The SHG policy module: projecting the effects of

The SHG policy module: projecting the effects of

The SHG policy module: projecting the effects of tobacco control policies through microsimulation CISNET Lung Group 1 The SHG Policy Module Figure 1. The Smoking History Generator Policy Module All-cause mortality rate Initiation probability Initiation modifier Cessation probability Cessation modifier Simulate an Individuals Life

Sample an Individual Derive prevalence, life years, and population deaths Smoking history; Initiation age, Cessation age, Age at death No Yes All Individuals Simulated SHG yields smoking prevalence and mortality estimates Policy module modifies initiation and cessation rates used by the SHG Modifiers adjust for - Age

- Year of policy implementation - Years since policy implementation 2 1. Increasing cigarette taxes Strongest evidence-base Individuals at younger ages are more price-responsive Highly effective tobacco control policy Revenue generating User inputs Baseline scenario Initial price per pack of cigarettes (): $4.00 to $10.50 Policy scenario Tax increase (): $1.00 to $5.00 Policy start year 2016, 2016, 2017,

2017, 2018, 2018, 2019, 2019, 2020 2020 % change in price 3 1. Cigarette taxes Estimates Price elasticities by age group Age group Cessation elasticity* Initiation elasticity* Ages 10-17 -0.4 Ages 18-24

-0.3 Ages 25-34 2.00 -0.2 35-64 0 *dueAges to the smaller number of studies examining initiation and cessation elasticities, Ages 65+ 0 these elasticities were developed to conform to and match prevalence elasticities Assumptions Tax is passed on directly to consumers Homogeneous price elasticity across price ranges Initiation effects are constant going forward Cessation effects decay over time

Model does not account for tax avoidance or evasion near state borders Effect of the tax increase does not erode with inflation 4 1. Cigarette taxes Policy effects (% ) 5 2. Smoke-free air laws Strong evidence-base Effective tobacco control policy Essentially no costs User inputs Baseline scenario Percent of existing smoke-free air law coverage in workplaces, restaurants, bars (: 0% to 100% Policy start year

2016, 100% coverage smoke2016, 2017, free air law applied to 2017, 2018, workplaces, 2018, 2019, restaurants, and/or bars 2019, 2020 2020 Policy scenario 6 2. Smoke-free air laws Estimates Comprehensive laws reduce smoking prevalence by 10% within 5 years for working population Retired population less affected by smoking bans in

workplaces (reduced by 5% ages 65+) With no existing coverage, comprehensive law reduces initiation rates by 10% and increases cessation by 50% Assumptions Relative effect of policy by venue workplaces: restaurants: bars: Initiation effects are constant going forward Cessation effects decay over time Model outcomes do not include the benefits of reduced secondhand smoke exposure 7 2. Smoke-free air laws Policy effects Age-specific scaling factor

= , , ( ) Sum the relative effects across venue types and scale these based on the level of existing coverage 8 3. Increasing TC expenditures Limited evidence on expenditures per se Well-funded comprehensive, coordinated tobacco control programs can be effective Costly to implement $$ User inputs Baseline scenario Initial level of expenditures as % of CDC recommendation (: 0% to 100% Policy scenario Policy level of expenditures as 100% of CDC

recommendation ( Policy start year 2016, 2016, 2017, 2017, 2018, 2018, 2019, 2019, 2020 2020 9 3. TC expenditures Estimates Effects of TC expenditures on smoking (assuming 0% initial funding) cessation increase initiation decrease 12.0% 10.0% 8.0% 6.0% 4.0%

2.0% 0.0% 0% 20% 40% 60% 80% 100% Funding as % of CDC recommendations ()) Assumptions Level of investment is maintained Initiation effects are constant going forward Cessation effects decay over time Increasing and then decreasing returns as the level of funding shifts from 0% to 100 10

3. TC expenditures Policy effects ( ) ( ) Effects of TC expenditures on smoking (assuming 0% initial funding) 12.0% 10.0% 8.0% Effect size 6.0% (E) 4.0% 2.0% 0.0% cessation increase initiation decrease Funding as % of CDC recommendations ()) 11 4. Minimum age of Legal Access Limited evidence-base, few studies at local level Effect sizes from the IOM are model assumptions No costs involved

User inputs Baseline scenario Percent of population already covered by MLA at age 19 or age 21 (: 0% to 100% Policy scenario Raise MLA to age 19, 21, or 25 ( Policy start year 2016, 2016, 2017, 2017, 2018, 2018, 2019, 2019, 2020 2020 12 4. MLA

Estimates Reduction in initiation by age group 0-14 15-17 18 18 19-20 19-20 21-25 21-25 Effect of raising the MLA 5% 10% 10% 10% 0% 0% 0% 0% 15% 25% 15% 15%

15% 15% 0% 0% 15% 30% 20% 20% 20% 20% 5% 5% Assumptions No impact on cessation Initiation effects are constant over time Local MLA policies are not affected 13 4. MLA Policy effects Effect of increasing the MLA from 19 to 21

14 Model outcomes 1. Smoking prevalence 2. Deaths avoided Calculate # of smoking-attributable deaths (SAD) in baseline vs. policy scenarios 3. Life years gained Calculate total years of life lost (YLL) due to smoking in baseline and policy scenarios 15 Deaths avoided Calculate # of smoking-attributable deaths (SAD) in baseline vs. policy scenarios # of population deaths attributable to current smoking = , Population

size # of population deaths attributable to former smoking ( ( ) + ( ) ) Difference in mortality rate between former Current smoker Current smoker smokers and never prevalence death rate smokers 16 Life years gained Calculate total years of life lost (YLL) due to smoking in baseline and policy scenarios = , ( ( ) + ( ) ) Life expectancy for

never smoker at given age and gender # of population deaths attributable to current smoking # of population deaths attributable to former smoking 17 State-level results SHG policy module is based on nationally-representative data National-level results directly scaled to the population sizes and smoking prevalence for 50 states + Washington, DC State population sizes and smoking prevalence from 2015 Census Bureau and BRFSS State-level estimates do not account for differences by geographic region or population heterogeneity across states 18

The Tobacco Control Policy (TCP) tool Interactive web-based user interface Targeted for decision-makers Displays SHG policy module results Scaled estimates for 50 states + DC State-level data Cigarette taxes: Campaign for Tobacco-Free Kids Smoke-free air: Americans for Nonsmokers Rights TC expenditures: CDC MLA: Tobacco Twenty-One www.tobaccopolicyeffects.org 19 References Smoking History Generator Jeon J, Meza R, Krapcho M, et al. Chapter 5: Actual and Counterfactual Smoking Prevalence Rates in the U.S. Population via Microsimulation. Risk Analysis 2012;32:S51-S68. doi: 10.1111/j.1539-6924.2011.01775.x Moolgavkar SH, Holford TR, Levy DT, et al. Impact of reduced tobacco smoking on lung cancer mortality in the United States during 1975-2000. Journal of the National Cancer Institute 2012;104(7):541-8. doi: 10.1093/jnci/djs136 [published Online First: 2012/03/17] Holford TR, Levy DT, McKay LA, et al. Patterns of birth cohortspecific smoking

histories, 19652009. Am J Prev Med 2014;46(2):e31e37. Cigarette taxes Smith K, Gilmore A, Chaloupka F, et al. IARC Handbooks of Cancer Prevention: Tobacco Control Volume 14 Effectiveness of Price and Tax Policies for Control of Tobacco. Lyon, France: International Agency for Research on Cancer 2011:31-90. Contreary KA, Chattopadhyay SK, Hopkins DP, et al. Economic impact of tobacco price increases through taxation: a community guide systematic review. American journal of preventive medicine 2015;49(5):800-08. Chaloupka FJ, Straif K, Leon ME. Effectiveness of tax and price policies in tobacco control. Tobacco control 2011;20(3):235-8. doi: 10.1136/tc.2010.039982 [published Online First: 2010/12/01] 20 References (cont.) Cigarette taxes (cont.) Chaloupka FJ, Yurekli A, Fong GT. Tobacco taxes as a tobacco control strategy. Tobacco Control 2012;21(2):172-80. [published Online First: 2012/02/22] Warner KE. Death and taxes: using the latter to reduce the former. Tobacco Control 2014;23:4-6. doi: 10.1136/tobaccocontrol-2013-051079 Sung H, Hu T-w, Keeler TE. Cigarette taxation and demand: an empirical model. Contemporary Economic Policy 1994;12(3):91-100. Ahmad S. Increasing excise taxes on cigarettes in California: a dynamic simulation of

health and economic impacts. Prev Med 2005;41(1):276-83. doi: 10.1016/j.ypmed.2004.10.024 [published Online First: 2005/05/27] Ahmad S, Franz GA. Raising taxes to reduce smoking prevalence in the US: a simulation of the anticipated health and economic impacts. Public Health 2008;122(1):3-10. doi: 10.1016/j.puhe.2007.02.020 [published Online First: 2007/07/06] Emery S, Ake CF, Navarro AM, et al. Simulated effect of tobacco tax variation on Latino health in California. Am J Prev Med 2001;21(4):278-83. [published Online First: 2001/11/10] Kaplan RM, Ake CF, Emery SL, et al. Simulated effect of tobacco tax variation on population health in California. Am J Public Health 2001;91(2):239-44. [published Online First: 2001/02/24] Ohsfeldt RL, Boyle RG, Capilouto EI. Tobacco taxes, smoking restrictions, and tobacco use. National Bureau of Economic Research Working Paper Series 1998 21 References (cont.) Cigarette taxes (cont.) Levy DT, Cummings KM, Hyland A. Increasing Taxes as a Strategy to Reduce Cigarette Use and Deaths: Results of a Simulation Model. Preventive medicine 2000;31(3):27986. doi: http://dx.doi.org/10.1006/pmed.2000.0696 The Community Preventive Services Task Force. Reducing Tobacco Use and Secondhand Smoke Exposure: Interventions to Increase the Unit Price for Tobacco Products 2014 [updated May 2014. Available from:

https://www.thecommunityguide.org/findings/tobacco-use-and-secondhand-smoke-ex posure-interventions-increase-unit-price-tobacco accessed May 29 2017 . Smoke-free air laws Hopkins DP, Razi S, Leeks KD, et al. Smokefree Policies to Reduce Tobacco Use: A Systematic Review. American Journal of Preventive Medicine 2010;38(2, Supplement):S275-S89. doi: https://doi.org/10.1016/j.amepre.2009.10.029 Farkas AJ, Gilpin EA, Distefan JM, et al. The effects of household and workplace smoking restrictions on quitting behaviours. Tobacco control 1999;8(3):261-65. Glasgow RE, Cummings KM, Hyland A. Relationship of worksite smoking policy to changes in employee tobacco use: findings from COMMIT. Community Intervention Trial for Smoking Cessation. Tobacco control 1997;6(suppl 2):S44. Levy DT, Friend K, Polishchuk E. Effect of clean indoor air laws on smokers: the clean air module of the SimSmoke computer simulation model. Tobacco control 2001;10(4):345-51. 22 References (cont.) Smoke-free air laws (cont.) The Community Preventive Services Task Force. Reducing Tobacco Use and Secondhand Smoke Exposure: Smoke-free Policies 2013 [updated June 2013. Available from: https://www.thecommunityguide.org/findings/tobacco-use-and-secondhand-smoke-ex posure-smoke-free-policies

accessed May 29 2017. Tobacco control expenditures The Community Preventive Services Task Force. Reducing Tobacco Use and Secondhand Smoke Exposure: Comprehensive Tobacco Control Programs 2014 [updated September 2014. Available from: https://www.thecommunityguide.org/findings/tobacco-use-and-secondhand-smoke-ex posure-comprehensive-tobacco-control-programs accessed May 29 2017. Farrelly MC, Pechacek TF, Chaloupka FJ. The impact of tobacco control program expenditures on aggregate cigarette sales: 1981-2000. J Health Econ 2003;22(5):84359. doi: 10.1016/s0167-6296(03)00057-2 [published Online First: 2003/08/30] Tauras JA, Chaloupka FJ, Farrelly MC, et al. State tobacco control spending and youth smoking. Am J Public Health 2005;95(2):338-44. doi: 10.2105/ajph.2004.039727 [published Online First: 2005/01/27] Farrelly MC, Pechacek TF, Thomas KY, et al. The impact of tobacco control programs on adult smoking. Am J Public Health 2008;98(2):304-9. doi: 23 10.2105/ajph.2006.106377 [published Online First: 2008/01/04] References (cont.) Tobacco control expenditures (cont.) Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs2014. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

Rhoads JK. The effect of comprehensive state tobacco control programs on adult cigarette smoking. J Health Econ 2012;31(2):393-405. doi: 10.1016/j.jhealeco.2012.02.005 [published Online First: 2012/03/31] Raising the minimum age of legal access (MLA) IOM (Institute of Medicine). Health Implications of Raising the Minimum Age for Purchasing Tobacco Products. Washington, DC: The National Academies Press, 2015. Kessel Schneider S, Buka SL, Dash K, et al. Community reductions in youth smoking after raising the minimum tobacco sales age to 21. Tob Control 2016;25(3):355-9. doi: 10.1136/tobaccocontrol-2014-052207 [published Online First: 2015/06/14] Preventing Tobacco Addiction Foundation. Tobacco Twenty-one State by State: List of all Tobacco 21 Cities 2017 [Available from: http://tobacco21.org/state-by-state/ accessed March 1 2017. 24

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