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

Tobacco control policies are examined utilizing a simulation model for California, the state with the longest running comprehensive program. We assess the impact of the California Tobacco Control Program (CTCP) and surrounding price changes on smoking prevalence and smoking-attributable deaths. Modeling begins in 1988 and progresses chronologically to 2004, and considers four types of policies (taxes, mass media, clean air laws, and youth access policies) independently and as a package. The model is validated against existing smoking prevalence estimates. The difference in trends between predicted smoking rates from the model and other commonly used estimates of smoking prevalence for the overall period were generally small. The model also predicted some important changes in trend, which occurred with changes in policy. The California SimSmoke model estimates that tobacco control policies reduced smoking rates in California by an additional 25% relative to the level that they would have been if policies were kept at their 1988 level. By 2004, the model attributes 59% of the reduction to price increases, 28% of the overall effect to media policies, 11% to clean air laws, and only a small percent to youth access policies. The model estimates that over 5000 lives will be saved in the year 2010 alone as a result of the CTCP and industry-initiated price increases, and that over 50,000 lives were saved over the period 1988-2010. Tobacco control policies implemented as comprehensive tobacco control strategies have significantly impacted smoking rates. Further tax increases should lead to additional lives saved, and additional policies may result in further impacts on smoking rates, and consequently on smoking-attributable health outcomes in the population.     

Italy SimSmoke: the effect of tobacco control policies on smoking prevalence and smoking attributable deaths in Italy

ABSTRACT: BACKGROUND: While Italy has implemented some tobacco control policies over the last few decades, which resulted in a decreased smoking prevalence, there is still considerable scope to strengthen tobacco control policies consistent with the World Health Organization (WHO) policy guidelines. The present study aims to evaluate the effect of past and project the effect of future tobacco control policies on smoking prevalence and associated premature mortality in Italy. METHODS: To assess, individually and in combination, the effect of seven types of policies, we used the SimSmoke simulation model of tobacco control policy. The model uses population, smoking rates and tobacco control policy data for Italy. RESULTS: Significant inroads to reducing smoking prevalence and premature mortality can be achieved through tobacco price increases, high intensity media campaigns, comprehensive cessation treatment program, strong health warnings, stricter smoke-free air regulations and advertising bans, and youth access laws. With a comprehensive approach, the smoking prevalence can be decreased by as much as 12 % soon after the policies are in place, increasing to a 30 % reduction in the next twenty years and a 34 % reduction by 30 years in 2040. Without effective tobacco control policies, a total of almost 300 thousand lives will be prematurely lost due to smoking by the year 2040. CONCLUSION: Besides presenting the benefits of a comprehensive tobacco control strategy, the model helps identify information gaps in surveillance and evaluation schemes that will promote the effectiveness of future tobacco control policy in Italy.     

The role of public policies in reducing smoking prevalence and deaths: the Argentina Tobacco Policy Simulation Model.

OBJECTIVES: To compare tobacco control policies independently and as a package through a simulation model to project smoking prevalence and associated future premature mortality in Argentina beginning in 2001. METHODS: A simulation model of tobacco control policies known as SimSmoke was modified using data for Argentina on population, fertility and mortality, smoking prevalence, and tobacco control policies in effect between 2001 and 2004. We used the Argentina Tobacco Policy Simulation model (ATPSM) to consider the effect on smoking prevalence of changes in taxes and prices, clean air laws, media campaigns, cessation programs, and youth access policies on smoking initiation and cessation rates. Smoking prevalence and relative risks of smoking were used to estimate smoking-attributable mortality. The ATPSM was used to project smoking prevalence and smoking-attributable deaths during the period 2001-2034. RESULTS: The largest reductions in smoking prevalence and premature mortality were predicted for a comprehensive tobacco control policy package, but relative reductions of as much as 30% were also predicted for large tax increases. Adding a media campaign along with programs to publicize and enforce clean air laws, advertising bans, and youth access laws would further reduce smoking rates by up to 45% by the year 2034, and would save almost 16 000 lives per year. CONCLUSIONS: Tobacco control policies can substantially reduce smoking rates, which can save many lives. Without such policies, deaths from smoking, and associated medical costs, will increase. The ATPSM is expected to provide guidance in filling the most important information gaps pertinent to both modeling and policy-making in Argentina, e.g., the lack of data on initiation and cessation rates, and the need for studies on the impact of policies. Similar models might be developed for other Latin American countries.     

Tobacco Policies in Louisiana: Recommendations for Future Tobacco Control Investment from SimSmoke,a Policy Simulation Model

Despite the presence of tobacco control policies, Louisiana continues to experience a high smoking burden and elevated smoking-attributable deaths. The SimSmoke model provides projections of these health outcomes in the face of existing and expanded (simulated) tobacco control polices. The SimSmoke model utilizes population data, smoking rates, and various tobacco control policy measures from Louisiana to predict smoking prevalence and smoking-attributable deaths. The model begins in 1993 and estimates are projected through 2054. The model is validated against existing Louisiana smoking prevalence data. The most powerful individual policy measure for reducing smoking prevalence is cigarette excise tax. However, a comprehensive cessation treatment policy is predicted to save the most lives. A combination of tobacco control policies provides the greatest reduction in smoking prevalence and smoking-attributable deaths. The existing Louisiana excise tax ranks as one of the lowest in the country and the legislature is against further increases. Alternative policy measures aimed at lowering prevalence and attributable deaths are: cessation treatments, comprehensive smoke-free policies, and limiting youth access. These three policies have a substantial effect on smoking prevalence and attributable deaths and are likely to encounter more favor in the Louisiana legislature than increasing the state excise tax.     

The role of public policies in reducing smoking and deaths caused by smoking in Vietnam: results from the Vietnam tobacco policy simulation model

A simulation model is developed for Vietnam to project smoking prevalence and associated premature mortality. The model examines independently and as a package the effects of five types of tobacco control policies: tax increases, clean air laws, mass media campaigns, advertising bans, and youth access policies. Predictions suggest that the largest reductions in smoking rates will result from implementing a comprehensive tobacco control policy package. Significant inroads may be achieved through tax increases. A media campaign along with programs to publicize and enforce clean air laws, advertising bans and youth access laws would further reduce smoking rates. Tobacco control policies have the potential to make large dents in smoking rates, which in turn could lead to many lives saved. In the absence of these measures, deaths from smoking will increase. The model also helps to identify information gaps pertinent both to modeling and policy-making.     

Mexico SimSmoke: how changes in tobacco control policies would impact smoking prevalence and smoking attributable deaths in Mexico

We examined the effect of tobacco control policies in Mexico on smoking prevalence and smoking-related deaths using the Mexico SimSmoke model. The model is based on the previously developed SimSmoke simulation model of tobacco control policy, and uses population size, smoking rates and tobacco control policy data for Mexico. It assesses, individually, and in combination, the effect of six tobacco control policies on smoking prevalence and smoking-related deaths. Policies included: cigarette excise taxes, smoke-free laws, anti-smoking public education campaigns, marketing restrictions, access to tobacco cessation treatments and enforcement against tobacco sales youth. The model estimates that, if Mexico were to adopt strong tobacco control policies compared to current policy levels, smoking prevalence could be reduced by 30% in the next decade and by 50% by 2053; an additional 470,000 smoking-related premature deaths could be averted over the next 40 years. The greatest impact on smoking and smoking-related deaths would be achieved by raising excise taxes on cigarettes from 55% to at least 70% of the retail price, followed by strong youth access enforcement and access to cessation treatments. Implementing tobacco control policies in Mexico could reduce smoking prevalence by 50%, and prevent 470,000 smoking-related deaths by 2053.     

Coronary heart disease deaths and decreased smoking prevalence in Massachusetts, 1993-2003

We used the previously validated IMPACT coronary heart disease (CHD) mortality model to estimate the CHD deaths attributable to reductions in smoking prevalence following the introduction of the Massachusetts Tobacco Control Program (MTCP) in 1993. A 29% and 31% decline in smoking prevalence and CHD mortality rates occurred, respectively (from 1993 to 2003). A total of 425 fewer CHD deaths, which generated approximately 3365 extra life-years, were attributable to decreased smoking prevalence. With these results in mind, a comprehensive tobacco control program should be sustained and supported.     

SimSmoke Model Evaluation of the Effect of Tobacco Control Policies in Korea: The Unknown Success Story

Objectives. We evaluated the effect of strict tobacco control policies, implemented beginning in 1995 in the Republic of Korea, on smoking prevalence and deaths.Methods. SimSmoke is a simulation model of the effect of tobacco control policies over time on smoking initiation and cessation. It uses standard attribution methods to estimate lives saved as a result of new policies. After validating the model against smoking prevalence, we used it to determine the Korean policies'' effect on smoking prevalence.Results. The model predicted smoking prevalence accurately between 1995 and 2006. We estimated that 70% of the 24% relative reduction in smoking rates over that period was attributable to tobacco control policies, mainly tax increases and a strong media campaign, and that the policies will prolong 104 812 male lives by the year 2027.Conclusions. Our results document Korea''s success in reducing smoking prevalence and prolonging lives, which may serve as an example for other Asian nations. Further improvements may be possible with higher taxes and more comprehensive smoke-free laws, cessation policies, advertising restrictions, and health warnings.Many Asian nations have smoking prevalence rates among males of at least 50%, leading to a large share of the world''s 5 million deaths attributable to smoking each year.¹ Worldwide, annual tobacco-related mortality is expected to increase to 10 million by 2030,¹ with an increasing share of those deaths in Asia, unless effective tobacco control measures are implemented.Most Asian nations have signed the Framework Convention for Tobacco Control, developed through the World Health Organization. This pact advocates high cigarette taxes, smoke-free indoor air laws, cessation treatment coverage, advertising bans, health warnings, and a well-organized media campaign. Thailand has implemented many of the suggested policies and has shown remarkable success in reducing male and female smoking rates.² Success in other Asian nations has not been documented.As recently as 1995, 67% of males smoked in the Republic of Korea.³ Taxes were increased gradually in the late 1990s, and some of the funds were allocated to tobacco control. The framework was ratified by Korea in May 2005. By the end of 2006, Korea had substantially increased the tax rate on cigarettes, implemented a strong antismoking campaign, strengthened clean air laws and health warnings, and made cessation treatments more accessible.³ No previous study evaluated the effect of these policies.When more than 1 policy is implemented, it is difficult for empirical studies to distinguish each policy''s effects.⁴ Simulation models combine information from diverse sources to examine the effects of different policies over time.^4,5 To determine these effects in Korea, we adopted the SimSmoke tobacco control policy model,^4,6–8 which simultaneously considers a broader array of public policies than do other smoking models.^9–14 The model has accurately explained trends in smoking rates for the United States as a whole and for several states,^7,15–17 as well as for other nations.²We used Korean data to develop a SimSmoke model for that country. We used the model to estimate the effect of individual and combined tobacco control policies implemented between 1995 and 2006 on male smoking prevalence and deaths.     

Reductions in smoking prevalence and cigarette consumption associated with mass-media campaigns

This paper examines reductions in smoking prevalence and cigarette consumption associated with state and local mass-media campaigns. We review the findings of the empirical literature on campaigns targeted at the general population. We then discuss the findings on state- and community-level youth-oriented campaigns. The results suggest that well-funded and implemented mass-media campaigns targeted at the general population and implemented at the state level, in conjunction with a comprehensive tobacco control program, are associated with reduced smoking rates among both adults and youth. Studies of youth-oriented interventions specifically have shown more mixed results, particularly for smaller, community-level media programs, but they indicate strong potential to influence underage smoking rates. We conclude by examining issues that warrant additional research. The scale and duration of expenditures, the content of ad messages, and other tobacco control polices are aspects of media programs that may help explain differences among study results. In particular, tobacco control polices that are implemented during the campaign often make it difficult to identify the specific influence of media campaigns alone.     

Tobacco policy regression in Arizona worksites

PURPOSE: To learn how worksite tobacco policies in Arizona changed between 1998 and 2001. DESIGN: Telephone survey panel design. SETTING: Arizona. SUBJECTS: Private workplaces with at least five employees (N = 1008). MEASURES: Workplace policies were rated as "smoke free" (no smoking by employees in any indoor areas or in company vehicles except for designated smoking areas enclosed by physical barriers and having separate ventilation systems), "partial" policies (restrictive tobacco policies that did not meet the "smoke-free" standard), or no tobacco policy. ANALYSIS: Bivariate statistical tests included chi2 and analysis of variance. Logistic regression was performed to identify the variables that best predicted the workplaces that weakened or eliminated their policies. RESULTS:. Tobacco policy in Arizona worksites improved overall, but 10.8% of worksites had weakened or eliminated tobacco policies present at baseline. Among worksites that were smoke free at baseline, 15.5% were no longer smoke free at follow-up. CONCLUSION:. Policy regression is a disturbing finding that should be further explored. Our findings suggest that efforts to promote workplace tobacco policies should not end when policies are in place.     

Gender and the social context of smoking behaviour

This paper examines the relative effect of both individual and societal factors that impinge directly on smoking behaviour of women and men. The societal factors are cigarettes price, tobacco control legislation, newspaper coverage of tobacco issues, overall economic factors, and social milieu characteristics. Three Canadian provinces are studied, from 1978 to 1995. A repeated cross-section design is used. Data are derived from national surveys and official documents. Results show that smoking occurs in social contexts within which the price of cigarettes appears to have a significant negative impact on the prevalence of smoking and the quantity of cigarettes smoked by men, but no effect on either the prevalence of smoking or the amount smoked by women. More comprehensive and restrictive no-smoking legislation and legislation on youth access to tobacco influence negatively the prevalence of smoking both for men and women. However, these laws do not have the same effects on the number of cigarettes smoked by women and men. Newspaper articles on the other hand, negatively influence smoking prevalence for women and men. As differences are observed in the responsiveness of men and women to tobacco control policies, policymakers and practitioners need to keep in mind that tobacco control policies have to be tailored to the broader context of the lives of women and men. Future work needs also to be done to clarify the interrelationships between social influences on smoking such as price, laws and media, and the relationships between these and intrapersonal and interpersonal factors, as well as other social and cultural factors.     

The effects of clean indoor air laws: what do we know and what do we need to know?

Our objective was to review the research on the effects of public clean air laws on smoking rates, compare these effects to those found in studies on the impact of private worksite restrictions and derive estimates of the potential reductions in smoking rates that might be expected from the implementation of the two types of policies. Data sources were computerized databases, references identified from pertinent peer-reviewed journal articles and books, and suggestions by experts on tobacco control policy. Comprehensive public clean air laws have the potential to reduce prevalence and consumption rates of the entire population (including non-working and non-indoor working smokers) by about 10%. Studies on private worksite regulations also suggest that strong worksite restrictions have the potential to reduce the prevalence rate of the entire population by about 6% over the long-term and the quantity smoked by continuing smokers by 28%, depending on the length of time after the ban. Further research is needed on the effects of the different types of public clean air policies on the entire smoking population and on different sociodemographic groups, how the effects of public clean indoor air laws depend on private restrictions already in place, and how the effect of private restrictions depend on whether or not they are supported by public clean air laws.     

State-level tobacco control policies and youth smoking cessation measures

ObjectiveResearch on the effects of state-level tobacco control policies targeted at youth has been mixed, with little on the effects of these policies and youth smoking cessation. This study explored the association between state-level tobacco control policies and youth smoking cessation behaviors from 1991 to 2006.MethodsThe study design was a population-based, nested survey of students within states. Study participants were 8th, 10th, and 12th graders who reported smoking “regularly in the past” or “regularly now” from the Monitoring the Future study. Main cessation outcome measures were: any quit attempt; want to quit; non-continuation of smoking; and discontinuation of smoking.ResultsResults showed that cigarette price was positively associated with a majority of cessation-related measures among high school smokers. Strength of sales to minors’ laws was also associated with adolescent non-continuation of smoking among 10th and 12th graders.ConclusionsFindings suggest that increasing cigarette price can encourage cessation-related behaviors among high school smokers. Evidence-based policy, such as tax increases on tobacco products, should be included as an important part of comprehensive tobacco control policy, which can have a positive effect on decreasing smoking prevalence and increasing smoking cessation among youth.     

The impact of tobacco control programs on adult smoking

Objectives. We examined whether state tobacco control programs are effective in reducing the prevalence of adult smoking.Methods. We used state survey data on smoking from 1985 to 2003 in a quasi-experimental design to examine the association between cumulative state antitobacco program expenditures and changes in adult smoking prevalence, after we controlled for confounding.Results. From 1985 to 2003, national adult smoking prevalence declined from 29.5% to 18.6% (P<.001). Increases in state per capita tobacco control program expenditures were independently associated with declines in prevalence. Program expenditures were more effective in reducing smoking prevalence among adults aged 25 or older than for adults aged 18 to 24 years, whereas cigarette prices had a stronger effect on adults aged 18 to 24 years. If, starting in 1995, all states had funded their tobacco control programs at the minimum or optimal levels recommended by the Centers for Disease Control and Prevention, there would have been 2.2 million to 7.1 million fewer smokers by 2003.Conclusions. State tobacco control program expenditures are independently associated with overall reductions in adult smoking prevalence.Recent data from the Centers for Disease Control and Prevention (CDC) showed that adult smoking remained constant at 20.8% from 2004 to 2005 after years of steady decline.1 The CDC study cited a 27% decline in funding for tobacco control programs from 2002 through 2006 and smaller annual increases in cigarette prices in recent years as 2 possible explanations for stalled smoking rates. Our study is a systematic assessment of the association between adult smoking, funding for state tobacco control programs, and state cigarette excise taxes.In 1989, California began the first comprehensive statewide tobacco control program in the United States after passage of a state ballot measure that raised cigarette excise taxes by $0.25.2 Comprehensive programs include interventions such as mass media campaigns, increased cigarette excise taxes, telephone quit lines, reduced out-of-pocket costs for smoking cessation treatment, health care provider assistance for cessation, and restrictions on secondhand smoke in public places.3^–6 Subsequently, other states, including Massachusetts in 1992, Arizona in 1995, and Florida in 1998, began similar large-scale state tobacco control programs.3 Multistate tobacco control interventions with substantial financial support began in the 1990s, with assistance from US government programs (e.g., the CDC’s Initiatives to Mobilize for the Prevention and Control of Tobacco Use [IMPACT] and the National Cancer Institute’s Americans Stop Smoking Intervention Study [ASSIST]) and other national programs.3Some states also committed resources from other sources, such as revenue from the 1998 Master Settlement Agreement (MSA) between the 4 largest tobacco companies in the United States and 46 US states.7 The MSA imposes restrictions on the advertising, promotion, and marketing or packaging of cigarettes, including a ban on tobacco advertising that targets people younger than 18, and requires the tobacco companies to pay $246 billion over 25 years to the states. The MSA also established a foundation that became the American Legacy Foundation.Extensive research has shown that state tobacco control programs, combined with other efforts, such as the American Legacy Foundation’s national truth campaign, have been effective in reducing adolescent tobacco use.3^,8^,9 Following a large increase in adolescent smoking during the mid-1990s, there has been an unprecedented decline, with the national prevalence among high school students dropping from 36.4% in 1997 to 21.9% in 2003.10In marked contrast, there has been little research into the effects of state programs on the prevalence of adult smoking, which is unfortunate given that smoking cessation confers substantial health benefits to adults.3^,11^,12 To date, findings from California, Massachusetts, and Arizona suggest that state tobacco control programs have had some effect on adults.13^–16 From 1988 through 1999, the prevalence of adult smoking in California declined from 22.8% to 17.1%, compared with an overall national decline from 28.1% to 23.5% (a relative percentage decline of 25% in California and 16% elsewhere).13^,14 From 1992 through 1999, the relative percentage decline in adult smoking was 8% in Massachusetts compared with 6% nationwide.14^,15 Findings from Arizona from 1996 to 1999 suggest a greater effect: the relative percentage decline was 21% compared with 8% nationwide.16 In addition, per capita cigarette sales—a proxy for cigarette consumption—have declined faster in Arizona, California, Massachusetts, and Oregon (where another large-scale program began in 1997) than in the rest of the United States since the programs’ implementation.17 The ASSIST evaluation showed that smoking prevalence decreased more in ASSIST states than in non-ASSIST states by the end of an 8-year intervention; by contrast, the evaluation found no difference in per capita cigarette consumption.6^,18These few state-specific studies on the prevalence of adult smoking had important limitations. First, state-specific findings may not be generalizable. Second, none of the studies considered the key role of cigarette price increases on prevalence (i.e., through higher cigarette excise taxes, which have consistently been shown to reduce cigarette consumption and prevalence)3 or controlled for other state characteristics, such as demographic changes or secular trends. Third, the studies did not assess the potential effects of programs on adults of different ages. Although the ASSIST evaluation provides a more comprehensive view of state tobacco control programs, it failed to control for baseline differences in state-level demographics and policy variables between ASSIST and non-ASSIST states. Finally, none of the studies considered the possible long-term effects of tobacco control programs on adult smoking.In 1999, the CDC published Best Practices for Comprehensive Tobacco Control Programs,19 which provided states with guidelines and recommendations for 9 tobacco control program activities (e.g., community programs, counter-marketing, cessation), along with minimum and optimum funding levels for each specific activity. On the basis of this document, in fiscal year 2006, states should have allocated $6.47 per capita minimum and $17.14 optimally to tobacco control programs (i.e., the $5.98 and $15.85, respectively, recommended in the 1999 CDC document, adjusted for inflation).We used data on state tobacco control program expenditures and periodic surveys of adult smoking prevalence conducted by the US Census Bureau from 1985 to 2003 to answer the following questions: (1) After control for potentially confounding factors (e.g., cigarette excise taxes), were increases in state tobacco control program expenditures independently associated with declines in adult smoking prevalence, and did effects differ by age group? (2) What would have been the predicted effect of state tobacco control program expenditures on adult smoking prevalence if all states had met CDC-recommended minimum or optimum per capita funding levels from 1995 to 2003?     

A model to predict the results of changes in smoking behaviour on smoking prevalence

BACKGROUND: Data are available on the prevalence of smoking states (never, current and ex). However, data on behaviour change rates (starting - never to current, quitting - current to ex and lapsing - ex to current) are not readily available and cannot be simply derived from or related to prevalence data. METHOD: A model was constructed to relate prevalence of smoking states to behaviour change rates. It was populated with prevalence of smoking status taken from the General Household Survey together with population structure, age- and sex-specific death rates, and birth rates for England and Wales. This model could be used to calculate past behaviour change given observed prevalence of smoking states or future prevalence of smoking given predicted rates of behaviour change. RESULTS: To fit data it was necessary to assume that as they age some ex smokers reclassify themselves as never smokers. In the age band 16-19 years about 9 percent of never smokers start smoking, and about 5 percent of current smokers quit. In the age band 20-24 years the corresponding figures for starting are about 4 percent in males and 2 percent in females, and for quitting about 2 percent in both. In older age bands the percentages starting are zero or less than zero (indicating reclassifying), and the percentage quitting rises with age. Net lapsing (shift from ex to current) occurred very infrequently and is quantitatively unimportant. If the current starting, quitting and lapsing rates are maintained the Smoking kills target will not be met. Future prevalence of smoking under different scenarios is examined. CONCLUSION: The model is useful in calculating the proportions changing smoking state from serial cross-sectional data on prevalence and for predicting future prevalence.     

Simulation modeling and tobacco control: creating more robust public health policies

Although previous empirical studies have shown that tobacco control policies are effective at reducing smoking rates, such studies have proven of limited effectiveness in distinguishing how the effect of policies depend on the other policies in place, the length of adjustment period, the way the policy is implemented, and the demographic groups considered.An alternative and complementary approach to purely statistical equations is simulation models. We describe the SimSmoke simulation model and how we used it to assess tobacco control policy in a specific case study. Simulation models are not only useful for policy prediction and planning but also may help to broaden our understanding of the role of different public health policies within a complex, dynamic social system.     

Economic benefits of achieving realistic smoking cessation targets in Australia

Objectives. We estimated the economic impact of reductions in the prevalence of tobacco smoking on health, production, and leisure in the 2008 Australian population.Methods. We selected a prevalence target of 15%. Cohort lifetime health benefits were modeled as fewer incident cases of tobacco-related diseases, deaths, and disability-adjusted life-years. We estimated production gains by comparing surveyed participation and absenteeism rates of adult smokers and ex-smokers valued according to the human capital and friction cost approaches. We estimated household production and leisure gains from time use surveys and valued these gains with the appropriate proxy.Results. In the 2008 Australian population, an absolute reduction in smoking prevalence of 8% would result in 158 000 fewer incident cases of disease, 5000 fewer deaths, 2.2 million fewer lost working days, and 3000 fewer early retirements and would reduce health sector costs by AUD 491 million. The gain in workforce production was AUD 415 million (friction cost) or AUD 863 million (human capital), along with gains of 373 000 days of household production and 23 000 days of leisure time.Conclusions. Lowering smoking prevalence rates can lead to substantial economic savings and health benefits.The deleterious impact of tobacco smoking on health is well understood,¹ and the health benefits of reducing the proportion of a country''s citizens who smoke tobacco have been quantified numerous times.^2,3 For example, in the most recent Australian Burden of Disease Study, conducted in 2003, tobacco use was responsible for the greatest disease burden (7.8%) in the country among the 14 risk factors reviewed.⁴ In recent years, with comprehensive tobacco control programs, Australian tobacco smoking prevalence rates have decreased by about 1 percentage point per year.⁵Australian tobacco control programs include media education campaigns, legislation (bans on smoking in public places, graphic warnings on packaging, point-of-sale advertising bans), and heavy tobacco product taxation. Although smoking-related cancers have declined after several decades of successful tobacco control efforts,⁶ further efforts to expand the range of effective prevention strategies are needed and should be similarly beneficial. In 2004 and 2005, 23% of adults (aged 18 years or older) in Australia were current tobacco smokers, with 21% smoking daily and 2% less than daily; 30% were ex-smokers; and 47% had never smoked.⁷Quantifying the importance of investing in further prevention initiatives is crucial given that only 3% of Australian health expenditures are devoted to prevention and health promotion.^8,9 Such efforts are timely in that they provide added impetus to the important work of the National Preventative Health Taskforce (which is focused on tobacco, obesity, and alcohol use)¹⁰ and lend support to the comprehensive strategies and work plans of important Australian health promotion organizations with tobacco control objectives (the Victorian Health Promotion Foundation and Quit).There is limited information about the potential impact of reducing the prevalence of tobacco smoking as opposed to attempting to completely eliminate it. The consequent impact of improved health on paid and unpaid production and on leisure time have similarly not been estimated for a scenario of realistic reduced smoking prevalence levels.We estimated the economic impact of reductions in the prevalence of tobacco smoking on health, production, and leisure in the 2008 Australian adult population. This study was part of a project funded by the Victorian Health Promotion Foundation, completed in 2009, that sought to evaluate the health, economic, and financial benefits of reductions in the prevalence of 6 important risk factors (alcohol use, physical inactivity, high body mass index, tobacco smoking, inadequate consumption of fruit and vegetables, and intimate partner violence). The project is described in greater detail elsewhere¹¹ (details are also available at http://vichealth.vic.gov.au/Resource-Centre/Publications-and-Resources/Research/Health-and-economic-benefits-of-reducing-disease-risk-factors.aspx).     

Setting a challenging yet realistic smoking prevalence target for Healthy People 2020: learning from the California experience

Objectives. We sought to outline an optimistic yet achievable goal for future US smoking prevalence rates based on empirical evidence reflecting the success of smoking control efforts in California.Methods. Using a dynamic model and the smoking initiation and cessation rates achieved in California as a guide, we projected US adult smoking prevalence rates through the year 2020.Results. If smoking initiation and cessation rates for the nation do not change, population dynamics will result in smoking prevalence rates falling to 19.1% in 2010 and 16.8% in 2020. If the country attains California’s initiation and cessation rates by 2010, adult smoking prevalence rates will be 18.5% in 2010 and 14.7% as of 2020.Conclusions. If California’s smoking initiation and cessation rates are attained nationwide, the US smoking prevalence rate could be 5.9 percentage points lower than the 2005 rate by the year 2020, and there would be 10.2 million fewer smokers than in 2005. A target of 14% smoking prevalence by 2020 is aggressive yet feasible, given that it takes into account the constraints imposed by population demographics.Adult smoking prevalence rates in the United States continue to decline, although painfully slowly. Despite enormous progress in smoking control during the past 40 years (the adult prevalence rate dropped from 42.4% in 1965 to 20.9% in 20051), cigarette smoking remains the leading cause of premature death among Americans, killing approximately 440 000 citizens annually.2 Currently, more than 44 million Americans smoke, and half of these individuals will die prematurely unless they abandon their addiction in time.3The overall US smoking prevalence rate of 20.9% in 2005 (the most recent year for which data were available at the time this article was written) reflects a diverse combination of rates stemming from the differences between states in terms of demographic characteristics and implementation of tobacco control efforts. Rates vary from a low of 11.5% in Utah, commonly attributed to the state’s large Mormon population, to a high of 28.7% in Kentucky, where population demographics, the prominence of tobacco in the history and economy of the state, and limited tobacco control efforts contribute to the persistently high prevalence of smoking.4We addressed the question of how much lower, and how much faster, overall US smoking prevalence rates would fall by the year 2020 if the initiation and cessation rates achieved as of 2005 in California, the state with the second lowest adult smoking prevalence in the country (15.2% in 2005), could be reproduced across the entire country. Assessing the degree to which there is a causal link between antismoking policies and declining smoking prevalence rates in California or any other state is challenging because it is plausible that regions with strong antitobacco attitudes are more likely to implement stringent smoking control measures.5However, proof of causality is not necessary to make our intended point. If we assume, correctly or otherwise, that smoking control policies are solely responsible for California’s smoking initiation and cessation rates—and therefore its low smoking prevalence—replicating those rates across the country would allow us to derive an optimistic scenario for smoking trends in the United States in the immediate future given the effectiveness of currently available tobacco control programs. Given that the government is currently initiating the process of setting objectives for its Healthy People 2020 program, an analysis of these trends could assist the nation in selecting a challenging yet potentially reachable smoking prevalence target for the year 2020 based on best-case effects of tobacco control programming.     

State-specific prevalence of current cigarette smoking among adults and secondhand smoke rules and policies in homes and workplaces--United States, 2005

Smoking causes premature death and disease in children and adults who do not smoke but are exposed to secondhand smoke (SHS). To assess the state-specific prevalence of current smoking among adults in the United States and the proportions of adults who report having smoke-free home rules and smoke-free policies in their workplace, CDC analyzed data from the 2005 Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes the results of that analysis, which indicated a threefold difference (from lowest to highest) in self-reported cigarette smoking prevalence in 50 states, the District of Columbia (DC), Puerto Rico (PR), and the U.S. Virgin Islands (USVI) (range: 8.3%-28.7%). Wide variations also were observed in USVI and the 14 states that assessed prevalence of smoke-free home rules (from 63.6% [Kentucky] to 82.9% [Arizona]) and smoke-free workplace policies (from 54.8% [Nevada] to 85.8% [West Virginia]). Evidence-based, comprehensive tobacco prevention and control programs that focus on decreasing smoking initiation, increasing smoking cessation, and establishing smoke-free workplaces, homes, and other venues should be continued and expanded to reduce smoking prevalence, exposure of nonsmokers to SHS, and smoking-related morbidity and mortality.