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.     

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

Arizona was one of the first few states to implement a comprehensive tobacco control program. The effect of that program is examined using a computer-simulation model (SimSmoke) developed for the purposes of evaluation, planning, and justifying policies. This approach assesses the impact to date of tobacco control policies on smoking prevalence and generates predictions about the effects of tobacco control policies on past and future smoking prevalence and associated future premature mortality. SimSmoke estimates indicate that tobacco control policies reduced smoking rates in Arizona by about 20 percent over the period 1993-2002. A previous CDC study obtains similar effects, but does not net out the effects of individual policies. SimSmoke attributes much of the reduction, about 61 percent, to price increases and attributes 38 percent of the overall effect to media policies, leaving only a small percentage of the smoking reductions attributed to quitlines, youth access policies, and the weak clean air laws. Tobacco control policies implemented as comprehensive strategies have significantly affected smoking rates in Arizona, which leads to large reductions in deaths attributable to smoking. It will be important to maintain these efforts over time to reduce or keep smoking prevalence down and to minimize smoking-attributable deaths.     

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.     

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.     

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.     

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.     

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.     

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.     

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 Status and Future Challenges of Tobacco Control Policy in Korea

Tobacco use is the most important preventable risk factor for premature death. The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), the first international public health treaty, came into force in 2005. This paper reviews the present status of tobacco control policies in Korea according to the WHO FCTC recommendations. In Korea, cigarette use is high among adult males (48.2% in 2010), and cigarette prices are the lowest among the Organization for Economic Cooperation and Development countries with no tax increases since 2004. Smoke-free policies have shown incremental progress since 1995, but smoking is still permitted in many indoor public places. More than 30% of non-smoking adults and adolescents are exposed to second-hand smoke. Public education on the harmful effects of tobacco is currently insufficient and the current policies have not been adequately evaluated. There is no comprehensive ban on tobacco advertising, promotion, or sponsorship in Korea. Cigarette packages have text health warnings on only 30% of the main packaging area, and misleading terms such as "mild" and "light" are permitted. There are nationwide smoking cessation clinics and a Quitline service, but cessation services are not covered by public insurance schemes and there are no national treatment guidelines. The sale of tobacco to minors is prohibited by law, but is poorly enforced. The socioeconomic inequality of smoking prevalence has widened, although the government considers inequality reduction to be a national goal. The tobacco control policies in Korea have faltered recently and priority should be given to the development of comprehensive tobacco control policies.     

Forecasting future tobacco control policy: where to next?

Objective: Effective tobacco control policies include price increases through taxes, restrictions on smoking in public and work places, adequately funded mass media campaigns, bans on advertising, health warnings on packages and cessation assistance. As these policies have been largely implemented in Australia, what next should the country do in tobacco control? Methods: Ninety‐one Australian tobacco control stakeholders took part in a web‐based survey about the future of tobacco control policies. Results: The policy deemed most important in decreasing smoking was to increase excise and customs duty by 30%. Other policies receiving high support included: funding mass media campaigns through tax hypothecation; introducing retail display bans; plain packaging of tobacco products; and banning smoking in outdoor dining areas. Reintroducing the sale of smokeless tobacco products received the least support. Conclusion: Countries that have largely implemented the provisions of the Framework Convention on Tobacco Control must maintain commitments to proven tobacco control measures, but also provide global leadership through the adoption of innovative policies. Implications: The release of the Australian 2009 National Preventative Health Taskforce's report presents an opportunity to translate these ideas into action.     

Evaluating the Strength of School Tobacco Policies: The Development of a Practical Rating System

BACKGROUND: School tobacco control policies vary widely in their strength, extensiveness, and enforcement. Currently, no standardized method exists to assess the comprehensiveness of school tobacco policies. The purpose of this study was to develop a new practical rating system for school tobacco policies, assess its reliability, and present preliminary validation data.
METHODS: This study presents the systematic development of a rating system to assess the strength of school tobacco policies. Based on the empirical literature and the expertise of an advisory panel consisting of educational leaders and tobacco control advocates and practitioners, a "gold standard" school tobacco policy was developed and guided the content of the 40-point rating system. The 4 domains of the School Tobacco Policy Index were: Tobacco-free environment (14 points), Enforcement (12 points), Prevention and treatment services (6 points), and Policy organization (8 points).
RESULTS: The Index was pilot-tested using 95 Missouri public school district tobacco policies and proved to be highly reliable among coders. The evaluated policies varied greatly between school districts, with the lowest total policy score of φ and the highest score of 21. School district policy scores were significantly related to a number of county-level tobacco policy characteristics, including support for a tobacco excise tax increase.
CONCLUSIONS: The Index is a user-friendly, practical tool for tobacco control professionals and educators, providing them with the ability to easily evaluate their own school policies. Their evaluation efforts will be useful in strengthening existing policies and developing new comprehensive policies to protect the health of students, staff, administrators, and visitors.     

Adult tobacco use levels after intensive tobacco control measures: New York City, 2002-2003

OBJECTIVES: We sought to determine the impact of comprehensive tobacco control measures in New York City. METHODS: In 2002, New York City implemented a tobacco control strategy of (1) increased cigarette excise taxes; (2) legal action that made virtually all work-places, including bars and restaurants, smoke free; (3) increased cessation services, including a large-scale free nicotine-patch program; (4) education; and (5) evaluation. The health department also began annual surveys on a broad array of health measures, including smoking. RESULTS: From 2002 to 2003, smoking prevalence among New York City adults decreased by 11% (from 21.6% to 19.2%, approximately 140000 fewer smokers). Smoking declined among all age groups, race/ethnicities, and education levels; in both genders; among both US-born and foreign-born persons; and in all 5 boroughs. Increased taxation appeared to account for the largest proportion of the decrease; however, between 2002 and 2003 the proportion of cigarettes purchased outside New York City doubled, reducing the effective price increase by a third. CONCLUSIONS: Concerted local action can sharply reduce smoking prevalence. However, further progress will require national action, particularly to increase cigarette taxes, reduce cigarette tax evasion, expand education and cessation services, and limit tobacco marketing.     

Caribbean pleasure industry: Tourism,sexuality and AIDS in the Dominican Republic

State-owned tobacco companies, which still account for 40% of global cigarette production, face continued pressure from, among others, the International Monetary Fund (IMF), to be privatised. This review of available literature on tobacco industry privatisation suggests that any economic benefits of privatisation may be lower than supposed, because private owners avoid competitive tenders (thus underpaying for assets), negotiate lengthy tax holidays and are complicit in the smuggling of cigarettes to avoid import and excise duties. It outlines how privatisation leads to increased marketing, more effective distribution and lower prices, creating additional demand for cigarettes among new and existing smokers, leading to increased cigarette consumption, higher smoking prevalence and lower age of smoking initiation. Privatisation also weakens tobacco control because private owners, in their drive for profits, lobby aggressively against effective policies and ignore or overturn existing policies.

This evidence suggests that further tobacco industry privatisation is likely to increase smoking and that instead of transferring assets from state to private ownership, alternative models of supply should be explored.     

A review of the impacts of tobacco industry privatisation: Implications for policy

State-owned tobacco companies, which still account for 40% of global cigarette production, face continued pressure from, among others, the International Monetary Fund (IMF), to be privatised. This review of available literature on tobacco industry privatisation suggests that any economic benefits of privatisation may be lower than supposed, because private owners avoid competitive tenders (thus underpaying for assets), negotiate lengthy tax holidays and are complicit in the smuggling of cigarettes to avoid import and excise duties. It outlines how privatisation leads to increased marketing, more effective distribution and lower prices, creating additional demand for cigarettes among new and existing smokers, leading to increased cigarette consumption, higher smoking prevalence and lower age of smoking initiation. Privatisation also weakens tobacco control because private owners, in their drive for profits, lobby aggressively against effective policies and ignore or overturn existing policies. This evidence suggests that further tobacco industry privatisation is likely to increase smoking and that instead of transferring assets from state to private ownership, alternative models of supply should be explored.     

The burden of mortality from smoking: Comparing Sweden with other countries in the European Union

We describe the mortality currently attributable to smoking in the European Union (EU), and the change that would result if all EU countries had the smoking prevalence of Sweden. Almost 500,000 smoking-attributable deaths occur annually among men in the EU; about 200,000 would be avoided at Swedish smoking rates. In contrast, only 1100 deaths would be avoided if EU women smoked at Swedish rates. The low smoking-related mortality among Swedish men probably is due to their use of snus (Swedish smokeless tobacco).     

Smoking attributable hospital treatment, treatment costs and smoking attributable mortality in the Czech Republic in 2002

OBJECTIVES: The main objective of this work is to quantify the number of hospitalizations caused by smoking, estimate the costs of hospital treatment and to estimate contribution of smoking to mortality in the Czech Republic (CR) in 2002. METHODS: The estimate of the proportion by which smoking contributed to hospitalizations and to mortality in the CR was computed using the method of smoking-attributable fractions (SAF). The SAF was computed from relative risks established in the American study Cancer Prevention Study II and from estimates of the prevalence of smoking in the CR from a nationwide study conducted in 2002. RESULTS: In 2002, based on data provided by the General Health Insurance Company, there were 145,336 hospitalizations, and the total cost of hospital treatment was estimated as 4.727,612 (in thousands) CZK. The total number of deaths caused by smoking was 20,550 (95% CI: 18,851-22,262), 14,525 in men and 6,025 in women. Deaths caused by smoking represented 19% of the total nationwide mortality for 2002. Earlier estimates were published by Peto and Lopez for 1995 (22,300 deaths caused by smoking) and 2000 (17,746 deaths). The estimate arrived by authors using the SAF method for 2002 corresponds quite well with that by Peto and Lopez for 2000. CONCLUSIONS: The high morbidity and mortality rate related to smoking is directly connected to high prevalence of smoking in the Czech Republic. An effective tobacco control policy, including restrictive measures on availability of tobacco products combined with preventive programmes and smoking cessation programmes, could contribute to the reduction of smoking and save lives and treatment costs caused by smoking.     

Modelling the impact of raising tobacco taxes on public health and finance

Objective

To investigate the potential for tobacco tax to contribute to the 2030 agenda for sustainable development by reducing tobacco use, saving lives and generating tax revenues.

Methods

A model of the global cigarette market in 2014 – developed using data for 181 countries – was used to quantify the impact of raising cigarette excise in each country by one international dollar (I$) per 20-cigarette pack. All currencies were converted into I$ using purchasing power parity exchange rates. The results were summarized by income group and region.

Findings

According to our model, the tax increase would lead the mean retail price of cigarettes to increase by 42% – from 3.20 to 4.55 I$ per 20-cigarette pack. The prevalence of daily smoking would fall by 9% – from 14.1% to 12.9% of adults – resulting in 66 million fewer smokers and 15 million fewer smoking-attributable deaths among the adults who were alive in 2014. Cigarette excise revenue would increase by 47% – from 402 billion to 593 billion I$ – giving an extra 190 billion I$s in revenue. This, in turn, could help create the fiscal space required to finance development priorities. For example, if the extra revenue was allocated to health budgets, public expenditure on health could increase by 4% globally.

Conclusion

Tobacco taxation can prevent millions of smoking-attributable deaths throughout the world and contribute to achieving the sustainable development goals. There is also potential for tobacco taxation to create the fiscal space needed to finance development, particularly in low- and middle-income countries.     

Tobacco use among school personnel in Orissa

Tobacco use prevalence, knowledge and attitude was assessed among school personnel in Orissa. A single cluster sample design with probability proportional to the enrolment in grades VIII-X was used. Statistical analysis was clone using SUDAAN and the C-sample procedure in Epi-Info. The school response rate was 100%. Over 72% of school personals participated in the survey, the proportion of men being 84%. Current cigarette smoking, bidi smoking and smokeless tobacco use was reported by 26.8%, 30.1% and 38.8% school personnel respectively. Current daily cigarette smoking, bidi smoking and smokeless tobacco use reported by 18.3%, 16.6% and 24.2% school personnel respectively. Men reported significantly more all kinds of daily tobacco use as compared to women. School tobacco control policy on three scales was reported poor (25-39%). However most of the school personnel felt need for such policies (88-98%). Teaching and training on tobacco was reported low (22.7%-35.9%). Most of the school personnel (87-95%) were supportive on different measures on tobacco control issues. Introduction of comprehensive school policies and enforcement on tobacco use may help to reduce adolescent and school personnel tobacco use.     

Tobacco control campaign in Uruguay: Impact on smoking cessation during pregnancy and birth weight

We analyzed a nationwide registry of all pregnancies in Uruguay during 2007–2013 to assess the impact of three types of tobacco control policies: (1) provider-level interventions aimed at the treatment of nicotine dependence, (2) national-level increases in cigarette taxes, and (3) national-level non-price regulation of cigarette packaging and marketing. We estimated models of smoking cessation during pregnancy at the individual, provider and national levels. The rate of smoking cessation during pregnancy increased from 15.4% in 2007 to 42.7% in 2013. National-level non-price policies had the largest estimated impact on cessation. The price response of the tobacco industry attenuated the effects of tax increases. While provider-level interventions had a significant effect, they were adopted by relatively few health centers. Quitting during pregnancy increased birth weight by an estimated 188 g. Tobacco control measures had no effect on the birth weight of newborns of non-smoking women.