Germany SimSmoke: the effect of tobacco control policies on future smoking prevalence and smoking-attributable deaths in Germany

The smoking and vaping model, A user-friendly model for examining the country-specific impact of nicotine VAPING product use: application to Germany

BACKGROUND

Simulation models play an increasingly important role in tobacco control. Models examining the impact of nicotine vaping products (NVPs) and smoking tend to be highly specialized and inaccessible. We present the Smoking and Vaping Model (SAVM),a user-friendly cohort-based simulation model, adaptable to any country, that projects the public health impact of smokers switching to NVPs.

METHODS

SAVM compares two scenarios. The No-NVP scenario projects smoking rates in the absence of NVPs using population projections, deaths rates, life expectancy, and smoking prevalence. The NVP scenario models vaping prevalence and its impact on smoking once NVPs became popular. NVP use impact is estimated as the difference in smoking- and vaping-attributable deaths (SVADs) and life-years lost (LYLs) between the No-NVP and NVP scenarios. We illustrate SAVM's adaptation to the German adult ages 18+ population, the Germany-SAVM by adjusting the model using population, mortality, smoking and NVP use data.

RESULTS

Assuming that the excess NVP mortality risk is 5% that of smoking, Germany-SAVM projected 4.7 million LYLs and almost 300,000 SVADs averted associated with NVP use from 2012 to 2060. Increasing the excess NVP mortality risk to 40% with other rates constant resulted in averted 2.8 million LYLs and 200,000 SVADs during the same period.

CONCLUSIONS

SAVM enables non-modelers, policymakers, and other stakeholders to analyze the potential population health effects of NVP use and public health interventions.

US Nicotine Vaping Product SimSmoke Simulation Model: The Effect of Vaping and Tobacco Control Policies on Smoking Prevalence and Smoking-Attributable Deaths

The public health impact of nicotine vaping products (NVPs) is subject to a complex set of uncertain transitions between NVP and cigarette use. Instead, we apply an indirect method to gauge the impact of NVP use on smoking prevalence and smoking-attributable deaths (SADs) using the well-established SimSmoke tobacco control policy simulation model. Upon validating the model before NVPs were more widely used, we project a No-NVP (i.e., in the absence of NVPs) while controlling for the impact of cigarette-oriented policies. The net impact of NVPs on smoking prevalence is inferred by comparing the projected No-NVP smoking trends to corresponding trends from two US national surveys. Using the TUS-CPS estimates for the period 2012-2018, we estimate that adult smoking prevalence declined in relative terms by 9.7% (95% CI: 7.5-11.7%) for males and 10.7% (95% CI: 9.1-13.0%) for females. Compared to NHIS, smoking prevalence declined by 10.7% (95% CI: 6.8-14.6%) for males and 11.3% (95% CI: 7.4-15.6%) for females. These impacts were confined mainly to ages 18-44. Vaping-related reductions in smoking prevalence were projected to avert nearly 0.4 million SADs between 2012 and 2052. Our analysis indicates that NVP use is associated with substantial reductions in US smoking prevalence among younger adults.

England SimSmoke: the impact of nicotine vaping on smoking prevalence and smoking-attributable deaths in England

BACKGROUND AND AIMS

Whereas the use of nicotine vaping products (NVPs) is widespread, their impact on smoking prevalence is controversial. This study considered the potential impact of NVPs on smoking prevalence in England.

DESIGN

Indirect simulation model. The England SimSmoke model is validated through 2012, before NVP use became more widely used by smokers. Because information on NVP-related transitions is limited, an indirect method is used; the difference in observed smoking prevalence (reflecting NVPs) is compared with a 2012-2019 counterfactual No-NVP scenario (without NVPs) to estimate the impact of NVPs on smoking and smoking-attributable deaths.

SETTING

England, 2000-2019.

PARTICIPANTS

Nationally representative sample of population.

MEASUREMENTS

England's population, mortality rates and smoking prevalence estimates from three national surveys and tobacco control policies.

FINDINGS

Between 2000 and 2012, SimSmoke projected a decline in age 18+ smoking prevalence of 23.5% in men and 27.0% in women. These projections, as well as those by specific age groups, were generally consistent with findings from the three national surveys. Comparing 2012-2019 relative reduction in age 18+ prevalence from the Annual Population Survey (males, 27.5%) with the model-predicted No-NVP reduction (males, 7.3%), the implied NVP-attributable relative reduction in adult smoking prevalence was 20.2% (95% CI, 18.8%-22.0%) for males and 20.4% (18.7%-22.2%) for females. The NVP-attributable reduction was 27.2% (22.8%-31.6%) for males and 31.7% (27.4%-36.5%) for females ages 18-24 and 18.6% (15.2%-21.8%) for males and 15.0% (11.1%-18.8%) for females ages 25-34, with similar reductions for ages 35+. The implied reduction in smoking prevalence between 2012 and 2019 equates to 165 660 (132 453-199 501) averted deaths by 2052. Other surveys yielded smaller, but relatively consistent results.

CONCLUSIONS

An indirect method of simulation modelling indicates that substantial reductions in smoking prevalence occurred in England from 2012-2019 coinciding with the growth in nicotine vaping product use.

Estimating the impact of tax policy interventions on the projected number and prevalence of adults with type 2 diabetes in Germany between 2020 and 2040

INTRODUCTION

As a population-wide intervention, it has been proposed to raise taxes on unhealthy products to prevent diseases such as type 2 diabetes. In this study, we aimed to estimate the effect of tax policy interventions in 2020 on the projected prevalence and number of people with type 2 diabetes in the German adult population in 2040.

RESEARCH DESIGN AND METHODS

We applied an illness-death model and the German Diabetes Risk Score (GDRS) to project the prevalence and number of adults with type 2 diabetes in Germany under a base case scenario and under a tax policy intervention scenario. For the base case scenario, we assumed constant age-specific incidence rates between 2020 and 2040. For the intervention scenario, we assumed a 50% price increase for sugar-sweetened beverages, tobacco and red meat products in the year 2020. Based on price elasticities, we estimated the impact on these risk factors alone and in combination, and calculated subsequent reductions in the age-specific and sex-specific GDRS. These reductions were used to determine reductions in the incidence rate and prevalence using a partial differential equation.

RESULTS

Compared with the base case scenario, combined tax interventions in 2020 resulted in a 0.95 percentage point decrease in the prevalence of type 2 diabetes (16.2% vs 17.1%), which corresponds to 640 000 fewer prevalent cases of type 2 diabetes and a relative reduction by 6%.

CONCLUSIONS

Taxation of sugar-sweetened beverages, tobacco products and red meat by 50% modestly lowered the projected number and prevalence of adults with type 2 diabetes in Germany in 2040. Raising taxes on unhealthy products as a stand-alone measure may not be enough to attenuate the future rise of type 2 diabetes.

Impact of Tobacco Control Policies on Smoking-Related Cancer Incidence in Germany 2020 to 2050-A Simulation Study

BACKGROUND

Germany is known for its weak tobacco control. We aimed to provide projections of potentially avoidable cancer cases under different tobacco control policy intervention scenarios.

METHODS

To estimate numbers and proportions of potentially avoidable cancer cases under different policy intervention scenarios (cigarette price increases, comprehensive marketing ban, and plain packaging), we calculated cancer site-specific potential impact fractions by age, sex, and year of study period (2020-2050), considering latency periods between reduction in smoking prevalence and manifestation in declining cancer excess risks. To obtain estimates of future incident case numbers, we assumed a continuation of recent smoking trends, and combined German cancer registry data with forecasted population sizes, published effect sizes, and national daily smoking prevalence data.

RESULTS

Over a 30-year horizon, an estimated 13.3% (men 14.0% and women 12.2%) of smoking-related cancer cases could be prevented if a combination of different tobacco control policies were to be implemented in Germany, with repeated price increases being the most effective single policy (men 8.5% and women 7.3%). Extensive sensitivity analyses indicated that the model is fairly robust.

CONCLUSIONS

Our results suggest that the expected cancer incidence in Germany could be considerably reduced by implementing tobacco control policies as part of a primary cancer prevention strategy.

IMPACT

Our straightforward modeling framework enables a comparison of the impact of different health policy measures. To further accelerate the currently observed tentative trend of declining smoking prevalence in Germany and thereby curtail smoking-related cancer incidence, there is a great need to urgently intensify efforts in tobacco control.

Public attitudes towards healthcare policies promoting tobacco cessation in Germany: results from the representative German study on tobacco use (DEBRA study)

OBJECTIVE

The aim of this study was to assess public acceptance of four possible healthcare policies supporting tobacco dependence treatment in line with the Framework Convention for Tobacco Control, Article 14 recommendations in Germany.

DESIGN

Cross-sectional household survey.

SETTING

Data were drawn from the German population and collected through computer-assisted, face-to-face interviews.

PARTICIPANTS

Representative random sample of 2087 people (>14 years) from the German population.

OUTCOME MEASURES

Public acceptance was measured regarding (1) treatment cost reimbursement, (2) standard training for health professionals on offering cessation treatment, and making cessation treatment a standard part of care for smokers with (3) physical or (4) mental disorders. Association characteristics with smoking status and socio-economic status (SES) were assessed.

RESULTS

Support for all policies was high (50%-68%), even among smokers (48%-66%). Ex-smokers and never-smokers were more likely to support standard training on cessation for health professionals than current smokers (OR 1.43, 95% CI 1.07 to 1.92; OR 1.43; 95% CI 1.14 to 1.79, respectively). Ex-smokers were also more likely than current smokers to support cessation treatment for smokers with mental disorders (OR 1.39, 95% CI 1.11 to 1.73). Men were less likely than women to support cessation treatment for smokers with physical diseases (OR 0.74, 95% CI 0.60 to 0.91) and free provision of treatment (OR 0.80, 95% CI 0.66 to 0.97). Offering cessation treatment to smokers with physical disorders was generally more accepted than to those with mental health issues.

CONCLUSIONS

The majority of the German population supports healthcare policies to improve the availability and affordability of tobacco dependence treatment. Non-smokers were more supportive than current smokers of two of the four policies, but odds of support were only about 40% higher. SES characteristics were not consistently associated with public acceptance.

TRIAL REGISTRATION NUMBER

DRKS00011322.

Cancers Due to Smoking and High Alcohol Consumption

BACKGROUND

Tobacco and alcohol consumption are known causes of cancer. We set out to estimate the absolute numbers and proportions of cancer attributable to smoking and high alcohol consumption in Germany in 2018.

METHODS

Numbers and proportions (population-attributable fractions, PAF) were calculated by sex and age group for ages 35 to 84 years based on population projections, national cancer incidence and exposure data, and published relative risks.

RESULTS

For the year 2018 we estimated the smoking-attributable cancer burden to be 85 072 cases (men 58 760, women 26 312), corresponding to 19% of all incident cancers. The highest PAF was seen for lung cancer: 89% of male and 83% of female lung cancer cases are attributable to smoking. The cancer burden attributable to high alcohol consumption was estimated to be 9588 (men 8117, women 1471) cases (2% of all incident cancers). The highest PAF were observed for cancer of the oral cavity and pharynx (men 34%, women 6%) and squamous cell carcinoma of the esophagus (men 30%; women 5%).

CONCLUSIONS

A considerable proportion of cancer cases are attributable to smoking and high alcohol consumption. More rigorous prevention efforts are required to achieve significant reductions in the prevalence of these risk factors and the attributable cancer burden.

German Public Support for Tobacco Control Policy Measures: Results from the German Study on Tobacco Use (DEBRA), a Representative National Survey

Smoking prevalence in Germany remains high at approximately 28%. We assessed public support for tobacco legislation and associations between level of support and smoking and socio-demographic characteristics. Data from 2087 people were collected as part of the German Study on Tobacco Use ("DEBRA"): a nationally representative, face-to-face household survey. Public support was measured on total ban of sale, raising the minimum age for sales, taxation of tobacco industry sales, research into e-cigarettes, and ban of smoking in cars when children are present. Associations were assessed with multivariate logistic regression. Over 50% of the German population support taxing industry profits (57.3%) and assessing e-cigarettes as an aid to quit smoking (55.5%). Over 40% support raising the legal age of sale (43.1%), and 22.9% support a total ban on tobacco sales. A smoking ban in cars when children are present was most popular (71.5%), even among current smokers (67.0%). There is public support for stricter tobacco control measures in Germany. A smoking ban in cars when children are present could be a feasible policy to implement.

German EstSmoke: estimating adult smoking-related costs and consequences of smoking cessation for Germany

AIMS

We compared predicted life-time health-care costs for current, never and ex-smokers in Germany under the current set of tobacco control polices. We compared these economic consequences of the current situation with an alternative in which Germany were to implement more comprehensive tobacco control policies consistent with the World Health Organization (WHO) Framework Convention for Tobacco Control (FCTC) guidelines.

DESIGN

German EstSmoke, an adapted version of the UK EstSmoke simulation model, applies the Markov modelling approach. Transition probabilities for (re-)currence of smoking-related diseases were calculated from large German disease-specific registries and the German Health Update (GEDA 2010). Estimations of both health-care costs and effect sizes of smoking cessation policies were taken from recent German studies and discounted at 3.5%/year.

SETTING

Germany.

PARTICIPANTS

German population of prevalent current, never and ex-smokers in 2009.

MEASUREMENT

Life-time cost and outcomes in current, never and ex-smokers.

FINDINGS

If tobacco control policies are not strengthened, the German smoking population will incur €41.56 billion life-time excess costs compared with never smokers. Implementing tobacco control policies consistent with WHO FCTC guidelines would reduce the difference of life-time costs between current smokers and ex-smokers by at least €1.7 billion.

CONCLUSIONS

Modelling suggests that the life-time healthcare costs of people in Germany who smoke are substantially greater than those of people who have never smoked. However, more comprehensive tobacco control policies could reduce health-care expenditures for current smokers by at least 4%.

Public health benefits from pictorial health warnings on US cigarette packs: a SimSmoke simulation

INTRODUCTION

While many countries have adopted prominent pictorial warning labels (PWLs) for cigarette packs, the USA still requires only small, text-only labels located on one side of the cigarette pack that have little effect on smoking-related outcomes. Tobacco industry litigation blocked implementation of a 2011 Food and Drug Administration's (FDA) rule requiring large PWLs. To inform FDA action on PWLs, this study provides research-based estimates of their public health impacts.

METHODS

Literature was reviewed to identify the impact of cigarette PWLs on smoking prevalence, cessation and initiation. Based on this analysis, the SimSmoke model was used to estimate the effect of requiring PWLs in the USA on smoking prevalence and, using standard attribution methods, on smoking-attributable deaths (SADs) and key maternal and child health outcomes.

RESULTS

Available research consistently shows a direct association between PWLs and increased cessation and reduced smoking initiation and prevalence. The SimSmoke model projects that PWLs would reduce smoking prevalence by 5% (2.5%-9%) relative to the status quo over the short term and by 10% (4%-19%) over the long term. Over the next 50 years, PWLs are projected to avert 652 800 (327 000-1 190 500) SADs, 46 600 (17 500-92 300) low-birth-weight cases, 73 600 (27 800-145 100) preterm births and 1000 (400-2000) cases of sudden infant death syndrome.

CONCLUSIONS

Requiring PWLs on all US cigarette packs would be appropriate for the protection of the public health, because it would substantially reduce smoking prevalence and thereby reduce SADs and the morbidity and medical costs associated with adverse smoking-attributable birth outcomes.

Seven years of progress in tobacco control: an evaluation of the effect of nations meeting the highest level MPOWER measures between 2007 and 2014

OBJECTIVE

Since WHO released the package of six MPOWER measures to assist nations with implementing the WHO Framework Convention for Tobacco Control (FCTC), 88 countries adopted at least one highest level MPOWER measure. We estimated the subsequent reduction in smoking-related deaths from all new highest level measures adopted between 2007 and 2014.

METHODS

Policy effect sizes based on previously validated SimSmoke models were applied to the number of smokers in each nation to determine the reduction in the number of smokers from policy adoption. On the basis of research that half of all smokers die from smoking, we derived the smoking-attributable deaths (SADs) averted of those smokers alive today.

FINDINGS

In total, 88 countries adopted at least one highest level MPOWER policy between 2007 and 2014, resulting in almost 22 million fewer projected SADs. The largest number of future SADs averted was due to increased cigarette taxes (7.0 million), followed by comprehensive smoke-free laws (5.4 million), large graphic health warnings (4.1 million), comprehensive marketing bans (3.8 million) and comprehensive cessation interventions (1.5 million).

CONCLUSIONS

These findings demonstrate the immense public health impact of tobacco control policies adopted globally since the WHO-FCTC and highlight the importance of more countries adopting highest level MPOWER measures to reduce the global burden of tobacco use. Substantial additional progress could be made, especially if heavily populated nations with high smoking prevalence were to reach highest level MPOWER measures.

Substanzkonsum in der Allgemeinbevölkerung in Deutschland

Zusammenfassung. Ziel: Die Verbreitung des Substanzkonsums in der erwachsenen Allgemeinbevölkerung Deutschlands soll anhand aktueller Daten dargestellt werden. Methodik: Datengrundlage bildete der Epidemiologische Suchtsurvey 2015, eine bundesweite Befragung in der Wohnbevölkerung von 18 bis 64 Jahren (n = 9,204; Rücklaufquote: 52.2 %). Probanden wurden zum Gebrauch von Tabak, Alkohol, illegalen Drogen und Medikamenten befragt. Ergebnisse: In den letzten 30 Tagen hatten 28.7 % der Befragten Tabakprodukte genutzt. Den Konsum von Alkohol in diesem Zeitraum berichteten 72.8 %. Hinweise auf klinisch relevanten Konsum in den letzten 12 Monaten wiesen 28.3 % (Männer) bzw. 9.6 % (Frauen) auf. Die 12-Monats-Prävalenz illegaler Drogen lag bei 6.1 % für Cannabis und bei maximal 1 % für alle anderen Substanzen. Unter Medikamenten hatten Schmerzmittel die höchste Gebrauchsprävalenz (47.1 %) sowie die geringste Prävalenz täglichen Gebrauchs unter Nutzern (8.6 %). Schlussfolgerungen: Die Ergebnisse belegen die nach wie vor hohe Verbreitung des Substanzkonsums in der Allgemeinbevölkerung. Konsumprävalenz sowie Hinweise auf klinisch relevanten Konsum sind in Bezug auf legale Substanzen, die eine hohe Verfügbarkeit charakterisiert, am häufigsten. Hinweise auf klinisch relevanten Konsum illegaler Drogen bestanden bei deutlich weniger Personen. Da es sich dabei jedoch um eine besondere Risikogruppe handelt, ist deren Erreichung durch adäquate Angebote sicherzustellen.

Complying with the framework convention for tobacco control: an application of the Abridged SimSmoke model to Israel

BACKGROUND

The World Health Organization Framework Convention for Tobacco Control (FCTC) established the MPOWER policy package to provide practical country-level guidance on implementing effective policies to reduce smoking rates. The Abridged SimSmoke tobacco control policy simulation model is applied to Israel to estimate the effects on reducing smoking-attributable mortality resulting from full implementation of MPOWER policies.

METHODS

Smoking prevalence from the 2014 Israel National Health Interview Survey 3 and population data from the Israel Central Bureau of Statistics were used to calculate the number of current smokers. The status of current Israeli policy was determined using information from MPOWER 2015 and from local sources. Based on existing knowledge that between 50 % and 65 % of smokers will die prematurely from smoking, the model is used to determine mortality reductions among current smokers from full implementation of MPOWER policies.

RESULTS

We estimate that between 547 and 711 thousand smokers of the current 1.1 million Israeli smokers will prematurely die due smoking. Within 40 years, complete implementation of MPOWER policies is projected to reduce smoking prevalence among current smokers by 34% and avert between 187 and 243 thousand deaths. Taxes, smoke-free air laws, marketing restrictions and media campaigns each reduce smoking by about 5 % within 5 years. Improved cessation treatment and health warnings each have smaller effects in the next five years, but their effects grow rapidly over time.

CONCLUSIONS

Israel Abridged SimSmoke shows that complete implementation of the MPOWER strategies has the potential to substantially reduce smoking prevalence, and avert premature deaths due to smoking. Additional benefits are also expected from reduced morbidity, reduced initiation among nonsmokers, and reduction in exposure of nonsmokers to tobacco smoke.

Application of the Abridged SimSmoke model to four Eastern Mediterranean countries

INTRODUCTION

The WHO established the MPOWER policy package to boost the implementation of the WHO Framework Convention for Tobacco Control (WHO FCTC) in 2008 and to provide practical guidance on policies effective at reducing smoking rates. An easily applied Abridged SimSmoke was developed to help countries gauge the effect of these policies using data from the WHO MPOWER/WHO Report (MPOWER Report) and is applied to four Eastern Mediterranean countries.

METHODS

The number of smokers in a country is calculated using the country's smoking prevalence and population. Policy effect sizes, based on previously validated SimSmoke models, are applied to the smoker populations to determine the reduction in the number of smokers resulting from implementing policies. The number of smoking-attributable deaths is derived based on findings that half of those smokers alive today will die from smoking.

RESULTS

Within 40 years, implementing the complete set of MPOWER policies is projected to reduce smoking prevalence by 29% (range 15%, 41%) and avert almost 1 (range 0.5, 1.4) million deaths in Egypt, reduce smoking prevalence by 52% (range 36%, 66%) and avert 156 000 (106 000, 196 000) deaths in Lebanon, reduce smoking prevalence by 56% (range 40%, 69%) and avert 3.5 (range 2.5, 4.3) million deaths in Pakistan, and reduce smoking prevalence by 37% (range 21%, 51%) and avert 245 000 (range 138 000, 334 000) deaths in Tunisia.

CONCLUSIONS

The Abridged SimSmoke model has been used to show the number of deaths from smoking and how MPOWER policies can be used to reach the WHO non-communicable deaths voluntary target for cigarette use reduction in four countries.

The role of public policies in reducing smoking prevalence: results from the Michigan SimSmoke tobacco policy simulation model

INTRODUCTION

Michigan has implemented several of the tobacco control policies recommended by the World Health Organization MPOWER goals. We consider the effect of those policies and additional policies consistent with MPOWER goals on smoking prevalence and smoking-attributable deaths (SADs).

METHODS

The SimSmoke tobacco control policy simulation model is used to examine the effect of past policies and a set of additional policies to meet the MPOWER goals. The model is adapted to Michigan using state population, smoking, and policy data starting in 1993. SADs are estimated using standard attribution methods. Upon validating the model, SimSmoke is used to distinguish the effect of policies implemented since 1993 against a counterfactual with policies kept at their 1993 levels. The model is then used to project the effect of implementing stronger policies beginning in 2014.

RESULTS

SimSmoke predicts smoking prevalence accurately between 1993 and 2010. Since 1993, a relative reduction in smoking rates of 22 % by 2013 and of 30 % by 2054 can be attributed to tobacco control policies. Of the 22 % reduction, 44 % is due to taxes, 28 % to smoke-free air laws, 26 % to cessation treatment policies, and 2 % to youth access. Moreover, 234,000 SADs are projected to be averted by 2054. With additional policies consistent with MPOWER goals, the model projects that, by 2054, smoking prevalence can be further reduced by 17 % with 80,000 deaths averted relative to the absence of those policies.

CONCLUSIONS

Michigan SimSmoke shows that tobacco control policies, including cigarette taxes, smoke-free air laws, and cessation treatment policies, have substantially reduced smoking and SADs. Higher taxes, strong mass media campaigns, and cessation treatment policies would further reduce smoking prevalence and SADs.

Impact of a comprehensive law on the prevalence of tobacco consumption in Spain: evaluation of different scenarios

OBJECTIVES

Since 2011, smoking legislation was hardened in Spain, banning tobacco consumption in all hospitality venues. Law 42/2010 was the first comprehensive tobacco control policy enacted in Spain. The aim of this paper is to evaluate the effect that this intervention has had in reducing the prevalence of tobacco consumption, setting up three scenarios on the basis of different theoretical levels of effect of the law.

METHODS

A predictive model based on Markov Chains was developed to distinguish the effect of tobacco control policies in different scenarios.

STUDY DESIGN

The model developed uses population, smoking rates and smoking characteristics from a non-transmissible disease surveillance system developed in Galicia (namely SICRI).

RESULTS

Results show that tobacco control policies hardly affect the predicted trend in a temporal frame of 10 years, with relative reduction in the predicted male smoking prevalence of 20.4% with no intervention, reaching a reduction of 26.1% under the maximum effect of the policies.

CONCLUSIONS

In the global population the effects of the law in the predicted prevalence have been barely perceived. For people under 25 years of age, interventions have had an important and positive effect, which proves that policies affecting this age group should be hardened.

Gauging the Effect of U.S. Tobacco Control Policies From 1965 Through 2014 Using SimSmoke

INTRODUCTION

The year 2014 marked the 50th Anniversary of the first Surgeon General's Report. This paper estimates the effect of tobacco control policies in the U.S. after the 1964 Report using the SimSmoke tobacco control simulation model.

METHODS

SimSmoke uses National Health Interview Survey data from 1965 through 2012 on smoking prevalence, initiation, and cessation rates, and incorporates policies implemented since 1965. The model projects smoking prevalence and smoking-attributable deaths (SADs) from 1965 through 2065 and is validated against National Health Interview Survey data. Counterfactual scenarios with policies constant since 1965 and with individual policies are estimated. Analysis was conducted in February 2014.

RESULTS

SimSmoke generally validated well during the time period from 1965 through 2012. As a result of all policies, smoking prevalence is estimated to have fallen by almost 55% by 2014, with a total of 2 million SADs averted from 1965 through 2014, increasing to 20.1 million SADs by 2065. The Fairness Doctrine is estimated to have reduced adult smoking prevalence by about 24% by 2014 and averted 10.4 million SADs by 2065, while price increases reduced smoking prevalence by 24% by 2014 and averted 7.3 million SADs by 2065. Smoke-free air laws, cessation treatment, and tobacco control spending individually reduced smoking rates by 3%-5.5% by 2014.

CONCLUSIONS

By 2014, SimSmoke predicts a 53% reduction in smoking rates and almost 2 million SADs averted due to polices implemented since the 1964 Surgeon General's Report, with most of the health benefit still to occur in future years.

Estimating the Potential Impact of Tobacco Control Policies on Adverse Maternal and Child Health Outcomes in the United States Using the SimSmoke Tobacco Control Policy Simulation Model

INTRODUCTION

Numerous studies document the causal relationship between prenatal smoking and adverse maternal and child health (MCH) outcomes. Studies also reveal the impact that tobacco control policies have on prenatal smoking. The purpose of this study is to estimate the effect of tobacco control policies on prenatal smoking prevalence and adverse MCH outcomes.

METHODS

The US SimSmoke simulation model was extended to consider adverse MCH outcomes. The model estimates prenatal smoking prevalence and, applying standard attribution methods, uses estimates of MCH prevalence and relative smoking risks to estimate smoking-attributable MCH outcomes over time. The model then estimates the effect of tobacco control policies on adverse birth outcomes averted.

RESULTS

Different tobacco control policies have varying impacts on the number of smoking-attributable adverse MCH birth outcomes. Higher cigarette taxes and comprehensive marketing bans individually have the biggest impact with a 5% to 10% reduction across all outcomes for the period from 2015 to 2065. The policies with the lowest impact (2%-3% decrease) during this period are cessation treatment, health warnings, and complete smoke-free laws. Combinations of all policies with each tax level lead to 23% to 28% decreases across all outcomes.

CONCLUSIONS

Our findings demonstrate the substantial impact of strong tobacco control policies for preventing adverse MCH outcomes, including long-term health implications for children exposed to low birth weight and preterm birth. These benefits are often overlooked in discussions of tobacco control.

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.

Public Health Effects of Restricting Retail Tobacco Product Displays and Ads

OBJECTIVES

To estimate the public health impact from restricting US retail point-of-sale (POS) tobacco product displays and advertising.

METHODS

Based on existing research, this paper estimates the effects on initiation and cessation rates from restricting POS tobacco product displays and ads in the US and uses the SimSmoke simulation model to project related smoking declines and health benefits.

RESULTS

New comprehensive POS restrictions are projected to reduce smoking prevalence by approximately 16% [range=3%-31%] relative to the status quo by 2065, preventing about 630,000 smoking-attributable deaths [range=108,000-1,225,000], 215,000 low birth weight births [range=33,000-421,000], 140,000 preterm births [range=22,000-271,000], and 1900 infant deaths from SIDSs [range=300-3800].

CONCLUSIONS

Federal, state, or local action to restrict POS tobacco product displays and ads would contribute to a substantial reduction in smoking-attributed death and disease.

Modeling the potential effects of new tobacco products and policies: a dynamic population model for multiple product use and harm

BACKGROUND

Recent declines in US cigarette smoking prevalence have coincided with increases in use of other tobacco products. Multiple product tobacco models can help assess the population health impacts associated with use of a wide range of tobacco products.

METHODS AND FINDINGS

We present a multi-state, dynamical systems population structure model that can be used to assess the effects of tobacco product use behaviors on population health. The model incorporates transition behaviors, such as initiation, cessation, switching, and dual use, related to the use of multiple products. The model tracks product use prevalence and mortality attributable to tobacco use for the overall population and by sex and age group. The model can also be used to estimate differences in these outcomes between scenarios by varying input parameter values. We demonstrate model capabilities by projecting future cigarette smoking prevalence and smoking-attributable mortality and then simulating the effects of introduction of a hypothetical new lower-risk tobacco product under a variety of assumptions about product use. Sensitivity analyses were conducted to examine the range of population impacts that could occur due to differences in input values for product use and risk. We demonstrate that potential benefits from cigarette smokers switching to the lower-risk product can be offset over time through increased initiation of this product. Model results show that population health benefits are particularly sensitive to product risks and initiation, switching, and dual use behaviors.

CONCLUSION

Our model incorporates the variety of tobacco use behaviors and risks that occur with multiple products. As such, it can evaluate the population health impacts associated with the introduction of new tobacco products or policies that may result in product switching or dual use. Further model development will include refinement of data inputs for non-cigarette tobacco products and inclusion of health outcomes such as morbidity and disability.

Modelling the implications of regular increases in tobacco taxation in the tobacco endgame

OBJECTIVE

We examine the potential role for taxation in the tobacco endgame in New Zealand, where the goal is to become 'smokefree' (less than 5% smoking prevalence) by 2025.

DESIGN

Modelling study using a dynamic population model.

SETTING AND PARTICIPANTS

New Zealand, Māori and non-Māori men and women.

INTERVENTIONS

Annual increases in tobacco excise tax of 5%, 10%, 15% and 20% (with 10% reflecting the annual increase recently legislated by the New Zealand Government to 2016).

RESULTS

With a continued commitment to annual 10% increases in tobacco excise tax, in addition to on-going Quitline and cessation support, New Zealand's smoking prevalence is projected to fall from 15.1% in 2013 to 8.7% (95% uncertainty interval 8.6% to 8.9%) by 2025. This is compared to 9.9% without any further tax rises. With annual tax increases of 20%, the prevalence is projected to fall to 7.6% (7.5% to 7.7%) by 2025. The potential reductions in smoking prevalence are substantial for both Māori and non-Māori populations, although annual tax increases as high as 20% will still only see Māori smoking prevalence in 2025 approaching the non-Māori smoking levels for 2013. Scenario analyses did not suggest that growth of the illicit tobacco market would substantively undermine the impact of tobacco tax rises. Nevertheless, unknown factors such as the gradual denormalisation of smoking and changes to the 'nicotine market' may influence sensitivity to changes in tobacco prices in the future.

CONCLUSIONS

Regular increases in tobacco taxation could play an important role in helping to achieve tobacco endgames. However, this modelling in New Zealand suggests that a wider range of tobacco endgame strategies will be needed to achieve a smoke-free goal of less than 5% prevalence for all social groups--a conclusion that could also apply in other countries.

Smoking-related deaths averted due to three years of policy progress

OBJECTIVE

To evaluate the global impact of adopting highest-level MPOWER tobacco control policies in different countries and territories from 2007 to 2010.

METHODS

Policy effect sizes based on previously-validated SimSmoke models were applied to determine the reduction in the number of smokers as a result of policy adoption during this period. Based on previous research suggesting that half of all smokers die from smoking, we also derived the estimated smoking-attributable deaths (SADs) averted due to MPOWER policy implementation. The results from use of this simple yet powerful method are consistent with those predicted by using previously validated SimSmoke models.

FINDINGS

In total, 41 countries adopted at least one highest-level MPOWER policy between 2007 and 2010. As a result of all policies adopted during this period, the number of smokers is estimated to have dropped by 14.8 million, with a total of 7.4 million SADs averted. The largest number of SADs was averted as a result of increased cigarette taxes (3.5 million), smoke-free air laws (2.5 million), health warnings (700,000), cessation treatments (380,000), and bans on tobacco marketing (306,000).

CONCLUSION

From 2007 to 2010, 41 countries and territories took action that will collectively prevent nearly 7.5 million smoking-related deaths globally. These findings demonstrate the magnitude of the actions already taken by countries and underscore the potential for millions of additional lives to be saved with continued adoption of MPOWER policies.

The benefits from complying with the framework convention on tobacco control: a SimSmoke analysis of 15 European nations

INTRODUCTION

This article compares the predicted impact of tobacco tax increases alone and as part of a comprehensive tobacco control strategy on smoking prevalence and smoking-attributable deaths (SADs) across 15 European countries.

METHODS

Country-specific population, smoking prevalence and policy data with modified parameter values have been applied to the previously validated SimSmoke model for 10 high-income and 5 middle-income European nations. The impact of past and potential future policies is modelled.

RESULTS

Models generally validated well across the 15 countries, and showed the impact of past policies. Without stronger future policies, 44 million lives would be lost due to smoking across the 15 study countries between 2011 and 2040, but effective policies could avert 7.7 million of those premature deaths.

CONCLUSIONS

Results suggest that past policies have been effective in reducing smoking rates, but there is also a strong potential for future policies consistent with the Framework Convention on Tobacco Control. When specific taxes are increased to 70% of retail price, strong smoke-free air laws, youth access laws and marketing restrictions are enforced, stronger health warnings are implemented, and cessation treatment and media campaigns are supported, smoking prevalence and SADs will fall substantially in European countries.

The Brazil SimSmoke policy simulation model: the effect of strong tobacco control policies on smoking prevalence and smoking-attributable deaths in a middle income nation

BACKGROUND

Brazil has reduced its smoking rate by about 50% in the last 20 y. During that time period, strong tobacco control policies were implemented. This paper estimates the effect of these stricter policies on smoking prevalence and associated premature mortality, and the effect that additional policies may have.

METHODS AND FINDINGS

The model was developed using the SimSmoke tobacco control policy model. Using policy, population, and smoking data for Brazil, the model assesses the effect on premature deaths of cigarette taxes, smoke-free air laws, mass media campaigns, marketing restrictions, packaging requirements, cessation treatment programs, and youth access restrictions. We estimate the effect of past policies relative to a counterfactual of policies kept to 1989 levels, and the effect of stricter future policies. Male and female smoking prevalence in Brazil have fallen by about half since 1989, which represents a 46% (lower and upper bounds: 28%-66%) relative reduction compared to the 2010 prevalence under the counterfactual scenario of policies held to 1989 levels. Almost half of that 46% reduction is explained by price increases, 14% by smoke-free air laws, 14% by marketing restrictions, 8% by health warnings, 6% by mass media campaigns, and 10% by cessation treatment programs. As a result of the past policies, a total of almost 420,000 (260,000-715,000) deaths had been averted by 2010, increasing to almost 7 million (4.5 million-10.3 million) deaths projected by 2050. Comparing future implementation of a set of stricter policies to a scenario with 2010 policies held constant, smoking prevalence by 2050 could be reduced by another 39% (29%-54%), and 1.3 million (0.9 million-2.0 million) out of 9 million future premature deaths could be averted.

CONCLUSIONS

Brazil provides one of the outstanding public health success stories in reducing deaths due to smoking, and serves as a model for other low and middle income nations. However, a set of stricter policies could further reduce smoking and save many additional lives. Please see later in the article for the Editors' Summary.

The effect of tobacco control policies on smoking prevalence and smoking-attributable deaths. Findings from the Netherlands SimSmoke Tobacco Control Policy Simulation Model

AIM

To develop a simulation model projecting the effect of tobacco control policies in the Netherlands on smoking prevalence and smoking-attributable deaths.

DESIGN, SETTING AND PARTICIPANTS

Netherlands SimSmoke-an adapted version of the SimSmoke simulation model of tobacco control policy-uses population, smoking rates and tobacco control policy data for the Netherlands to predict the effect of seven types of policies: taxes, smoke-free legislation, mass media, advertising bans, health warnings, cessation treatment and youth access policies.

MEASUREMENTS

Outcome measures were smoking prevalence and smoking-attributable deaths.

FINDINGS

With a comprehensive set of policies, as recommended by MPOWER, smoking prevalence can be decreased by as much as 21% in the first year, increasing to a 35% reduction in the next 20 years and almost 40% by 30 years. By 2040, 7706 deaths can be averted in that year alone with the stronger set of policies. Without effective tobacco control policies, almost a million lives will be lost to tobacco-related diseases between 2011 and 2040. Of those, 145,000 can be saved with a comprehensive tobacco control package.

CONCLUSIONS

Smoking prevalence and smoking-attributable deaths in the Netherlands can be reduced substantially through tax increases, smoke-free legislation, high-intensity media campaigns, stronger advertising bans and health warnings, comprehensive cessation treatment and youth access laws. The implementation of these FCTC/MPOWER recommended policies could be expected to show similar or even larger relative reductions in smoking prevalence in other countries which currently have weak policies.