SimSmoke: The effect of tobacco control policies on smoking prevalence and smoking-attributable deaths in 16 European Nations David Levy Pacific Institute for Research and Evaluation, United States,

Modeling in Public Health Simulation models/computational models = used in other fields, now common in public health, esp in the fields of tobacco control and obesity Useful where there are dynamic systems with many stages (e.g., policy -> environment -> behaviors -> health outcomes) and where the effects unfold over time. Generally combine information from different sources using best available data The predictions are usually validated with survey data over past time period

Objective Using adapted versions of the dynamic SimSmoke tobacco control policy simulation model, this study develops models for 15 countries to examine –the effect of past policies and –the effect on smoking prevalence and related mortality of raising excise taxes to 70% and implementing tobacco control policies that would be fully consistent with the FCTC

Methods SimSmoke is an excel-based model that simulates the dynamics of cigarette use and tobacco-attributable deaths and the effects of policies on these outcomes. Basic structure of the model: –Population model begins with initial year population and moves through time with births and deaths (Markov model) –Tobacco use model distinguishes population as never tobacco users, current tobacco users and former tobacco users and moves through time with initiation, cessation and relapse (Markov model) –Tobacco-attributable deaths depend on tobacco use rates and relative risks –Policy modules consider each of the FCTC policies with independent effects on tobacco use rates

Population Never Smoker Ever Smoker* Current Smoker** Ex-SmokerInitiation Not quit Relapse Cessation (quit) Not initiate * Usually as smoked 100 cigarettes lifetime ** usually as smoked some or all days Smoking Model: Evolution of Tobacco Users

Smoking-Attributable Deaths Smoking attributable deaths = (Smoker death rate – never smoker death rate) * # Smokers +   years quit (Ex-smoker death rate – never smoker death rate) * # Ex-smokers Total Deaths Deaths Attributable to Smoking Death rates by smoking status Relative risks % smokers and ex- smokers

7 SimSmoke shows The effects of individual policies –Taxes –Smoke-free air laws –Tobacco control/Media campaigns –Health warnings –Advertising and marketing bans –Cessation treatment policies –Youth access policies Synergistic effects of combined policies

Types of Models Tracking Model: starts from initial year with data available, and continues to most recent year = 2010 – Can be used to: Calibrate (adjust parameters) in the model Validate (test) the model (on part not calibrated) Examine the role of past policies Future Projection Model: examine the effect of policies from current year forward, starts from 2011

Nation Models: Initial Year and 2010 Prevalence COUNTRY AL- BANIA CZECH REP FIN- LANDFRANCE GER- MANY GREAT BRITAIN IRE- LANDITALY NETHER- LANDS PO- LANDRUSSIASPAINSWEDENTURKEYUKRAINE Initial Year MALE Initial Year Prev 64.4%37.1%30.6%33.9%36.9%29.4%33.4%31.8%39.1%37.8%61.3%39.2%25.1%50.0%65.9% 2010 Prev 63.3%34.6%25.2%27.1%31.3%22.8%26.1%26.8%29.6%37.8%61.1%31.7%22.3%43.4%49.6% FEMALE Initial Year Prev 18.9%23.4%20.6%26.7%0.0%26.3%31.0%16.7%30.0%24.8%14.5%24.4%26.3%17.8%19.9% 2010 Prev 18.4%23.1%18.6%22.9%0.0%20.5%25.1%15.0%24.9%24.1%16.6%21.7%23.6%16.1%

Ireland SimSmoke: Example Model begins in 1998 with population and smoking data Smoking prevalence from Survey of Lifestyles Attitudes and Nutrition (SLÁN), a nationally representative, stratified random sample. –SLÁN conducted in 1998, 2002 and 2007 –We use 2002 to calibrate the model and 2007 to validate –In 2007, sampling change to include many more immigrants (with higher smoking rates) Also used OTC smoking prevalence annual data (2002 to present) to validate

Ireland Tobacco Control Policies Some large recent tax/price increases. Tax now 63% of price,Some large recent tax/price increases. Tax now 63% of price, Smoke-free air laws since 2004,Smoke-free air laws since 2004, Increased advertising and marketing restrictions,Increased advertising and marketing restrictions, Stronger health warnings since 2002, andStronger health warnings since 2002, and Some increase in tobacco control spending and cessation treatment policies since 1998, but both are still not at high levels.Some increase in tobacco control spending and cessation treatment policies since 1998, but both are still not at high levels.

Ireland Male Smoking Prevalence, 18 years and above,

Counterfactual: What would have happened in the absence of policies? Without the policies implemented since 1998, the model projected a very slow downward trend for male and female smoking prevalence. With policies implemented, male and female smoking prevalence were each 22% (i.e., reduced by more than a fifth) below the levels that they would have been in As a result, the model projected that a total of 1,716 lives were saved by 2010, increasing to 50,215 lives by Since actual reductions were slightly more than we predicted, these estimates may be understated. The model was then used to show the effect of past policies

United Kingdom SimSmoke: Predicted vs Survey,

Comparison of 14 Nations: Effect of Past Policies Of EU nations, UK has implemented the strongest overall policies, and has reduced smoking prevalence substantially since 1999 (outperformed model, due to comprehensive cessation tx policy?) Ireland implemented most policies, and has also seen relatively large reductions in prevalence after controlling for immigration Turkey has been very active in recent years, and has seen large reductions in smoking prevalence Netherland, Finland, Poland and Sweden have implemented many of the FCTC policies and show moderate reductions in prevalence

Past Policies (continued) Italy and Spain implemented many policies, but effects on prevalence slightly less than predicted by model France implemented many policies and did worse than the model predictions (why?) Germany has few policies implemented, but model predicts well over long time period Czech Republic, Russia and Ukraine with weak policies and mostly stagnant prevalence, the models predict well

Impact of Future Policies Once the model is validated, it is used to predict the effect of future policies relative to the status quo (policies maintained at 2010 levels) The policies are implemented in 2011 and main- tained. The effect of future policies depend on the change from the level of policies in –Tax goal = excise taxes raised to 70% of price with value added taxes added on. –Other future policies are in terms of FCTC-consistent policies as embodied in MPOWER specifications plus well enforced youth access policy

Effect on Male Prevalence of Raising Excise Taxes to 70% CountryExcise % of retail price in 2010 Smoking prevalence (2010) Czech Republic 64.0%34.6%-5.8%-6.6%-8.3%-9.9% Finland 60.0%25.2%-10.6%-12.4%-15.7%-18.5% France 63.6%27.1%-6.5%-7.5%-9.3%-10.6% Germany 60.0%31.3%-6.6%-7.5%-9.0%-10.4% Ireland 63.0%26.1%-7.6%-8.6%-10.8%-12.9% Italy 58.5%26.8%-8.0%-9.0%-10.9%-12.6% Netherlands 57.0%29.6%-9.2%-10.3%-12.5%-14.5% Poland 68.0%37.8%-2.2%-2.6%-3.4%-4.1% Russia 21.5%61.1%-19.9%-22.7%-28.2%-32.5% Spain 64.0%31.7%-5.2%-6.1%-8.4%-10.3% Sweden 52.0%22.3%-14.0%-15.8%-19.3%-22.6% Turkey 63.6%43.4%-6.2%-6.9%-8.2%-9.3% Ukraine 43.3%49.6%-19.0%-20.3%-23.0%-25.7% United Kingdom 63.0%22.8%-6.5%-7.5%-9.4%-11.1%

Effect on Smoking-Attributable Deaths of Raising Excise Taxes to 70% CountryExcise as % of retail price in 2010 SADs in 2010 Absolute change in SADs (deaths averted) due to a tax increase Czech Republic 64.0% 22, ,042 19,008 Finland 60.0% 8, ,702 France 63.6% 85,485 1,277 3,470 4,511 73,568 Germany 60.0% 143,083 3,122 7,596 8, ,468 Ireland 63.0% 6, ,474 Italy 58.5% 91,050 2,138 5,022 5, ,204 Netherlands 57.0% 32, ,960 2,149 40,839 Poland 68.0% 68, ,302 1,572 27,094 Russia 21.5% 485,932 31,111 75,654 96,273 1,619,165 Spain 64.0% 59, ,241 2,881 46,737 Sweden 52.0% 15, ,281 1,372 26,780 Turkey 63.6% 84,891 1,900 5,878 8, ,915 Ukraine 43.3% 144,247 7,804 17,193 18, ,542 United Kingdom 63.0% 94,312 1,234 2,957 3,493 62,753

Effects of Increasing Excise Taxes to 70% The largest reductions in prevalence are in Russia and Albania (where taxes are both less than 35% of the price). For Russia, a 20% reduction is expected in smoking prevalence within 5 years increasing to 37% by Between 2011 and 2040,1.6 million deaths are averted with the increase in taxes. Other countries with the potential to avert many deaths through a price increase are the Ukraine (362.5 thousand), Turkey (125 thousand), and Italy (105 thousand), all with tax rates less than 60%. Smaller reductions in prevalence are seen for Poland, the Czech Republic, France, Spain because they have excise taxes of 63.5% or above.

Example: Ireland SimSmoke Male Prevalence with Individual FCTC Policies Policies/Year Status Quo Policies 26.1%25.9%24.1%21.8%20.0% Independent Policy Effects Tax 70% of Retail Price26.1%25.1%23.1%20.6%18.7% Complete Smoke Free & Enforcement26.1%25.9%24.1%21.7%20.0% Comprehensive Ad Ban & Enforcement26.1%25.8%24.0%21.6%19.9% High Intensity Tobacco Control Campaign26.1%24.3%22.4%20.0%18.2% Strong Health Warnings26.1%25.6%23.8%21.4%19.7% Strong Youth Access Enforcement26.0%25.8%23.5%20.8%18.8% Cessation Treatment Policies26.1%25.4%23.1%20.6%18.8% Combined Policy Effects All above, including Youth Access26.0%22.4%19.3%16.4%14.4% % Change in Smoking Prevalence from Status Quo Independent Policy Effects Tax 70% of Retail Price-3.3%-4.3%-5.5%-6.6% Complete Smoke Free & Enforcement-0.2%-0.3% Comprehensive Ad Ban & Enforcement-0.5%-0.6%-0.7% High Intensity Tobacco Control Campaign-6.3%-7.3%-8.2%-8.9% Strong Health Warnings-1.2%-1.5%-1.6% Strong Youth Access Enforcement-0.4%-2.5%-4.2%-6.0% Cessation Treatment Policies-2.2%-4.3%-5.5%-5.9% Combined Policy Effects All above, including Youth Access-13.5%-19.9%-24.6%-28.1%

Potential Future Effect of Implementing all FCTC Policies, Males for 15 EU Nations Status quow/ Full FCTC PoliciesDeaths averted POLICY/YEARS % change ALBANIA63.3%57.9%26.3%-54.5% 57,951 CZECH REPUBLIC34.6%27.5%16.4%-40.1% 113,023 FINLAND25.2%19.5%12.8%-34.6% 23,045 FRANCE27.1%21.5%14.7%-31.6% 258,879 GERMANY31.3%25.5%15.7%-38.2% 744,400 IRELAND26.1%20.0%14.4%-28.1% 28,064 ITALY26.8%20.3%13.4%-34.0% 329,570 NETHERLANDS29.6%23.1%14.0%-39.5% 144,769 POLAND63.3%57.9%26.3%-54.5% 467,312 RUSSIA61.1%59.1%26.3%-55.6% 3,550,230 SPAIN31.7%22.5%14.6%-34.9% 257,336 SWEDEN22.3%16.6%10.6%-36.3% 53,486 TURKEY43.4%37.5%24.7%-34.1% 643,762 UKRAINE49.6%35.9%15.3%-57.4% 889,384 GREAT BRITAIN22.8%18.6%13.6%-26.7% 163,986

Implementing all FCTC Policies Including Taxes to 70% of Price If all policies are simultaneously implemented in Russia, SimSmoke predicts an initial reduction in smoking prevalence of 38%, compared to 20% if only tax policy is implemented. The reduction increases to 56% by A total of 3.6 million deaths due to smoking are averted. Other countries with relatively weak policies, such as Ukraine, Poland, Germany and the Czech Republic can also expect reductions of 38% or above with the complete set of FCTC-consistent policies. Even some of the countries with relatively strong policies, such as Ireland and the UK, are predicted to see reductions in smoking prevalence of above 25%.

Conclusions Some European countries, particularly the UK, have made substantial progress in implementing tobacco control policies, and many have seen substantial benefits in terms of reduced smoking prevalence and fewer premature deaths due to smoking. Most countries still have a ways until meeting MPOWER recommended targets. Those with low tax rates and weak policies can substantially reduce smoking rates and avert large numbers of deaths. Some can still reduce smoking rates by more than 50%, especially those Eastern Bloc countries with high male rates and increasing female rates.