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Abstract Background Legislation is one of the most powerful weapons for improving population health and is often used by policy and decision makers. Little research exists to guide them as to whether legislation is feasible and/or will succeed. We aimed to produce a coherent and transferable evidence based framework of threats to legislative interventions to assist the decision making process and to test this through the 'case study' of legislation to ban smoking in cars carrying children. Methods We conceptualised legislative interventions as a complex social interventions and so used the realist synthesis method to systematically review the literature for evidence. 99 articles were found through searches on five electronic databases (MEDLINE, HMIC, EMBASE, PsychINFO, Social Policy and Practice) and iterative purposive searching. Our initial searches sought any studies that contained information on smoking in vehicles carrying children. Throughout the review we continued where needed to search for additional studies of any type that would conceptually contribute to helping build and/or test our framework. Results Our framework identified a series of transferable threats to public health legislation. When applied to smoking bans in vehicles; problem misidentification; public support; opposition; and enforcement issues were particularly prominent threats. Our framework enabled us to understand and explain the nature of each threat and to infer the most likely outcome if such legislation were to be proposed in a jurisdiction where no such ban existed. Specifically, the micro-environment of a vehicle can contain highly hazardous levels of second hand smoke. Public support for such legislation is high amongst smokers and non-smokers and their underlying motivations were very similar - wanting to practice the Millian principle of protecting children from harm. Evidence indicated that the tobacco industry was not likely to oppose legislation and arguments that such a law would be 'unenforceable' were unfounded. Conclusion It is possible to develop a coherent and transferable evidence based framework of the ideas and assumptions behind the threats to legislative intervention that may assist policy and decision makers to analyse and judge if legislation is feasible and/or likely to succeed.

Intro -- Preface -- Contents -- Contributor Bio -- List of Figures -- List of Tables -- List of Boxes -- Chapter 1: Diary of a Policymaker -- References -- Chapter 2: The Scourge of Modern Lifestyles -- 2.1 Tobacco Use -- 2.1.1 Prevalence of Tobacco Use -- 2.1.2 Health Consequences of Tobacco Use -- 2.1.3 Tobacco Control Policies -- 2.1.4 Tobacco Control: Looking Forward -- 2.2 Physical Activity -- 2.2.1 Prevalence of Physical Activity -- 2.2.2 Getting More People Moving and Moving More -- 2.2.3 Policies to Address Physical Activity -- 2.2.4 Physical Activity: Looking Forward -- 2.3 Breastfeeding -- 2.3.1 Prevalence of Breastfeeding -- 2.3.2 Economic Cost of Suboptimal Breastfeeding -- 2.3.3 Breastfeeding Support Policies: Looking Forward -- References -- Chapter 3: ROI Analysis: Art or Science? -- 3.1 The Science of ROI Analysis -- 3.2 Applicability of ROI Analysis in Public Health -- 3.3 The Art of ROI Analysis -- References -- Chapter 4: What Is ROI, By The Way? -- 4.1 Defining the Decision Problem -- 4.1.1 Defining the Audience -- 4.1.2 Framing the Decision Problem -- 4.2 Developing Conceptual Framework and Economic Model -- 4.2.1 Population of Interest -- 4.2.2 Perspective of Analysis -- 4.2.3 Disease Process -- 4.2.4 Interventions -- 4.2.5 Resources and Costs -- 4.2.6 Timeframe of Analysis -- 4.2.7 ROI Metrics -- 4.2.8 Understanding the Current Situation -- 4.2.9 Usability Requirements -- 4.3 Collection of Supporting Data to Populate the Model -- 4.4 Using ROI Results to Make Business Cases -- References -- Chapter 5: Modelling the ROI of Public Health Interventions -- 5.1 Objective -- 5.2 Defining the Audience and Assessing Their Needs -- 5.3 Population of Interest -- 5.4 Perspectives of Analyses -- 5.5 The Economic Model -- 5.6 Model Structure -- 5.6.1 Modelling Smokers -- 5.6.2 Intervention Efficacy, Uptake and Costs.

Introduction: Tobacco smoking claims 700 000 lives every year in Europe and the cost of tobacco smoking in the EU is estimated between €98 and €130 billion annually; direct medical care costs and indirect costs such as workday losses each represent half of this amount. Policymakers all across Europe are in need of bespoke information on the economic and wider returns of investing in evidence-based tobacco control, including smoking cessation agendas. EQUIPT is designed to test the transferability of one such economic evidence base—the English Tobacco Return on Investment (ROI) tool—to other EU member states. Methods and analysis: EQUIPT is a multicentre, interdisciplinary comparative effectiveness research study in public health. The Tobacco ROI tool already developed in England by the National Institute for Health and Care Excellence (NICE) will be adapted to meet the needs of European decision-makers, following transferability criteria. Stakeholders' needs and intention to use ROI tools in sample countries (Germany, Hungary, Spain and the Netherlands) will be analysed through interviews and surveys and complemented by secondary analysis of the contextual and other factors. Informed by this contextual analysis, the next phase will develop country-specific ROI tools in sample countries using a mix of economic modelling and Visual Basic programming. The results from the country-specific ROI models will then be compared to derive policy proposals that are transferable to other EU states, from which a centralised web tool will be developed. This will then be made available to stakeholders to cater for different decision-making contexts across Europe. Ethics and dissemination: The Brunel University Ethics Committee and relevant authorities in each of the participating countries approved the protocol. EQUIPT has a dedicated work package on dissemination, focusing on stakeholders' communication needs. Results will be disseminated via peer-reviewed publications, e-learning resources and policy briefs. ...