cause report: dementia

05/06/2016 Dementia (Alzheimer's Disease)

https://www.givingwhatwecan.org/report/dementia/ 1/15

Dementia (Alzheimer's Disease)

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Updated 14 Apr 2016

The following causelevel investigation was completed as part of a bespoke report for anindividual donor. Giving What We Can has not prioritised dementia as a primary cause areaand our investigation to date has not suggested a high level of costeffectiveness or ofneglectedness. In addition, for this report we only considered charities working within theUnited Kingdom. Although antitobacco advocacy groups in general are likely to be one ofthe more costeffective methods of reducing dementia prevalence, they may be a great dealmore or less costeffective than Action on Smoking and Health UK. Given this, the followingreport may provide some useful insights into dementia as a cause area, but we do notrecommend donations in this area or to this charity as one of the most effective ways toimprove overall human health.

Summary

Dementia, particularly Alzheimer’s disease, constitutes a large portion of the burden of disease andtotal mortality in highincome countries (HICs) such as the United Kingdom (see Section 2). However,no effective treatments are currently available for Alzheimer’s disease nor is there a clearunderstanding of the causal mechanism by which the disease develops (see Sections 1 and 3).

Nevertheless, there is a large body of evidence linking the disease to tobacco use, and it has beenestimated that smokers have a 4079% greater probability of developing Alzheimer’s disease (seeSection 4). This indicates that mortality and morbidity due to the disease might be greatly reduced byreducing the number of people who smoke, and this led us to evaluate the UK advocacy charityAction on Smoking and Health (ASH), given its relative costeffectiveness.

It is likely that there are opportunities in the developing world to more costeffectively reduceAlzheimer’s prevalence through tobacco control, particularly due to the large projected increase inprevalence over the coming decades (see Section 2). However, for this report we restricted ourscope to domestic UK charities in accordance with the donor's wishes.

Nonetheless, we are quite confident that, of the charities operating in the UK, ASH is one of the mostcosteffective in reducing the incidence of Alzheimer’s disease and improving health. Although itworks through indirect means, through tobacco control and also through lobbying, and although itscosteffectiveness does not exceed that of our top recommended charities, we do believe that theexpected impact of ASH’s activities on Alzheimer’s morbidity and mortality are quite considerable.This is due to the consistently high quality of its implementation, how wellplaced it is to effectively

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lobby and advocate for tobacco control, its past successes (which were both sizeable and alsoachieved on quite a low budget), its strategic approach to future activities, and the projected costeffectiveness of those future activities.

We estimate that for every £1 spent throughout the year, ASH’s public advocacy is able to reach281 viewers through the news media as well as 1,079 online viewers. In the past, ASH’sactivities have reduced annual deaths at a cost of £283,000£525,000 per Alzheimer’s death per year(£14,000£26,000 per death prevented over 20 years, undiscounted). We estimate that, in the future,ASH’s activities over the next 5 years may continue to do so at a cost of £531,800£985,000per Alzheimer’s death per year (£26,600£49,200 per death over 20 years, undiscounted). Thisfigure improves significantly if other ill health due to smoking, such as lung cancer, stroke and otherhealth conditions would also be included, falling to £30,600 per death per year and £1,800 perDALY per year (£1,500 per death and £90 per DALY over 20 years, undiscounted). Overall,tobacco control and antismoking campaigns are some of the most costeffective health interventionsavailable in the United Kingdom, with some estimates suggesting that they might as low as £4991per additional qualityadjusted life year gained. For Alzheimer’s disease specifically, these figuresindicate that ASH’s costeffectiveness is not as high as for the top charities working in developingcountries, but it still appears to be one of the best opportunities for reducing the burden ofAlzheimer’s disease and improving overall health in the UK.

1.

1. What is Alzheimer’s disease?

Alzheimer’s disease is the most common form of dementia, constituting 6070% of cases and thebulk of its disease burden, and will hence be the primary focus of this report. However, anotherrelatively common form is vascular dementia, which is responsible for 17% of cases. Together, andincluding mixed cases, Alzheimer’s and vascular dementia account for close to 90% of all dementiacases. Also, notably, the risk of both Alzheimer’s and vascular dementia is increased by smoking bya similar amount (see Section 4). Thus, the scope of this report will be largely restricted to these twoforms, with a particular focus on Alzheimer’s.

Alzheimer’s disease is characterised by a progressive decline in cognitive and motor function, whichbegins with minor symptoms such as memory loss but later results in severe brain damage anddeath. However, research into the disease has been somewhat inconclusive thus far. Asyet, the exact biological changes which cause Alzheimer’s are unknown, as are the reasons for itprogressing more quickly in some patients than in others, and also how it might be prevented oreffectively treated. It has been observed that the brains of Alzheimer’s patients have reducedmass, larger cavities for cerebrospinal fluid production, a large percentage of dead neurons, andmuch smaller mass in areas related to memory. Two abnormal protein structures have alsobeen observed in the brains of Alzheimer’s patients amyloid plaques and tau tangles thoughresearch has not established the exact causal relation between these structures and the diseaseitself. Notably, these physical changes begin approximately 20 years before symptoms are

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exhibited.

Commonly observed symptoms include: memory loss; impairment of problemsolving and planningability; difficulty in performing even familiar tasks; confusion regarding location and time; loss of visualcomprehension and spatial reasoning ability; difficulty with speaking and writing; impaired judgement;social withdrawal; mood and personality changes, including depression.

It is believed that, in a small proportion of patients, Alzheimer’s disease develops due to specificgenetic mutations and that individuals who inherit this mutation have a 95% likelihood of developingthe disease. However, this accounts for only 1% of all cases. There is also some evidencelinking Alzheimer’s disease more broadly to the herpes simplex virus and several different types ofbacteria, although the exact causal relation is not yet fully understood and this remains the focus ofongoing research.

For Alzheimer’s cases more generally, although no specific causes have been established, a varietyof probable risk factors have been identified:

family history those with parents and relatives who experienced Alzheimer’s are more likely tocontract it;age the vast majority of those diagnosed with Alzheimer’s disease are over the age of 65;**cardiovascular disease and poor cardiovascular health particularlydue to and exhibited by smoking, hypertension, obesity, and diabetes which, unlike the otherfactors listed here, is supported by not only correlational but also causal evidence;traumatic brain injury;lack of social and cognitive engagement throughout life;education lower levels of education have been linked with increased risk of Alzheimer’s diseaselater in life;

Of these risk factors, many seem to correlate, but cardiovascular problems are the only factorwhich is clearly causal. In addition, cardiovascular problems are likely to be the mosteasily preventable.2.

2. How does it affect people?

In addition to the symptoms mentioned in Section 1, which may cause considerable suffering forAlzheimer’s patients and their families, the disease is ultimately fatal.

Alzheimer’s is a significant contributor to global mortality, accounting for 3.02% of all deaths (seeFigure 1 below) this equates to 1.66 million deaths each year. 919,000 of these deathsoccurred in developed nations while only 737,000 occurred in developing nations. This representsa sizeable overrepresentation of developed nations as the total population size of developed nationsis significantly smaller for comparison, Alzheimer’s causes only 1.76% of all deaths in developingnations, while it causes 7.02% of all deaths in developed nations. Thus, it is somewhat accurate todescribe Alzheimer’s as primarily a developedworld disease. However, Alzheimer’s prevalence is

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expected to increase considerably in developing countries over the coming decades (see below).

Figure 1: Annual deaths due to Alzheimer’s disease and other forms of dementia, as a proportion oftotal global mortality.

As for disabilityadjusted life years, Alzheimer’s disease accounts for a lower proportion, only 0.91%of total DALYs incurred (see Figure 2 below), because it primarily affects those over the age of65 and so a death caused by Alzheimer’s does not result in as many years of life lost as, say, thedeath of an under 5 year old due to malaria or a middle aged person dying due to heart disease.

This percentage of DALYs rises to 2.84% in developed nations and falls to only 0.55% indeveloping nations. In comparison, malaria accounts for 2.68% for DALYs globally and 3.18% ofDALYs in developing nations, suggesting that the impact of Alzheimer’s on morbidity and mortalitymay be comparatively small.

Figure 2: Disabilityadjusted life years (DALYs) incurred by Alzheimer’s disease and other forms ofdementia each year, as a proportion of total disease burden.

Alzheimer’s and dementia also result in a considerable economic burden. Worldwide, $818 billion inhealthcare costs associated with dementia were incurred in 2015. Approximately $200 billion ofthese were in the United States, and £26 billion (approximately $37 billion) in the United Kingdomeach year.

The prevalence and costs of dementia are projected to increase greatly over the coming decades. Itis estimated that neurodegenerative diseases such as these will surpass cancer to become thesecond most common cause of death worldwide by 2040. By 2030, dementia cases will havealmost doubled from 46.8 million in 2015 to 74.7 million, and continue to increase to 131.5 million in2050. Global economic costs are also expected to increase greatly, reaching $2 trillion by 2030.

Notably, much of the increase in prevalence of dementia over the coming decades is expected tooccur in low and middle income countries (see Figure 3). This indicates that interventions which focuson dementia prevention and which take some time to have an effect, such as tobacco control (seeSection 4), may therefore have greater impact in developing countries. Nevertheless, at a domesticlevel, dementia appears to be comparatively tractable and highimpact due to its current highprevalence. Also, tobacco control and antismoking campaigns are some of the most costeffectiveoverall health interventions available in the United Kingdom, with some methods costing only £4991per additional qualityadjusted life year gained. This surprisingly low cost, combined with the highprevalence of dementia in the United Kingdom (at 8.46% of all deaths), has led us to recommenda domestic British charity for this cause area specifically. It is worth noting, however, that the similartobacco control interventions may be even more costeffective when conducted in developingcountries and may prevent many more cases of dementia, particularly in regions that are poorlyequipped to properly care for dementia patients.

Figure 3: Predicted number of dementia cases from 2015 to 2050, separated into HICs and LMICs.

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3.

3. How can you address the problem?

Based on the current scientific understanding, there are few proven interventions to treat or preventAlzheimer’s disease, and it is impossible to predict with any accuracy whether any particularintervention will interrupt the causal mechanism that results in any particular patient contracting thedisease and later dying from it. Broadly, potential interventions to reduce the incidence of Alzheimer’scan be categorised into: direct treatment of the condition; activities which focus on the prevention ofAlzheimer’s cases; and further research into the disease. Of these, there does exist one interventionwhich we are fairly confident may greatly reduce the probability of contracting the disease and,thereby, costeffectively prevent a large portion of Alzheimer’s cases namely, smoking cessation,which will be discussed below.

3.1.

Treatment

At present, treatment is not a promising form of intervention. There exist only six drugs which havebeen approved by the United States’ Food and Drug Administration for Alzheimer’s treatment andnone of these are able to slow down or halt the progress of the disease in damaging neurons andresulting in death. Each of these drugs has been shown to be effective only in temporarilyalleviating symptoms of the disease, and only for a minority of patients. In addition to these,there exist several nonpharmacologic treatments which have been observed to have some effect.These include general exercise, music therapy, reminiscence therapy, and others. Again,these therapies do not slow down or halt progress of the disease but merely alleviate symptoms suchas depression, memory problems, and agitation. They are also lacking in clear evidence, and fewhave been subjected to randomised control trials. Thus, neither pharmacologic ornonpharmacologic treatment is promising as an effective health intervention.

Prevention is more promising. From above, there is evidence that certain characteristics do correlatewith incidence of Alzheimer’s disease: family history; age; poor cardiovascular health, ascontributed to by smoking, hypertension, obesity, and diabetes; tobacco use in general (in additionto its effects specifically on cardiovascular health);, traumatic brain injury; lack of social andcognitive engagement throughout life; and low levels of education. Not only is it unclear ifseveral of these are causally linked with the disease or simply correlated, but most of them are alsounlikely to provide costeffective means of reducing the disease burden of Alzheimer’s. For example,greatly improving the education system of an alreadydeveloped nation is extremely costly. Reducingthe incidence of traumatic brain injury would be quite a difficult endeavour, and potentially not at allneglected, with strict laws already in place in the UK regarding occupational health and safety, themandatory use of motorcycle helmets, and so forth. Improving social and cognitive engagementover individuals’ entire lives would likely be extremely costly and intractable to implement (as well as itbeing least likely to be causally related), although the cobenefits might be considerable. Intervening

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on family history, that is genetics, is not possible. Antiaging research could have considerable cobenefits, but does not seem to be very tractable as it requires more basic research at this point.

This leaves only the improvement of cardiovascular health and the reduction of smoking. Thelatter might be most easily achieved through tobacco control and smoking cessation campaigns. Theformer might be achieved through combating obesity, diabetes, hypertension, poor diet and, again,tobacco control. Of the available interventions in these areas, tobacco control and broadersmoking cessation appear to be the least costly (even in developed countries) and also most easilytractable. See Section 4 for an indepth discussion of this.

3.2.

Research

Research is another area which initially appears promising. After all, there is still a lack of effectivetreatments available and a lack of evidence in favour of many costeffective methods of prevention(with the exception of tobacco cessation). Further research into Alzheimer’s disease andpotential interventions is the only method by which such treatments and prevention methods might bedeveloped. Hence, if there do exist other effective methods of treating Alzheimer’s and dementia thenresearch is first necessary in order to develop them. However, the outcomes of research are highlyuncertain and, if costeffective interventions already exist, then there is very low probability that morecosteffective interventions will quickly arise from additional research. As will be addressed below,tobacco control may already provide the opportunity to costeffectively reduce the burden ofAlzheimer’s disease, and thereby of dementia in general, at a potentially netneutral cost (seeSection 4.2). Even lobbying for tobacco control may reduce the burden of Alzheimer’s at a ratepotentially as low as £14,000£26,000 per life saved over 20 years, undiscounted (see Section 4.4).Alzheimer’s research, which focuses largely on rather costly treatments and diagnostic methods,

is unlikely to uncover interventions which reduce the disease burden at a comparablecost at any point in the near future. Even if costeffective treatments are discovered throughresearch, the cost of delivering those treatments aggregated with the substantial cost of research isunlikely to be less than the currently quite low cost of prevention through tobacco control. Notably,there is promising work being done on potential methods of vaccination, but it is still extremelyunclear how efficacious this might be, and the likely cost of the therapy per QALY gained is stillprohibitive.

In addition, it is questionable whether Alzheimer’s research is sufficiently neglected for additionaldonations to do more good here than for other conditions which have a greater disease burden dementia in general accounts for only 0.91% of global DALYs while, for example, back pain accountsfor 2.94%, migraines for 1.18%, diabetes for 2.27%, and HIV for 2.84% (with prevalence currentlyincreasing at 5.1% per year). $800 million is spent on dementia research each year by G7nations. This is a larger allocation per DALY than for tropical diseases (which, along with otherdiseases which make up 90% of the global disease burden, typically receive less than 10% ofresearch funding), migraines (only $13 million per year in the United States, for instance),

diabetes and back pain which are not even widely recognised as warranting focussed research

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programmes, and even HIV, which is considered quite wellfunded (at $1.25 billion per year). Inparticular, given the recent large increases in public funding of dementia research in the UnitedKingdom and internationally (with annual UK spending doubling between 2010 and 2013 to £74million, the establishment of the $100 million Dementia Discovery Fund by G8 health ministers,

and the UK government’s £300 million commitment to further research ), it seems veryunlikely that additional private donations to dementia and Alzheimer’s research will have a highmarginal impact, particularly in comparison to conditions which receive less funding but also incomparison to existing prevention strategies such as tobacco control.

4.

4. Tobacco control

There is a growing body of evidence supporting the claim that tobacco use, and secondhand smoke,greatly increases Alzheimer’s and dementia risk.

This may be through several different mechanisms. Tobacco use increases the levels ofhomocysteine in the body, which then increase the risk of neurological changes associated withdementia. It also increases oxidative stress, which has also been linked to Alzheimer’s disease.

Most importantly, smoking impacts negatively on cardiovascular health and also contributes tohigher incidence of diabetes and stroke. Each of these is a major risk factor for Alzheimer’sdisease, and dementia more broadly, but cardiovascular health specifically has been suggested to becausally linked to dementia incidence (based on a natural experiment looking at reduction of alcoholtaxes in Finland).

A variety of extensive studies and metaanalyses have established empirically that current smokersincrease their risk of developing Alzheimer’s disease by between 40% and 79%.

Other research has indicated that highconsumption smokers also have a greater risk ofAlzheimer’s later in life compared to lowconsumption smokers, increasing their chances ofAlzheimer’s by roughly 100% (118% for medium smokers versus 140% for heavy smokers).

There is also a sizeable body of evidence of a clear doseresponse relationship between tobaccoexposure and Alzheimer’s risk, indicating that incremental increases in exposure are associated withincreases in the risk of contracting the disease. For vascular dementia, it is much thesame case, as smoking is estimated to increase risk by 3578%.

It is estimated that one third of all cases of dementia would be prevented if the basic risk factor ofpoor cardiovascular health were addressed by completely eliminating smoking, poor diets, excessalcohol consumption, lack of exercise and excess weight. This may be overly ambitious, butcomputational modelling has also estimated that dementia risk would reduce by 2% for every 5percentage point reduction in tobacco use in developed countries (with a low estimate of 1.86% anda high estimate of 3.45%). The World Health Organisation estimates that 14% of all cases ofAlzheimer’s worldwide may be attributed to smoking, and hence potentially preventable.

Assuming that this percentage is consistent with the percentage of mortality and morbidity due to

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smoking, this indicates that smoking results in 232,000 dementia deaths per year and 3.11 millionDALYs (of a total of 1.66 million deaths and 22.24 million DALYs), all of which might be preventedthrough smoking cessation.

4.1.

4.1 How does it work?

Among the most effective largescale interventions for tobacco control are those available to nationalgovernments taxation of tobacco, health education, restrictions on sales, advertising and packaging,and various other legislative methods although awareness campaigns which reach a wide audiencemay also be highly effective. For private philanthropists, it is therefore likely that the greatestopportunities lie in funding lobbying and advocacy efforts, as well as in the funding of awarenesscampaigns to curb smoking uptake.

4.2.

4.2 Tractability and costeffectiveness

Tobacco control may be tractable or intractable in two distinct senses: tractable in that there existhighly effective policies or initiatives which can be implemented (and which have not already beenimplemented, such that there remain simple improvements which may be made); and intractable inthat lobbying efforts and awareness campaigns by their very nature, might not succeed in leadingany changes in policy or in general awareness.

Reducing smoking through tax increases, thereby increasing cigarette price, has been shown to bequite tractable on a governmental level, particularly when it comes to reducing smoking amongstyoung people. A report by the World Bank estimated that for every 10% increase incigarette cost, tobacco consumption would drop by 4% in highincome countries such as the UK.

Young people, who obtain the greatest benefit from quitting, are also more likely to quit andless likely to start when prices are high. The WHO therefore recommends that excise taxesshould account for 70% of cigarette cost.

Initially, it appears that tobacco control may not be sufficiently tractable in HICs due to existingregulations and the crowdedness of public health relative to LMICs. Indeed, the UK already hasmandatory standardised packaging for tobacco products, laws prohibiting smoking in almostall enclosed public spaces, and a tobacco duty of 16.5% of retail price, plus £3.79 per pack of20, for cigarettes which is applied alongside 20% VAT. Tobacco manufacturers have argued thatthis is much higher than nearby European countries, and that this already constitutes 77% of the costof a typical pack of cigarettes although, excluding VAT, the excise taxes appear to still be onlyapproximately 60% of total cost slightly lower than is recommended by the WHO.

Nevertheless, for Alzheimer’s prevention specifically, lobbying and government policy impact on anational (or subnational) level and hence will generally be more tractable in nations with highAlzheimer’s prevalence that is, HICs such as the UK. As shown in Figure 4 below, the disease

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burden of dementia in many HICs (in DALYs per 100,000 population each year) is roughly 10 times

higher than many LMICs. The UK rate, for instance, is 4.5 times higher than the developing worldaverage (877 versus 193 DALYs/100,000). Even in agestandardised figures it is still considerablyhigher (448 versus 348 DALYs/100,000). This indicates that, even though Alzheimer’s prevalence

in developing countries is set to increase enormously alongside life expectancy over the comingdecades (see Figure 3 in Section 2 above), it still disproportionately affects HIC such as the UK and islikely to continue to. Thus, the tractability of Alzheimer’s prevention, through tobacco control orotherwise, is unlikely to be a great deal less in HICs.

Figure 4: Disabilityadjusted life years (DALYs) incurred by Alzheimer’s disease and other forms ofdementia each year per 100,000 people, by location.

In addition, there is also still an opportunity for further progress (or for a reversal of progress). 2015marked the end of the UK government’s Tobacco Control Plan, so there is currently a gap in thegovernment’s strategy for the future and an excellent opportunity for advocacy groups to push for anew strategy which minimises mortality and morbidity as much as possible (however it also poses anopportunity for protobacco lobbying to do the opposite). This suggests that the issue is particularlytractable at present.

In addition, there are a variety of promising policies which have yet to be implemented, asrecommended by ASH, and these include :

The announcement of specific goals, such as the reduction of smoking prevalence to 5% in allsocioeconomic groups by 2035 (there is currently substantial inequality in smoking rates, withroutine and manual workers smoking more than twice as much as professionals and managers);

Greater funding of mass media campaigns, which are particularly neglected (see Section4.3 below);A direct levy on tobacco companies to fund smoking cessation services and other tobaccocontrol initiatives;Requiring tobacco companies to make their sales data, marketing strategies and lobbyingactivities public;Increased funding for the NHS’s Stop Smoking Services, and improvements in the availability ofthis service to all smokers, particularly to lower socioeconomic groups;Including instruction on smoking cessation in medical training;Regulation of the market of nicotine products which do not contain tobacco (e.g. ‘vaping’), in orderto maximise their availability to smokers for smoking cessation and minimise the chance of uptakeby nonsmokers;Further increasing the excise tax on tobacco products, including an increase in the tax escalator toat least 5% above the rate of inflation;Removing the tax differential between manufactured and handrolled cigarettes;A positive licensing scheme for all tobacco retailers;Consultation about the prohibition of smoking in select outdoor areas; and

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Warnings and possible reclassification for films and television shows containing tobacco use.

ASH claims that such policies would likely be sufficient to reduce smoking among adults to 13% by2020 and 9% by 2025, and to achieve the goal of reducing smoking among all socioeconomic groupsto less than 5% by 2035.

As for the lobbying required to bring such policy about, it appears that it may be quite tractable. Ofcourse, the tractability of lobbying may vary enormously depending on the exact policy being lobbiedfor, the exact methods used, the reputation and connections of the charity doing the lobbying, andmany factors which are impossible to accurately predict. For this, therefore, there is a great deal ofuncertainty. Due to this, and the potentially enormous differences between charities lobbying on thesame issue, it is much more useful to consider the tractability and effectiveness of individual charities.The charity we recommend in this report, Action on Smoking and Health, does appear to find a greatdeal of traction in its lobbying work and has a number of demonstrated past successes for instance,the implementation of standardised packaging in March of 2015 was recognised by the ShadowPublic Health Minister as largely the result of ASH’s work. See Section 4.4 for further details.

Mass media awareness campaigns also appear to be highly tractable, given their extremely highcosteffectiveness and current neglectedness (see Positive Wider Impacts and Section 4.3 below).

4.2.1.

Costeffectiveness

Based on the available evidence, tobacco control and smoking cessation activities appear to be quitecosteffective for reducing the prevalence of Alzheimer’s disease, as well as for improving healthmore generally. However, there is the additional question of whether lobbying for such policies andactivities is also costeffective, which is highly dependent on the organisation in question and willtherefore be discussed in Section 4.4.

It has been estimated that dementia risk reduces by 2% for every 5 percentage point reduction intobacco use in developed countries, although this is quite uncertain and also based on data from theUnited States rather than the United Kingdom. Based on our analysis of the morecomprehensive studies mentioned above, which estimated that smokers have a 4079% greaterchance of dementia than nonsmokers, the estimated impact of a 5 percentage point reduction intobacco use ranges from a 1.86% to a 3.45% reduction in dementia prevalence, morbidity andmortality. This equates to a case of dementia being prevented each year for every 109202smokers who quit, a death due to dementia being prevented each year for every 1,8963,511smokers who quit, and one DALY averted for every 167310(distributions shown below in Figure5). (None of this includes health impacts other than dementia.) This is extremely useful as it allowsus to estimate the reduction in dementia prevalence for any reduction in smoking.

Given that tobacco consumption would drop by 4% for every 10% increase in cigarette cost (through

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Figure 5: Modelled distributions for, on average, the number of UK smokers needed to quit to prevent a case ofdementia, a death due to dementia, or a DALY due to dementia (generated with the assistance of Guesstimate.com).

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taxation or otherwise), we can estimate that every 12.5% rise in the cost of cigaretteswould result in approximately 2% fewer cases of dementia (or 1.863.45% by our own modelling)and presumably a reduction of approximately 2% in both morbidity and mortality due to dementia,although this is all with a high degree of uncertainty. For the UK, where there are 559,000 DALYs and49,350 deaths due to dementia each year, this would equate to roughly 11,200 DALYs and 987deaths averted each year (or 10,40019,300 DALYs and 9201,700 deaths). However, a 12.5%higher cigarette cost due to taxation is likely to last more than one year and, over the first 20 years,would potentially result in 19,740 lives saved and 223,600 DALYs averted (or 18,39034,060lives and 208,400385,900 DALYs; also, all estimates undiscounted see below). Of course, this is ata netnegative cost to government but a significant, but difficult to estimate, cost to those whocontinue to smoke. Therefore, a costeffectiveness analysis is difficult to perform. However, the WHOclaims that a tax rate of 70%oftotalcost is optimal, so it seems unlikely that tax increases up to thispoint would not have netpositive effects (particularly as tobacco smuggling is presumably not asmuch of a problem in richer countries). Given that even an increase in cost of even half the amountmentioned above would likely save almost 10,000 lives over the next 20 years (undiscounted), anincrease in the excise tax for tobacco may hence be highly costeffective in reducing Alzheimer’smorbidity and mortality, all the more so if it is at a negligible or netnegative cost. Notably, an increasein excise tax, according to a tax escalator which outpaces inflation is one of the policies which ASHcontinue to advocate (see Section 4.4).

Another extremely costeffective policy for reducing tobacco use, also advocated by ASH, is forincreased funding of antismoking mass media campaigns. These are currently quite neglected,receiving only £5.86 million in public funding per year and, although they can vary in efficacy dueto many design and implementation factors, can improve general health at a cost of only £49 peradditional QALY. The National Institute for Health and Care Excellence (NICE) estimates thatsuch campaigns have an estimated costeffectiveness of £162 per child prevented from taking upsmoking. This equates to a cost of roughly £17,670 £32,730 per case ofdementia averted each year (£883 £1,636 over 20 years, undiscounted), and of £306,800 £568,100 per death due to dementia averted (£15,300 £28,400 over 20 years, undiscounted). Thisstill does not compare favourably to some of the most costeffective charities, but it is still more costeffective than a great many other dementia interventions, as there is not currently any effectivemeans of treatment and reduction in smoking prevalence is still the most straightforward meansof prevention.

NICE has also recommended smoking cessation interventions which are not much less costeffectivethan childhood prevention campaigns (£49 per QALY) for overall health, such as programmes whichimprove access to smoking cessation services (£136£195 per QALY), clientcentredcessation services (£50 per QALY), programmes to identify and reach populations in deprivedareas (£460£510 per QALY), dropin community cessation schemes (£50 per QALY),

and various others. Overall, we are confident that there are a variety of health interventions inthis area which can reduce smoking prevalence with high costeffectiveness.

4.2.2.

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Positive wider impacts

Alzheimer’s disease makes up only a small fraction of the total disease burden attributable to tobaccosmoke. Exposure to tobacco smoke has long been confirmed as a major risk factor for various formsof cancer (particularly lung cancer), heart disease, lung disease, stroke, aneurysm,

diabetes, asthma, and lower respiratory infections (see Figure 6). Despite the factthat only 19% of the population are smokers, it is estimated that smoking causes more than78,000 deaths in England each year. This includes 36,800 cancer deaths, 23,800 deaths due torespiratory diseases, 900 due to digestive diseases, and 16,700 due to diseases related to thecirculatory system. With reductions in smoking prevalence expected to lead to reductions in all ofthese disease burdens, it is therefore fairly certain that tobacco control will have benefits muchgreater than just the reduction in Alzheimer’s prevalence.

Figure 6:_ Proportion of DALYs attributable to tobacco smoke in the United Kingdom each year,excluding those due to dementia, represented by the shaded areas._[204]

For tax increases, for instance, it is estimated that for every 10% increase in cost there will be a 4%drop in consumption. From this, it can be very roughly estimated that a 10% increase in costwould save 3,100 lives per year that it is in effect in the UK (in addition to 790 for dementia) 62,400 over the first 20 years (in addition to 15,800 for dementia). This is for a policy which not onlydoes not cost any sizeable amount of public funds, but in fact brings in revenue which can then beused for other health interventions.

Likewise, other tobacco control strategies such as mass media campaigns also have sizeable cobenefits. It has been found that such campaigns can improve overall health at a rate of £4991 perQALY, making them one of the single most costeffective health interventions available.

While the increased risk of dementia due to smoking is indeed considerable, even without thisincreased risk, the broader health benefits still provide an extremely compelling case for tobaccocontrol and ensure that awareness and lobbying activities may still be extremely costeffective from acauseneutral perspective.

4.2.3.

Due diligence: Possible offsetting/negative impacts

4.2.3.1.

Would more funding decrease smoking at the same level of costeffectiveness?

Tobacco consumption decreases by 4% for every 10% increase in price in HICs such as the UK, so if additional funding would achieve higher tax increases over the same time period, it would

do even more good. However, it is unclear whether the costeffectiveness of doing so would remainconstant after already achieving several tax increases does achieving a 20% increase in price coststwice as much as achieving a 10% increase within the same time period, or does it cost half or 4times or 10 times as much? Advocacy work is particularly vulnerable to this uncertainty is there a

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point of diminishing returns, or perhaps some level of taxation beyond which a serious publicbacklash might occur? These are extremely difficult questions and the answers are unclear. Thisintroduces considerable uncertainty into our estimates of costeffectiveness, although it is fairlycertain that additional work on tobacco control will continue to have netpositive impacts.

4.2.3.2.

Are the benefits too far in the future? (If discounted with time, are they still greater than for other interventions?)

Whether to discount lives saved (or DALYs averted) with time is a controversial moral question. Notethat tobacco control as a health intervention in particular, any costeffectiveness estimates might besubstantially higher once they are time discounted. This means that because the positive healtheffects from reduced smoking often only occur in many years from the time of the intervention, onemay choose to discount their value, and instead prefer other health interventions that have animmediate pay off. This is not only because interventions that have immediate effects might havesocietal benefits, but also because we might have costeffective treatment for dementia in the future.In other words, there is an opportunity cost involved in donating money to a cause now when thesame donation could instead be made later and still have the same effect at the same time however, this does not seem to be a significant factor for donations to antitobacco lobbying as theactions which are taken to improve health, and for which donations are required, are taken within ayear or two and hence discounting is not a major problem in this sense.

More problematic is the cost of having health improvements occur later rather than at present, whichresults in the flowon effects of better health only beginning sometime in the distant future. We havenot considered such flowon effects in our analysis of tobacco control and Alzheimer’s disease, but itremains the case that the consideration of such effects may result in other interventions being foundto be more costeffective. This is particularly due to Alzheimer’s disease taking approximately 20years to develop (see Section 1), the potential delay between price changes (and other tobaccocontrol measures) and individuals quitting smoking, and the delay between lobbying efforts andlegislative changes. In total, this may potentially delay the health benefits (for Alzheimer’s specifically)by perhaps 30 years. At a 3% annual discount rate (as is often used by economists), this reduces theeffect size by 69% and increases the cost per case, death and DALY averted by 142% (for instance,for ASH, from £531,800£985,000 per one life saved per year to £755,200£1,399,000). This is quiteconcerning, as the effects may be discounted to less than half of what we estimated above.

One possible objection to this level of discounting would be that there was a relatively short timebefore followup used in the studies which demonstrate the link between smoking and dementia. Thisis true although the followup time varied in these studies from 1 year to 47 years, the majority wereless than 10 years. However, there is likely a very strong correlation for individualsbetween smoking at present and smoking in previous years so, although the followup time may beless than 10 years, the tobacco use which is relevant to whether an individual had developeddementia at the time of followup may still have occurred 20 years beforehand. Given this, it remainsplausible that the benefits of reducing Alzheimer’s prevalence may still occur several decades afterindividuals initially quit smoking.

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Despite this, the continuing benefits over time still appear to outweigh the discount rate. Even if thebenefits of lobbying do not occur until 30 years afterwards, the accrued benefits over the following 20years still add to 629% of the initial peryear effect size (or 971% over 40 years) for example, thisreduces the cost per life saved after a 30 year delay from £755,200£1,399,000 per life per year to£120,100£222,500 per life over 50 years. With a lower discount rate of 1% or 2% as isoccasionally used for some purposes, this effect size is even larger (and closer to . Thus, we do notbelieve that discounting is likely to reduce the costeffectiveness of tobacco control for reducingAlzheimer’s prevalence by a great deal.

Also, tobacco control remains highly costeffective in improving general health. The figures of lessthan £100 per additional QALY mentioned above already have discounting accounted for. Thus, weare still confident that tobacco control is highly costeffective in reducing overall morbidity andmortality, with or without discounting.

4.3.

4.3 Neglectedness

We have previously investigated the neglectedness of tobacco control and awareness raising indeveloping countries, but it is less clear whether it is as neglected in developing countries such asthe UK. However, given that tobacco control in the UK is currently lower (in proportion to diseaseburden) than for other health initiatives, that funding for awareness campaigns is far less than isspent on protobacco advertising, and that funding for antitobacco lobbying remains far less than forprotobacco lobbying, we can conclude that it does remain a sufficiently neglected cause area.

Firstly, current funding for smoking cessation is relatively low. The NHS spends roughly £88 millioneach year on its Stop Smoking Services, HMRC spends approximately £90.7 million oncombating tobacco smuggling, public funding for antismoking mass media campaigns in Englandand Wales is only £5.86 million per year (despite this being one of the single most costeffectivehealth interventions available, at £49 per QALY gained), and there are also minorexpenditures on the efforts of local authorities to combat smoking, on the National Centre forSmoking Cessation and Training, and on antismuggling media campaigns. Including theunknown costs of policing tobacco sales, this equates to little more than £200 million per year ontobacco control, which is responsible for more than 11% of the total disease burden in the UK (inDALYs). In comparison, all forms of cancer combined make up 17% of the disease burden,

yet £5 billion is spent each year by the NHS on cancer treatment. Even moredisproportionately, mental health and and neurological disorders constitute 18% of national diseaseburden, yet more than £11 billion is spent each year on their treatment. Given this sizeabledisparity, prevention of deaths due to tobacco appears to be relatively neglected and it is quite likelythat a redistribution of funds could potentially reduce the overall burden of disease significantly.

Expenditure on antismoking awareness campaigns is also relatively low. Public funding, the primarysource of funding for these campaigns, provides only £5.86 million per year. In comparison,before tobacco advertising and sponsorship was outlawed, £25 million was spent each year by

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tobacco companies on advertising in the UK. In addition, more than £10 million is currently spenton ecigarette advertising each year. Given that £25 million could be used productively toincrease tobacco use, it seems plausible that a comparable amount could be used productively todecrease it (particularly as tobacco use is still at 18.4% in the UK, compared to 26% in 2002).

For political advocacy in particular, the lobbying against tobacco appears to be severelyunderfunded. ASH, seemingly the most prominent single organisation in this area, spent only£723,000 in 2015 on all of its activities, of which lobbying is only a small percentage. To compareto corporate protobacco lobbying is quite difficult, as there is little information about lobbyingspending made available to the public. Nonetheless, tobacco sales in the UK totaled more than £18billion in 2013, and annual industry profits are estimated to be in the range of £1.11.7 billion in theUK alone. In addition, of all companies involved in the practice, Philip Morris International hasbeen ranked as the single biggest spender on lobbying in the European parliament (for which there isinformation available) with an expenditure of more than £4 million in 2013. Given the sizeableprofits made on tobacco products in the UK and the practices of tobacco companies elsewhere (aswell as evidence of their lobbying activities in the UK), it seems that it is extremely unlikelythat the funding for antismoking lobbying is at all comparable. Thus, it is quite likely that politicaladvocacy against tobacco would continue to benefit from further funding, as a relativelyneglected area.

Finally, it appears that ASH is in particular need of donations at present. Recent policy changes at theDepartment of Health require that grants made to charities such as ASH (which was previouslyfunded largely by government) not be used for any form of political lobbying. Given that a largeportion of ASH’s activities involve political lobbying, and that £200,000 of ASH’s funding in 2015 camefrom the Department of Health, this may lead to ASH experiencing a large funding gap in future.

4.4.

4.4 Charities working in this area

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cause report: dementia

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