Moving beyond just TRIED and TRUE, something BOLD, something NEW!? Using simulation modelling to estimate the future smoking prevalence, health and cost impacts of tobacco endgame strategies.

Objective There is growing international interest in advancing ‘the tobacco endgame’. Achieving endgame goals will require substantive action for most countries, ie, ‘tobacco endgame strategies’. Yet, little modelling work has been done to estimate the future prevalence, health and cost impacts of such strategies, and their timing. Such evidence is important as it could inform tobacco endgame planning. New Zealand, given its Smokefree goal for 2025, was used as an experimental setting to model the impacts on smoking prevalence, health gains (quality-adjusted life-years [QALYs]) and cost-savings of: • 10% annual tobacco tax increases • Restricting tobacco sales to pharmacies only • A substantial outlet reduction strategy • A tobacco-free generation [TFG] strategy • A sinking lid on commercial tobacco supply strategy • A combination of tax, outlet reduction and TFG Methods A dynamic population forecasting model was used to estimate the impact of tobacco endgame strategies on future smoking prevalence by sex, age and ethnicity (Māori (indigenous population) and non-Māori) over and above business-as-usual [BAU] trends in smoking uptake and cessation. A closed cohort multi-state life-table [MSLT] model including 16 tobacco-related diseases was used to estimate the impacts of endgame strategies on future population health (in QALYs) and health system costs (in 2011 NZ dollars). This applied to the New Zealand population ‘alive’ in 2011 (4.4 million), and the model was run until death or age 110 years. In addition, to learn more about the practicality of endgame strategies and to inform modelling, key informant interviews were held in Iceland to learn more about the parliamentary resolution to sell tobacco exclusively from pharmacies. A survey explored Wellington pharmacists’ attitudes towards such a potential endgame strategy for New Zealand. Results All tobacco endgame strategies were associated with further reductions in smoking prevalence by 2025 compared to BAU, ranging from down to 17.8% (95% uncertainty interval [UI]: 14.3% to 22.4%) for Māori and 7.3% (95%UI: 5.7% to 9.4%) for non-Māori under a substantial outlet reduction to 0% for both ethnic groups under the sinking lid strategy. Major health gains accrued over the remainder of the 2011 population’s lives ranging from 28,900 QALYs (95%UI: 16,500 to 48,200; outlet reduction) to 282,000 QALYs (95%UI: 189,000 to 405,000; sinking lid). All endgame strategies resulted in at least three times larger QALY gains per capita for Māori compared to non-Māori. The projected health gains were accompanied by substantive cost-savings to the New Zealand health system. The timing of health gain and cost-savings greatly differed for the various strategies (with accumulated health gain peaking in 2040 for the sinking lid and 2070 for the TFG). The interviews in Iceland highlighted the practicality of, interest in, and support for tobacco endgame strategies in real world settings. The survey suggested moderate levels of pharmacist support for a potential endgame strategy that would restrict tobacco sales to pharmacies only in New Zealand – especially if it can be shown to work elsewhere. Conclusions Tobacco endgame strategies will probably be needed if New Zealand (and other countries with endgame ambitions) is to achieve its endgame goal for 2025. Given such strategies are new, modelling studies provide provisional information on what approaches may be best. As empirical evidence on the effectiveness of endgame interventions arises from other jurisdictions, modelling such as undertaken in this study can be validated and improved