a number of
areas. Adding iodine to salt helps prevent iodine deficiency (13, 14). Intensive support and
encouragement to reduce salt intake has led to a reduction in salt eaten, and also lower
blood pressure (15). Replacing some saturated (animal) fats with plant oils and unsaturated spreads reduces the risk of cardiovascular events (16). Dietary advice on the reduction of salt
and fat intake and an increase in the intake of fruit, vegetables, and fibre lead to modest improvements in cardiovascular risk factors, such as blood pressure and cholesterol levels
(17, 18). Denmark’s trans-fatty acid ban virtually eliminated artificial trans-fat in the food supply by 2005 (18), and an industry-led initiative to remove trans-fatty acids from food in
the Netherlands has been estimated to have reduced the annual number of deaths from
ischemic heart disease in the Netherlands by 10% (19).
Fertility, pregnancy and childbirth
Access to contraceptive services also reduces unwanted pregnancies and adolescent pregnancies; having an unplanned or unintended pregnancy places women at greater risk for
poor outcomes, such as preterm delivery or having a low birth-weight infant (20). Smoking

cessation programs offered during antenatal care reduce smoking and have an impact on
low birth-weight and preterm birth (21). Screening for congenital anomalies is associated
with lower perinatal mortality, and with a lower live birth prevalence of certain lethal or
incurable congenital anomalies (22). Safe delivery services reduce maternal mortality, and
delivery of pre-term infants in maternity units with on-site neonatal intensive care is
associated with lower mortality and higher survival without disability (23).
Child health
Vaccination of children against diphtheria, measles and other childhood infections is highly
effective in preventing morbidity and mortality (24). Promoting a supine sleeping position helps to reduce post neonatal mortality by cot death (25-27). Child-safe shackles help to reduce child intoxications (26, 27). Risks of drowning can be reduced by pool fencing (28), providing trained lifeguards at pools and beaches (29) and by mandatory swimming lessons in school curricula (27).
Infectious diseases
Vaccination against influenza prevents pneumonia, hospital admissions and deaths among
elderly people (30), although the evidence is no longer considered entirely convincing (31).
Effective means of preventing the transmission of HIV include voluntary counselling and
testing (32), treatment with anti-retrovirals (33), programmes using active learning methods to address sexual risk taking behaviour (34), and needle exchange programmes for
intravenous drug users (35). Improved hand hygiene, contact precautions and admission
screening can reduce infections with Methicillin Resistant Staphylococcus aureus (MRSA)
(36), as can “search and destroy” programmes (37).
Hypertension detection and treatment
Adequate control of hypertension by drugs reduces risks of cardiovascular disease
considerably (38, 39), also among elderly patients (40). Within primary care, organized
systems for regular follow-up, implementation of drug therapy by means of a vigorous stepped care approach, and self-monitoring and appointment reminders are useful adjuncts
to improve blood pressure control (41).
Cancer screening
Most experts agree that screening for cervical and breast cancer is effective (42, 43). The
available evidence suggests that well-organised screening programmes for cervical
cancer substantially reduce incidence and mortality from this disease (44). Effectiveness of
screening for breast cancer has been assessed by means of randomised controlled trials with
long-term follow up (45), although it is important to note that there is persisting controversy about its effectiveness (46).
Road safety
There are many interventions that have been shown to reduce road traffic injuries. The most important ones are controlling speed, stopping driving when under the influence of alcohol, enforcing use of safety equipment such as motorcycle and cycle helmets and seat belts, increasing conspicuousness of road users, improving vehicle crash protection, and making infrastructural changes to road design to ensure that speed is controlled and that vulnerable road users are not exposed to unnecessary risk by mixing them with motorized

traffic (47, 48).
Air pollution
Adverse effects of air pollution on human health have been well documented (49). National
and international policies to reduce emissions, e.g. by setting ceilings for emissions during combustion of fuels in power plants and industry and on the sulphur content of fuels, have
been effective in reducing sulphur dioxide emissions (50). Similar policies have contributed
to the decline of emissions of particulate matter and nitrogen oxide, and to a reduction of
the number of days in which ozone concentrations exceeded a maximum value (51).

Table A1. Health policy performance indicators, by country a. Tobacco, alcohol and food policies b. Fertility/pregnancy/childbirth, child health, and infectious disease control policies c. Hypertension, cancer screening, road traffic safety, and air pollution policies d. Summary score
Notes for table 2a:
- TCS=Tobacco Control Scale (source:(52)).
- Msmok=Male smoking prevalence (%) (source: WHO HFA Database ( http://data.euro.who.int/hfadb/ ) ).
- MLungca=Male lung cancer mortality rate(source: WHO HFA Database ( http://data.euro.who.int/hfadb/ ) ).
- BtG=Bridging the Gap Alcohol Policy Score (source: (53)).
- AlcCons=Alcohol consumption including unrecorded consumption (source:(54)).
- MLivcir=Male liver cirrhosis mortality (source: WHO HFA Database ( http://data.euro.who.int/hfadb/ ) ).
- IodDef=Iodine deficiency (source: (55).
- Fat intake=Total energy available from fat (source: WHO HFA Database ( http://data.euro.who.int/hfadb/ ) ).
- Fruit&veg intake=Fruits and vegetable available per year (source: WHO HFA Database
( http://data.euro.who.int/hfadb/ ) ).
Notes for table 2b:
- TeenPregn=Percentage of teenage pregnancies (source: WHO HFA Database ( http://data.euro.who.int/hfadb/ ) ).
- NeonatMo=Neonatal mortality (source: WHO HFA Database ( http://data.euro.who.int/hfadb/ ) ).
- MaternMo=Maternal mortality (source: WHO HFA Database ( http://data.euro.who.int/hfadb/ ) ).
- MeasImmun=Measles immunization rate (source: WHO HFA Database ( http://data.euro.who.int/hfadb/ ) ).
- SafetyScore=Child Safety Alliance safety grade (source: (56).
- PostneoMo=Post neonatal mortality (source: WHO HFA Database ( http://data.euro.who.int/hfadb/ ) ).
- AidsInc=Incidence of Aids (source: WHO HFA Database ( http://data.euro.who.int/hfadb/ ) ).
- MRSA infections = infections with Methicillin Resistant Staphylococcus Aureus (source: (57))
- Inflvacc=Influenza vaccination coverage among 65 and older (source:(58)).
Notes for table 2c:
- MSBP=Male average systolic blood pressure (source: (59).
- FStrokeMo=Female stroke mortality (source: WHO HFA Database ( http://data.euro.who.int/hfadb/ ) ).
- BreastScr=breast cancer screening implementation Source: (43).
- CervcaMo=Cervical cancer mortality (source: WHO HFA Database ( http://data.euro.who.int/hfadb/ ) ).
- Seatbelt=Seatbelt wearing among front seat car occupants (source: (60)).
- OccupMort=Road traffic injury mortality among car occupants, per 10000 registered vehicles (calculated from data in (60).
- PedMort=Road traffic injury mortality among pedestrians, per 10000 registered vehicles (calculated from data in (60).
- SO2=Sulphur dioxide emissions (source: Eurostat ( http://epp.eurostat.ec.europa.eu/ ) ).
- UrbanOzone=Urban population exposure to air pollution by ozone (source: Eurostat
( http://epp.eurostat.ec.europa.eu/ ) ).
Notes for Ошибка! Источник ссылки не найден.d: Summary scores were calculated from data in Tables 2a-2c. First, the total number of observations was determined. Then, for each country the percentage of scores falling in the upper tertile and the percentage of scores falling in the lower tertile of all available scores were calculated. Finally, for each country a summary score was calculated as the difference between the percentage of scores falling in the upper and the percentage of scores falling in the lower tertile.

Indicator
Unit
Year
Nordic
Finland
Sweden
Norway
Iceland
Denmark
Britain & Ireland
United Kingdom
Ireland
Continental
Netherlands
Belgium
Luxembourg
Germany
Switzerland
Austria
Mediterranean
France
Spain
Portugal
Italy
Malta
Greece
Cyprus
Western Balkans
Slovenia
Croatia
Bosnia-Hercegovina
Serbia
Montenegro
TFYR Macedonia
Albania
Centre & East
Poland
Czech Republic
Slovakia
Hungary
Romania
Bulgaria
(f) Soviet Union
Estonia
Latvia
Lithuania
Belarus
Ukraine
Republic of Moldova
Russian Federation
Georgia
Armenia
Azerbaijan
Tobacco
TCS
0-100
2010
Alcohol
MSmok MLungca BtG
% d/100000 0-40
2008 2007 2005
Food
AlcCons MLivcir IodDef Fat intake Fruit&veg intake l/cap d/100000 %<100ug/l%Energy kg/cap
2009 2008 <2007 2007 2007
52
51
62
61
46
77
69
46
50
33
37
48
32
55
46
43
47
52
32
40
44
43
34
41
34
45
40
43
44
41
26
13
21
21
28
22
31
32
25
28
23
27
32
31
29
26
39
22
31
37
30
32
39
45
39
53
50
51
55
38
45
28
45
48
63
52
53
68
79
64
54
44
47
62
65
43
60
44
69
31
73
85
83
79
91
71
69
106
67
62
86
76
79
69
60
50
74
32
85
17
32
36
35
17
25
26
16
12
6
6
14
6
14
10
7
4
5
8
9
10
16
5
9
14
8
7
16
14
13
12
9
8
8
13
13
13
10
12
13
13
11
13
13
13
13
10
8
11
10
15
13
13
7
14
17
15
14
16
11
14
13
29
8
5
3
15
9
6
17
9
22
16
13
17
13
9
8
9
40
39
17
27
25
40
70
61
32
38
25
56
106
29
28
30
47
19
48
69
56
31
67
33
39
36
21
33
35
47
50
0
41
24
22
22
9
17
10
57
55
13
15
57
47
11
67
77
60
14
56
27
58
4
6
13
36
36
35
39
36
38
35
37
40
39
37
40
39
42
42
35
39
29
37
39
34
33
40
26
36
29
30
36
34
39
28
31
25
36
27
33
26
21
25
21
25
16
172
205
220
222
209
218
219
239
201
276
182
169
251
214
243
287
295
318
404
269
197
193
174
168
187
205
153
108
184
102
394
180
144
154
195
209
132
211
234
256
299
222

Indicator
Unit
Year
Nordic
Finland
Sweden
Norway
Iceland
Denmark
Britain & Ireland
United Kingdom
Ireland
Continental
Netherlands
Belgium
Luxembourg
Germany
Switzerland
Austria
Mediterranean
France
Spain
Portugal
Italy
Malta
Greece
Cyprus
Western Balkans
Slovenia
Croatia
Bosnia-Hercegovina
Serbia
Montenegro
TFYR Macedonia
Albania
Centre & East
Poland
Czech Republic
Slovakia
Hungary
Romania
Bulgaria
(f) Soviet Union
Estonia
Latvia
Lithuania
Belarus
Ukraine
Republic of Moldova
Russian Federation
Georgia
Armenia
Azerbaijan
%
2008
1.3
3.7
10.5
6.5
5.7
6.5
5.0
2.0
2.9
4.4
1.4
6.8
2.8
1.8
9.9
13.8
14.0
9.1
14.3
5.4
7.0
5.6
6.4
8.7
4.9
3.1
6.6
6.1
11.8
12.7
1.4
2.8
1.8
2.3
0.9
3.3
2.2
1.6
2.4
3.4
1.5
6.2
3.0
d/1000 d/100000 %
2009 2007-9 2008
2.0
1.6
2.1
1.0
2.7
3.2
2.3
2.9
2.6
1.4
2.6
3.1
2.5
2.4
2.1
3.4
2.5
5.7
2.0
1.9
1.6
4.3
10.5
4.9
4.1
8.6
2.5
4.0
1.6
3.1
3.4
5.5
5.0
3.2
5.0
2.8
3.1
5.6
7.8
6.4
11.8
8.1
6.0
3.9
4.2
4.5
0.0
7.8
7.6
3.2
4.7
5.2
5.0
3.0
7.2
3.4
5.3
2.2
7.9
10.0
11.6
19.2
13.9
17.1
3.1
3.7
5.0
14.7
21.7
7.9
28.2
4.9
5.6
20.2
26.4
21.7
28.6
29.2
28.5
99
99
100
95
97
99
99
95
95
95
99
96
98
92
89
95
95
97
96
97
91
72
99
97
97
96
83
98
97
97
99
98
94
98
89
92
93
0-60
2009
40
29
28
30
35
34
33
39
41
42
37
27
32
41
39
43
49
40
31
46
30
Infectious diseases
PostneoMort MRSA Inflvacc d/1000 c/100000 %insensitive
2009 2009 2010 2008
0.6
0.9
1.0
0.8
0.7
1.5
1.0
1.0
1.4
0.7
1.3
0.9
1.3
1.1
1.2
1.6
1.0
2.4
1.1
1.4
0.8
1.0
4.1
2.1
1.7
3.2
5.3
1.6
1.2
2.6
1.7
4.3
3.6
1.8
2.7
2.1
3.8
4.1
4.3
4.7
3.1
3.7
3.8
0.5
0.7
0.4
0.6
0.7
1.2
0.6
1.5
1.1
1.4
0.6
1.9
0.8
1.6
3.0
5.1
1.6
2.2
0.9
1.5
0.5
0.3
0.5
0.5
0.4
0.8
0.4
0.3
0.0
0.2
1.0
0.4
4.6
4.6
1.6
4.0
2.4
2.6
5.3
2.6
0.7
0.4
0.3
0.0
0.0
0.0
5.7
2.5
2.6
2.1
18.2
0.2
1.7
0.2
1.1
17.3
13.2
0.0
3.2
5.9
2.2
3.0
1.2
1.1
4.7
13.5
5.3
12.5
47
55
53
73
61
82
63
51
65
9
29
33
67
67
50
66
28

Indicator
Unit
Year
Nordic
Finland
Sweden
Norway
Iceland
Denmark
Britain & Ireland
United Kingdom
Ireland
Continental
Netherlands
Belgium
Luxembourg
Germany
Switzerland
Austria
Mediterranean
France
Spain
Portugal
Italy
Malta
Greece
Cyprus
Western Balkans
Slovenia
Croatia
Bosnia-Hercegovina
Serbia
Montenegro
TFYR Macedonia
Albania
Centre & East
Poland
Czech Republic
Slovakia
Hungary
Romania
Bulgaria
(f) Soviet Union
Estonia
Latvia
Lithuania
Belarus
Ukraine
Republic of Moldova
Russian Federation
Georgia
Armenia
Azerbaijan
Hypertension
MSBP
Cancer screening
FStrokeMort
Road traffic safety Air pollution
PedMort SO2 Urban Ozone mmHg d/100000 0-2
2008 2008 <2000 d/100000 %
2008 2007 2007 2007 2009 2009
135
132
135
130
130
131
135
131
129
131
133
131
131
131
130
135
131
132
129
131
136
136
137
135
134
134
135
134
136
136
133
133
139
137
137
137
137
134
132
40
39
37
35
45
39
34
40
27
32
24
34
70
43
51
83
41
53
105
140
78
64
71
82
76
154
163
63
123
110
141
184
210
2
2
2
2
1
2
1
2
1
2
1
1
1
2
2
1
1
0
1
2
1
0
0
0
0
0
1
2
0
1
0
0
2
1
1
0
0
0
0
0
0
0
1.5
2.3
3.0
0.0
3.1
2.6
4.7
2.4
3.5
2.9
1.2
2.9
2.3
2.6
4.8
2.0
2.4
2.2
1.7
3.5
5.5
5.0
12.5
8.5
13.4
4.2
7.8
5.2
6.5
7.8
16.2
9.1
7.9
9.9
11.5
6.6
8.3
10.4
8.1
6.3
12.3
7.0
89
96
93
88
91
86
94
79
95
86
89
98
89
90
65
96
75
81
85
55
30
74
90
71
80
90
77
33
0.9
0.7
0.8
1.2
0.6
1.2
0.5
1.2
0.6
0.5
1.0
0.9
1.2
1.1
0.8
0.2
1.6
1.1
1.9
2.1
4.6
3.7
5.2
2.6
8.5
2.1
1.8
2.8
2.2
5.5
3.3
2.5
2.5
2.6
3.1
9.9
8.0
8.7
10.8
0.2
0.1
0.1
0.1
0.2
0.4
0.1
0.2
0.1
0.2
0.3
0.2
0.3
0.3
0.2
0.2
0.5
0.4
0.3
0.8
1.8
1.6
1.4
2.1
7.5
1.4
0.6
1.9
0.9
0.8
1.3
0.7
1.9
1.5
2.6
5.9
4.6
4.3
5.7
6.9
11.1
3.2
3.3
2.7
6.5
7.4
2.3
7.1
6.3
5.5
1.7
2.5
4.9
9.4
7.2
3.8
18.0
38.0
21.5
5.7
22.6
16.6
11.8
8.0
21.4
86.5
40.9
1.8
10.8
1689
2013
879
2446
1123
1197
1360
2787
3130
4701
5097
3859
5207
3268
6196
8084
4959
3112
4288
8051
6809
4420
3265
1675
1260
2304

Nordic
Finland
Sweden
Norway
Iceland
Denmark
Britain & Ireland
United Kingdom
Ireland
Continental
Netherlands
Belgium
Luxembourg
Germany
Switzerland
Austria
Mediterranean
France
Spain
Portugal
Italy
Malta
Greece
Cyprus
Western Balkans
Slovenia
Croatia
Bosnia-Hercegovina
Serbia
Montenegro
TFYR Macedonia
Albania
Centre & East
Poland
Czech Republic
Slovakia
Hungary
Romania
Bulgaria
(f) Soviet Union
Estonia
Latvia
Lithuania
Belarus
Ukraine
Republic of Moldova
Russian Federation
Georgia
Armenia
Azerbaijan
Summary score
24
25
23
25
24
24
26
18
10
18
17
14
15
15
18
16
14
25
25
25
16
15
15
26
24
25
24
25
26
27
23
24
27
27
23
20
27
27
25
23
21
27
26
17
32
17
12
8
8
35
11
10
11
18
21
33
7
17
13
14
12
4
12
13
13
20
54
54
40
54
56
50
33
52
58
67
59
35
45
67
89
84
83
48
48
46
-4
12
-17
-28
-42
-33
15
-17
-60
-17
-18
0
-13
-73
-56
-69
-50
-67
-32
-32
-28
-25
-33
31
42
16
33
52
35
19
35
46
48
56
17
25
63
89
84
78
43
37
38
21
20
35
40
50
42
19
28
70
28
35
21
47
80
72
81
64
44
36
40
38
80
53
23
13
24
21
4
15
15
17
13
19
4
17
20
11
8
0
4
4
0
5

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