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32 Heponiemi T, Kouvonen A, Vanska J, et al. Effects of active on-call hours on physicians’ turnover intentions and well-being. Scand J Work Environ Health 2008; 34:356–63. 33 Lowell B, Gerova S. Immigrants and the health care workforce: profiles and shortages. Work Occup 2004;31:474–98. 34 Aycan Z, Kanungo R, Mendonca M, et al. Impact of culture on human resources practicies: a 10-country comparison. Appl Psychol 2000;49:192–221. 35 Bernstein B. The professional self-evaluation of immigrant physicians from the former Soviet Union in Israel. J Immigr Health 2000;2:183–90. 36 La¨msa¨ R, Manderbacka K, Kuusio H, Aalto A-M, Elovainio M. Ylila¨a¨ka¨rien ja ulkomaalaistaustaisten la¨a¨ka¨rien kokemuksia toimilupaprosessista. [Chief medical
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officers’ and foreign physicians’ experiences of the Finnish licensing system. Suomen La¨a¨ka¨rilehti [Finnish Medical Journal] 2012;67:2555–60. 37 Heponiemi T, Kouvonen A, Vanska J, Halila H, Sinervo T, Kivimaki M, et al. Health, psychosocial factors and retirement intentions among Finnish physicians. Occup Med (Lond) 2008;58:406–12. 38 WHO. The WHO global CODE of Practice on the international recruiment of health personnel. Available at: http://www.who.int/hrh/migration/code/code_en.pdf (10 January 2014 last date accessed). 39 Buchan J. Health worker migration in Europe: assessing the policy options. Euro Heatlh 2007;13:6–8.
......................................................................................................... European Journal of Public Health, Vol. 24, No. 3, 451–458 ß The Author 2013. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/ckt178 Advance Access published on 27 November 2013
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Sweden SimSmoke: the effect of tobacco control policies on smoking and snus prevalence and attributable deaths Aimee M. Near1, Kenneth Blackman2, Laura M. Currie3, David T. Levy1 1 Department of Oncology, Georgetown University, Lombardi Cancer Center, Washington, DC, USA 2 Econometrica, Incorporated, Bethesda, MD, USA 3 Division of Population Health, Royal College of Surgeons in Ireland, Dublin, Ireland. Correspondence: David T. Levy, Lombardi Comprehensive Cancer Center, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC 20007, Tel: +202-687-0863, Fax: +202-687-0305, E-mail:
[email protected]
Background: This study examines the effect of past tobacco control policies and projects the effect of future policies on smoking and snus use prevalence and associated premature mortality in Sweden. Methods: The established SimSmoke model was adapted with population, smoking rates and tobacco control policy data from Sweden. SimSmoke evaluates the effect of taxes, smoke-free air, mass media, marketing bans, warning labels, cessation treatment and youth access policies on smoking and snus prevalence and the number of deaths attributable to smoking and snus use by gender from 2010 to 2040. Results: Sweden SimSmoke estimates that significant inroads to reducing smoking and snus prevalence and premature mortality can be achieved through tax increases, especially when combined with other policies. Smoking prevalence can be decreased by as much as 26% in the first few years, reaching a 37% reduction within 30 years. Without effective tobacco control policies, almost 54 500 lives will be lost in Sweden due to tobacco use by the year 2040. Conclusion: Besides presenting the benefits of a comprehensive tobacco control strategy, the model identifies gaps in surveillance and evaluation that can help better focus tobacco control policy in Sweden.
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Introduction ith more than 5 million deaths each year attributable to 1 the World Health Organization (WHO) has set out the Framework Convention for Tobacco Control (FCTC) and the MPOWER report2 has defined a set of policies that are consistent with the FCTC. MPOWER suggests that each nation impose taxes on cigarettes that constitute at least 70% of the retail price; require large, bold and graphic health warnings; provide broad access to cessation treatments; conduct a well-funded tobacco control campaign and implement and enforce comprehensive smoke-free indoor air laws and advertising/marketing restrictions. Sweden was one of the first countries to sign (2003) and ratify (2005) the FCTC. Sweden has had a long history of tobacco control dating back to 1975, when advertising restrictions and other policies were first implemented. Since 1994, Sweden has increased taxes on cigarettes, implemented smoke-free air policies, increased access to cessation treatments, restricted marketing and strengthened health warnings.
Wsmoking,
Sweden is also the only European nation besides Norway to allow commercialization of snus, a smokeless tobacco product that has been legally sold since 1976. Most tobacco control laws and programmes apply to snus as well as cigarettes. While some have claimed that snus use has been responsible for a large reduction in cigarette use and lung cancer deaths,3–5 others claim that these reductions could have occurred with stricter tobacco control policies.6,7 With smokeless tobacco use increasing in many countries,8–10 it is important to consider the potential role of policies in affecting that use. To examine the potential role of policies in furthering the aims of tobacco control, this study uses a modified version of the SimSmoke tobacco control policy simulation model (Sweden SimSmoke). SimSmoke simultaneously considers a broad array of public policies and has been validated for many countries.11–17 While several models have examined the hypothetical effect of allowing smokeless tobacco use,18,19 no study has considered actual smokeless tobacco use along with cigarettes. Sweden SimSmoke applies data from Sweden, and is used here to examine
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the effect of implementing FCTC-consistent policies on the prevalence of and deaths attributable to smoking and snus use in Sweden.
Methods
Initiation rates at each age are measured as the difference between the smoking rate at that age year and the rate at the previous age year. We allowed initiation through age 30 for both genders, as snus initiation and switching occur until these ages.
Smoking and attributable deaths
SimSmoke includes population, smoking, tobacco-attributable deaths and policy modules.11,13–17 The model has been extended to distinguish users of cigarettes only, snus only and combined (‘dual’) cigarette and snus users. SimSmoke begins in a baseline year with the population divided into current, former and never smokers and snus users by age and gender. Sweden SimSmoke begins in 2004 based on the availability of data and stability of policies for that period. A discrete time, first-order Markov process is assumed to project population growth and tobacco use rates from the base year to future years. Population growth evolves through births and deaths, and smoking and snus rates evolve through smoking initiation, cessation and relapse. Smoking rates may shift due to changes in tobacco control policies. Smoking-attributable deaths are calculated as the excess mortality risk of current and former tobacco users relative to never users. Data sources are summarized in table 1.
Population and smoking data SimSmoke was adapted with gender and age-specific population data from Statistics Sweden.20 Smoking and snus sole and dual use prevalence data for 2004 through 2010 were available from the Health on Equal Terms of the National Public Health Survey. Smoking and snus prevalence was based on participant self-report as never, former or current tobacco use. Based on the percent of smokers who quit in the past year, we apply a cessation rate of 5% for cigarette sole and dual use, and 3% for snus only. Because that rate does not incorporate relapse, we apply a 50% relapse rate, as consistent with previous studies.21,22 Data on relapse was not available for Sweden, so we use US relapse rates for cigarette smokers23,24 and assume those same rates for single and dual cigarette and snus use.
Because smoking history and the standard of living in Sweden are similar to the United States, we use relative risk estimates from the US Cancer Prevention Study II.25,26 For ex-smokers, we allow relative risks to decline at the rate observed in US studies.25 Based on a literature review and the advice of an expert panel,27 mortality relative risks for snus users are set at 1.1 for ages 35–49 and at 1.05 for ages 50. We assume the same risks for dual users as for cigarette only users. The relative risks of snus sole and dual use are assumed to decline with years quit at the same rate as for smokers.
Tobacco control policies The policy parameters in SimSmoke are based on thorough reviews of the literature coupled with the advice of an expert panel. Policy effect sizes are applied as percent reductions to the smoking prevalence in the year in which the policy is implemented and are applied to initiation and cessation rates in future years if the policy is sustained. Table 2 summarizes policies and potential effect sizes in Sweden. The effect of a policy depends on its current level that is based on information in the MPOWER report2 with corroboration from Swedish tobacco control correspondents.
Model outcomes SimSmoke estimates the effects over time for two primary outcomes: smoking/snus prevalence and smoking (and/or snus)-attributable deaths. Prevalence is projected for the population ages 16–85 separately by gender. The model estimates these outcomes for the tracking period (2004–10) and projects future outcomes through 2040. We validate model projections against survey estimates through 2008, due to the instability of smoking behaviours after the 2008 economic recession.33
Table 1 Data used in Sweden SimSmoke Input
Source
Specifications
I. Population A. Population B. Fertility rates C. Mortality rates
Statistics Sweden website (http://pxweb2.stat.fi/Dialog/varval.asp?) Statistics Sweden website (http://pxweb2.stat.fi/Dialog/varval.asp?) Statistics Sweden website (http://pxweb2.stat.fi/Dialog/varval.asp?)
Breakdowns by age and gender groups Breakdowns by age and gender groups Breakdowns by age and gender groups
II. Smoking and attributable deaths A. Baseline smoking rates
2004 Health on Equal Terms Survey
Breakdown of current, former and never smokers by age and gender groups Breakdowns by age and gender groups Breakdowns by age and gender groups Breakdowns by age Breakdowns by age and gender
B. Initiation rates C. First-year cessation rates D. Relapse rates E. Relative risks of current and ex-smokers III. Policies A. Taxes B. Smoke-free air laws
Change in smoking rates between contiguous age groups 2004 Health on Equal Terms Survey USDHHS (1989) and other studies Cancer Prevention Study II (NCI 1997)
Statistics Sweden (http://www.scb.se) WHO website and tobacco control staff in Sweden
C. Media and other educational campaigns D. Marketing bans E. Warning labels F. Cessation treatment policies
WHO website and tobacco control staff in Sweden
G. Youth access
WHO website and tobacco control staff
WHO website and tobacco control staff in Sweden WHO website and tobacco control staff WHO website and tobacco control staff
Prices and taxes Types of laws (worksite, restaurant and other places) and their stringency Classification based on expenditures per capita and audience Extent of bans Strictness of labels Financial reimbursement, quitlines and brief interventions Enforcement checks, penalties, publicity, self-service and vending machine bans
Moderate
Health warnings Strong
Enforcement and publicity
Total advertising ban
Marketing bans Comprehensive marketing ban
Moderately publicized campaign
Mass media campaigns Highly publicized campaign
Enforcement and publicity
Restaurant total ban Restaurant ban, except separate areas Other places total ban
Labels are large, bold and graphic. Covers at least 50% of the display area and includes all seven MPOWER warning criteria Labels cover one-third of package, not bold or graphic
Ban is applied to television, radio, print, billboard, instore displays, sponsorships and free samples Ban is applied to all media television, radio, print and billboard Government agency is designated to enforce the laws
Campaign publicized heavily on TV (at least 2 months of the year) and at least some other media Campaign publicized sporadically on TV and in at least some other media, and a local programme
Ban in all areas Smoking restricted to ventilated areas in all indoor workplaces Ban in all indoor restaurants in all areas Ban in all restaurants, except in designated areas Ban in 3 of 4 (malls, retail stores, public transportation and elevators) Government agency is designated to enforce and publicize the laws
Cigarette price index, taxes measured in absolute terms
Tax policy Tax policy
Smoke-free air laws Worksite total ban Worksite ban, except ventilated areas
Description
Policy
Table 2 Policies, description and effect sizes of the SimSmoke model and policies in Sweden
0.75% reduction in prevalence, 0.5% reduction in initiation rates and 2% increase in cessation rates
1% reduction in prevalence and initiation and 5% increase in cessation rate
5% reduction in prevalence, 6% reduction in initiation and 3% increase in cessation rates 3% reduction in prevalence, 4% reduction in initiation and 2% increase in cessation rates Effects reduced by as much as 50% if 0 enforcement
3.25% effect (doubled when accompanied by local programmes) 1.8% effect (doubled when accompanied by local programmes)
Effects reduced by as much as 50% if 0 enforcement
1% effect 0.5% effect 1% effect
6% with variations by age and gender 4% with variations by age and gender
0.3 ages 15–24 0.2 ages 25–34 0.1 ages 35 and above
Through price elasticity:
Potential percentage effecta,b
(continued)
Sweden has had moderate health warnings since 200431
A ban on most types of direct and indirect advertising has been in place since 2003 in Sweden, with the sale of cigarettes in packages of less than 20 prohibited in 2006. Therefore, we categorize Sweden as having a complete advertising ban until 2003, and partial ban on marketing (50% total advertising and 50% marketing) until 2006, increasing to 75% marketing and 25% advertising in 2007. Enforcement is set at 8 for all years30
Sweden has been spending about US $0.50 per person since before 2004; therefore, a medium-intensity campaign is assigned. The same campaign level is applied to snus, with the exception that a highintensity campaign was implemented in 2009
Sweden is considered to have had mid-level worksite laws, but strong laws in other public places since 1993. In 2006, smoke-free air laws were extended to bars and restaurants (set at 50% for both), with an exclusion for ventilated areas. Enforcement level is set to 8 out of 10 for 200830
Immediate change in taxes and price by raising excise taxes to 70% of retail price. Price effects are assumed to be the same as in the US model (28,29). Elasticities are half as great for snus as for cigarettes and assume no cross price effects. The effects of changing both the snus and cigarette price are applied for dual users. A consumer price index (CPI), cigarette price index (1985–2009) and snus price index (1985–2009) were obtained for Sweden. Seventy-three percent of cigarette price is taxes, of which 52% is specific taxes (39.2% ad valorem and 12.6% specific). The excise tax rate on snus in 2009 was 38%, having increased from 25% in 2006
Policies in Sweden
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a: Unless otherwise specified, the same percentage effect is applied as a percentage reduction in the prevalence and initiation rate and a percentage increase in the cessation rate, and is applied to all ages and both genders. The effect sizes are shown relative to the absence of any policy. b: Unless synergies are specified, the effect of a second policy simultaneously implemented is reduced by (1 the effect of the first policy).
Well enforced
Youth access policy incorporates enforcement, publicity and self-service and vending machine bans. In Sweden, youth access is considered to be enforced at a medium level with no bans on vending machine or self-service displays 30% reduction for age
