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

Cost-Effectiveness of Four Tobacco Control Interventions in Mongolia

INTRODUCTION

The aim of this study is to quantify the cost-effectiveness of four tobacco control interventions: Tobacco taxation, mass media campaigns, school programs, and cessation support, and to illustrate how available evaluation tools can be adapted to the local setting.

AIMS AND METHODS

We used the dynamic population health modeling-health impact assessment tool to project the future smoking prevalence associated with the interventions and to simulate the resulting smoking-related disease burden over time. Applying the most recent available national Mongolian data as input, the costs and effects of four interventions were compared to a business-as-usual scenario, resulting in costs per life year gained and per disability-adjusted life years (DALYs) averted.

RESULTS

Three years after implementation, all interventions reduce the prevalence of current smoking, with the strongest reduction observed with the increase in tobacco tax (5.1% points), followed by mass media campaigns (1.6% points), school programs (1.3% points), and cessation support interventions (0.6% points). School programs were a cost-saving tobacco control intervention compared to current practice in Mongolia, while the other programs resulted in additional costs compared to business as usual. Compared to the World Health Organization (WHO) thresholds, all interventions would be considered "very cost-effective" in terms of cost per DALY averted (below US$ 4295 per DALY averted) in Mongolia.

CONCLUSIONS

Large-scale interventions such as taxation and mass media campaigns result in both cost-effectiveness and important health benefits in relation to intervention costs. Reducing the prevalence of smoking among the male population would be particularly worthwhile in Mongolia.

IMPLICATIONS

This study shows that in Mongolia school programs were a cost-saving intervention, while the cost-effectiveness ratios were US$ 25 per disability-adjusted life year (DALY) averted for mass media campaigns, US$ 74 for taxation, and US$ 1961 for cessation support interventions. Compared to the WHO thresholds, all interventions would be considered "very cost-effective" in terms of expenses per DALY averted ( Collapse

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MESH Headings

• Humans
• Male
• Cost-Benefit Analysis
• Tobacco Control
• Mongolia/epidemiology
• Smoking/epidemiology
• Cost of Illness

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Grants

• Mongolian government and the UMCG

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Affiliation(s)

Ariuntuya Tuvdendorj Department of Health Policy, School of Public Health, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
Talitha Feenstra Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands Faculty of Science and Engineering, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands Faculty of Science and Engineering, Centre for Nutrition, Prevention, and Health Services, Institute for Public Health and the Environment, Bilthoven, The Netherlands
Erik Buskens Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands

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Identifying best modelling practices for tobacco control policy simulations: a systematic review and a novel quality assessment framework

BACKGROUND

Policy simulation models (PSMs) have been used extensively to shape health policies before real-world implementation and evaluate post-implementation impact. This systematic review aimed to examine best practices, identify common pitfalls in tobacco control PSMs and propose a modelling quality assessment framework.

METHODS

We searched five databases to identify eligible publications from July 2013 to August 2019. We additionally included papers from Feirman et al for studies before July 2013. Tobacco control PSMs that project tobacco use and tobacco-related outcomes from smoking policies were included. We extracted model inputs, structure and outputs data for models used in two or more included papers. Using our proposed quality assessment framework, we scored these models on population representativeness, policy effectiveness evidence, simulated smoking histories, included smoking-related diseases, exposure-outcome lag time, transparency, sensitivity analysis, validation and equity.

FINDINGS

We found 146 eligible papers and 25 distinct models. Most models used population data from public or administrative registries, and all performed sensitivity analysis. However, smoking behaviour was commonly modelled into crude categories of smoking status. Eight models only presented overall changes in mortality rather than explicitly considering smoking-related diseases. Only four models reported impacts on health inequalities, and none offered the source code. Overall, the higher scored models achieved higher citation rates.

CONCLUSIONS

While fragments of good practices were widespread across the reviewed PSMs, only a few included a 'critical mass' of the good practices specified in our quality assessment framework. This framework might, therefore, potentially serve as a benchmark and support sharing of good modelling practices.

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.

Modeling cigarette smoking disparities between people with and without serious psychological distress in the US, 1997-2100

Cigarette smoking rates are significantly higher among people with serious psychological distress (SPD) compared to the general population. US simulation models that project future smoking disparities by SPD status could inform policy interventions, but have not been developed. We calibrated two compartmental models to the National Health Interview Survey 1997-2018 for populations with and without SPD, calculating smoking prevalence, mortality, and life-years lost by SPD status under different scenarios from 2023 to 2100. Under the Status Quo, smoking prevalence among women with SPD falls from 27.0% in 2023 to 10.7% in 2100 (men: 30.1% to 12.2%). For women without SPD, it declines from 9.4% to 3.1% (men: 11.5% to 4.0%). The absolute difference in smoking prevalence between those with and without SPD decreases over time, whereas the relative smoking prevalence ratio increases. From 2023 to 2100, 609,000 premature smoking-attributable deaths would occur in the SPD population, with 8 million life-years lost. Under an ideal tobacco control scenario for people with SPD, in which all smokers quit in 2023 and no new smoking initiation occurs thereafter, up to 386,000 of these premature deaths could be averted with 4.9 million life-years gained. Preventing smoking initiation could avert up to 18% of these deaths, while improving smoking cessation could avert up to 82%. Smoking-related disparities for people with SPD will persist unless a shift in tobacco control substantially improves cessation and prevents initiation in this subpopulation. Smoking disparities by SPD may widen in relative but narrow in absolute terms, so both perspectives should be evaluated.

Cost-Effectiveness Analysis of Smoking Cessation Interventions With Behavioral Support: A Study Based on the Benefits of Smoking Cessation on Outcomes (BENESCO) Model

INTRODUCTION

Few studies have compared cost-effectiveness of different smoking cessation interventions (SCIs) that include behavioral support, considering smoking-related diseases. Therefore, we compare the cost-effectiveness of SCIs with behavioral support in South Korea using the Benefits of Smoking Cessation on Outcomes (BENESCO) model.

AIMS AND METHODS

We used the BENESCO model to estimate the cost and utility of the SCIs with behavioral support, including pharmacist counseling with nicotine replacement therapy (pharmacist+NRT), expert counseling with NRT (expert+NRT), and expert counseling with varenicline (expert+varenicline). The target population was adult smokers who wanted to cease smoking within 1 month. We applied transitional probabilities and epidemiological data from the literature. Medical costs and utilities were calculated using claims and national survey data, respectively. Cost-effectiveness was evaluated within the threshold (17 926 USD per quality-adjusted life years [QALYs]) by incremental cost-effectiveness ratio (ICER).

RESULTS

The model cohort included 1 219 390 male and 298 511 female smokers. The pharmacist+NRT group had 32 842 more QALYs gained and 26 689 958 USD less expended than the expert+NRT group. The ICER for the expert+varenicline group versus the pharmacist+NRT and expert+NRT groups was 27 247 and 4074 USD per QALY, respectively. The robustness of the results was confirmed by sensitivity analyses, except for the discount rate and cost of the expert+varenicline group.

CONCLUSIONS

In Korea, pharmacist counseling with NRT showed higher QALY gains and lower costs than expert counseling with NRT. Expert counseling with varenicline was more effective for smoking cessation and more cost-effective than expert counseling with NRT but was not cost-effective compared with pharmacist counseling with NRT.

IMPLICATIONS

This study provides evidence for decision-making on smoking cessation programs by evaluating the cost-effectiveness of SCIs. Furthermore, we attempted to use the BENESCO model to compare and evaluate the cost-effectiveness of SCIs with behavioral support. It is meaningful because this study showed the availability of using the BENESCO model in the future cost-effectiveness analysis of various SCIs.

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.

Estimated Prevalence of Smoking and Smoking-Attributable Mortality Associated With Graphic Health Warnings on Cigarette Packages in the US From 2022 to 2100

Importance

Starting in 2022, the US Food and Drug Administration (FDA) plans to require all cigarette packages in the US to display graphic health warnings depicting health harms associated with smoking. The FDA originally planned to implement such warnings in 2012, but tobacco industry litigation delayed the effort.

Objective

To assess the estimated population health outcomes associated with a policy requiring graphic health warnings on cigarette packages in the US and with a 10-year delay in implementation.

Design Setting and Participants

This decision analytical model used simulation modeling of smoking prevalence and smoking-attributable mortality in the US from 2012 to 2100, using the Cancer Intervention and Surveillance Modeling Network smoking population model. The study was conducted from October 2020 to July 2021.

Main Outcomes and Measures

The primary outcomes were annual adult smoking prevalence, smoking-attributable deaths averted, and life-years gained vs the baseline scenario. A baseline scenario assuming no graphic health warnings was compared with expected outcomes of implementing graphic health warnings in 2022 vs 2012. Policy effects were considered under varying assumptions of the association of the policy with smoking initiation and cessation, ranging from most conservative to most optimistic. A maximum smoking reduction scenario in which all smoking would stop by the end of 2022 was evaluated.

Results

In the baseline scenario, an estimated 13.2 million smoking-attributable deaths would have occurred from 2012 to 2100. Under a maximum smoking-reduction scenario, 5.5 million of these deaths would be averted. Implementation of graphic health warnings from 2022 to 2100 would be associated with 539 000 (range, 275 000-794 000) smoking-attributable deaths averted and 7.9 million (range, 4.0-11.6 million) life-years gained, representing less than 10% of the 5.5 million estimated smoking-attributable deaths averted and 81.8 million life-years gained in the maximum smoking-reduction scenario. Implementation from 2012 to 2100 would be associated with 33.2% (range, 32.9%-33.5%) more deaths averted (718 000; range, 365 000 to 1.1 million) and 42.7% (range, 42.3%-43.1%) more life-years gained (11.2 million; range, 5.7-16.6 million) compared with implementation in 2022.

Conclusions and Relevance

This decision analytical model estimated that FDA cigarette graphic health warnings, if implemented in 2022, would be associated with public health benefits. The model also estimated that more smoking-attributable deaths would have been averted if the policy had been implemented in 2012. Industry litigation and delays to implementing tobacco regulations may have been harmful for public health.

What is the likely impact on surgical site infections in Australian hospitals if smoking rates are reduced? A cost analysis

INTRODUCTION

Assisting smokers to quit before surgery reduces surgical site infection (SSI) risk. The short-term economic benefits of reducing SSIs by embedding tobacco dependence treatment in Australian hospitals are unknown. Estimated annual number of SSIs prevented, and hospital bed-days (HBD) and costs saved from reducing smoking before surgery are calculated.

METHODS

The most recent number of surgical procedures and SSI rates for Australia were sourced. The number of smokers and non-smokers having a SSI were calculated using the UK Royal College of Physicians reported adjusted odds ratio (1.79), and the proportion of SSIs attributable to smoking calculated. The potential impact fraction was used to estimate reductions in SSIs and associated HBDs and costs from reducing the smoking rates among surgical patients from 23.9% to 10% or 5% targets. Uncertainty around the final estimates was calculated using probabilistic sensitivity analysis.

RESULTS

In 2016-17, approximately 40,593 (95% UI 32,543, 50,239) people having a surgical procedure in Australia experienced a SSI leading to 101,888 extra days (95% UI 49,988, 200,822) in hospital. If the smoking rate among surgical patients was reduced to 10%, 3,580 (95% UI 2,312, 5,178) SSIs would be prevented, and 8,985 (95% UI 4,094, 19,153) HBDs and $19.1M (95% UI $7.7M, $42.5M) saved in one year. If the smoking rate was reduced to 5%, 4,867 (95% UI 3,268, 6,867) SSIs would be prevented, and 12,217 (95% UI 5,614, 25,642) HBDs and $26.0M (95% UI $10.8M, $57.0M) would be saved.

CONCLUSIONS

The findings suggest achieving smoking rate targets of 10% or 5% would provide substantial short-term health and economic benefits through reductions in SSIs. Embedding tobacco dependence treatment in Australian hospitals would provide value for money by reducing costs and improving clinical quality and safety. A more comprehensive, modelled economic evaluation synthesising the best available evidence is needed to confirm findings.

Tobacco Control Policy Simulation Models: Protocol for a Systematic Methodological Review

Background

Tobacco control models are mathematical models predicting tobacco-related outcomes in defined populations. The policy simulation model is considered as a subcategory of tobacco control models simulating the potential outcomes of tobacco control policy options. However, we could not identify any existing tool specifically designed to assess the quality of tobacco control models.

Objective

The aims of this systematic methodology review are to: (1) identify best modeling practices, (2) highlight common pitfalls, and (3) develop recommendations to assess the quality of tobacco control policy simulation models. Crucially, these recommendations can empower model users to assess the quality of current and future modeling studies, potentially leading to better tobacco policy decision-making for the public. This protocol describes the planned systematic review stages, paper inclusion and exclusion criteria, data extraction, and analysis.

Methods

Two reviewers searched five databases (Embase, EconLit, PsycINFO, PubMed, and CINAHL Plus) to identify eligible studies published between July 2013 and August 2019. We included papers projecting tobacco-related outcomes with a focus on tobacco control policies in any population and setting. Eligible papers were independently screened by two reviewers. The data extraction form was designed and piloted to extract model structure, data sources, transparency, validation, and other qualities. We will use a narrative synthesis to present the results by summarizing model trends, analyzing model approaches, and reporting data input and result quality. We will propose recommendations to assess the quality of tobacco control policy simulation models using the findings from this review and related literature.

Results

Data collection is in progress. Results are expected to be completed and submitted for publication by April 2021.

Conclusions

This systematic methodological review will summarize the best practices and pitfalls existing among tobacco control policy simulation models and present a recommendation list of a high-quality tobacco control simulation model. A more standardized and quality-assured tobacco control policy simulation model will benefit modelers, policymakers, and the public on both model building and decision making.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42020178146; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020178146

International Registered Report Identifier (IRRID)

DERR1-10.2196/26854

Overview of tobacco use transitions for population health

The Family Smoking Prevention and Tobacco Control Act provided the US Food and Drug Administration authority to regulate tobacco products using a population health standard. Models have been developed to estimate the population health impacts of tobacco initiation, cessation and relapse transitions. Models should be informed by high-quality, longitudinal data to estimate these constructs. Simulation studies have generated data to predict the impact of various tobacco control interventions, including the influence of regulations on tobacco use behaviours and health. The purpose of this paper is to provide a high-level conceptual overview for understanding tobacco transition behaviours and correlates of these behaviours using data from the Population Assessment of Tobacco and Health (PATH) Study, a US nationally representative longitudinal tobacco study of about 46 000 persons aged 12+ years. The papers that follow in this journal issue build and expand on this conceptual overview using data from the first three waves of the PATH Study. These papers describe use patterns of different tobacco products and their correlates, and can serve as foundations for more in-depth papers that will help the research community better understand the population health impacts and drivers of different tobacco use patterns.

Estimating the Population Health Impact of Recently Introduced Modified Risk Tobacco Products: A Comparison of Different Approaches

INTRODUCTION

Various approaches have been used to estimate the population health impact of introducing a Modified Risk Tobacco Product (MRTP).

AIMS AND METHODS

We aimed to compare and contrast aspects of models considering effects on mortality that were known to experts attending a meeting on models in 2018.

RESULTS

Thirteen models are described, some focussing on e-cigarettes, others more general. Most models are cohort-based, comparing results with or without MRTP introduction. They typically start with a population with known smoking habits and then use transition probabilities either to update smoking habits in the "null scenario" or joint smoking and MRTP habits in an "alternative scenario". The models vary in the tobacco groups and transition probabilities considered. Based on aspects of the tobacco history developed, the models compare mortality risks, and sometimes life-years lost and health costs, between scenarios. Estimating effects on population health depends on frequency of use of the MRTP and smoking, and the extent to which the products expose users to harmful constituents. Strengths and weaknesses of the approaches are summarized.

CONCLUSIONS

Despite methodological differences, most modellers have assumed the increase in risk of mortality from MRTP use, relative to that from cigarette smoking, to be very low and have concluded that MRTP introduction is likely to have a beneficial impact. Further model development, supplemented by preliminary results from well-designed epidemiological studies, should enable more precise prediction of the anticipated effects of MRTP introduction.

IMPLICATIONS

There is a need to estimate the population health impact of introducing modified risk nicotine-containing products for smokers unwilling or unable to quit. This paper reviews a variety of modeling methodologies proposed to do this, and discusses the implications of the different approaches. It should assist modelers in refining and improving their models, and help toward providing authorities with more reliable estimates.

Informing policy makers on the efficiency of population level tobacco control interventions in Asia: A systematic review of model-based economic evaluations

BACKGROUND

Economic evaluations of tobacco control interventions support decisions regarding resource allocation in public health policy. Our systematic review was aimed at identifying potential bias in decision models used to estimate the long-term costs and effects of population-based tobacco control interventions in Asia.

METHODS

We included studies conducted in Asian countries and using a modelling technique to evaluate the economic impacts of one or more population-based tobacco interventions in line with the Framework Convention on Tobacco Control (FCTC). We assessed the structure, input parameters, and risk of bias for each model, and performed a narrative synthesis of the included studies.

RESULTS

Nine model-based economic evaluation studies of population-based tobacco interventions were identified. About 60% of the criteria for reporting quality were met in all studies, indicating that reporting generally lacked transparency. The studies were highly heterogeneous in terms of the scope, types, and structures of their models and the quality of input parameters. One-third of the models applied in the studies scored a high risk of bias, with problems mostly falling into the following categories: model type, time horizons, and smoking transition probabilities.

CONCLUSIONS

More data are needed to provide high-quality evidence regarding the cost-effectiveness of tobacco control policies in Asia. Strong evidence at the country level hinges on the availability of accurate estimates of the effects of the interventions, the relative risks of smoking, and the price elasticity of the demand for tobacco. Simple transfers of models built in Western populations do not suffice.

PROTOCOL REGISTRATION

PROSPERO CRD 42019141679.

Simulating future public health benefits of tobacco control interventions: a systematic review of models

BACKGROUND

To prioritise tobacco control interventions, simulating their health impacts is valuable. We undertook a systematic review of tobacco intervention simulation models to assess model structure and input variations that may render model outputs non-comparable.

METHODS

We applied a Medline search with keywords intersecting modelling and tobacco. Papers were limited to those modelling health outputs (eg, mortality, health-adjusted life years), and at least two of cancer, cardiovascular and respiratory diseases. Data were extracted for each simulation model with ≥3 arising papers, including: model type, untimed or with time steps and trends in business-as-usual (BAU) tobacco prevalence and epidemiology.

RESULTS

Of 1911 papers, 186 met the inclusion criteria, including 13 eligible simulation models. The SimSmoke model had the largest number of publications (n=46), followed by Benefits of Smoking Cessation on Outcomes (n=12) and Tobacco Policy Model (n=10). Two of 13 models only estimated deaths averted, 1 had no time steps, 5 had no future trends in BAU tobacco prevalence, 9 had no future trends in BAU disease epidemiology and 7 had no time lags from quitting tobacco to reversal of health harm.

CONCLUSIONS

Considerable heterogeneity exists in simulation models, making outputs substantively non-comparable between models. Ranking of interventions by one model may be valid. However, this may not be true if, for example, interventions that differentially affect age groups (eg, a tobacco-free generation policy vs increased cessation among adults) do not account for plausible future trends. Greater standardisation of model structures and outputs will allow comparison across models and countries, and for comparisons of the impact of tobacco control interventions with other preventive interventions.

Risk Assessment for Tobacco Regulation

Risk assessment is a process that uses a transparent, reproducible and pre-established methodology to evaluate alternatives for managing health-related risks. Although an array of federal agencies regularly use risk assessment to inform regulatory decisions, its application to tobacco regulation is new. By comparing examples of FDA risk assessments for food and tobacco, this paper highlights some of the challenges inherent in applying risk assessment methodologies to tobacco regulation. In doing so, it calls upon researchers to work with the FDA to develop a tobacco-specific approach to risk assessment that reflects the Tobacco Control Act's regulatory framework and the distinctive features of tobacco products and tobacco use.

Estimates of effectiveness and reach for 'return on investment' modelling of smoking cessation interventions using data from England

BACKGROUND AND AIMS

Estimating 'return on investment' (ROI) from smoking cessation interventions requires reach and effectiveness parameters for interventions for use in economic models such as the EQUIPT ROI tool (http://roi.equipt.eu). This paper describes the derivation of these parameter estimates for England that can be adapted to create ROI models for use by other countries.

METHODS

Estimates were derived for interventions in terms of their reach and effectiveness in: (1) promoting quit attempts and (2) improving the success of quit attempts (abstinence for at least 12 months). The sources were systematic reviews of efficacy supplemented by individual effectiveness evaluations and national surveys.

FINDINGS

Quit attempt rates were estimated to be increased by the following percentages (with reach in parentheses): 20% by tax increases raising the cost of smoking 5% above the cost of living index (100%); 10% by enforced comprehensive indoor public smoking bans (100%); 3% by mass media campaigns achieving 400 gross rating points (100%); 40% by brief opportunistic physician advice (21%); and 110% by use of a licensed nicotine product to reduce cigarette consumption (12%). Quit success rates were estimated to be increased by the following ratios: 60% by single-form nicotine replacement therapy (NRT) (5%); 114% by NRT patch plus a faster-acting NRT (2%);124% by prescribed varenicline (5%); 60% by bupropion (1%); 100% by nortriptyline (0%), 10) 298% by cytisine (0%); 40% by individual face-to-face behavioural support (2%); 37% by telephone support (0.5%); 88% by group behavioural support (1%); 63% by text messaging (0.5%); and 19% by printed self-help materials (1%). There was insufficient evidence to obtain reliable, country-specific estimates for interventions such as websites, smartphone applications and e-cigarettes.

CONCLUSIONS

Tax increases, indoor smoking bans, brief opportunistic physician advice and use of nicotine replacement therapy (NRT) for smoking reduction can all increase population quit attempt rates. Quit success rates can be increased by provision of NRT, varenicline, bupropion, nortriptyline, cytisine and behavioural support delivered through a variety of modalities. Parameter estimates for the effectiveness and reach of these interventions can contribute to return on investment estimates in support of national or regional policy decisions.

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.

Application of Discrete-Choice Experiment Methods in Tobacco Control: A Systematic Review

BACKGROUND

Economic evidence relating to tobacco control is generally derived from the cost effectiveness of smoking-cessation programs or the economic impact of tobacco-induced disease, based on revealed-preference data. However, empirical estimates from stated-preference data on tobacco users' preferences, smoking behaviour and smoking cessation aids using analytical techniques such as discrete-choice experiments (DCEs) could be important for policy decision making in tobacco control.

OBJECTIVES

Our objective was to review the practice and utility of DCE methodology across nicotine- and tobacco-related issues, particularly smoking and smoking-cessation behaviour, anti-smoking policies and preferences for smoking-cessation aids.

METHODS

We searched the PubMed, MEDLINE and ECONLIT databases for full-text original research articles on tobacco-related issues published between January 2000 and April 2016 that used a DCE method. We summarised the evidence and methodological characteristics of DCEs according to Lancsar and Louviere, 2008.

RESULTS

Our review of the 12 eligible studies showed that DCE methodology was used to elicit smoker preferences and to evaluate tobacco-control policies. The majority of the studies were published in the last 5 years. The areas of application were smoking cessation, smoking behaviour, electronic cigarette use, water-pipe smoking and tobacco packaging. Monetary attributes were the most influential attributes in all studies. The design of the DCEs varied.

CONCLUSION

DCE studies of tobacco-related issues were methodologically consistent with guidelines proposed for conducting health-related DCEs.

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%.

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.

Impact of five tobacco endgame strategies on future smoking prevalence, population health and health system costs: two modelling studies to inform the tobacco endgame

OBJECTIVE

There is growing international interest in advancing 'the tobacco endgame'. We use New Zealand (Smokefree goal for 2025) as a case study to model the impacts on smoking prevalence (SP), health gains (quality-adjusted life-years (QALYs)) and cost savings of (1) 10% annual tobacco tax increases, (2) a tobacco-free generation (TFG), (3) a substantial outlet reduction strategy, (4) a sinking lid on tobacco supply and (5) a combination of 1, 2 and 3.

METHODS

Two models were used: (1) a dynamic population forecasting model for SP and (2) a closed cohort (population alive in 2011) multistate life table model (including 16 tobacco-related diseases) for health gains and costs.

RESULTS

All selected tobacco endgame strategies were associated with reductions in SP by 2025, down from 34.7%/14.1% for Māori (indigenous population)/non-Māori in 2011 to 16.0%/6.8% for tax increases; 11.2%/5.6% for the TFG; 17.8%/7.3% for the outlet reduction; 0% for the sinking lid; and 9.3%/4.8% for the combined strategy. Major health gains accrued over the remainder of the 2011 population's lives ranging from 28 900 QALYs (95% Uncertainty Interval (UI)): 16 500 to 48 200; outlet reduction) to 282 000 QALYs (95%UI: 189 000 to 405 000; sinking lid) compared with business-as-usual (3% discounting). The timing of health gain and cost savings greatly differed for the various strategies (with accumulated health gain peaking in 2040 for the sinking lid and 2070 for the TFG).

CONCLUSIONS

Implementing endgame strategies is needed to achieve tobacco endgame targets and reduce inequalities in smoking. Given such strategies are new, modelling studies provide provisional information on what approaches may be best.

Modelling the implications of reducing smoking prevalence: the public health and economic benefits of achieving a 'tobacco-free' UK

INTRODUCTION

Smoking is still the most preventable cause of cancer, and a leading cause of premature mortality and health inequalities in the UK. This study modelled the health and economic impacts of achieving a 'tobacco-free' ambition (TFA) where, by 2035, less than 5% of the population smoke tobacco across all socioeconomic groups.

METHODS

A non-linear multivariate regression model was fitted to cross-sectional smoking data to create projections to 2035. These projections were used to predict the future incidence and costs of 17 smoking-related diseases using a microsimulation approach. The health and economic impacts of achieving a TFA were evaluated against a predicted baseline scenario, where current smoking trends continue.

RESULTS

If trends continue, the prevalence of smoking in the UK was projected to be 10% by 2035-well above a TFA. If this ambition were achieved by 2035, it could mean 97 300 +/- 5 300 new cases of smoking-related diseases are avoided by 2035 (tobacco-related cancers: 35 900+/- 4 100; chronic obstructive pulmonary disease: 29 000 +/- 2 700; stroke: 24 900 +/- 2 700; coronary heart disease: 7600 +/- 2 700), including around 12 350 diseases avoided in 2035 alone. The consequence of this health improvement is predicted to avoid £67 +/- 8 million in direct National Health Service and social care costs, and £548 million in non-health costs, in 2035 alone.

CONCLUSION

These findings strengthen the case to set bold targets on long-term declines in smoking prevalence to achieve a tobacco 'endgame'. Results demonstrate the health and economic benefits that meeting a TFA can achieve over just 20 years. Effective ambitions and policy interventions are needed to reduce the disease and economic burden of smoking.

Medical costs and quality-adjusted life years associated with smoking: a systematic review

BACKGROUND

Estimated medical costs ("T") and QALYs ("Q") associated with smoking are frequently used in cost-utility analyses of tobacco control interventions. The goal of this study was to understand how researchers have addressed the methodological challenges involved in estimating these parameters.

METHODS

Data were collected as part of a systematic review of tobacco modeling studies. We searched five electronic databases on July 1, 2013 with no date restrictions and synthesized studies qualitatively. Studies were eligible for the current analysis if they were U.S.-based, provided an estimate for Q, and used a societal perspective and lifetime analytic horizon to estimate T. We identified common methods and frequently cited sources used to obtain these estimates.

RESULTS

Across all 18 studies included in this review, 50 % cited a 1992 source to estimate the medical costs associated with smoking and 56 % cited a 1996 study to derive the estimate for QALYs saved by quitting or preventing smoking. Approaches for estimating T varied dramatically among the studies included in this review. T was valued as a positive number, negative number and $0; five studies did not include estimates for T in their analyses. The most commonly cited source for Q based its estimate on the Health Utilities Index (HUI). Several papers also cited sources that based their estimates for Q on the Quality of Well-Being Scale and the EuroQol five dimensions questionnaire (EQ-5D).

CONCLUSIONS

Current estimates of the lifetime medical care costs and the QALYs associated with smoking are dated and do not reflect the latest evidence on the health effects of smoking, nor the current costs and benefits of smoking cessation and prevention. Given these limitations, we recommend that researchers conducting economic evaluations of tobacco control interventions perform extensive sensitivity analyses around these parameter estimates.