SimSmokeFinn: how far can tobacco control policies move Finland toward tobacco-free 2040 goals?

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.

An argument for phasing out sales of cigarettes

The successes of tobacco control in some countries and locales have led to discussions of ending the tobacco epidemic, often called the 'endgame'. In this paper, we recommend articulating the endgame goal as phasing out sales of cigarettes, a goal once called 'unthinkable'. We develop a logic and argumentation for ending cigarette sales intended to move the discussion beyond the shadow of 'prohibition', proposing an approach that appeals to consumer protection standards and suggesting that the effort be led by low-prevalence communities. While phasing out cigarettes will not happen everywhere all at once, and may unfold differently along several lines, we argue that the gradual phase-out approach we propose will reduce the likelihood of the negative consequences often predicted to come with such a policy. To continue permitting widespread sales of the single most deadly consumer product in history is a public health failure that must be addressed.

Recommendations on how to achieve tobacco-free nations in Europe

European countries vary widely in the development and implementation of effective tobacco-control programs and policies. Why some countries lag behind others is inherently a political matter. National-level policymakers struggle between the need to protect public health and the need to recognize economic and ideological considerations. Within this context, use of scientific evidence plays an important role in the policy making process. Articles 20 and 22 of the World Health Organisation's Framework Convention of Tobacco Control (FCTC) oblige countries to develop and coordinate research on aspects of tobacco control and require of them to facilitate knowledge transfer and capacity building between countries. This paper considers various ways how EU and national policy makers may accomplish this. We conclude that progress in three areas is needed: 1) generation of more scientific evidence relevant for each country; 2) facilitation of policy learning between countries; and 3) building capacity and collaborations between researchers and tobacco-control advocates to bridge the gap from research to policy, especially in countries with weak tobacco-control infrastructures.

Strategies and barriers to achieving the goal of Finland's tobacco endgame

Objectives

Finland boldly legislated the end of tobacco use in its 2010 Tobacco Act, and subsequently expanded the goal in 2016 to eradicate other nicotine-containing products. This study explored stakeholders’ perceptions about the strengths, barriers, solutions and rationale for Finland’s comprehensive but conventional strategy to achieve its nicotine-free goal.

Design

Study participants were selected based on expertise in policy or practice of tobacco control (n=32). Semi-structured interviews, conducted in 2017 and 2018, covered topics ranging from consensus among stakeholders to Finland’s ranking on the 2016 Tobacco Control Scale. The framework method was chosen for analysing interview transcripts.

Results

A perceived strength of Tobacco-Free Finland 2030 was the consensus and cooperation among members of the tobacco control community. The objective of becoming a nicotine- versus smoke-free society had almost unanimous support, challenged by a small minority who argued for greater discussion of harm reduction approaches. The need for maintaining legitimacy and historical successes in tobacco control were reasons for using a conventional strategy. Barriers to achieving the endgame goal included insufficient funding and over-reliance on non-governmental organisations, political/legal constraints, impact of institutional practices on tobacco disparities, ambivalence about the role of mass media and lack of prioritising smoking cessation.

Conclusions

Stakeholders’ broad confidence in reaching the goal of Finland’s tobacco endgame suggests that future policy initiatives will reflect the current, conventional strategy. If the Finnish government chooses to continue this approach, then it should designate separate funds for Tobacco-Free Finland 2030 and implement structural changes that will facilitate tobacco control initiatives.

Estimating the effect of a potential policy to restrict tobacco retail availability in New Zealand

Introduction

Reducing tobacco retailer density is suggested to be a key component of tobacco endgames. Where tobacco retail reduction policies exist, ‘grandfathering’ is typically used, where existing retailers are exempt from restrictions aimed at reducing outlet density. We examined the possible impact on tobacco outlet density in New Zealand of a policy preventing new retail outlets from selling tobacco, but allowing existing retail outlets to continue selling tobacco until they ceased trading or relocated.

Methods

We obtained data on numbers of tobacco outlets and the number of outlet closures recorded annually from 2006 to 2016. We calculated the mean and the lowest and highest 3-year rolling average closure rates for each type of tobacco outlet. We projected decreases in the number of tobacco outlets that would hypothetically be permitted to sell tobacco from 2020 onwards and estimated when the combined number of tobacco outlets would decline by 50% and 95%.

Results

Based on mean annual closure rates, the total number of tobacco outlets would decrease by 50% by 2032 and a 95% reduction could be achieved by 2072. By 2025, the number of tobacco outlets would decrease by 27%; by 2050, this reduction would reach 84%.

Conclusion

A tobacco retail reduction policy that prevented new retail outlets from selling tobacco and grandfathered existing retailers would be unlikely to achieve New Zealand’s target of a 95% reduction in tobacco outlet density within several decades of being enacted. Nonetheless, this policy could achieve a 50% reduction in tobacco retail availability in the first decade of implementation.

Social climate on tobacco control in an advanced tobacco control country: A population-based study in Finland

Aims

Finland has implemented a gradually tightening tobacco control policy for decades. Recently the objective of a tobacco-free Finland was introduced. Still, the population's acceptance of tobacco control policy has not been measured. More knowledge is needed on differences in attitudes and factors associated with tobacco control opinions for future policy-making.

Methods

A population-based study with quantitative analysis. Attitudes on smoking and tobacco control policy were assessed within the National FINRISK 2012 Study in Finland involving 25-74-year-old adults (N = 4905). In analyses, smoking status groups were compared.

Results

In general, attitudes differed systematically by smoking status. Differences increased or decreased when moving from never smokers to other smoking groups. Similarities in attitudes were found particularly on youth smoking, while differences between smoking groups were notable on statements regarding smoking on balconies and availability of tobacco products. The adjusted analysis showed that smoking status was most strongly associated with attitudes on different tobacco control policy measures. Daily smokers viewed stricter tobacco control policy and workplace smoking bans more negatively than others, though they viewed societal support for quitters and sufficiency of tobacco control policy more positively compared with others. Differences were vast compared with non-smokers, but also occasional smokers differed from daily smokers.

Conclusions

Tightening tobacco control and workplace smoking bans were supported by the Finnish adult population, but societal support for quitters to a lesser extent. Attitude change, where smokers are seen as deserving help to quit smoking, is important.

Policy coherence, integration, and proportionality in tobacco control: Should tobacco sales be limited to government outlets?

Multiple factors, including marijuana decriminalization/legalization, tobacco endgame discourse, and alcohol industry pressures, suggest that the retail regulatory environment for psychoactive or addictive substances is a dynamic one in which new options may be considered. In most countries, the regulation of tobacco, marijuana, and alcohol is neither coherent, nor integrated, nor proportional to the potential harms caused by these substances. We review the possible consequences of restricting tobacco sales to outlets run by government-operated alcohol retail monopolies, as well as the likely obstacles to such a policy. Such a move would allow governments more options for regulating tobacco sales, and increase coherence, integration, and proportionality of substance regulation. It might also serve as an incremental step toward an endgame goal of eliminating sales of commercial combustible tobacco.

Changes in Smoking Rates Among Pregnant Women and the General Female Population in Australia, Finland, Norway, and Sweden

Introduction:

Smoking rates have dropped substantially in most developed countries in recent decades. This general trend has, however, not always been evident among women—particularly younger women. Smoking habits do, however, often change in connection with pregnancy and the aim of this study is to determine whether smoking during pregnancy follows general trends in smoking rates in the general female population in four countries with active anti-tobacco policies and decreasing population smoking rates.

Methods:

Changes in rates of persistent smoking, that is, smoking in late pregnancy or daily smoking among all women of childbearing age were described according to age groups. Data were retrieved from the Australian Household Drug Surveys during 2000–2013 and from registries and surveys in Finland, Norway, and Sweden between 1995 and 2014.

Results:

In general, persistent smoking has decreased and late-pregnancy smoking rates are lower than daily smoking rates among all women. However, younger women are more likely to be persistent smokers regardless of pregnancy status. In Norway and Finland, persistent smoking was most common among young pregnant women and in Sweden there was an increased polarization between age groups. In Australia, a steady decrease in smoking rates appears to have stalled in younger pregnant women.

Conclusion:

Although smoking has declined substantially in recent decades, there are groups lagging behind this general trend. Young pregnant women are of particular concern in this respect. The possibility that these findings reflect the changing characteristics of younger pregnant women is discussed.

Implications:

This study puts recent trends in maternal smoking into a broader context by relating developments to changes in smoking rates among women in general. By using similar data from four countries we were able to follow changes in smoking rates “within” groups of women within the four countries without being limited by methodological problems related to cross-country or inter-group comparisons. We were above all able to show that aggregate data disclose the strong age gradient in maternal smoking habits.

The need for a comprehensive framework

To facilitate individual and population-level behavior change, we need policies based on science. We must develop coherent policies that explicitly consider the benefits and risks of different classes of nicotine delivery products, rather than continuing the current ad-hoc approach which fails to adequately address the product itself.

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.

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.

Association of Cigarette Prices with the Prevalence of Smoking in Korean University Students: Analysis of Effects of the Tobacco Control Policy

BACKGROUND

Increased pricing of cigarettes might be one of the most effective approaches for reducing the prevalence of smoking. This study aimed to investigate the effects of increasing cigarette prices through taxation by a tobacco intervention policy on the changes in smoking prevalence in Korean university students.

MATERIALS AND METHODS

The participants in this study were 23,047 healthy university students aged 18-29 years from a health examination in 2011-2015. We investigated the adjusted prevalence of daily and occasional smoking before and after increasing cigarette prices through taxation.

RESULTS

The prevalence of occasional smoking was significantly decreased in 2015 from 2014 in both male (from 10.7% in 2014 to 5.4%) and female (from 3.6% to 1.1%) students, but the prevalence of daily smoking did not decrease significantly. The frequency of individuals who had attempted smoking cessation during the past year was significantly higher among occasional smokers in male students (90.2%) compared with daily smokers (64.9%). For female students, there were no differences in experience of smoking cessation, willingness for smoking cessation, or E-cigarette experience between daily and occasional smokers.

CONCLUSIONS

We found that a policy of increasing cigarette prices through taxation is associated with decreases in the prevalence of occasional smokers, who have relatively lower nicotine dependence compared with individuals who smoke daily. The results of our study suggest that social support and direct intervention for smoking cessation at the community level are needed for university students alongside the pricing policy.

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.

Theoretical impacts of a range of major tobacco retail outlet reduction interventions: modelling results in a country with a smoke-free nation goal

OBJECTIVE

To inform endgame strategies in tobacco control, this study aimed to estimate the impact of interventions that markedly reduced availability of tobacco retail outlets. The setting was New Zealand, a developed nation where the government has a smoke-free nation goal in 2025.

METHODS

Various legally mandated reductions in outlets that were phased in over 10 years were modelled. Geographic analyses using the road network were used to estimate the distance and time travelled from centres of small areas to the reduced number of tobacco outlets, and from there to calculate increased travel costs for each intervention. Age-specific price elasticities of demand were used to estimate future smoking prevalence.

RESULTS

With a law that required a 95% reduction in outlets, the cost of a pack of 20 cigarettes (including travel costs) increased by 20% in rural areas and 10% elsewhere and yielded a smoking prevalence of 9.6% by 2025 (compared with 9.9% with no intervention). The intervention that permitted tobacco sales at only 50% of liquor stores resulted in the largest cost increase (∼$60/pack in rural areas) and the lowest prevalence (9.1%) by 2025. Elimination of outlets within 2 km of schools produced a smoking prevalence of 9.3%.

CONCLUSIONS

This modelling merges geographic, economic and epidemiological methodologies in a novel way, but the results should be interpreted cautiously and further research is desirable. Nevertheless, the results still suggest that tobacco outlet reduction interventions could modestly contribute to an endgame goal.

The effect of tobacco control policy on smoking cessation in relation to gender, age and education in Lithuania, 1994-2010

BACKGROUND

This study aimed to evaluate the association between tobacco control policies and trends in smoking cessation according to gender, age and educational level in Lithuania in 1994-2010.

METHODS

The data were obtained from nine cross-sectional postal surveys conducted biennially within the framework of Finbalt Health Monitor project during 1994-2010. Each survey was based on a nationally representative random sample drawn from the National population register. The sample consisted of 3000 citizens aged 20-64 in 1994-2008 surveys and 4000 in the 2010 survey. In total, 17161 individuals participated in all surveys. The development of tobacco control policy in Lithuania was assessed using the Tobacco Control Scale (TCS). The association of the TCS scores with short-term and long-term quitting according to gender, age and education was examined using logistic regression analysis with control for secular trends.

RESULTS

Over the last two decades, a large improvement in the development of tobacco control policy has been achieved in Lithuania. At the same time, this progress was associated with the increase in smoking cessation. A significant increase in both short-term and long-term quit ratios was found among people aged 20-44. An increase by 10 points on the TCS was associated with 17% increase in the odds of short-term quitting and with 15% increase in the odds of long-term quitting. The association between tobacco control policies and long-term quitting was stronger among younger than older people. No differential effect of tobacco control policies on smoking cessation was found in relation to gender and educational level.

CONCLUSIONS

The improvement in Lithuanian tobacco control policies was associated with an increase in smoking cessation in long-term perspective. These policies have not only benefitted highly educated groups, but lower educated groups as well. Nonetheless, further development of comprehensive tobacco control policies is needed in order to decrease social inequalities in smoking cessation.

Support for a tobacco endgame strategy in 18 European countries

OBJECTIVE

The feasibility of a tobacco endgame strategy, aiming to bring smoking prevalence to near-zero levels, is currently under debate. We provide information on public support for such a strategy in Europe.

METHODS

In 2010 we conducted a face-to-face representative survey in 18 European countries (Albania, Austria, Bulgaria, the Czech Republic, Croatia, England, Finland, France, Greece, Hungary, Ireland, Italy, Latvia, Poland, Portugal, Romania, Spain and Sweden). The present analysis is based on 16,947 individuals aged ≥ 15 years providing information on their attitudes towards a complete ban on the use or sale of tobacco.

RESULTS

Overall, 34.9% of adults (32.8% in men and 37.0% in women; p<0.001) supported a complete ban strategy on use or sale of tobacco, 41.2% of never, 29.4% of ex- and 25.6% of current smokers. The highest support was observed in southern Europe (42.5%), followed by eastern (39.1%), northern (27.5%) and western Europe (23.0%; p<0.001). A significant inverse trend was observed with both age and education.

CONCLUSION

Approximately one in three adults (and one in four smokers) supports a comprehensive tobacco endgame intervention. This first study in Europe provides a baseline for evaluating future trends in public support for extreme propositions to end or drastically cut smoking.

Systematic review of the effect of pictorial warnings on cigarette packages in smoking behavior

We used a structured approach to assess whether active smokers presented with pictorial warnings on cigarette packages (PWCP) had a higher probability of quitting, reducing, and attempting to quit smoking than did unexposed smokers. We identified 21 articles from among nearly 2500 published between 1993 and 2013, prioritizing coverage over relevance or quality because we expected to find only a few studies with behavioral outcomes. We found very large heterogeneity across studies, poor or very poor methodological quality, and generally null or conflicting findings for any explored outcome. The evidence for or against the use of PWCP is insufficient, suggesting that any effect of PWCP on behavior would be modest. Determining the single impact of PWCP on behavior requires studies with strong methodological designs and longer follow-up periods.

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.

Sweden SimSmoke: the effect of tobacco control policies on smoking and snus prevalence and attributable deaths

BACKGROUND

This study examines the effect of past tobacco control policies and projects the effect of future policies on smoking and snus use prevalence and associated premature mortality in Sweden.

METHODS

The established SimSmoke model was adapted with population, smoking rates and tobacco control policy data from Sweden. SimSmoke evaluates the effect of taxes, smoke-free air, mass media, marketing bans, warning labels, cessation treatment and youth access policies on smoking and snus prevalence and the number of deaths attributable to smoking and snus use by gender from 2010 to 2040.

RESULTS

Sweden SimSmoke estimates that significant inroads to reducing smoking and snus prevalence and premature mortality can be achieved through tax increases, especially when combined with other policies. Smoking prevalence can be decreased by as much as 26% in the first few years, reaching a 37% reduction within 30 years. Without effective tobacco control policies, almost 54 500 lives will be lost in Sweden due to tobacco use by the year 2040.

CONCLUSION

Besides presenting the benefits of a comprehensive tobacco control strategy, the model identifies gaps in surveillance and evaluation that can help better focus tobacco control policy in Sweden.

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.

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 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.