Effect of policies directed at youth access to smoking: results from the SimSmoke computer simulation model

Comparison of smoking prevalence in Canada before and after nicotine vaping product access using the SimSmoke model

OBJECTIVES

The public health impact of nicotine vaping products (NVPs) is subject to complex transitions between NVP and cigarette use. To circumvent the data limitations and parameter instability challenges in modeling transitions, we indirectly estimate NVPs' impact on smoking prevalence and resulting smoking-attributable deaths using the SimSmoke simulation model.

METHODS

Canada SimSmoke uses age- and sex-specific data on Canadian population, smoking prevalence and tobacco control policies. The model incorporates the impact of cigarette-oriented policies on smoking prevalence but not the explicit contribution of NVPs. The model was calibrated from 1999 to 2012, thereby projecting smoking prevalence before NVPs were widely used in Canada. The NVP impact on smoking prevalence is inferred by comparing projected 2012-2020 smoking trends absent NVPs to corresponding trends from two Canadian national surveys. We further distinguish impacts before and after NVPs became regulated in 2018 and more available.

RESULTS

Comparing 2012-2020 survey data of post-NVP to SimSmoke projected smoking prevalence trends, one survey indicated an NVP-related relative reduction of 15% (15%) for males (females) age 15+, but 32% (52%) for those ages 15-24. The other survey indicated a 14% (19%) NVP-related smoking reduction for ages 18+, but 42% (53%) for persons ages 18-24. Much of the gain occurred since Canada relaxed NVP restrictions. NVP-related 2012-2020 smoking reductions yielded 100,000 smoking-attributable deaths averted from 2012 to 2060.

CONCLUSION

Smoking prevalence in Canada, especially among younger adults, declined more rapidly once NVPs became readily available. The emergence of NVPs into the Canadian marketplace has not slowed the decline in smoking.

The Kentucky SimSmoke Tobacco Control Policy Model of Smokeless Tobacco and Cigarette Use

BACKGROUND

Smokeless tobacco (SLT) prevalence was decreasing in Kentucky before 2007, but has since increased. This study examines the impact of policies on cigarette and SLT use by applying the SimSmoke tobacco control policy simulation model.

METHODS

Using data from the large-scale Tobacco Use Supplement of the Current Population Survey (TUS-CPS) and information on state-specific tobacco policies, Kentucky SimSmoke is updated and extended to incorporate exclusive SLT and dual cigarette and SLT use. The model is validated using survey data through 2017. The model was used to estimate the impact on smoking and SLT prevalence and attributable deaths of policies implemented between 1993 and 2018 and the impact of stronger future policies implemented in 2018 and maintained through 2060.

RESULTS

SimSmoke generally reflects trends in exclusive cigarette use from the TUS-CPS and the Behavioral Risk Factor Surveillance System (BRFSS), but underestimated the increase in SLT prevalence in recent years. SimSmoke projects that policies implemented between 1993 and 2018 reduced male and female cigarette use by 23.7% and 23.0%, and male and female SLT use by 4.9% by 2018, averting 9018 tobacco-attributable deaths by 2018, increasing to 89 547 by 2060. The largest reductions in cigarette and SLT use were attributed to cigarette price increases. Strengthening tobacco control policies could reduce smoking prevalence by 41% and 40%, and reduce SLT prevalence by 33% and 25% for males and females by 2060.

CONCLUSION

Our results suggest that cigarette-oriented policies were effective in reducing SLT use but have been less successful in recent years. Future use rates can be further reduced through more restrictive statewide policies, which also target non-combustible nicotine products.

Do Longitudinal Trends in Tobacco 21-Related Media Coverage Correlate with Policy Support? an Exploratory Analysis Using Supervised and Unsupervised Machine Learning Methods

Media coverage can impact support for health policies and, ultimately, compliance with those policies. Prior research found consistent, high support for Tobacco 21 policies, which raise the minimum legal age of tobacco purchase to 21, among adults and nonsmoking youth. However, a recent study found support (i.e., agreement with the statement: "The legal age to buy tobacco cigarettes should be increased from 18 to 21") among 13-20-year-old smokers increased from 2014 until mid-2016 and then declined steadily through mid-2017. To assess whether media coverage could be related to young smokers' changing support, we conducted an exploratory content analysis to identify texts about Tobacco 21 in a large corpus of tobacco texts (N = 135,691) published in four popular media sources from 2014 to 2017. For this content analysis, we developed a novel methodological approach that combined supervised and unsupervised machine learning methods and could be useful in other areas of communication research. We found that the prevalence of Tobacco 21 media coverage and Tobacco 21 support among young smokers exhibited similar temporal patterns for much of the study period. These findings highlight the need for continued research into the effects of media coverage on Tobacco 21 support among young smokers, a group that must comply with Tobacco 21 policies in order to ensure maximum effectiveness. This research is of particular utility following the 2019 passage of a federal Tobacco 21 regulation, as the public health impact of this regulation could be limited by low public support, and thus low rates of policy compliance.

US Nicotine Vaping Product SimSmoke Simulation Model: The Effect of Vaping and Tobacco Control Policies on Smoking Prevalence and Smoking-Attributable Deaths

The public health impact of nicotine vaping products (NVPs) is subject to a complex set of uncertain transitions between NVP and cigarette use. Instead, we apply an indirect method to gauge the impact of NVP use on smoking prevalence and smoking-attributable deaths (SADs) using the well-established SimSmoke tobacco control policy simulation model. Upon validating the model before NVPs were more widely used, we project a No-NVP (i.e., in the absence of NVPs) while controlling for the impact of cigarette-oriented policies. The net impact of NVPs on smoking prevalence is inferred by comparing the projected No-NVP smoking trends to corresponding trends from two US national surveys. Using the TUS-CPS estimates for the period 2012-2018, we estimate that adult smoking prevalence declined in relative terms by 9.7% (95% CI: 7.5-11.7%) for males and 10.7% (95% CI: 9.1-13.0%) for females. Compared to NHIS, smoking prevalence declined by 10.7% (95% CI: 6.8-14.6%) for males and 11.3% (95% CI: 7.4-15.6%) for females. These impacts were confined mainly to ages 18-44. Vaping-related reductions in smoking prevalence were projected to avert nearly 0.4 million SADs between 2012 and 2052. Our analysis indicates that NVP use is associated with substantial reductions in US smoking prevalence among younger adults.

Policy options for endgame planning in tobacco control: a simulation modelling study

OBJECTIVE

To investigate the potential impacts of several tobacco control interventions on adult daily smoking prevalence in the Australian state of Queensland, using a system dynamics model codeveloped with local and national stakeholders.

METHODS

Eight intervention scenarios were simulated and compared with a reference scenario (business as usual), in which all tobacco control measures currently in place are maintained unchanged until the end of the simulation period (31 December 2037).

FINDINGS

Under the business as usual scenario, adult daily smoking prevalence is projected to decline from 11.8% in 2017 to 5.58% in 2037. A sustained 50% increase in antismoking advertising exposure from 2018 reduces projected prevalence in 2037 by 0.80 percentage points. Similar reductions are projected with the introduction of tobacco wholesaler and retailer licensing schemes that either permit or prohibit tobacco sales by alcohol-licensed venues (0.65 and 1.73 percentage points, respectively). Increasing the minimum age of legal supply of tobacco products substantially reduces adolescent initiation, but has minimal impact on smoking prevalence in the adult population over the simulation period. Sustained reductions in antismoking advertising exposure of 50% and 100% from 2018 increase projected adult daily smoking prevalence in 2037 by 0.88 and 1.98 percentage points, respectively.

CONCLUSIONS

These results suggest that any prudent approach to endgame planning should seek to build on rather than replace existing tobacco control measures that have proved effective to date. Additional interventions that can promote cessation are expected to be more successful in reducing smoking prevalence than interventions focussing exclusively on preventing initiation.

Tobacco 21 Laws in Europe: A Policy Whose Time Has Come

INTRODUCTION

A 21 tobacco age of sale has been proposed for European nations.

METHODS

We briefly review past studies of underage purchase policies and their enforcement.

RESULTS

Past evaluations and modeling studies indicate important public health gains from 21 tobacco age of sale laws. However, further attention should be given to issues of compliance, the availability of social sources, and the breadth of coverage. In particular, the application of the law to e-cigarettes merits further attention.

CONCLUSIONS

Past literature indicates potential benefits of a 21 tobacco age of sale in terms of reducing tobacco use in European nations.

IMPLICATIONS

We review past studies of underage purchase laws, and the potential implications of applying that law to e-cigarettes. Past studies indicate the effectiveness of raising tobacco age of sale laws to 21. This law should be implemented and enforced in Europe.

Tobacco control within and beyond WHO MPOWER: outcomes from Taiwan SimSmoke

INTRODUCTION

Adult smoking prevalence in Taiwan rapidly declined from 26.5% in 2005 to 20.0% in 2015. Nevertheless, future projections on smoking-attributable deaths and current per capita consumption do not paint an equally bright picture.

METHODS

We used SimSmoke, a tobacco control simulation model to assess the impact of tax increases and other policies by predicting past and projecting over future decades smoking rates and smoking-attributable mortality.

RESULTS

The model accurately depicts the decline in smoking prevalence observed in Taiwan from 2000 to 2015. Nonetheless, under the 'status quo' scenario, smoking-attributable mortality is projected to continue growing, peaking at 26 602 annual deaths in 2039 and cumulative deaths >1 million by 2044. By comparing projections with current policies with a counterfactual scenario based on the 2000 policy levels, SimSmoke estimates that tobacco control in Taiwan has been able to reduce smoking prevalence by 30% in 2015 with 450 000 fewer smoking-attributable deaths by 2060. Modified scenarios show that doubling the retail price of cigarettes and fully implementing the remaining MPOWER measures would avert approximately 45 000 lives by 2040 and 130 000 by 2060.

CONCLUSIONS

Tobacco will be a leading cause of death in Taiwan for the coming decades, showing yet again the long-term consequences of smoking on public health. The MPOWER package, even if adopted at the highest level with a large tax increase, is unlikely to reduce smoking prevalence to the endgame goal of 5% in the next five decades.

The Minnesota SimSmoke Tobacco Control Policy Model of Smokeless Tobacco and Cigarette Use

INTRODUCTION

A previous Minnesota SimSmoke tobacco control policy model is extended to more recent years and to include smokeless tobacco use.

METHODS

Using data from the 1993 Tobacco Use Supplement and information on state policies, the Minnesota SimSmoke model was updated and extended to incorporate smokeless tobacco (both exclusive and dual use) and smokeless tobacco-attributable deaths. The model was then validated against the 2002, 2006/2007, and 2014/2015 Tobacco Use Supplement and the 1999, 2007, 2014, and 2018 Minnesota Adult Tobacco Survey and used to estimate the impact of policies implemented between 1993 and 2018. Analysis was conducted in April 2019.

RESULTS

The model validated well for cigarette and earlier smokeless tobacco use, but it predicted smokeless tobacco use less well in recent years. The model projected that male (female) smoking prevalence was 35% (36%) lower in relative terms by 2018 and 43% (44%) lower by 2040 owing to policies, with lesser reductions projected for male smokeless tobacco use. Tobacco-attributable deaths were reduced by 7,800 by 2018 and 46,900 by 2040. Price increases, primarily through taxes, were projected to have had the greatest impact on cigarette use followed by smoke-free air laws, cessation treatment policies, tobacco control campaign expenditures, and youth access enforcement. Similar effects were projected for smokeless tobacco use, except that smoke-free air laws had smaller effects.

CONCLUSIONS

As cigarettes remain the dominant form of nicotine delivery product, cigarette-oriented policies may be an effective means of reducing the use of all nicotine delivery products. However, noncigarette-oriented policies may also play an important role.

The US SimSmoke tobacco control policy model of smokeless tobacco and cigarette use

Background

Smokeless tobacco (SLT) prevalence had been declining in the US prior to 2002 but has since increased. Knowledge about the impact of tobacco control policies on SLT and cigarette use is limited. This study examines the interrelationship between policies, cigarette use, and SLT use by applying the SimSmoke tobacco control policy simulation model.

Methods

Using data from large-scale Tobacco Use Supplement and information on policies implemented, US SimSmoke was updated and extended to incorporate SLT use. The model distinguishes between exclusive SLT and dual use of SLT and cigarettes, and considers the effect of implementing individual and combined tobacco control policies on smoking and SLT use, and on deaths attributable to their use. After validating against Tobacco Use Supplement (TUS) survey data through 2015, the model was used to estimate the impact of policies implemented between 1993 and 2017.

Results

SimSmoke reflected trends in exclusive cigarette use from the TUS, but over-estimated the reductions, especially among 18–24 year olds, until 2002 and under-estimated the reductions from 2011 to 2015. By 2015, SimSmoke projections of exclusive SLT and dual use were close to TUS estimates, but under-estimated reductions in both from 1993 to 2002 and failed to estimate the growth in male exclusive SLT use, especially among 18–24 year olds, from 2011 to 2015. SimSmoke projects that policies implemented between 1993 and 2017 reduced exclusive cigarette use by about 35%, dual use by 32.5% and SLT use by 16.5%, yielding a reduction of 7.5 million tobacco-attributable deaths by 2067. The largest reductions were attributed to tax increases.

Conclusions

Our results indicate that cigarette-oriented policies may be effective in also reducing the use of other tobacco products. However, further information is needed on the effect of tobacco control policies on exclusive and dual SLT use and the role of industry.

Computational Models Used to Assess US Tobacco Control Policies

INTRODUCTION

Simulation models can be used to evaluate existing and potential tobacco control interventions, including policies. The purpose of this systematic review was to synthesize evidence from computational models used to project population-level effects of tobacco control interventions. We provide recommendations to strengthen simulation models that evaluate tobacco control interventions.

METHODS

Studies were eligible for review if they employed a computational model to predict the expected effects of a non-clinical US-based tobacco control intervention. We searched five electronic databases on July 1, 2013 with no date restrictions and synthesized studies qualitatively.

RESULTS

Six primary non-clinical intervention types were examined across the 40 studies: taxation, youth prevention, smoke-free policies, mass media campaigns, marketing/advertising restrictions, and product regulation. Simulation models demonstrated the independent and combined effects of these interventions on decreasing projected future smoking prevalence. Taxation effects were the most robust, as studies examining other interventions exhibited substantial heterogeneity with regard to the outcomes and specific policies examined across models.

CONCLUSIONS

Models should project the impact of interventions on overall tobacco use, including nicotine delivery product use, to estimate preventable health and cost-saving outcomes. Model validation, transparency, more sophisticated models, and modeling policy interactions are also needed to inform policymakers to make decisions that will minimize harm and maximize health.

IMPLICATIONS

In this systematic review, evidence from multiple studies demonstrated the independent effect of taxation on decreasing future smoking prevalence, and models for other tobacco control interventions showed that these strategies are expected to decrease smoking, benefit population health, and are reasonable to implement from a cost perspective. Our recommendations aim to help policymakers and researchers minimize harm and maximize overall population-level health benefits by considering the real-world context in which tobacco control interventions are implemented.

Gauging the Effect of U.S. Tobacco Control Policies From 1965 Through 2014 Using SimSmoke

INTRODUCTION

The year 2014 marked the 50th Anniversary of the first Surgeon General's Report. This paper estimates the effect of tobacco control policies in the U.S. after the 1964 Report using the SimSmoke tobacco control simulation model.

METHODS

SimSmoke uses National Health Interview Survey data from 1965 through 2012 on smoking prevalence, initiation, and cessation rates, and incorporates policies implemented since 1965. The model projects smoking prevalence and smoking-attributable deaths (SADs) from 1965 through 2065 and is validated against National Health Interview Survey data. Counterfactual scenarios with policies constant since 1965 and with individual policies are estimated. Analysis was conducted in February 2014.

RESULTS

SimSmoke generally validated well during the time period from 1965 through 2012. As a result of all policies, smoking prevalence is estimated to have fallen by almost 55% by 2014, with a total of 2 million SADs averted from 1965 through 2014, increasing to 20.1 million SADs by 2065. The Fairness Doctrine is estimated to have reduced adult smoking prevalence by about 24% by 2014 and averted 10.4 million SADs by 2065, while price increases reduced smoking prevalence by 24% by 2014 and averted 7.3 million SADs by 2065. Smoke-free air laws, cessation treatment, and tobacco control spending individually reduced smoking rates by 3%-5.5% by 2014.

CONCLUSIONS

By 2014, SimSmoke predicts a 53% reduction in smoking rates and almost 2 million SADs averted due to polices implemented since the 1964 Surgeon General's Report, with most of the health benefit still to occur in future years.

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.

Tobacco outlet density, retailer cigarette sales without ID checks and enforcement of underage tobacco laws: associations with youths' cigarette smoking and beliefs

AIMS

To estimate the relationships of tobacco outlet density, cigarette sales without ID checks and local enforcement of underage tobacco laws with youth's life-time cigarette smoking, perceived availability of tobacco and perceived enforcement of underage tobacco laws and changes over time.

DESIGN

The study involved: (a) three annual telephone surveys, (b) two annual purchase surveys in 2000 tobacco outlets and (c) interviews with key informants from local law enforcement agencies. Analyses were multi-level models (city, individual, time).

SETTING

A sample of 50 mid-sized non-contiguous cities in California, USA.

PARTICIPANTS

A total of 1478 youths (aged 13-16 at wave 1, 52.2% male); 1061 participated in all waves.

MEASUREMENTS

Measures at the individual level included life-time cigarette smoking, perceived availability and perceived enforcement. City-level measures included tobacco outlet density, cigarette sales without ID checks and compliance checks.

FINDINGS

Outlet density was associated positively with life-time smoking [OR = 1.12, P < 0.01]. An interaction between outlet density and wave (OR = 0.96, P < 0.05) suggested that higher density was associated more closely with life-time smoking at the earlier waves when respondents were younger. Greater density was associated positively with perceived availability (β = 0.02, P < 0.05) and negatively with perceived enforcement (β = -0.02, P < 0.01). Sales rate without checking IDs was related to greater perceived availability (β = 0.01, P < 0.01) and less perceived enforcement (β = -0.01, P < 0.01). Enforcement of underage tobacco laws was related positively to perceived enforcement (β = 0.06, P < 0.05).

CONCLUSIONS

Higher tobacco outlet density may contribute to life-time smoking among youths. Density, sales without ID checks and enforcement levels may influence beliefs about access to cigarettes and enforcement of underage tobacco sales laws.

Youth retail tobacco access in Canada: regional variation, perceptions, and predictors from YSS 2010/2011

PURPOSE

Retail tobacco access is an important determinant of youth smoking prevalence. This study examines perceptions of ease in obtaining cigarettes and how prevalence of self-reported retail tobacco access among youth smokers varies by province in Canada. Additionally, relevant retail experiences, such as being asked for identification by a store clerk, are described.

METHODS

Data from grades 9-12 students who participated in the 2010/2011 Youth Smoking Survey, a nationally generalizable sample of Canadian students (n=31396) were used to examine retail tobacco access and related experiences. Logistic regression models were used to examine differences in retail tobacco access and retail tobacco experiences by sociodemographic and regional characteristics.

RESULTS

79% of students who never smoked thought it would be easy to get cigarettes. About one-quarter of smokers reported usually buying cigarettes from stores, and the percent of student smokers usually buying cigarettes in stores ranged from 16% in British Columbia to 36% in Quebec. Compared to grade 9 students, grade 12 students had higher odds of report being asked for identification (OR=6.3, 95% CI 1.9-21.5).

CONCLUSIONS

Retail tobacco access appears to be a significant source of cigarette access among Canadian youth. Retail tobacco access varies significantly by province, which suggests provincial policies should be strengthened.

Estimating the Potential Impact of Tobacco Control Policies on Adverse Maternal and Child Health Outcomes in the United States Using the SimSmoke Tobacco Control Policy Simulation Model

INTRODUCTION

Numerous studies document the causal relationship between prenatal smoking and adverse maternal and child health (MCH) outcomes. Studies also reveal the impact that tobacco control policies have on prenatal smoking. The purpose of this study is to estimate the effect of tobacco control policies on prenatal smoking prevalence and adverse MCH outcomes.

METHODS

The US SimSmoke simulation model was extended to consider adverse MCH outcomes. The model estimates prenatal smoking prevalence and, applying standard attribution methods, uses estimates of MCH prevalence and relative smoking risks to estimate smoking-attributable MCH outcomes over time. The model then estimates the effect of tobacco control policies on adverse birth outcomes averted.

RESULTS

Different tobacco control policies have varying impacts on the number of smoking-attributable adverse MCH birth outcomes. Higher cigarette taxes and comprehensive marketing bans individually have the biggest impact with a 5% to 10% reduction across all outcomes for the period from 2015 to 2065. The policies with the lowest impact (2%-3% decrease) during this period are cessation treatment, health warnings, and complete smoke-free laws. Combinations of all policies with each tax level lead to 23% to 28% decreases across all outcomes.

CONCLUSIONS

Our findings demonstrate the substantial impact of strong tobacco control policies for preventing adverse MCH outcomes, including long-term health implications for children exposed to low birth weight and preterm birth. These benefits are often overlooked in discussions of tobacco control.

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.

Geographic variations in cardiovascular health in the United States: contributions of state- and individual-level factors

Background

Improving cardiovascular health (CVH) of all Americans by 2020 is a strategic goal of the American Heart Association. Understanding the sources of variation and identifying contextual factors associated with poor CVH may suggest important avenues for prevention.

Methods and Results

Cross-sectional data from the Behavioral Risk Factor Surveillance System for the year 2011 were linked to state-level coronary heart disease and stroke mortality data from the National Vital Statistics System and to state-level measures of median household income, income inequality, taxes on soda drinks and cigarettes, and food and physical activity environments from various administrative sources. Poor CVH was defined according to the American Heart Association definition using 7 self-reported CVH metrics (current smoking, physical inactivity, obesity, poor diet, hypertension, diabetes, and high cholesterol). Linked micromap plots and multilevel logistic models were used to examine state variation in poor CVH and to investigate the contributions of individual- and state-level factors to this variation. We found significant state-level variation in the prevalence of poor CVH (median odds ratio 1.32, P<0.001). Higher rates of poor CVH and cardiovascular disease mortality were clustered in the southern states. Minority and low socioeconomic groups were strongly associated with poor CVH and explained 51% of the state-level variation in poor CVH; state-level factors explained an additional 28%. State-level median household income (odds ratio 0.89; 95% CI 0.84–0.94), taxes on soda drinks (odds ratio 0.94; 95% CI 0.89–0.99), farmers markets (odds ratio 0.91; 95% CI 0.85–0.98), and convenience stores (odds ratio 1.09; 95% CI 1.01–1.17) were predictive of poor CVH even after accounting for individual-level factors.

Conclusions

There is significant state-level variation in poor CVH that is partly explained by individual- and state-level factors. Additional longitudinal research is warranted to examine the influence of state-level policies and food and physical activity environments on poor CVH.

Rating the effectiveness of local tobacco policies for reducing youth smoking

Important questions remain regarding the effectiveness of local tobacco policies for preventing and reducing youth tobacco use and the relative importance of these policies. The aims of this paper are to: (1) compare policy effectiveness ratings provided by researchers and tobacco prevention specialists for individual local tobacco policies, and (2) develop and describe a systematic approach to score communities for locally-implemented tobacco policies. We reviewed municipal codes of 50 California communities to identify local tobacco regulations in five sub-domains. We then developed an instrument to rate the effectiveness of these policies and administered it to an expert panel of 40 tobacco researchers and specialists. We compared mean policy effectiveness ratings obtained from researchers and prevention specialists and used it to score the 50 communities. High inter-rater reliabilities obtained for each sub-domain indicated substantial agreement among the raters about relative policy effectiveness. Results showed that, although researchers and prevention specialists differed on the mean levels of policy ratings, their relative rank ordering of the effectiveness of policy sub-domains were very similar. While both researchers and prevention specialists viewed local outdoor clean air policies as least effective in preventing and reducing youth cigarette smoking, they rated tobacco sales policies and advertising and promotion as more effective than the other policies. Moreover, we found high correlations between community scores generated from researchers' and prevention specialists' ratings. This approach can be used to inform research on local policies and prevention efforts and help bridge the gap between research and practice.

Parental and retail supply of tobacco to minors: findings from a community-based social supply intervention study

AIM

We report on findings from a quasi-experimental community trial of a complex intervention aimed at reducing social and commercial supply of cigarettes to young people.

MATERIALS AND METHODS

The intervention comprised a package of school, community and home-based smokefree strategies implemented over three years from 2007 to 2009 in a low-income area of Auckland, New Zealand, with another area serving as the control population. The main outcome measures were relative change in parental and retailer behaviour and in attitudes to the provision of tobacco to youth. We analysed baseline and follow-up data from questionnaires administered to parents and children living in the intervention and control areas using PASW Statistics 18.

RESULTS

No difference was found between groups in parents' permissiveness of smoking and in retailer compliance to the tobacco sale legislation over the course of the study, either because our intervention had no or only a limited effect, or alternatively because limitations in the study design diluted any effect.

CONCLUSIONS

Nevertheless, a key finding was that parents and retailers persisted as important sources of cigarettes for young people. Further study is required to identify effective interventions to address this issue.

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

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 reductions of 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 impact of local U.S. tobacco policies on youth tobacco use: A critical review

Tobacco use continues to be the leading preventable cause of premature death in the United States, killing over 430,000 people annually. Tobacco initiation and use among youth remains a significant public health concern. Despite declines in U.S. youth tobacco use in recent years, state and national survey results are still cause for alarm. Although traditional school-based curricular programs are the most common strategy to prevent or reduce youth tobacco use, their effectiveness may be limited because young people are immersed in a broader social context in which tobacco is readily available. Environmental strategies change this social context by focusing on policy, enforcement, and media. A compelling body of evidence suggests that interventions at the state and federal levels can, when implemented in combination, reduce youth tobacco use. The impact of policies implemented at the local levels is less well understood and effects of environmental strategies on smokeless tobacco consumption have been largely ignored. The purpose of this paper is to review the literature on environmental strategies implemented at the local level on youth use of both cigarettes and smokeless tobacco. We highlight results of the extant literature, hypothesize possible effects where research is lacking, and suggest where future studies might be warranted.

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.

Environmental and societal influences acting on cardiovascular risk factors and disease at a population level: a review

It has long been known that cardiovascular disease (CVD) rates vary considerably among populations, across space and through time. It is now apparent that most of the attributable risk for myocardial infarction 'within' populations from across the world can be ascribed to the varying levels of a limited number of risk factors among individuals in a population. Individual risk factors (e.g. blood pressure) can be modified with resulting health gains. Yet, the persistence of large international variations in cardiovascular risk factors and resulting CVD incidence and mortality indicates that there are additional factors that apply to 'populations' that are important to understand as part of a comprehensive approach to CVD control. This article reviews the evidence on why certain populations are more at risk than others.

Methodologies used to estimate tobacco-attributable mortality: a review

BACKGROUND

One of the most important measures for ascertaining the impact of tobacco on a population is the estimation of the mortality attributable to its use. To measure this, a number of indirect methods of quantification are available, yet there is no consensus as to which furnishes the best information. This study sought to provide a critical overview of the different methods of attribution of mortality due to tobacco consumption.

METHOD

A search was made in the Medline database until March 2005 in order to obtain papers that addressed the methodology employed for attributing mortality to tobacco use.

RESULTS

Of the total of 7 methods obtained, the most widely used were the prevalence methods, followed by the approach proposed by Peto et al, with the remainder being used in a minority of studies.

CONCLUSION

Different methodologies are used to estimate tobacco attributable mortality, but their methodological foundations are quite similar in all. Mainly, they are based on the calculation of proportional attributable fractions. All methods show limitations of one type or another, sometimes common to all methods and sometimes specific.

The spatial distribution of underage tobacco sales in Los Angeles

OBJECTIVE

Underage tobacco sales is considered a serious public health problem in Los Angeles. Anecdotally, rates have been thought to be quite high. In this paper, using spatial statistical techniques, we describe underage tobacco sales, identifying areas with high levels of sales and hot spots controlling for sociodemographic measures.

METHODS

Six hundred eighty-nine tobacco outlets were investigated throughout the city of Los Angeles in 2001. We consider the factors that explain vendor location of illegal sales of tobacco to underage youth and focus on those areas with especially high rates of illegal sales when controlling for other independent measures. Using data from the census, the LA City Attorney's Office, and public records on school locations in Los Angeles, we employ general least-squares (GLS) estimators in order to avoid biased estimates.

MAIN OUTCOME MEASURE

vendor location of underage tobacco compliance checks, violators, and nonviolators.

RESULTS

Underage tobacco sales in Los Angeles were very high (33.5%) for the entire city in 2001. In many zip codes this rate is considerably higher (60%-100%). When conducting spatial modeling, lower income and ethnicity were strongly associated with increases in underage tobacco sales. Hotspot areas of underage tobacco sales also had much lower mean family income and a much higher percentage of foreign born and greater population density.

CONCLUSIONS

Spatial techniques were used to better identify areas where vendors sell tobacco to underage youth. Lower income areas were much more likely to both have higher rates of underage tobacco sales and to be a hot spot for such sales. Population density is also significantly associated with underage tobacco sales. The study's limitations are noted.

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.

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.

Limiting youth access to tobacco: comparing the long-term health impacts of increasing cigarette excise taxes and raising the legal smoking age to 21 in the United States

Although many states in the US have raised cigarette excise taxes in recent years, the size of these increases have been fairly modest (resulting in a 15% increase in the per pack purchase price), and their impact on adult smoking prevalence is likely insufficient to meet Healthy People 2010 objectives. This paper presents the results of a 75-year dynamic simulation model comparing the long-term health benefits to society of various levels of tax increase to a viable alternative: limiting youth access to cigarettes by raising the legal purchase age to 21. If youth smoking initiation is delayed as assumed in the model, increasing the smoking age would have a minimal immediate effect on adult smoking prevalence and population health, but would affect a large drop in youth smoking prevalence from 22% to under 9% for the 15-17-year-old age group in 7 years (by 2010)-better than the result of raising taxes to increase the purchase price of cigarettes by 100%. Reducing youth initiation by enforcing a higher smoking age would reduce adult smoking prevalence in the long-term (75 years in the future) to 13.6% (comparable to a 40% tax-induced price increase), and would produce a cumulative gain of 109 million QALYs (comparable to a 20% price increase). If the political climate continues to favor only moderate cigarette excise tax increases, raising the smoking age should be considered to reduce the health burden of smoking on society. The health benefits of large tax increases, however, would be greater and would accrue faster than raising the minimum legal purchase age for cigarettes.

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.

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.

Closing the youth access gap: The projected health benefits and cost savings of a national policy to raise the legal smoking age to 21 in the United States

Current youth access laws, even if strictly enforced, do not prevent teenagers from obtaining cigarettes through social sources. To reduce the number of legal buyers a typical teenager routinely encounters, and to lessen ambiguity for vendors determining if a teen is of legal purchasing age, legislation raising the minimum legal purchase age (MLPA) for cigarettes to 21 has been discussed in several states. To estimate how a national law raising the smoking age to 21 would impact smoking prevalence, net costs (in terms of compliance enforcement, ID checking, and medical care) and health benefits (in terms of life years and QALYs) to the population over time, a dynamic computer simulation model was developed using publicly available secondary data. The model simulations were carried out for several scenarios assuming varying impacts of the policy change on smoking initiation probability over a 50-year period. One scenario assumes that smoking initiation probabilities for individuals under 21 shift by 3 years so a 18-year old in the simulation, for example, is as likely to initiate smoking as an 15-year old in the status quo. Under this assumption, raising the smoking age would reduce smoking prevalence for adults (age 18+) from the status quo level of 22.1-15.4% after 50 years. Prevalence would drop from 20 to 6.6% for 14-17-year olds, from 26.9 to 12.2% for 18-20-year olds, and from 21.8 to 15.5% for the 21+ group. The policy would produce a net cumulative savings to society of 212 billion US dollars (driven by reduced medical costs), and the accumulation of nearly 13 million additional QALYs over the period.

Recent trends in smoking and the role of public policies: results from the SimSmoke tobacco control policy simulation model

AIMS

After a period of steady decline in smoking prevalence, smoking rates leveled off in the United States between 1990 and 1997, but began falling between 1997 and 2003. Trends in smoking prevalence, and the role of tobacco control policies in affecting those rates, are examined.

DESIGN

A computer simulation model is used in which smoking prevalence evolves through initiation and cessation, which are in turn influenced by tobacco control policies.

METHODS

The results of the model are compared to smoking prevalence measures from the US National Health Interview Survey between 1993 and 2003. We also consider the role of tax/price, clean air laws, media campaigns and youth access policies in influencing these rates.

FINDINGS

Both the SimSmoke model and data for recent years indicate that adult smoking prevalence changed little between 1993 and 1997, and even increased among youth. Between 1997 and 2003, smoking prevalence has been declining. Most age, gender and racial-ethnic groups show patterns similar to that of the entire population, with differences for those aged 18-24 years. The predominant trends were explained mainly by changes in price, with some residual effect of clean air laws, media campaigns and youth access laws.

CONCLUSIONS

Among public tobacco control policies, price had the dominant effect on smoking prevalence between 1993 and 2003, because few states implemented other policies to the degree necessary to affect much change. Through continued tax increases, stronger clean air laws, extensive media campaigns and broader cessation treatment programs, there is the potential to have much larger reductions in smoking prevalence.

The Healthy People 2010 smoking prevalence and tobacco control objectives: results from the SimSmoke tobacco control policy simulation model (United States)

OBJECTIVES

Healthy People 2010 (HP2010) set a goal of reducing the adult smoking prevalence to 12% by 2010. Smoking prevalence rates do not appear to be declining at or near the rate targeted in the HP2010 goals. The purpose of this paper is to examine the attainability of HP2010 smoking prevalence objectives through the stricter tobacco control policies suggested in HP2010.

METHODS

A tested dynamic simulation model of smoking trends, known as SimSmoke, is applied. Smoking prevalence evolves over time through initiation and cessation, behaviors which are in turned influenced by tobacco control policies. We consider the effect of changes in taxes/prices, clean air laws, media campaigns, cessation programs and youth access policies on projected smoking prevalence over the period 2003-2020, focusing on the levels in 2010.

RESULTS

The SimSmoke model projects that the aging of older cohorts and the impact of policies in years prior to 2004 will yield a reduction in smoking rates to 18.4% by 2010, which is substantially above the 2010 target of 12%. When policies similar to the HP2010 tobacco control policy objectives are implemented, SimSmoke projects that smoking rates could be reduced to 16.1%. Further reductions might be realized by increasing the tax rate by $1.00.

CONCLUSIONS

The SimSmoke model suggests that the HP2010 smoking prevalence objective is unlikely to be attained. Although we are unlikely to reach the goals by meeting the HP2010 policy objectives, they could get us much closer to the goal. Emphasis should be placed on meeting the tax, clean air, media/comprehensive campaigns, and cessation treatment objectives.

Interventions for preventing tobacco sales to minors

BACKGROUND

Laws restricting sales of tobacco products to minors exist in many countries, but young people may still purchase cigarettes easily.

OBJECTIVES

The review assesses the effects of interventions to reduce underage access to tobacco by deterring shopkeepers from making illegal sales.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction group trials register, MEDLINE and EMBASE. Date of the most recent searches: September 2004.

SELECTION CRITERIA

We included controlled trials and uncontrolled studies with pre- and post intervention assessment of interventions to change retailers' behaviour. The outcomes were changes in retailer compliance with legislation (assessed by test purchasing), changes in young people's smoking behaviour, and perceived ease of access to tobacco products.

DATA COLLECTION AND ANALYSIS

One reviewer prescreened studies for relevance, and both reviewers independently assessed the studies for inclusion. One reviewer extracted data from included studies and the second checked them. Study designs and types of intervention were heterogeneous so results were synthesized narratively, with greater weight given to controlled studies.

MAIN RESULTS

We identified 34 studies of which 14 had data from a control group for at least one outcome. Giving retailers information was less effective in reducing illegal sales than active enforcement or multicomponent educational strategies, or both. No strategy achieved complete, sustained compliance. In three controlled trials, there was little effect of intervention on youth perceptions of access or prevalence of smoking.

AUTHORS' CONCLUSIONS

Interventions with retailers can lead to large decreases in the number of outlets selling tobacco to youths. However, few of the communities studied in this review achieved sustained levels of high compliance. This may explain why there is limited evidence for an effect of intervention on youth perception of ease of access to tobacco, and on smoking behaviour.

The effects of tobacco control policies on smoking rates: a tobacco control scorecard

This article reviews studies of the effect of tobacco control policies on smoking rates with the aim of providing guidance on the importance of different policies. Based on past studies, we estimate the magnitude of effects of major tobacco control policies, how their effects depend on the manner in which the policies are implemented, the relationship between the different policies, and the barriers to implementation. The most successful campaigns have implemented a combination of tobacco control policies. Of those policies, substantial evidence indicates that higher taxes and clean air laws can have a large impact on smoking rates. Evidence also indicates that media campaigns when implemented with other policies are important. Research on greater access to treatment and telephone support hotlines indicates a strong potential to increase quit rates and may be important in affecting heavier smokers. Direct evidence on the effects of advertising bans and health warnings is mixed, but these policies appear to be important in some of the countries that have had success in reducing smoking rates. School education programs and limits on retail sales are not likely to have much impact if implemented alone, but may be more important when combined with other policies.

Prevention of smoking-related deaths in the United States

BACKGROUND

Tobacco is the leading cause of death in the United States. The majority of people who smoke begin before age 18.

OBJECTIVE

Determine the number of smoking-attributable deaths and years of potential life lost (YPLL) in adults that might be saved through interventions to reduce smoking prevalence among children and adolescents.

METHODS

Calculation of the smoking-attributable mortality and years of potential life lost by age 85 among the cohort of people aged 18 in 2000.

RESULTS

By age 85, there would be 127,670 smoking-attributable deaths among women and 284,502 deaths among men, for a total 412,172 smoking-attributable deaths in the United States among the cohort of 3,964,704 people aged 18 years alive in 2000. Through large-scale multimedia campaigns and a $1 increase in the price per pack of cigarettes, smoking prevalence could be reduced by 26% and would result in an annual savings of 108,466 lives and 1.6 million YPLL.

CONCLUSIONS

Interventions to decrease smoking prevalence among children and adolescents can have large effects on adult mortality.

Youth tobacco access: adult attitudes, awareness, and perceived self-efficacy in two Arizona counties

While a variety of steps have been taken to restrict youth access to tobacco, little has been done to explore adult attitudes, beliefs, and behaviors concerning this issue. To ameliorate this knowledge gap, 828 adults from Arizona's Maricopa and Pima counties were surveyed. Overall, adults perceived that the prevention of youth tobacco access was: an important issue, an issue they are willing to spend money on, and a responsibility shared by all adults. Further, when asked who was most responsible for keeping tobacco away from minors, 65.4% of adults surveyed perceived parents of the youth purchasing tobacco as most responsible. Responding to items soliciting opinions regarding appropriate penalties for minors purchasing tobacco and for those selling tobacco to minors, respondents recommended stiffer punishment for the sellers of tobacco. Almost 10% recommended a night in jail for vendors caught selling tobacco products to minors. Interestingly, respondents exhibited low perceived self-efficacy regarding the prevention of youth tobacco access. The majority of adults agreed that it is easy for minors to gain access to tobacco and that there is nothing they or the community can do to stop minors who wish to purchase tobacco. Future research efforts should investigate how adult self-efficacy can be increased and the impact that such a change would have on efforts to prevent youth tobacco access.

The ID effect on youth access to cigarettes

OBJECTIVE

To estimate the effect on cigarette sales rates when minors present identification (ID).

DESIGN

Controlled experiment in which minors attempting to purchase cigarettes either carried a valid photo ID (documenting they were minors) or carried no ID, and were instructed to show the ID or admit having no ID if the clerk requested proof of age.

SETTING

Census of retail stores in six urban and suburban Colorado counties.

SUBJECTS

Retail cigarette clerks, uninformed of the study.

MAIN OUTCOME MEASURES

Relative risk (RR) of cigarette sale to a minor when ID was requested and presented versus requested but not presented.

RESULTS

When clerks requested ID, sales were more than six times as frequent if minors presented ID than if they did not (12.2% v 2.0%, RR 6.2, p < 0.0001). The relative risk remained substantially unchanged under adjustment for demographic and circumstantial covariates.

CONCLUSIONS

Presentation of photo ID in compliance checks increases illegal cigarette sales to minors. The impact may vary among states or locales and depends strongly on how often clerks request proof of age. Clerk training and responsible cigarette sales practices should include age calculations from photo ID. Programmes relying on investigative purchase attempts to estimate actual rates of cigarette sales to minors should ascertain and replicate local ID presenting behaviours that minors typically use during genuine attempts to buy cigarettes.

The approach of comprehensive tobacco control in cancer prevention: elements and evidence

The aim of this overview is to present measures of comprehensive tobacco control (CTC) and recent evidence according to their efficacy. CTC includes eight measures: raising taxes, consumer regulations, information about tobacco products, advertisement and sponsoring, economic alternatives to the production of tobacco, programmes for the support of the motivation to stop smoking and maintain tobacco abstinence, including the change of attitudes and norms in the population to support non-smoking, financial and human resources of CTC, and quality assurance of CTC. These measures include single elements such as activities against smuggling, to be considered in conjunction with tax increases. Evidence, particularly from single US states, reveals the efficacy of CTC. As discussed, the literature shows that programmes have not yet included all single elements. This is due to individual, programme-related and external limiting factors. It is concluded that in spite of these, CTC programmes are effective in adults as well as minors. A dose-response relationship between CTC and reduction of smoker rates, the amount of tobacco consumption and tobacco-attributable mortality is probable.

The use of simulation models for the surveillance, justification and understanding of tobacco control policies

Debates over national tobacco legislation and the use of state settlement funds demonstrate a need for information on the effects of tobacco control policies. Computer simulation models that are based on empirical evidence and that account for the variety of influences on tobacco use can be useful tools for informing policy makers. They can identify the effects of different policies, convey the importance of policy approaches to tobacco control, and help policy planners and researchers to better understand policies. This paper examines the role of simulation models in public policy, and discusses several recent models and limitations of those models.

Examining the effects of tobacco treatment policies on smoking rates and smoking related deaths using the SimSmoke computer simulation model

OBJECTIVES

To develop a simulation model to predict the effects of different smoking treatment policies on quit rates, smoking rates, and smoking attributable deaths.

METHODS

We first develop a decision theoretic model of quitting behaviour, which incorporates the decision to quit and the choice of treatment. A model of policies to cover the costs of different combinations of treatments and to require health care provider intervention is then incorporated into the quit model. The policy model allows for the smoker to substitute between treatments and for policies to reduce treatment effectiveness. The SimSmoke computer simulation model is then used to examine policy effects on smoking rates and smoking attributable deaths.

RESULTS

The model of quit behaviour predicts a population quit rate of 4.3% in 1993, which subsequently falls and then increases in recent years to 4.5%. The policy model suggests a 25% increase in quit rates from a policy that mandates brief interventions and the coverage of all proven treatments. Smaller effects are predicted from policies that mandate more restricted coverage of treatments, especially those limited to behavioural treatment. These policies translate into small reductions in the smoking rate at first, but increase to as much as a 5% reduction in smoking rates. They also lead to substantial savings in lives.

CONCLUSIONS

Tobacco treatment policies, especially those with broad and flexible coverage, have the potential to increase smoking cessation substantially and decrease smoking rates in the short term, with fairly immediate reductions in deaths.

Interventions for preventing tobacco sales to minors

BACKGROUND

Laws restricting sales of tobacco products to minors exist in many countries, but young people may still purchase cigarettes easily.

OBJECTIVES

The review assesses the effects of interventions to reduce underage access to tobacco by deterring shopkeepers from making illegal sales.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction group trials register, MEDLINE and EMBASE. Date of the most recent searches: October 2001.

SELECTION CRITERIA

We included controlled trials and uncontrolled studies with pre- and post intervention assessment of interventions to change retailers' behaviour. The outcomes were changes in retailer compliance with legislation (assessed by test purchasing), changes in young people's smoking behaviour, and perceived ease of access to tobacco products.

DATA COLLECTION AND ANALYSIS

Studies were prescreened for relevance by one person and assessed for inclusion by two people independently. Data from included studies were extracted by one person and checked by a second. Study designs and types of intervention were heterogeneous so results were synthesised narratively, with greater weight given to controlled studies.

MAIN RESULTS

We identified 30 studies of which 13 were controlled. Giving retailers information was less effective in reducing illegal sales than active enforcement and/or multicomponent educational strategies. No strategy achieved complete, sustained compliance. In three controlled trials, there was little effect of intervention on youth perceptions of access or prevalence of smoking.

REVIEWER'S CONCLUSIONS

Interventions with retailers can lead to large decreases in the number of outlets selling tobacco to youths. However, few of the communities studied in this review achieved sustained levels of high compliance. This may explain why there is limited evidence for an effect of intervention on youth perception of ease of access to tobacco, and on smoking behaviour.