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Application of A System Dynamics Model To Inform Investment in Smoking Cessation Services in New Zealand
Application of A System Dynamics Model To Inform Investment in Smoking Cessation Services in New Zealand
1274 | Research and Practice | Peer Reviewed | Tobias et al. American Journal of Public Health | July 2010, Vol 100, No. 7
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elsewhere.25 We constructed the model with time since quitting), and nonsmokers exposed to attributable-mortality; this process involved mi-
the iThink software package version 9.0,26 and it secondhand smoke (derived from the New Zea- nor tweaking of initiation and quit rates.
is available from M. I.T. or R. Y.C. The model land Census–Mortality Study)28; and demo- We then checked the population projections
comprises a population aging chain that simu- graphic data from Statistics New Zealand (in- generated by the model to 2051 (4.89 million
lates the New Zealand population over a 50-year cluding fertility and household composition people) against the national population pro-
period (from 2001 to 2051) by age, period, and data). We also included peer and parent feed- jections published by Statistics New Zealand
cohort, stratified by smoking status. back on smoking initiation by adolescents in the (series 5, medium fertility, medium mortality,
The main input variables were smoking model; we derived values for these parameters 10 000 per year net migration assumptions).31
initiation and net quit rates derived from the from a national cross-sectional survey of year 10 We adjusted for net migration flows (5.48
2006 NZTUS5 and quitting effectiveness data (14-year-old) students.29 The main output vari- million – 0.5 million =4.98 million), confirming
from a Cochrane review27; NZTUS data on ables were current smoking prevalence, tobacco that our model was reflecting feasible population
smoking intensity (which affects both tobacco consumption, and tobacco-attributable mortality. dynamics and projections for New Zealand over
consumption and, after a 10-year delay, smoking the simulation period (2001–2051).
mortality hazard ratios); average tobacco weight Calibrating and Testing the System We validated the model by verifying that (1)
per factory-made and roll-your-own cigarette Dynamics Model the business-as-usual scenario (usual scenario)
and ratio of factory-made to roll-your-own ciga- We subjected the model to appropriate reproduced recent trends in current smoking
rettes smoked (all derived from the 2006 verification and validation tests.30 First, we prevalence, tobacco consumption, and tobacco-
NZTUS); mortality hazard ratios for current calibrated the model by checking that the base attributable mortality; (2) prevalence increased
smokers (dependent on duration and intensity of case reproduced current prevalence (2001– if relative risk of mortality related to smoking
smoking), ex-smokers (dependent on elapsed 2004) by age, tobacco consumption, and tobacco decreased; (3) prevalence, consumption, and
Note. AS = adult smoker; R1 = peer feedback; R2 = parental feedback; XS = ex-smoker; YS = youth smoker. Boxes represent population stocks; arrows with valve symbols represent physical flows;
cloud symbols represent births and deaths; single-line arrows represent causal links; circles represent other factors and influences; hexagons indicate tobacco control policies. The actual model is
structured into 10-year age groups rather than in youths and adults. Tobacco control policies in general can influence smoking initiation rates and excess mortality risks, as well as quitting
behaviors and smoking intensity (the parameters affected by smoking cessation policies).
FIGURE 1—Causal structure of the New Zealand tobacco system dynamics model.
July 2010, Vol 100, No. 7 | American Journal of Public Health Tobias et al. | Peer Reviewed | Research and Practice | 1275
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tobacco-attributable mortality behaved appro- We further defined the short-term unassisted New Zealand, from 22% to 30%. Both these
priately if initiation and quit rates changed; (4) quitting success rate as S and the rate ratio changes should be achievable within 5 years of
smoking prevalence among youths changed Sassisted/Sunassisted as E. implementation, allowing for both administrative
appropriately if parental or peer feedback in- Figure 2 shows that and behavioral lags.
fluences changed; and (5) mortality attribut- Although the evidence for effectiveness of
ð1Þ Q ¼ ½C A E S ð12RÞ
able to secondhand smoke changed appropri- relapse prevention is unclear, a decline in the
1 ½C ð12AÞ S ð12RÞ:
ately if living arrangements changed. proportion of quitters who relapse within 6
These experiments and the structure of the Simplifying equation 1 yielded the following months from 48% to 45% over a 5-year period
model were discussed extensively with subject model for Q: would be feasible, if long-term use of NRT and
matter experts in New Zealand, lending the varenicline was permitted (and subsidized)
model additional validity. In addition, the ð2Þ Q ¼ C S ð12RÞ ½A ðE21Þ 1 1: and if visual cues relating to smoking (e.g.,
policy and scenario experiments described in visibility of cigarette displays in retail outlets)
our previous research demonstrated the val- Age-specific population cessation (net quit) were reduced.33
idity (and suitability) of the New Zealand rates could then be estimated with equation 2, Although effectiveness of assistance could
tobacco system dynamics model for policy taking age-specific estimates for quitting and increase (from 2.0 to perhaps 3.0) with wider
analysis.25 These policy experiments included relapsing behaviors (C, A, and R) from surveys, use of varenicline in combination with NRT or
fiscal strategies involving less affordable ciga- along with values for short-term unassisted through discovery of new drugs, over a rela-
rettes (through raising the excise tax rate on quitting success rate and effectiveness of as- tively short simulation horizon we assumed the
tobacco products), harm minimization strategies sistance from randomized controlled trials. ratio of assisted to unassisted quit attempts to
involving either less addictive cigarettes or less Feasible change in quitting behaviors. A review be stable at 2.0 (assistance doubles the chance
toxic cigarettes, and combinations of these strat- of what other countries, in particular the United of successfully quitting, at least in the short
egies. States, had already achieved suggested that term). Similarly, we held the unassisted quitting
a feasible change in quit attempts (proportion success rate stable at 0.07 (7% of quit attempts
New Zealand Tobacco Use Survey of smokers making at least 1 quit attempt per are successful in the short term, without assis-
The NZTUS is an annual survey, with the year) for New Zealand would be an approxi- tance).27 The recalculated rate for the net quit
first wave fielded in 2006. The survey uses mately 14% increase, that is, from 44% to rates in equation 2 implied that the population
a stratified multistage design with an areal 50%.32 The US experience also indicated that cessation (net quit) rate at each age would
(census meshblock) frame to generate a nation- the proportion of quit attempts that were assisted increase by approximately 25% if these changes
ally representative sample of youths and adults could be increased by approximately 36% in in quitting and relapsing behaviors took place.
aged 15 to 64 years. The final sample size
was 5703, corresponding to an overall res-
ponse rate of approximately 75.4%. The
questionnaire (derived from the Canadian To-
bacco Use Monitoring Survey instrument and
validated for the New Zealand population by
the University of Auckland) was administered
through computer-assisted personal interviews
by trained interviewers in the respondents’
own homes. The survey was approved by the
Multi Regional Ethics Committee. More detail
on the NZTUS is reported elsewhere.5
In the New Zealand tobacco system dy-
namics model, net quit rates were provided for
each age group (i.e., cessation rate minus re-
lapse rate). The population actual cessation (net
quit) rate (Q) depended on the proportion of
smokers who made 1 or more quit attempts per
year (C), defined as abstaining for a week or
more; the proportion of quit attempts that were Note. C = proportion of smokers who made 1 or more quit attempts per year; A = proportion of quit attempts that were
assisted (A), defined as multisession behavioral assisted; R = proportion of quitters who relapsed; S = short-term unassisted quitting success rate; E = rate ratio Sassisted/
support plus NRT, bupropion, or varenicline; Sunassisted.
and the proportion of quitters who relapsed (R), FIGURE 2—Smoking cessation tree diagram.
defined as less than 6 months of abstinence.
1276 | Research and Practice | Peer Reviewed | Tobias et al. American Journal of Public Health | July 2010, Vol 100, No. 7
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Feasible change in smoking intensity. Cessa- after introduction of the policy) and progress example, by the simulation horizon (2051),
tion enhancement policies can be expected to steadily to reach full effect by 2016, reflecting smoking prevalence under the usual scenario
affect smoking intensity as well as the net quit both administrative delays in implementing was projected to be 8.1% (optimistic case),
rate. That is, in response to the intervention, the intervention package and behavioral re- 10.1% (base case), and 11.9% (pessimistic
some current smokers may cut down rather sponse lags, after which the rates of change in case), a range of approximately 40%. We
than quit altogether. In the absence of relevant these parameters would revert to those in the found similar ranges for the enhanced cessa-
data from the NZTUS or other New Zealand usual scenario. tion scenario and for all main model output
sources, we estimated from US studies that We entered into the model the net quit rates variables.
average smoking intensity could decline by up shown in equation 2, derived from our as-
to 5% within 5 years of program implementa- sumptions about feasible changes in quit at- Smoking Prevalence and Per Capita
tion.34 tempts, proportion of assisted attempts, and Tobacco Consumption
relapse rates, which yielded an average annual Current smoking prevalence (daily plus
Simulations percentage change of 5% in net quit rates at all nondaily) was predicted to decline over the
For the usual scenario, we assumed a con- ages during the peak change years of 2011 to simulation period under both the usual and
tinuing decline in initiation rates of 2% per 2016 (in the usual scenario, the change would enhanced cessation scenarios (Figure 3).
year and an increase in population smoking be only 1%). Calculations taking into account However, the rate of decline would be faster
cessation rates (net quit rates) at all ages of our assumptions about the impact of the in- with the intervention, reflecting higher net
1% per year from the base year (2001); we tervention on average smoking intensity per quit rates. The sensitivity analysis indicated
based these assumptions on historical trends smoker predicted a 1% average annual reduc- that smoking prevalence by the end of the
in smoking prevalence and limited survey tion in smoking intensity during the same simulation horizon (2051) under the usual
evidence of trends in these rates.1 Average period (i.e., from 12 cigarette equivalents per scenario is likely to be in the range of 8% to
smoking intensity was assumed to remain day in 2011 to 11.4 cigarette equivalents per 12%, with a base case estimate of 9%. The
stable at 12 cigarette equivalents per day; we day in 2016). range would be 7% to 11% under the en-
derived this base year estimate from survey data1 hanced cessation scenario (Table 1). In each
and Statistics New Zealand annual tobacco Sensitivity Tests case, prevalence would be approximately 11%
returns. Because several behavioral parameters in lower under the enhanced cessation than the
The proposed intervention package aims to the model were estimated with less certainty under the usual scenario by the simulation
trigger quit attempts through a media campaign than we could achieve with the demographic horizon.
and by further reducing cigarette affordability and other epidemiological parameters, we The difference between the usual and
(including equalizing the excise tax on roll- conducted multivariate sensitivity analysis enhanced cessation scenarios was predicted
your-own and factory-made cigarettes); to in- with these parameters: initial smoking initia- to be greater for per capita tobacco con-
crease the chances of short-term quitting suc- tion rate, peer and adult feedback effects on sumption than for prevalence, reflecting the
cess by widening access to NRT, bupropion, initiation, and initial net quit rates for each age assumption that some smokers will cut down
and varenicline, to be achieved by extending group. (reduce smoking intensity) and others will
the national quit line and by improving smok- We changed the base case values of these quit (Figure 3). By 2051, per capita tobacco
ing cessation services in the primary health parameters by plus or minus 10% to represent consumption was projected to be approxi-
care setting through training and incentives; the range of uncertainty in these estimates. We mately 15% to 17% lower under the en-
and to reduce the risk of late relapse through constructed an optimistic case by changing all hanced cessation scenario (290–440 ciga-
provision of long-term NRT and varenicline the behavioral parameters in a favorable di- rette equivalents per year) than under the
and by reducing cues that could trigger relapse, rection (which would result in lower future usual scenario (360–520 cigarette equiva-
for example, by promoting establishment of smoking prevalence in New Zealand) and lents per year). The base case estimate was
more healthy environments, such as smoke- a pessimistic case by changing all these pa- approximately 370 cigarette equivalents per
free homes and cars, and by reducing visibility rameters simultaneously in an unfavorable di- year for the enhanced cessation scenario and
of cigarette displays in retail outlets. rection. We then simulated the model for both 440 cigarette equivalents per year for the
For the enhanced cessation scenario, we the usual scenario and enhanced cessation usual scenario.
assumed that initiation rates would be un- scenario under the base, optimistic, and pessi-
affected at first (they should fall later as mistic cases. Tobacco-Attributable Mortality
a result of peer group and parent feedback The absolute burden of excess mortality
loops), but more smokers would quit as a re- RESULTS attributable to tobacco use reflects both
sult of the intervention and others would cut smoking behavior patterns and demographic
down. We further assumed that the incre- Our model was relatively insensitive to forces affecting the size and age structure of
mental effect on net quit rates and on smok- variation in behavioral parameter values the population. Under the usual scenario, this
ing intensity would begin in 2011 (3 years through their plausible ranges (Table 1). For burden would initially increase and then fall
July 2010, Vol 100, No. 7 | American Journal of Public Health Tobias et al. | Peer Reviewed | Research and Practice | 1277
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TABLE 1—Key Projections of the New Zealand Tobacco Policy Model for the Business-as-Usual and Enhanced
Cessation Scenarios for 2001–2051
Base casea
2001 Initial values 22.7 744 000 996 3 259 110 4 260
2006 Business as usual 21.8 739 000 955 3 239 113 4 537
2011 Business as usual 20.7 721 000 905 3 160 112 4 616
Optimistic caseb
2031 Business as usual 12.8 500 000 562 2 192 83 3 776
Enhanced cessation 11.6 454 000 485 1 891 76 3 441
Difference 1.2 38 77 301 7.0 335
Percentage difference 9.4% 6.6% 13.7% 13.7% 8.4% 8.9%
Pessimistic casec
2031 Business as usual 16.5 642 000 723 2 812 92 4 170
Enhanced cessation 15.3 597 000 638 2 484 84 3 814
Difference 1.2 38 85 328 8.0 356
Percentage difference 7.3% 6.6% 11.8% 11.7% 8.7% 8.5%
Note. The business-as-usual scenario reproduced recent trends in current smoking prevalence, tobacco consumption, and tobacco-attributable mortality. The enhanced cessation scenario
estimated the effects of a proposed intervention package aiming to trigger more quit attempts, and increase short- and long-term quitting success rates.
a
Smoking prevalence in 2001 to 2004.
b
All behavioral parameters were changed to be 10% more favorable (e.g., greater decrease in smoking prevalence).
c
All behavioral parameters were changed to be 10% less favorable (e.g., smaller decrease in smoking prevalence).
slowly. Under the enhanced cessation sce- combined effects of quitting and cutting 3580 (for both active and passive smoking
nario, the early rise would be the same as in down. effects) under the usual scenario. However,
the usual scenario, but the subsequent decline By 2051, the annual tobacco death toll was under the enhanced cessation scenario, the
would be greater (Figure 3), reflecting the projected to decline to between 3120 and reduction would be greater—to between 2710
1278 | Research and Practice | Peer Reviewed | Tobias et al. American Journal of Public Health | July 2010, Vol 100, No. 7
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July 2010, Vol 100, No. 7 | American Journal of Public Health Tobias et al. | Peer Reviewed | Research and Practice | 1279
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effects were captured by mortality only and so Our simulation represents a relatively sim- Note. This article is published with the approval of the
deputy director-general of health, Health and Disability
were not comprehensive. ple and straightforward application of the
Systems Strategy Directorate, New Zealand Ministry of
Our model did not include net migration model; it involved exogenous change in only 2 Health. However, opinions expressed are ours and do not
flows, because these are only a small propor- model parameters (quit rates and smoking necessarily reflect the policy advice of the ministry.
tion of total population and are difficult to intensity) in response to policy changes. Other
predict. The model as currently structured also behavioral change estimates, such as reduc- Human Participant Protection
No protocol approval was needed for this study because
did not capture all relevant dimensions of tions in adolescent smoking initiation rates,
only secondary data were used.
industry behavior or tobacco control. Finally, were based on feedback processes built into
New Zealand data could not be found for the model. The full value of system dynamics
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