Reaching Healthy People 2010 by 2013: A SimSmoke simulation

Global smoking-related deaths averted due to MPOWER policies implemented at the highest level between 2007 and 2020

BACKGROUND

In response to the harm caused by tobacco use worldwide, the World Health Organization (WHO) World Health Assembly actioned the WHO Framework Convention on Tobacco Control (FCTC) in 2005. To help countries meet their FCTC obligations, the WHO introduced in 2008 the MPOWER policy package and by 2020 the FCTC had been ratified by 182 parties. The package consists of six evidence-based demand reduction smoking cessation policies to assist countries to achieve best practice. We used published evaluation results and replicated the published model to estimate current policy achievement and demonstrate the impact and equity of the MPOWER policy package in reducing the global number of smokers and smoking-attributable deaths (SADs) between 2007 and 2020.

METHODS

We replicated an evaluation model (the Abridged SimSmoke model) used previously for country impact assessments and validated our replicated reduction in SADs for policies between 2014 and 2016 against the published results. The replicated model was then applied to report on the country level SADs averted from achieving the highest level of implementation, that is best practice in MPOWER policies, between 2016 and 2020. The latest results were then combined with past published results to estimate the reduction in SADs since the commencement of the MPOWER policy package. Country level income status was used to investigate the equity in the uptake of MPOWER policies worldwide.

RESULTS

Identical estimates for SADs in 41 out of 56 MPOWER policies implemented in 43 countries suggested good agreement in the model replication. The replicated model overestimated the reduction in SADs by 159,800 (1.5%) out of a total of 10.5 million SADs with three countries contributing to the majority of this replication discrepancy. Updated analysis estimated a reduction of 8.57 million smokers and 3.37 million SADs between 2016 and 2020. Between 2007 and 2020, 136 countries had adopted and maintained at least one MPOWER policy at the highest level which was associated with a reduction in 81.0 million smokers and 28.3 million SADs. Seventy five percent of this reduction was in middle income countries, 20% in high income and less than 5% in low income countries.

CONCLUSIONS

Considerable progress has been made by MPOWER policies to reduce the prevalence of smokers globally. However, there is inequality in the implementation and maintenance, reach and influence, and the number of SADs averted. Future research to modify the model could provide a more comprehensive evaluation of past and future progress in tobacco control policies, worldwide.

Healthy People Countdown 2030: reaching 5% cigarette smoking prevalence among US adults through state cigarette excise tax increases

OBJECTIVE

The Healthy People 2030 goal is to reduce US current adult cigarette smoking prevalence to 5% by 2030. The objective of this report is to investigate if this goal is achievable using state cigarette excise tax increases.

METHODS

State-specific linear trends in smoking prevalence over 2011-2019 were determined using fractional logit regression and compared with the desired linear trends for achieving 5% smoking prevalence by 2030 in individual states and the District of Columbia (DC). The gaps between price-adjusted and desired trends were used in a simulation model for identifying state-specific systematic annual increases in state cigarette excise tax rates based on state-specific price elasticity of smoking prevalence, maintaining the status quo in other non-tax tobacco control measures.

RESULTS

The price-adjusted trends in smoking prevalence observed over 2011-2019 exceed the desired trends for achieving 5% smoking prevalence target by 2030 in only five states (eg, Washington, Utah, Rhode Island, Massachusetts and Maryland) and the DC. It suggests that majority of states and USA overall will miss the target smoking prevalence at the current rate of reduction in smoking. 45 states would need systematic annual increases in cigarette excise tax rate in a range of $0.02-$1.37 per pack over 2022-2030 to meet the target.

CONCLUSIONS

The feasibility of reaching the Healthy People 2030 goal would critically depend on the acceleration of progress in tobacco control. Tax increases tailored to the needs of individual states combined with scaled-up non-tax tobacco control policy interventions can help achieve the desired progress.

A Decision-Theoretic Public Health Framework for Heated Tobacco and Nicotine Vaping Products

Markets for nicotine vaping products (NVPs) and heated tobacco products (HTPs) have grown as these products became positioned as harm-reduction alternatives to combusted tobacco products. Herein, we present a public health decision-theoretic framework incorporating different patterns of HTP, NVP, and cigarette use to examine their impacts on population health. Our framework demonstrates that, for individuals who would have otherwise smoked, HTP use may provide public health benefits by enabling cessation or by discouraging smoking initiation and relapse. However, the benefits are reduced if more harmful HTP use replaces less harmful NVP use. HTP use may also negatively impact public health by encouraging smoking by otherwise non-smokers or by encouraging initiation or relapse into smoking. These patterns are directly influenced by industry behavior as well as public policy towards HTPs, NVPs, and cigarettes. While substantial research has been devoted to NVPs, much less is known about HTPs. Better information is needed to more precisely define the health risks of HTPs compared to cigarettes and NVPs, the relative appeal of HTPs to consumers, and the likelihood of later transitioning to smoking or quitting all products. While our analysis provides a framework for gaining that information, it also illustrates the complexities in distinguishing key factors.

Cancer systems epidemiology: Overcoming misconceptions and integrating systems approaches into cancer research

Patricia Mabry and coauthors discuss application of systems approaches in cancer research.

Budgetary impact from multiple perspectives of sustained antitobacco national media campaigns to reduce the harms of cigarette smoking

BACKGROUND

High-intensity antitobacco media campaigns are a proven strategy to reduce the harms of cigarette smoking. While buy-in from multiple stakeholders is needed to launch meaningful health policy, the budgetary impact of sustained media campaigns from multiple payer perspectives is unknown.

METHODS

We estimated the budgetary impact and time to breakeven from societal, all-payer, Medicare, Medicaid and private insurer perspectives of national antitobacco media campaigns in the USA. Campaigns of 1, 5 and 10 years of durations were assessed in a microsimulation model to estimate the 10 and 20-year health and budgetary impact. Simulation model inputs were obtained from literature and both pubic use and proprietary data sets.

RESULTS

The microsimulation predicts that a 10-year national smoking cessation campaign would produce net savings of $10.4, $5.1, $1.4, $3.6 and $0.2 billion from the societal, all-payer, Medicare, Medicaid and private insurer perspectives, respectively. National antitobacco media campaigns of 1, 5 and 10-year durations could produce net savings for Medicaid and Medicare within 2 years, and for private insurers within 6-9 years. A 10-year campaign would reduce adult cigarette smoking prevalence by 1.2 percentage points, prevent 23 500 smoking-attributable deaths over the first 10 years. In sensitivity analysis, media campaign costs would be offset by reductions in medical care spending of smoking among all payers combined within 6 years in all tested scenarios.

CONCLUSIONS

1, 5 and 10-year antitobacco media campaigns all yield net savings within 10 years from all perspectives. Multiyear campaigns yield substantially higher savings than a 1-year campaign.

Claire AW, Keller PA, Xu Z, Schillo BA. The 20-year impact of tobacco price and tobacco control expenditure increases in Minnesota, 1998-2017

Introduction

Tobacco control programs and policies reduce tobacco use and prevent health and economic harms. The majority of tobacco control programs and policies in the United States are implemented at local and state levels. Yet the literature on state-level initiatives reports a limited set of outcomes. To facilitate decision-making that is increasingly focused on costs, we provide estimates of a broader set of measures of the impact of tobacco control policy, including smoking prevalence, disease events, deaths, medical costs, productivity and tobacco tax revenues, using the experience of Minnesota as an example.

Methods

Using the HealthPartners Institute’s ModelHealth^™: Tobacco MN microsimulation, we assessed the impact of the stream of tobacco control expenditures and cigarette price increases from 1998 to 2017. We simulated 1.3 million individuals representative of the Minnesota population.

Results

The simulation estimated that increased expenditures on tobacco control above 1997 levels prevented 38,400 cancer, cardiovascular, diabetes and respiratory disease events and 4,100 deaths over 20 years. Increased prices prevented 14,600 additional events and 1,700 additional deaths. Both the net increase in tax revenues and the reduction in medical costs were greater than the additional investments in tobacco control.

Conclusion

Combined, the policies address both short-term and long-term goals to reduce the harms of tobacco by helping adults who wish to quit smoking and deterring youth from starting to smoke. States can pay for initial investments in tobacco control through tax increases and recoup those investments through reduced expenditures on medical care.

The Impact of Implementing Tobacco Control Policies: The 2017 Tobacco Control Policy Scorecard

The Tobacco Control Scorecard, published in 2004, presented estimates of the effectiveness of different policies on smoking rates. Since its publication, new evidence has emerged. We update the Scorecard to include recent studies of demand-reducing tobacco policies for high-income countries. We include cigarette taxes, smoke-free air laws, media campaigns, comprehensive tobacco control programs, marketing bans, health warnings, and cessation treatment policies. To update the 2004 Scorecard, a narrative review was conducted on reviews and studies published after 2000, with additional focus on 3 policies in which previous evidence was limited: tobacco control programs, graphic health warnings, and marketing bans. We consider evaluation studies that measured the effects of policies on smoking behaviors. Based on these findings, we derive estimates of short-term and long-term policy effect sizes. Cigarette taxes, smoke-free air laws, marketing restrictions, and comprehensive tobacco control programs are each found to play important roles in reducing smoking prevalence. Cessation treatment policies and graphic health warnings also reduce smoking and, when combined with policies that increase quit attempts, can improve quit success. The effect sizes are broadly consistent with those previously reported for the 2004 Scorecard but now reflect the larger evidence base evaluating the impact of health warnings and advertising restrictions.

The Minnesota SimSmoke Tobacco Control Policy Model of Smokeless Tobacco and Cigarette Use

INTRODUCTION

A previous Minnesota SimSmoke tobacco control policy model is extended to more recent years and to include smokeless tobacco use.

METHODS

Using data from the 1993 Tobacco Use Supplement and information on state policies, the Minnesota SimSmoke model was updated and extended to incorporate smokeless tobacco (both exclusive and dual use) and smokeless tobacco-attributable deaths. The model was then validated against the 2002, 2006/2007, and 2014/2015 Tobacco Use Supplement and the 1999, 2007, 2014, and 2018 Minnesota Adult Tobacco Survey and used to estimate the impact of policies implemented between 1993 and 2018. Analysis was conducted in April 2019.

RESULTS

The model validated well for cigarette and earlier smokeless tobacco use, but it predicted smokeless tobacco use less well in recent years. The model projected that male (female) smoking prevalence was 35% (36%) lower in relative terms by 2018 and 43% (44%) lower by 2040 owing to policies, with lesser reductions projected for male smokeless tobacco use. Tobacco-attributable deaths were reduced by 7,800 by 2018 and 46,900 by 2040. Price increases, primarily through taxes, were projected to have had the greatest impact on cigarette use followed by smoke-free air laws, cessation treatment policies, tobacco control campaign expenditures, and youth access enforcement. Similar effects were projected for smokeless tobacco use, except that smoke-free air laws had smaller effects.

CONCLUSIONS

As cigarettes remain the dominant form of nicotine delivery product, cigarette-oriented policies may be an effective means of reducing the use of all nicotine delivery products. However, noncigarette-oriented policies may also play an important role.

Comparing and contrasting responses to tobacco control and obesity policies: a qualitative study

OBJECTIVE

To explore people's perceptions of, and responses to, obesity and tobacco policies with a particular focus on motivation; and to compare and contrast responses to explore the potential for translating learning across domains.

DESIGN

A theoretically informed comparative qualitative study involving semi-structured interviews with two groups of participants (smokers and ex-smokers; those who have previously or are currently attempting to lose weight). Data were analysed inductively using thematic analysis and interpreted through the lens of Self-Determination Theory.

SETTING

Community-based.

PARTICIPANTS

Interviews were conducted with five smokers and four ex-smokers around tobacco policy, and seventeen people acting to control their weight around obesity policy.

RESULTS

Three primary themes were identified. (i) Participants believed social norms to be crucial to supporting health behaviour change and responses to policy; not smoking was perceived as socially normal, whereas being physically active and eating healthily were perceived to go against social norms. (ii) Policies influencing the physical environment were perceived to support stopping smoking (e.g. smoke-free laws, advertising bans), but to undermine attempts to lose or control weight (e.g. high visibility, availability and low cost of energy-dense foods). (iii) While policies for both domains were considered necessary and legitimate, both groups found policy interventions neither motivating nor undermining of their sense of autonomy.

CONCLUSIONS

The results suggest those trying to lose weight respond similarly to obesity-related policy as smokers do to tobacco policy. Environmental interventions are perceived to be more helpful than appealing to people's motivation to change for their own sake.

Projecting the effects of tobacco control policies in the USA through microsimulation: a study protocol

INTRODUCTION

Smoking remains the leading cause of preventable death in the USA but can be reduced through policy interventions. Computational models of smoking can provide estimates of the projected impact of tobacco control policies and can be used to inform public health decision making. We outline a protocol for simulating the effects of tobacco policies on population health outcomes.

METHODS AND ANALYSIS

We extend the Smoking History Generator (SHG), a microsimulation model based on data from the National Health Interview Surveys, to evaluate the effects of tobacco control policies on projections of smoking prevalence and mortality in the USA. The SHG simulates individual life trajectories including smoking initiation, cessation and mortality. We illustrate the application of the SHG policy module for four types of tobacco control policies at the national and state levels: smoke-free air laws, cigarette taxes, increasing tobacco control programme expenditures and raising the minimum age of legal access to tobacco. Smoking initiation and cessation rates are modified by age, birth cohort, gender and years since policy implementation. Initiation and cessation rate modifiers are adjusted for differences across age groups and the level of existing policy coverage. Smoking prevalence, the number of population deaths avoided, and life-years gained are calculated for each policy scenario at the national and state levels. The model only considers direct individual benefits through reduced smoking and does not consider benefits through reduced exposure to secondhand smoke.

ETHICS AND DISSEMINATION

A web-based interface is being developed to integrate the results of the simulations into a format that allows the user to explore the projected effects of tobacco control policies in the USA. Usability testing is being conducted in which experts provide feedback on the interface. Development of this tool is under way, and a publicly accessible website is available at http://www.tobaccopolicyeffects.org.

Agent-based modeling as a tool for program design and evaluation

Recently, systems thinking and systems science approaches have gained popularity in the field of evaluation; however, there has been relatively little exploration of how evaluators could use quantitative tools to assist in the implementation of systems approaches therein. The purpose of this paper is to explore potential uses of one such quantitative tool, agent-based modeling, in evaluation practice. To this end, we define agent-based modeling and offer potential uses for it in typical evaluation activities, including: engaging stakeholders, selecting an intervention, modeling program theory, setting performance targets, and interpreting evaluation results. We provide demonstrative examples from published agent-based modeling efforts both inside and outside the field of evaluation for each of the evaluative activities discussed. We further describe potential pitfalls of this tool and offer cautions for evaluators who may chose to implement it in their practice. Finally, the article concludes with a discussion of the future of agent-based modeling in evaluation practice and a call for more formal exploration of this tool as well as other approaches to simulation modeling in the field.

Computational Models Used to Assess US Tobacco Control Policies

INTRODUCTION

Simulation models can be used to evaluate existing and potential tobacco control interventions, including policies. The purpose of this systematic review was to synthesize evidence from computational models used to project population-level effects of tobacco control interventions. We provide recommendations to strengthen simulation models that evaluate tobacco control interventions.

METHODS

Studies were eligible for review if they employed a computational model to predict the expected effects of a non-clinical US-based tobacco control intervention. We searched five electronic databases on July 1, 2013 with no date restrictions and synthesized studies qualitatively.

RESULTS

Six primary non-clinical intervention types were examined across the 40 studies: taxation, youth prevention, smoke-free policies, mass media campaigns, marketing/advertising restrictions, and product regulation. Simulation models demonstrated the independent and combined effects of these interventions on decreasing projected future smoking prevalence. Taxation effects were the most robust, as studies examining other interventions exhibited substantial heterogeneity with regard to the outcomes and specific policies examined across models.

CONCLUSIONS

Models should project the impact of interventions on overall tobacco use, including nicotine delivery product use, to estimate preventable health and cost-saving outcomes. Model validation, transparency, more sophisticated models, and modeling policy interactions are also needed to inform policymakers to make decisions that will minimize harm and maximize health.

IMPLICATIONS

In this systematic review, evidence from multiple studies demonstrated the independent effect of taxation on decreasing future smoking prevalence, and models for other tobacco control interventions showed that these strategies are expected to decrease smoking, benefit population health, and are reasonable to implement from a cost perspective. Our recommendations aim to help policymakers and researchers minimize harm and maximize overall population-level health benefits by considering the real-world context in which tobacco control interventions are implemented.

Potential deaths averted in USA by replacing cigarettes with e-cigarettes

Introduction

US tobacco control policies to reduce cigarette use have been effective, but their impact has been relatively slow. This study considers a strategy of switching cigarette smokers to e-cigarette use (‘vaping’) in the USA to accelerate tobacco control progress.

Methods

A Status Quo Scenario, developed to project smoking rates and health outcomes in the absence of vaping, is compared with Substitution models, whereby cigarette use is largely replaced by vaping over a 10-year period. We test an Optimistic and a Pessimistic Scenario, differing in terms of the relative harms of e-cigarettes compared with cigarettes and the impact on overall initiation, cessation and switching. Projected mortality outcomes by age and sex under the Status Quo and E-Cigarette Substitution Scenarios are compared from 2016 to 2100 to determine public health impacts.

Findings

Compared with the Status Quo, replacement of cigarette by e-cigarette use over a 10-year period yields 6.6 million fewer premature deaths with 86.7 million fewer life years lost in the Optimistic Scenario. Under the Pessimistic Scenario, 1.6 million premature deaths are averted with 20.8 million fewer life years lost. The largest gains are among younger cohorts, with a 0.5 gain in average life expectancy projected for the age 15 years cohort in 2016.

Conclusions

The tobacco control community has been divided regarding the role of e-cigarettes in tobacco control. Our projections show that a strategy of replacing cigarette smoking with vaping would yield substantial life year gains, even under pessimistic assumptions regarding cessation, initiation and relative harm.

Mathematical Modeling in Tobacco Control Research: Initial Results From a Systematic Review

OBJECTIVES

The US Food and Drug Administration has expressed interest in using mathematical models to evaluate potential tobacco policies. The goal of this systematic review was to synthesize data from tobacco control studies that employ mathematical models.

METHODS

We searched five electronic databases on July 1, 2013 to identify published studies that used a mathematical model to project a tobacco-related outcome and developed a data extraction form based on the ISPOR-SMDM Modeling Good Research Practices. We developed an organizational framework to categorize these studies and identify models employed across multiple papers. We synthesized results qualitatively, providing a descriptive synthesis of included studies.

RESULTS

The 263 studies in this review were heterogeneous with regard to their methodologies and aims. We used the organizational framework to categorize each study according to its objective and map the objective to a model outcome. We identified two types of study objectives (trend and policy/intervention) and three types of model outcomes (change in tobacco use behavior, change in tobacco-related morbidity or mortality, and economic impact). Eighteen models were used across 118 studies.

CONCLUSIONS

This paper extends conventional systematic review methods to characterize a body of literature on mathematical modeling in tobacco control. The findings of this synthesis can inform the development of new models and the improvement of existing models, strengthening the ability of researchers to accurately project future tobacco-related trends and evaluate potential tobacco control policies and interventions. These findings can also help decision-makers to identify and become oriented with models relevant to their work.

Evaluating the impacts of screening and smoking cessation programmes on lung cancer in a high-burden region of the USA: a simulation modelling study

OBJECTIVE

While the US Preventive Services Task Force has issued recommendations for lung cancer screening, its effectiveness at reducing lung cancer burden may vary at local levels due to regional variations in smoking behaviour. Our objective was to use an existing model to determine the impacts of lung cancer screening alone or in addition to increased smoking cessation in a US region with a relatively high smoking prevalence and lung cancer incidence.

SETTING

Computer-based simulation model.

PARTICIPANTS

Simulated population of individuals 55 and older based on smoking prevalence and census data from Northeast Pennsylvania.

INTERVENTIONS

Hypothetical lung cancer control from 2014 to 2050 through (1) screening with CT, (2) intensified smoking cessation or (3) a combination strategy.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes were lung cancer mortality rates. Secondary outcomes included number of people eligible for screening and number of radiation-induced lung cancers.

RESULTS

Combining lung cancer screening with increased smoking cessation would yield an estimated 8.1% reduction in cumulative lung cancer mortality by 2050. Our model estimated that the number of screening-eligible individuals would progressively decrease over time, indicating declining benefit of a screening-only programme. Lung cancer screening achieved a greater mortality reduction in earlier years, but was later surpassed by smoking cessation.

CONCLUSIONS

Combining smoking cessation programmes with lung cancer screening would provide the most benefit to a population, especially considering the growing proportion of patients ineligible for screening based on current recommendations.

Combining Community-Based Participatory Research (CBPR) with a Random-Sample Survey to Assess Smoking Prevalence in an Under-Served Community

ACKNOWLEDGMENTS

The authors would like to thank Laura McClure for her help with the manuscript submission, the Liberty City Community Health Advisory Board for its collaboration on this study, as well as the survey interviewers, and the survey participants.

INTRODUCTION

Underserved communities might lag behind Healthy People 2010 objectives of smoking reduction because of smoking behavior disparities. This possibility was investigated through a random-sample survey conducted in a disenfranchised community in Miami-Dade County, Florida, using a Community-Based Participatory Research (CBPR) framework. The survey was triggered by our finding that this community had higher than expected incidence of tobacco-associated cancers.

METHODS

Survey methods, resulting from a dialog between the Community Advisory Board and academic researchers, included: (a) surveying adult residents of a public housing complex located within the community; (b) probability sampling; (c) face-to-face interviews administered by trained community residents. 250 households were sampled from 750 addresses provided by the county Public Housing Agency. The completed surveys were reviewed by the academic team, yielding 204 questionnaires for the current analysis.

RESULTS

Of the 204 respondents, 38% were current smokers. They estimated the percentages of smokers in their household and among their five best friends at 33% and 42%, respectively, and among adults and youth in the community at 72% and 53%, respectively.

CONCLUSIONS

A mix of state-of-art methodology with CBPR principles is seldom encountered in the current literature. It allowed the research team to find a high smoking prevalence in an underserved community, twice the statewide and nationwide estimates. Similar or higher levels of smoking were perceived in respondent's entourage. Such disparity in smoking behavior, unlikely to result from self-selection bias because of our rigorous methodology, calls for community-specific tobacco control efforts commensurate to the magnitude of the problem.

Utilization of evidence-based smoking cessation treatments by psychiatric inpatient smokers with depression

OBJECTIVES

Although smoking is a major health issue among depressed psychiatric inpatients and interest in quitting is high, successful quit rates remain low among this population. We sought to understand preferences that depressed inpatient smokers may have for cessation treatments.

METHODS

Eighty smokers (60% women, mean age 38.75 ± 11.20) with major depressive disorder and nicotine dependence receiving psychiatric inpatient services provided information on current depressive symptoms, smoking status and nicotine dependence, quit attempts, perceived barriers to quitting, and smoking consequences.

RESULTS

Almost half (46%) of participants endorsed a past-year quit attempt. Emotional barriers to quitting were uniquely associated with fewer past-year quit attempts, and depression severity was related to greater emotional barriers to quitting. Nicotine dependence severity was related to a variety of emotional, financial, weight concern, and self-efficacy barriers, but only weight gain concern was associated with decreased odds of making a past-year quit attempt. The number of lifetime quit attempts was positively associated with negative smoking consequences. With regard to interest in smoking cessation treatment, 86% and 92% of smokers reported a willingness to try behavioral counseling and nicotine replacement products, respectively, but fewer smokers reported a willingness to try medication, print or Web-based materials, or an unaided quit attempt.

CONCLUSIONS

Although half of our sample reported recent quit attempts, many people did not make an attempt using an evidence-based treatment. On the basis of consumer preferences identified herein, clinical recommendations for reinforcing the use of evidence-based smoking cessation treatments for depressed psychiatric inpatient smokers are provided.

Mainstreaming modeling and simulation to accelerate public health innovation

Dynamic modeling and simulation are systems science tools that examine behaviors and outcomes resulting from interactions among multiple system components over time. Although there are excellent examples of their application, they have not been adopted as mainstream tools in population health planning and policymaking. Impediments to their use include the legacy and ease of use of statistical approaches that produce estimates with confidence intervals, the difficulty of multidisciplinary collaboration for modeling and simulation, systems scientists' inability to communicate effectively the added value of the tools, and low funding for population health systems science. Proposed remedies include aggregation of diverse data sets, systems science training for public health and other health professionals, changing research incentives toward collaboration, and increased funding for population health systems science projects.

Systems science: a good investment for the public's health

This supplement of Health Education & Behavior showcases the current state of the field of systems science applications in health promotion and public health. Behind this work lies a steady stream of public dollars at the federal level. This perspective details nearly a decade of investment by the National Institutes of Health's Office of Behavioral and Social Sciences Research. These investments have included funding opportunity announcements, training programs, developing resources for researchers, cross-disciplinary fertilization, and publication. While much progress has been made, continuing investment is needed in the future to ensure the viability and sustainability of this young but increasingly important field.

Evaluation of a mass media campaign promoting using help to quit smoking

BACKGROUND

Although there is evidence that promoting individual cessation aids increases their utilization, mass media campaigns highlighting the benefit of using help to quit have not been evaluated.

PURPOSE

The effects of a Philadelphia adult smoking-cessation media campaign targeting using help in ad taglines were analyzed from March to November 2012. This study distinctively analyzed the campaign's impact at both the population level (effects on the average person) and the individual level (effects among those who reported exposure).

METHODS

The 16-month mass media campaign aired in Philadelphia PA from December 2010 to March 2012. A representative sample of adult Philadelphia smokers was interviewed by telephone at baseline (n=491) and new samples were interviewed monthly throughout the campaign (n=2,786). In addition, a subsample of these respondents was reinterviewed 3 months later (n=877).

RESULTS

On average, participants reported seeing campaign ads four times per week. Among individual respondents, each additional campaign exposure per week increased the likelihood of later reporting using help (OR=1.08, p<0.01), adjusting for baseline use of help and other potential confounders. This corresponded to a 5% increase in the use of help for those with average exposure relative to those with no exposure. Cross-sectional associations between individual campaign exposure and intentions to use help were consistent with these lagged findings. However, there was no evidence of population-level campaign effects on use of help.

CONCLUSIONS

Although the campaign was effective at the individual level, its effects were too small to have a population-detectable impact.

The potential effects of tobacco control in China: projections from the China SimSmoke simulation model

OBJECTIVE

To use a computer simulation model to project the potential impact in China of tobacco control measures on smoking, as recommended by the World Health Organization Framework Convention on Tobacco Control (FCTC), being fully implemented.

DESIGN

Modelling study.

SETTING

China.

POPULATION

Males and females aged 15-74 years.

INTERVENTION

Incremental impact of more complete implementation of WHO FCTC policies simulated using SimSmoke, a Markov computer simulation model of tobacco smoking prevalence, smoking attributable deaths, and the impact of tobacco control policies. Data on China's adult population, current and former smoking prevalence, initiation and cessation rates, and past policy levels were entered into SimSmoke in order to predict past smoking rates and to project future status quo rates. The model was validated by comparing predicted smoking prevalence with smoking prevalence measured in tobacco surveys from 1996-2010.

MAIN OUTCOME MEASURES

Projected future smoking prevalence and smoking attributable deaths from 2013-50.

RESULTS

Status quo tobacco policy simulations projected a decline in smoking prevalence from 51.3% in 2015 to 46.5% by 2050 in males and from 2.1% to 1.3% in females. Of the individual FCTC recommended tobacco control policies, increasing the tobacco excise tax to 75% of the retail price was projected to be the most effective, incrementally reducing current smoking compared with the status quo by 12.9% by 2050. Complete and simultaneous implementation of all FCTC policies was projected to incrementally reduce smoking by about 40% relative to the 2050 status quo levels and to prevent approximately 12.8 million smoking attributable deaths and 154 million life years lost by 2050.

CONCLUSIONS

Complete implementation of WHO FCTC recommended policies would prevent more than 12.8 million smoking attributable deaths in China by 2050. Implementation of FCTC policies would alleviate a substantial portion of the tobacco related health burden that threatens to slow China's extraordinary gains in life expectancy and prosperity.

The effect of tobacco control measures during a period of rising cardiovascular disease risk in India: a mathematical model of myocardial infarction and stroke

BACKGROUND

We simulated tobacco control and pharmacological strategies for preventing cardiovascular deaths in India, the country that is expected to experience more cardiovascular deaths than any other over the next decade.

METHODS AND FINDINGS

A microsimulation model was developed to quantify the differential effects of various tobacco control measures and pharmacological therapies on myocardial infarction and stroke deaths stratified by age, gender, and urban/rural status for 2013 to 2022. The model incorporated population-representative data from India on multiple risk factors that affect myocardial infarction and stroke mortality, including hypertension, hyperlipidemia, diabetes, coronary heart disease, and cerebrovascular disease. We also included data from India on cigarette smoking, bidi smoking, chewing tobacco, and secondhand smoke. According to the model's results, smoke-free legislation and tobacco taxation would likely be the most effective strategy among a menu of tobacco control strategies (including, as well, brief cessation advice by health care providers, mass media campaigns, and an advertising ban) for reducing myocardial infarction and stroke deaths over the next decade, while cessation advice would be expected to be the least effective strategy at the population level. In combination, these tobacco control interventions could avert 25% of myocardial infarctions and strokes (95% CI: 17%-34%) if the effects of the interventions are additive. These effects are substantially larger than would be achieved through aspirin, antihypertensive, and statin therapy under most scenarios, because of limited treatment access and adherence; nevertheless, the impacts of tobacco control policies and pharmacological interventions appear to be markedly synergistic, averting up to one-third of deaths from myocardial infarction and stroke among 20- to 79-y-olds over the next 10 y. Pharmacological therapies could also be considerably more potent with further health system improvements.

CONCLUSIONS

Smoke-free laws and substantially increased tobacco taxation appear to be markedly potent population measures to avert future cardiovascular deaths in India. Despite the rise in co-morbid cardiovascular disease risk factors like hyperlipidemia and hypertension in low- and middle-income countries, tobacco control is likely to remain a highly effective strategy to reduce cardiovascular deaths.

Computational modeling and multilevel cancer control interventions

This chapter presents an overview of computational modeling as a tool for multilevel cancer care and intervention research. Model-based analyses have been conducted at various "beneath the skin" or biological scales as well as at various "above the skin" or socioecological levels of cancer care delivery. We review the basic elements of computational modeling and illustrate its applications in four cancer control intervention areas: tobacco use, colorectal cancer screening, cervical cancer screening, and racial disparities in access to breast cancer care. Most of these models have examined cancer processes and outcomes at only one or two levels. We suggest ways these models can be expanded to consider interactions involving three or more levels. Looking forward, a number of methodological, structural, and communication barriers must be overcome to create useful computational models of multilevel cancer interventions and population health.

Tobacco control policy in the UK: blueprint for the rest of Europe?

INTRODUCTION

With male smoking prevalence at ~30% in 1998, the UK implemented stricter tobacco control policies, including a comprehensive cessation treatment programme. We evaluate their effect.

METHODS

Data for the UK (excluding Northern Ireland) are applied to 'SimSmoke', a simulation model used to examine the effect of tobacco control policies over time on smoking initiation and cessation. Upon validating the model against smoking prevalence, the model is used to distinguish the effect of policies implemented between 1998 and 2009 on smoking prevalence. Using standard attribution methods, the model estimates lives saved as a result of policies.

RESULTS

The model predicts smoking prevalence accurately between 1998 and 2009. A relative reduction of 23% in smoking rates over that period is attributed to tobacco control policies, mainly tax increases, smoke-free air laws, advertising restrictions and cessation treatment programmes. The model estimates that 210 000 deaths will be averted by the year 2040, as a consequence of policies implemented between 1998 and 2010.

CONCLUSIONS

The results document the UK's success in reducing smoking prevalence and prolonging lives, thereby providing an example for other European nations. When Framework Convention for Tobacco Control- (FCTC) consistent policies are also implemented, the model projects that smoking prevalence will fall by another 28% with an additional 168,000 deaths averted by 2040.

Online social networks and smoking cessation: a scientific research agenda

BACKGROUND

Smoking remains one of the most pressing public health problems in the United States and internationally. The concurrent evolution of the Internet, social network science, and online communities offers a potential target for high-yield interventions capable of shifting population-level smoking rates and substantially improving public health.

OBJECTIVE

Our objective was to convene leading practitioners in relevant disciplines to develop the core of a strategic research agenda on online social networks and their use for smoking cessation, with implications for other health behaviors.

METHODS

We conducted a 100-person, 2-day, multidisciplinary workshop in Washington, DC, USA. Participants worked in small groups to formulate research questions that could move the field forward. Discussions and resulting questions were synthesized by the workshop planning committee.

RESULTS

We considered 34 questions in four categories (advancing theory, understanding fundamental mechanisms, intervention approaches, and evaluation) to be the most pressing.

CONCLUSIONS

Online social networks might facilitate smoking cessation in several ways. Identifying new theories, translating these into functional interventions, and evaluating the results will require a concerted transdisciplinary effort. This report presents a series of research questions to assist researchers, developers, and funders in the process of efficiently moving this field forward.

Changing the future of obesity: science, policy, and action

The global obesity epidemic has been escalating for four decades, yet sustained prevention efforts have barely begun. An emerging science that uses quantitative models has provided key insights into the dynamics of this epidemic, and enabled researchers to combine evidence and to calculate the effect of behaviours, interventions, and policies at several levels--from individual to population. Forecasts suggest that high rates of obesity will affect future population health and economics. Energy gap models have quantified the association of changes in energy intake and expenditure with weight change, and have documented the effect of higher intake on obesity prevalence. Empirical evidence that shows interventions are effective is limited but expanding. We identify several cost-effective policies that governments should prioritise for implementation. Systems science provides a framework for organising the complexity of forces driving the obesity epidemic and has important implications for policy makers. Many parties (such as governments, international organisations, the private sector, and civil society) need to contribute complementary actions in a coordinated approach. Priority actions include policies to improve the food and built environments, cross-cutting actions (such as leadership, healthy public policies, and monitoring), and much greater funding for prevention programmes. Increased investment in population obesity monitoring would improve the accuracy of forecasts and evaluations. The integration of actions within existing systems into both health and non-health sectors (trade, agriculture, transport, urban planning, and development) can greatly increase the influence and sustainability of policies. We call for a sustained worldwide effort to monitor, prevent, and control obesity.

Using the internet to understand smokers' treatment preferences: informing strategies to increase demand

BACKGROUND

Most smokers attempt to quit on their own even though cessation aids can substantially increase their chances of success. Millions of smokers seek cessation advice on the Internet, so using it to promote cessation products and services is one strategy for increasing demand for treatments. Little is known, however, about what cessation aids these smokers would find most appealing or what predicts their preferences (eg, age, level of dependence, or timing of quit date).

OBJECTIVE

The objective of our study was to gain insight into how Internet seekers of cessation information make judgments about their preferences for treatments, and to identify sociodemographic and other predictors of preferences.

METHODS

An online survey assessing interest in 9 evidence-based cessation products and services was voluntarily completed by 1196 smokers who visited the American Cancer Society's Great American Smokeout (GASO) webpage. Cluster analysis was conducted on ratings of interest.

RESULTS

In total, 48% (572/1196) of respondents were "quite a bit" or "very much" interested in nicotine replacement therapy (NRT), 45% (534/1196) in a website that provides customized quitting advice, and 37% (447/1196) in prescription medications. Only 11.5% (138/1196) indicated similar interest in quitlines, and 17% (208/1196) in receiving customized text messages. Hierarchical agglomerative cluster analysis revealed that interest in treatments formed 3 clusters: interpersonal-supportive methods (eg, telephone counseling, Web-based peer support, and in-person group programs), nonsocial-informational methods (eg, Internet programs, tailored emails, and informational booklets), and pharmacotherapy (NRT, bupropion, and varenicline). Only 5% (60/1196) of smokers were "quite a bit" or "very much" interested in interpersonal-supportive methods compared with 25% (298/1196) for nonsocial-informational methods and 33% (399/1196) for pharmacotherapy. Multivariate analyses and follow-up comparisons indicated that level of interest in pharmacotherapy ("quite a bit or "very much" vs. "not at all") varied as a function of education (n = 575, χ(2) (3) =16.6, P = .001), age (n = 528, χ(2) (3) = 8.2, P = .04), smoking level (n = 514, χ(2) (3) = 9.5, P = .02), and when smokers were planning to quit (n = 607, χ(2) (4) = 34.0, P < .001). Surprisingly, greater age was associated with stronger interest in nonsocial-informational methods (n = 367, χ(2) (3) = 10.8, P = .01). Interest in interpersonal-supportive methods was greater if smokers had used a quitline before (n = 259, χ(2) (1) = 18.3, P < .001), or were planning to quit earlier rather than later (n = 148, χ(2) (1) = 4.9, P = .03).

CONCLUSIONS

Smokers accessing the Internet for information on quitting appear to differentiate cessation treatments by how much interpersonal interaction or support the treatment entails. Quitting date, smoking level, and sociodemographic variables can identify smokers with varying levels of interest in the 3 classes of cessation methods identified. These results can potentially be used to more effectively target and increase demand for these treatments among smokers searching the Internet for cessation information.

Exploring scenarios to dramatically reduce smoking prevalence: a simulation model of the three-part cessation process

OBJECTIVES

We used a simulation model to analyze whether the Healthy People 2010 goal of reducing smoking prevalence from the current 19.8% rate to 12% by 2010 could be accomplished by increasing quit attempts, increasing the use of treatments, or increasing the effectiveness of treatment.

METHODS

We expanded on previous versions of the tobacco control simulation model SimSmoke to assess the effects of an increase in quit attempts, treatment use, and treatment effectiveness to reduce smoking prevalence. In the model, we considered increases in each of these parameters individually and in combination.

RESULTS

Individually, 100% increases in quit attempts, treatment use, and treatment effectiveness reduced the projected 2020 prevalence to 13.9%, 16.7%, and 15.9%, respectively. With a combined 100% increase in all components, the goal of a 12% adult smoking prevalence could be reached by 2012.

CONCLUSIONS

If we are to come close to reaching Healthy People 2010 goals in the foreseeable future, we must not only induce quit attempts but also increase treatment use and effectiveness. Simulation models provide a useful tool for evaluating the potential to reach public health targets.

Modeling the impact of smoking-cessation treatment policies on quit rates

BACKGROUND

Smoking-cessation treatment policies could yield substantial increases in adult quit rates in the U.S.

PURPOSE

The goals of this paper are to model the effects of individual cessation treatment policies on population quit rates, and to illustrate the potential benefits of combining policies to leverage their synergistic effects.

METHODS

A mathematical model is updated to examine the impact of five cessation treatment policies on quit attempts, treatment use, and treatment effectiveness. Policies include: (1) expand cessation treatment coverage and provider reimbursement; (2) mandate adequate funding for the use and promotion of evidence-based, state-sponsored telephone quitlines; (3) support healthcare system changes to prompt, guide, and incentivize tobacco treatment; (4) support and promote evidence-based treatment via the Internet; and (5) improve individually tailored, stepped-care approaches and the long-term effectiveness of evidence-based treatments.

RESULTS

The annual baseline population quit rate is 4.3% of all current smokers. Implementing any policy in isolation is projected to increase the quit rate to between 4.5% and 6%. By implementing all five policies in combination, the quit rate is projected to increase to 10.9%, or 2.5 times the baseline rate.

CONCLUSIONS

If fully implemented in a coordinated fashion, cessation treatment policies could reduce smoking prevalence from its current rate of 20.5% to 17.2% within 1 year. By modeling the policy impacts on the components of the population quit rate (quit attempts, treatment use, treatment effectiveness), key indicators are identified that need to be analyzed in attempts to improve the effect of cessation treatment policies.

Boosting population quits through evidence-based cessation treatment and policy

Only large increases in adult cessation will rapidly reduce population smoking prevalence. Evidence-based smoking-cessation treatments and treatment policies exist but are underutilized. More needs to be done to coordinate the widespread, efficient dissemination and implementation of effective treatments and policies. This paper is the first in a series of three to demonstrate the impact of an integrated, comprehensive systems approach to cessation treatment and policy. This paper provides an analytic framework and selected literature review that guide the two subsequent computer simulation modeling papers to show how critical leverage points may have an impact on reductions in smoking prevalence. Evidence is reviewed from the U.S. Public Health Service 2008 clinical practice guideline and other sources regarding the impact of five cessation treatment policies on quit attempts, use of evidence-based treatment, and quit rates. Cessation treatment policies would: (1) expand cessation treatment coverage and provider reimbursement; (2) mandate adequate funding for the use and promotion of evidence-based state-sponsored telephone quitlines; (3) support healthcare systems changes to prompt, guide, and incentivize tobacco treatment; (4) support and promote evidence-based treatment via the Internet; and (5) improve individually tailored, stepped-care approaches and the long-term effectiveness of evidence-based treatments. This series of papers provides an analytic framework to inform heuristic simulation models in order to take a new look at ways to markedly increase population smoking cessation by implementing a defined set of treatments and treatment-related policies with the potential to improve motivation to quit, evidence-based treatment use, and long-term effectiveness.