Decision Analysis in Investments Decision analysis is a major tenet in the rational decision-making process. This means using logic and data, evaluating alternatives, assigning probabilities, and calculating expected values in order to make a choice. Decision analysis has two basic components: dividing and conquering. In decision analysis, complex problems must be broken down into simpler problems, and then a plan can be put together to take care of all of the smaller problems in a logical way that will fix the overarching problem. We will use this logic when we discuss decisions about investments. The term behavioral finance is used to convey how we apply what we know about common judgment errors in investments. It focuses on how biases affect individuals as well as investment markets. We have discussed motivation, optimism, and confirmation biases, and how these same biases come in to play when people with money in the market think they have a bright future in their investment choices. We also have discussed that even bright people make poor decisions that cost time and money. The same is true for investment decisions. There is overwhelming evidence that people pay excessively high fees for actively managed hedge funds and mutual funds for brokers to select stocks and for electronic trading companies to trade money (Bazerman & Moore, 2013). Many of these investment companies have come up with ingenious ways to charge fees and confuse investors about performance Factors to Consider in Investment Decisions Overconfidence is another factor in poor investment choices. People believe, based on their limited knowledge, that their predictions about the market and their investments are going to be good ones. This belief that they know where the market is headed can lead to bad investment decisions. Investing in an index fund is a wiser strategy than frequent stock trading. Another low-cost alternative is to have a diversified portfolio of stocks and do nothing for many years and let the market do its job and grow your wealth (Bazerman & Moore, 2013). A simple explanation as to why so many investors engage in active trading that is hazardous to their wealth is overconfidence. Optimism is another factor in poor investment decisions and is closely related to overconfidence. Once investors have made a decision, they tend to be overly optimistic about its future profitability. They maintain their optimism over time by recalling good performance of the past. They tend to stay optimistic, even when results are readily available through investment performance records (Bazerman & Moore, 2013). This optimism helps people justify their past behaviors and allows them to maintain an illusion of superiority of their investment strategy. Optimism encourages investors to continue to actively trade instead of choosing wiser, timesaving strategies such as investing in index funds. People tend to deny that random events are random. This is another factor in bad investment decisions. Many investors deny that there is a great deal of randomness in the investment arena (Bazerman & Moore, 2013). We should be a little wary of anyone that says he or she can predict an investment’s future on the past performance of that investment. Generally, funds do not stay hot for long periods. The role of chance plays a part on any future outcomes. Since the past is not an accurate predictor of the future, we should be more comfortable in admitting we cannot predict the future, so a safe bet is to stick with index funds for future stable growth. People spend too much time trading their investments and not enough time thinking about their asset allocations and developing a long-term plan. For younger people, more of their asset allocation should be in stocks, and then it should shift slowly over time as they get close to retirement to less risky options. A study of investment history will show that money invested in stocks for a retirement fund for decades will offer the best returns. People tend to procrastinate about making investments. Companies that offer automatic enrollment in 401(k)s are a step ahead and provide great opportunities for people to enroll and start contributing. If a company will match what the employee puts in the 401(k), then take full advantage and contribute the maximum that they will match. It is like getting free money and is a tremendous advantage to help build wealth for retirement. Investing online rather than using a broker is a good idea for those who follow a more long-term strategy of buying and holding. This strategy keeps your costs low and your potential growth high. Daytrading is a term that refers to those investors who initiate and close out high-value positions by the end of the trading day. It generally refers to short-term trades. Daytraders try to capitalize on fluctuations in the market of highly volatile stocks (Bazerman & Moore, 2013). Many daytraders pay fees to buy or sell stocks to someone who has better information and more experience. Most daytraders do not fare well because, as we have learned in previous units, people are generally not too good at considering the other side of the transaction. If you have not done so already, you should develop your retirement plan now. Put your plan on paper or your computer, and refer to it at least annually. How much will you save daily, weekly, monthly? Invest regularly and automatically. Do you have a 401(k) retirement plan (or equivalent)? Are you maximizing your contribution? Are you staying on track, or are you spending too much and saving too little (like most Americans). You cannot achieve a goal you have not set. Recall our discussions about want versus should, and apply what you have learned when developing your retirement plan. Most employers provide incentives to save through 401(k) plans. The government provides incentives to save through tax policies. It is up to you to take advantage of these opportunities to build your long-term wealth. Fairness and Ethics in Investment Decisions We have already spent a lot of time in Unit V discussing fairness and ethics in decision-making. How does this same topic apply to investment decisions? First, let’s address fairness, and then we will focus on ethics. For investments, we look for the cost to make the investment to determine fairness. We have discussed that many fund managers make a lot of money by charging high fees and making trades regularly. To get fair rates, an individual needs to request accurate information on how all charges and the fund manager calculates fees. Once you have an honest breakdown of those fees, you can compare it to industry averages or the per-trade fee that some brokerage firms charge. You are the one who has to decide if what the fund manager charges is a fair fee. It is best to shop around among the top firms that have a successful record to determine which one has a good long-term investment strategy and has acceptable and fair costs to manage your portfolio. Generally, when you work for a company that offers a 401(k) retirement savings plan, the company has already researched and determined several choices of investment fund strategies from which to choose. If they did proper due diligence in their research, they have determined the fairness of the rates for each of the fund choices before selecting the ones that offer good returns at a fair price. If you leave a company after being vested and you have a 401(k) plan, you can easily transfer those funds to a different 401(k) plan with another company or move it to a 401(k) plan that you manage. Again, at this point, you want to make sure that the new choices are fair in cost and offer the type of return based on your own personal long-term strategy for your retirement funds. Remember, it is best to pick a fund and leave the investment alone for the long-term benefit of stock growth over time and not make trades too often. What about ethics in investment? Everyone has heard of the Bernie Madoff Ponzi scheme that defrauded many people out of millions of dollars. He was an American stockbroker and financier who developed a very systematic scheme to acquire money from individuals with large sums of money and supposedly invest it in the stock market using his own private strategy to offer 10% to 12% steady returns on their investment. It seemed too good to be true, but everyone who knew the man highly recommended his service and trusted him to make great returns on their investment. If an investor had $1 million invested with Madoff at 10% return a month, he could make $10,000. If an investor wanted his return of $10,000, Madoff would send it. The only problem is that the original $1 million never went into the stock market. The money went into Madoff’s bank account. As long as Madoff deposited large amounts of money in the account and paid out small amounts, everything was great for Madoff, and no one was complaining. In fact, everyone was very happy until the 2008 stock market crash. That is when investors discovered Madoff could not pay all of the money they were trying to withdraw because of the crash, and the scheme soon fell apart. Many people were substantially hurt financially, and at least one person committed suicide because of the total loss of income. Madoff’s scheme lasted at least 15 years until finally his family turned him in to the authorities (Company Man, 2018). For more information about this unethical scheme, just research Bernie Madoff, and many stories, articles, and information can be found. The point of this story is that not everyone claiming to be an expert in investments is honest and ethical. It is best to do your research before investing your funds with an investment manager. Check as many sources as you can to be relatively confident that you have found an ethical individual or company. Many were fooled by Bernie Madoff, and even the U.S. Securities and Exchange Commission (SEC) was blinded for many years by his scheme. Recall the following well-known saying: “If it sounds too good to be true, it probably is.” This saying is a good rule of thumb that can be used as an additional check. References Bazerman, M. H., & Moore, D. A. (2013). Judgment in managerial decision making (8th ed.). Hoboken, NJ: Wiley. Company Man. (2018, March 14). The Bernie Madoff scandal – a simple overview [Video file]. Retrieved from Elnur. (n.d.). The business in Ponzi scheme concept. Information, employer [Image]. Retrieved from Embe2006. (2014). Stock market ticker [Image]. Retrieved from EDITORIAL doi:10.1111/add.14175 EQUIPTMOD as a basis for rational investment decisions in tobacco control EQUIPTMOD is an economic modelling tool that can be used by national and regional governments in Europe to assess the return on investment (ROI) of different tobacco control scenarios using the best available evidence, and so provides a rational basis for decision-making in this crucial area of population health. INTRODUCTION With regard to tobacco consumption, evidence could not be clearer in two areas: (a) that smoking is the cause of a wide range of conditions including neoplasms, cardiovascular and respiratory diseases; and (b) that smoking kills [1,2]. Recent estimates are available to show how this burden actually translates to colossal economic (opportunity) costs globally: US$422 billion in 2012 just in health-care costs (i.e. 5.7% of global health expenditure) and US $1436 billion (i.e. 1.8% of the world’s annual gross domestic product) when productivity losses were added [3]. Europe is particularly affected, as the tobacco epidemic in the continent is most advanced—some 28% of the European Union (EU) population still smokes [4]. The health and economic burden of tobacco use therefore calls for the ‘urgent need for countries to implement stronger tobacco control measures to address these costs’ [3]. This suggestion immediately begs an important policy question: how can countries do that? In particular, policymakers throughout Europe are in need of bespoke information on the economic and wider returns of investing in evidencebased tobacco control so that they can make stronger business cases for better tobacco control. A broad spectrum of policy measures exist in the EU member states: from regulation of tobacco products to advertising restrictions, from creation of smoke-free environments, tax structures and activities against illicit trade to anti-smoking campaigns and stop smoking services [4]. The implementation of these measures is often countered by massive lobbying of the tobacco industry [5]. The Framework Convention on Tobacco Control (FCTC), arguably the most important international step to combat the scourge of tobacco, has established a landmark reference, but only parts of this comprehensive framework have indeed been accomplished [6]. For example, only approximately a third of European countries that managed to increase tobacco taxes also have established laws on smoke-free public places, and even fewer offer cessation programmes [2]. As a result, more investment in tobacco © 2018 Society for the Study of Addiction control is needed. Equally, countries need to look for alternative strategies to improve the value for money of current provision of services as well as consider where they could disinvest from less effective services to allow them to reinvest that money to more effective tobacco control measures. Investment decisions involve much more than how much to spend on tobacco control; it is crucial to have a rational basis for adoption of different strategies or scenarios. EQUIPTMOD is designed specifically for this kind of modelling. For example, the budget holders (e.g. local authority service commissioners in England, social health insurance companies in Germany or the national health services in Spain) may want to continue providing most services at their current levels but at the same time may want to scale up certain services and stop providing more costly and/or less effective services. This creates opportunities for ‘prospective investment scenarios’, the utility of which could be assessed against the baseline (i.e. current practice). This assessment is vital, as it would allow policymakers to be explicit about the returns that their bespoke tobacco control agendas could generate. In 2012, the National Institute of Health and Care Excellence (NICE) published the first Tobacco Control Return on Investment (ROI) tool [7] as a series of initiatives to support local authorities (LAs). The policy context was that the newly enacted Health and Social Care Act 2012 put LAs in the forefront of public health, including tobacco control. This tool was well received by relevant stakeholder communities and was instrumental in informing the development by NICE of similar ROI tools in other areas of public health. The tool was an economic model that synthesized the existing best evidence around smoking cessation services and allowed LAs to estimate the ROI from what they were currently doing (i.e. ROI of the current package of interventions). In addition, the tool encouraged LAs to think about how they could do things differently (i.e. consider alternative package of interventions). The ‘mix-and-match’ of interventions to create an alternative investment package allowed by the tool was attractive, and thus led to several business cases, informed spending reviews and supported the development of local/subnational tobacco control strategies [8]. The NICE Tobacco ROI tool was developed by a research consortium led by the Health Economics Research Group (HERG) at Brunel University London. Building upon the success of the NICE ROI tool in England, the consortium applied to and received—after a competitive bidding Addiction, 113 (Suppl. 1), 3–6 4 Editorial process—funding from the European Commission to transfer the ROI tool to other European member states. This massive undertaking, essentially a comparative effectiveness research (CER) entitled ‘European-study on quantifying utility of investment in protection from tobacco (EQUIPT)’, was guided by a complex protocol and was designed to test the transferability of the NICE Tobacco ROI tool to other EU Member States by adapting it to meet the needs of European decision-makers, following the transferability criteria described in Pokhrel et al. [9]. Stakeholders’ needs and intention to use ROI tools in Germany, Hungary, Spain, the Netherlands and the United Kingdom, collected via interviews and surveys, were analysed [10]. This analysis was complemented by secondary analysis of the contextual and other factors. Informed by this contextual analysis, country-specific ROI tools have been developed using a mix of economic modelling and Visual Basic programming. The ultimate aim of the EQUIPT study is to make this tool available to European stakeholders to support decision-making in tobacco control. The EQUIPT ROI Tool, available freely from http://equipt. eu, can be used to compare various policy scenarios, including new or continued investment strategies or stopping services that are less effective. Based on the tool, the researchers conducted extensive analyses of the cost-effectiveness of alternative strategies for tobacco control throughout the countries included in this project. This Supplement to Addiction now presents those analyses, as well as the description of the methods underpinning the EQUIPTMOD, and has a collection of nine papers and an editorial comment. The papers included in this Supplement represent the highest level of scholarly analyses addressing a key question: what is the ROI of alternative tobacco control strategies in a country in question? These analyses, based on the EQUIPTMOD, are brought together in the pages of one scientific journal via this collection of papers. The collection is divided into two themes. The first theme covers the methodological issues and provides an overview of how the ROI tool was developed. The second theme covers country-specific applications of the tool, leading to rigorous policy analyses in each of the five EQUIPT countries. Theme 1: methods and challenges around the development of EQUIPTMOD Developing a ROI tool to support decision-making is challenging for a number of reasons. For example, the tool must be underpinned by robust economic model that is not only capable of capturing life-time outcomes and costs as current smokers choose to make quit attempts, but also reflects the current decision context in which the tool is expected to serve. The decision context (in this case, the public sector) itself poses a number of further challenges: © 2018 Society for the Study of Addiction public finance operates in a ‘myopic’ fashion, thus costs and benefits in the short to medium terms are key ingredients to decision-making and so are costs and benefits falling outside health care (e.g. productivity). Coyle and colleagues [11] consider these specific challenges and describe the methods of the economic model (EQUIPTMOD) underpinning the EQUIPT ROI tool. Using examples from England, they demonstrate how the tool can provide consistent estimates of the health and wider returns that investing in bespoke tobacco control interventions could generate for countries. An economic model is as good as the assumptions underlying it. Therefore, EQUIPTMOD required estimates of intervention effects, reach and costs. West and colleagues [12] reviewed the recent literature on the effect and reach of various population level interventions intended to increase quit attempts as well as individual-level interventions intended to increase the success rates (abstinence for at least 12 months). To derive effect sizes of the interventions included in the EQUIPTMOD, they used systematic reviews of efficacy supplemented by individual effectiveness evaluations and national surveys. TraperoBertran and colleagues [13] developed a standardized method to source both economic costs of tobacco smoking and costs of implementing cessation interventions. Although both type of costs varied substantially across the countries, they contributed to the ROI estimates in support of national or regional policy options (Theme 2 papers). Finally, Nemeth and colleagues [14] tested the transferability of the ROI tool to other countries. They found that collecting data on a small number of model inputs made EQUIPTMOD transferable, thus showing the ROI tool’s potential to facilitate transfer of tobacco control-related economic evidence to new jurisdictions. Taken together, the collection of Theme 1 papers picks up on the subtle challenges around modelling ROI in the contemporary European decision contexts related to public health. The availability of a co-created (with stakeholders) user-friendly, rigorously tested, transferable, ROI tool is thus expected to support tobacco control decision-making in Europe. Theme 2: country-specific application of EQUIPTMOD and policy analyses A useful feature of ROI tools such as the EQUIPTMOD is to demonstrate the health and economic value of the current provision of tobacco control services compared to a counterfactual in which no such provision is assumed. A more useful feature, however, is the tool’s ability to provide estimates of health and wider returns from investing in tobacco control strategies that could serve as alternatives to the current practice. For example, what if we changed the current provision by increasing the reach of a service, Addiction, 113 (Suppl. 1), 3–6 Editorial introduced new and effective interventions to current provision of services, or even stopped the current provision of costly and/or potentially less effective service? Theme 2 papers provide a number of such context-specific policy analyses. Compared with the United Kingdom, smoking cessation aids are used less frequently in Germany while the smoking prevalence is higher. This underscores the need for more economic evidence to drive investment in tobacco control in Germany. Huber and colleagues [15] evaluated the cost-effectiveness of the increased reach of specific smoking cessation interventions using the EQUIPTMOD and found that a cost-effective strategy in Germany could be to increase the reach of group-based behavioural support, financial incentives and varenicline for smoking cessation by just 1% of current annual quit attempts. Similarly, the analysis conducted by Trapero-Bertran and colleagues [16] shows that if Spanish authorities expanded the reach of existing general practitioner (GP) brief interventions for smoking cessation, provided proactive telephone support and reimbursed smoking cessation medication to smokers trying to stop, such policies would more than pay for themselves in the long term. In Hungary, Nemeth and colleagues [17] show that doubling the reach of existing group-based behavioural support therapies and proactive telephone support provides a good return on investment. An important policy question in the contemporary public health funding climate, dominated mainly by austerity measures throughout Europe, is whether or not it would be cost-effective to provide a new intervention to complement the current provision of smoking cessation services. In their analyses, Cheung and colleagues [18] demonstrate that providing internet-based smoking cessation interventions as a complement to the current practice could be a cost-saving policy option in the Netherlands. Similarly, in Hungary, introducing a social marketing campaign would more than pay for itself in the long term, as Nemeth and colleagues [17] have shown. Sequential analysis is a method in health economics that allows the identification of optimal investment options given a set of investment choices. Often, policymakers want to know which of the proposed changes in the services described above provides the best value for money. Using the EQUIPTMOD, Anraad and colleagues [19] compared five investment choices (i.e. potential changes to the current practice) related to tobacco control in England and the Netherlands, the two EQUIPT counties with similar current provision of smoking cessation services. They found that the inclusion of cytisine (a smoking cessation medication) and increasing the reach of brief physician advice, text-messaging support and group-based therapy would be a cost-effective policy in both countries. © 2018 Society for the Study of Addiction 5 The analysis by Anraad and colleagues [19] highlights how valuable cytisine can be for stop smoking services. Cytisine, a plant-based nicotine receptor partial agonist, aims to reduce withdrawal symptoms and thus increase the chance of success in quit attempts. Cytisine, a similar medication to varenicline, is not yet licensed for use in the Netherlands and the United Kingdom but has been found to be effective [risk ratio (RR) = 3.98] in trials [20] and potentially cost-effective in modelling studies [21]. The analysis by Anraad and colleagues [19] thus confirms a long-held hypothesis that including cytisine, which is significantly cheaper than varenicline, to the current provision of smoking cessation services provides better value for money and thus makes the business case for licensing and using it in the United Kingdom and the Netherlands. The collection of Theme 2 papers collectively conveys a single, powerful message: that current government action on smoking is good for a country’s wealth, as well as its health, but governments can do much better than this. The question is how. The analyses presented in this Supplement demonstrate the cost-effectiveness of several alternative strategies. The need of the hour is to translate this knowledge to policymaking. An earlier evaluation study clearly shows that countries that implement ‘evidencebased tobacco control’ are the ‘winners’ [22]. Thus, there is a reason to be hopeful that EQUIPT ROI tool could facilitate this knowledge translation. CONCLUSION The papers in this Supplement provide a wealth of information to support evidence-based decision-making in tobacco control throughout five countries in Europe, and potentially wider. The EQUIPTMOD is a valuable decision-support tool available to European policymakers and wider stakeholders. The way forward is to use it to support investment decisions for evidence-based tobacco control. Declaration of interests R.W. undertakes research and consultancy for companies that develop and manufacture smoking cessation medicines. He is an adviser to the UK’s National Centre for Smoking Cessation and Training. His research is funded mainly by Cancer Research UK. Acknowledgements This is one of a series of papers published in the Supplement to Addiction entitled: ‘EQUIPTMOD as a basis for rational investment decisions in tobacco control’. The papers are based on the European study on quantifying utility of investment in protection from tobacco (EQUIPT). The Addiction, 113 (Suppl. 1), 3–6 6 Editorial EQUIPT project has received funding from the European Union’s Seventh Framework Programme for research, technological development and demonstration under grant agreement no. 602270 (EQUIPT). Funding for the publication of this Supplement was provided by Brunel University London. We thank the entire EQUIPT team and the stakeholders who provided valuable inputs to the project. 11. 12. SUBHASH POKHREL1 & ROBERT WEST2 Health Economics Research Group, Brunel University London, London, 13. UK1 and Institute of Epidemiology and Health, University College London, London, UK2 E-mail: [email protected] 14. References 1. Thun M. J., Carter B. 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