TheCzechRepublic SimSmoke : The Effect of Tobacco Control Policies on Smoking Prevalence and Smoking Attributable Deaths in the Czech Republic

Background. The Czech Republic has a weak tobacco control record. This paper describes a simulation model examining the effect of future tobacco control policies in the Czech Republic on smoking prevalence and associated future premature mortality. Methods. The model is developed using the SimSmoke simulation model of tobacco control policy. The model uses population, smoking rates and tobacco control policy data for the Czech Republic. It assesses, individually and in combination, the effect of taxes, smoke-free air laws, mass media campaigns, advertising bans, warning labels, cessation treatment, and youth access policies. Results. With a comprehensive set of policies, smoking prevalence can be reduced by as much as 22% in the first year, by 35% in 20 years, and up to 40% in 30 years. By 2040, 5,873 deaths can be averted in that year alone. Without these policies, 113,004 people in the Czech Republic will die prematurely in the next 30 years. Conclusions. The model shows that significant inroads to reducing smoking prevalence and premature mortality can be achieved through tax increases, a high intensity media campaign, a comprehensive cessation treatment program, strong health warnings, stronger smoke-free air laws and marketing bans, and well-enforced youth access laws.


Introduction
Globally, 5 million premature deaths each year are attributable to smoking [1].Approximately, 18,000 of these deaths are in the Czech Republic (CR), a country in the heart of Europe with a population of 10 million [1].To reduce this toll, the World Health Organization has set out the Framework Convention for Tobacco Control (FCTC).Substantial evidence indicates that higher cigarette taxes, clean air laws, advertising bans, and media campaigns can appreciably reduce adult smoking rates, especially when combined as a comprehensive strategy [2,3].MPOWER [4] suggests specific policies consistent with the FCTC.
The CR has signed, but not yet ratified the FCTC, thus being the only country in the European Union not a party to the FCTC.The CR has a notably high rate of smoking (35% of men and 27% of women smoke) [5], with policy makers openly supporting the tobacco industry [6].Since 1995, the CR has increased cigarette taxes and strengthened health warnings in order to comply with EU regulations, but has done little else, and cigarette prices are still low relative to other EU nations and the local standard of living [7].
Since the ability of purely statistical studies to distinguish the effects of different policies on smoking rates is limited, simulation models combine information from different sources to provide a useful tool for examining how the effects of public policies unfold over time [8,9].SimSmoke simultaneously considers a broader array of public policies than other models [10] and has been validated in several countries [11,12] and US states [13][14][15].

Methods
SimSmoke includes population, smoking, SADs, and policy modules [9].The model begins in a baseline year with the population divided into current, never, and former smokers by age and gender.The baseline year, 2002, is based on the availability of a large scale survey for that year and stability of policies during that period.A discrete time first-order Markov process is employed to project future population growth through fertility and deaths, and smoking rates through smoking initiation, cessation, and relapse.Smoking rates, and thereby SADs, change over time in response to changes in tobacco control policies.

Smoking Model.
Within the smoking model, individuals are classified as never smokers from birth until they initiate smoking or die.They may evolve from current to former smoker through cessation or may return to smoker through relapse.The extent of relapse depends on the number of years quit.
The 2002 data on smoking prevalence is from the Sample Survey of the Health Status of the Czech Population of UZIS (Institute of Health Information and Statistic), a nationally representative multistage cluster sample, interviewer administered questionnaire with a sample size of about 2,500 respondents 15 years and above.The survey is also available for 1995, 1999, 2005, and 2008.According to those surveys, the smoking rate dropped from 1995 to 1999 and was stable between 1999 and 2002 and relatively stable with a small decline between 2002 and 2005.
The UZIS interviewer asks "Do you smoke?" and asks those who answer "no" if they ever smoked.In the model, occasional and everyday smokers of any tobacco products are included as current smokers.However, since the sample was small, former smokers were distinguished by years quit using the Netherlands data from 1996, when their smoking rates (prior to major policies) were comparable to 2002 CR rates.
Due to empirical challenges in measuring initiation and cessation and in order to ensure internal consistency of the model, 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.Upon examining smoking rates in 2002 and earlier years, initiation was set to continue through age 30 for males and through age 35 for females.
In calibrating the model, smoking rates for ages 18-28 were examined to confirm our choice of maximum initiation age.
Data was not available for cessation rates.We initially chose a first year cessation rate of 4% and allowed 50% relapse, yielding rates consistent with estimates from Great Britain [17] and the Netherlands [18].Because data were not available for the CR, we used US relapse rates [19,20].
2.3.Smoking-Attributable Deaths.Death rates by age, gender, and smoking status were calculated from death rates, smoking rates, and relative risks.The number of current and former smokers at each age was multiplied by their respective excess risk and summed to obtain total SADs.
Large-scale studies of smoking risk were not available for the CR.Because the CR is a high income nation with a similar smoking history to the US, we use relative risk estimates from the US Cancer Prevention Study II [21].Similar risks have been found for Great Britain [22] and for post-transition Russia [23].For exsmokers, relative risks were assumed to decline at rates observed in US studies [21].

Policies.
Policy effect sizes are in terms of percentage reductions applied to smoking prevalence in the year when a policy is implemented, and, unless otherwise specified, applied to initiation and cessation rates in future years.Policies and effect sizes are summarized in Table 1.
The effect of implementing a policy depends on the prior level of that policy.We input data on policy levels for each year from 2002 through 2010 based on MPOWER reports [4] and information provided by staff in the CR.
Tax policy in SimSmoke uses inflation-adjusted cigarette prices as the policy input through 2010, and uses the total cigarette excise (including ad valorem and specific) tax to adjust future prices.A cigarette price index (measured with a 0.5 weight each to a local brand and Marlboro) was obtained from the EIU [24], deflated by the CPI [25].In future years, price increases in absolute terms by the amount of the cigarette tax increase per unit [26].Based on information from the European Union, the excise tax rate in 2010 was 64%.The MPOWER target-specific tax rate is 70% of the retail price, upon adjusting for their reduced percentage in overall price due to value added taxes.Changes in price are translated into changes in smoking prevalence through elasticities.A price elasticity estimate was not found for the CR, but estimates from Germany [27] are comparable to the US price elasticities of −0.3 for those through age 24, −0.2 for ages 25-34, and −0.1 for ages 35 and above are applied.
Smoke-free air policy considers smoking restrictions in: (1) worksites, (2) restaurants and bars, and (3) other places, with their effect dependent on enforcement and publicity (based on the level of tobacco control campaigns).No studies of the effect of smoke-free indoor air laws were found for the CR.We primarily rely on US studies, but also considered the CR's unemployment rate and the percent of the workers employed in agriculture (<5%) [16].With strong enforcement and publicity, the effect of a ban in restaurants was estimated as 2%, in pubs and bars 1%, in worksites 6%, and in other public places 1%, with the full effects dependent on enforcement [28].The 1989 Tobacco Act gave limited scope to smoke-free air laws (e.g., smoking ban in restaurants applied only for parts of the day without hours clearly specified).The Act was amended in 1999 to include smoke-free working places (within limited areas, for sport and culture facilities).The CR is considered to have a weak worksite ban, no ban in restaurants, pubs or bars, and a 50% ban in all other public places for all years.From MPOWER [4], the enforcement level is set to 4 (out of 10).
MPOWER [4] distinguishes enforcement and 3 levels of direct (advertising and point of sale) and indirect (sponsorships, branding, or promotional discounts) marketing bans: minimal, moderate, and complete.With a complete ban, prevalence is reduced by 5% and initiation by 6%, and cessation is increased by 3% [3,29].Since 1995, the CR has had a ban on television and radio advertising for certain hours, with some additional restrictions added in 2001.There are some limitations on sponsorship and branding, but no limitations on point of sale advertising.The level is set to 3 from 2002 to the present.Enforcement is set to 7 [4].
MPOWER provides 3 levels for health warnings: minimal (<30% of the principal display area), moderate (≥30% of display area and rotating) and strong (≥50% of the display area, rotating bold, graphic, and a ban on deceitful terms).Based on a review [3] and recent studies [30,31], strong health warnings reduce prevalence by 2% and initiation by 1%, and increases cessation by 5%.When moderate (low), prevalence is reduced by 0.75% (0.5%), cessation is increased by 2.5% (1.0%) and initiation is reduced by 0.5% (0.5%), with an added impacted of tobacco control campaigns (an additional 1% reduction in prevalence and 2% increase in cessation).The CR had minimal health warnings from 1991 to 2003, when they became moderate, covering 30% of one side of the box.
SimSmoke specifies three levels for tobacco control campaigns-low: a national agency and minimal funding or employees; medium: 10+ employees or per capita expenditures over $0.10 (USD) per capita; high: expenditures over $0.50 (USD) per capita, and incorporates synergies from publicity surrounding other policies.Based on reviews [3,32], a wellfunded tobacco control campaign in conjunction with other policies yields an effect size of 6.5%, compared to an effect size of 1% for a low intensity campaign.MPOWER [4] does not provide expenditure data, but indicates the absence of a tobacco control agency.Czech staff indicated that there were sporadic campaigns.Tobacco control campaigns is set to low for all years A strongly enforced policy restricting cigarette purchases by youth reduces smoking prevalence by those under age 18 by as much as 25% [33].Since 1999, the purchase of tobacco products by those under the age of 18 has been illegal.However, over 70% of 13-15 years olds who attempted to buy cigarettes in a store were not refused purchase [34,35].Therefore, youth access enforcement is set to low, with no bans on vending machines or self-service displays.
Cessation treatment includes four subpolicies.Treatment coverage is based on the places providing cessation treatments.With publicity, prevalence is reduced by 2.25%, and cessation rate increased by 12% [36].The effect of a wellpublicized quitline reduces prevalence by 0.5% and increases cessation 5% [36].With bupropion available by prescription and NRT available over-the-counter, prevalence is reduced by 1.0%, and cessation increased 6% [37,38].Brief interventions involves advice and assistance by health care providers, which reduces prevalence by up to 0.5%, and increase cessation 10% [36].With all subpolicies implemented, prevalence is reduced 4.75% and cessation increased 40%.
Since at least 2002, NRT has been available in pharmacies, and bupropion has been available by prescription.Treatments are provided in some primary care facilities, hospitals, and offices of health professionals [4], with 30 centres providing treatment covered partly by national health insurance.These policies are assumed to have been in place since 2002, with community coverage beginning in 2007.A quitline has been operating since 2005, but is underfunded, operates limited hours and is not publicized.Doctors are not reimbursed for brief interventions, which, according to patients, are provided during less than 20% of visits [39] and is set to 20%.

Model Outcomes.
The model projects two primary outcomes over time: smoking prevalence and SADs.To calibrate the model, we compared trends in smoking prevalence from the model over the period from 1993 to 2002 to trends gleaned from UZIS surveys over the period 1993-2002.To validate the model, we compare projected smoking prevalence to trends from Sovinová et al. [40].
The effect of implementing MPOWER policies in 2011 is gauged relative to the status quo scenario, where tobacco control policies are maintained at their 2010 level.Results for smoking prevalence are presented in relative terms, that is, the difference in smoking prevalence from the status quo divided by status quo smoking prevalence.Lives saved are calculated as the difference in the number of SADs with the policy and under the status quo.We consider tobacco control policies in isolation and through a comprehensive strategy simultaneously implementing all policies.

Smoking Prevalence from 2002 to 2010. Between 2002
and 2010, the model predicts that male smoking rates (as a percent of the population ages 15 and above) decrease from 37.3% to 34.6% (a 10% decrease in relative terms) and that female smoking rates remain almost constant, decreasing from 23.2% to 23.1%.These predictions are consistent with survey data [40] that show that smoking rates have been slowly falling while female rates have stay stayed quite constant from 1999 to 2009.Like external data [40], the model predicts slow declines in smoking rates for all age groups, except the older ages where there is a slow increase.

Future Policies to Reduce Smoking Prevalence and SADs.
Predicted smoking prevalence under the status quo and under varying policy scenarios are shown in Tables 2(a) and 2(b) for males and females, respectively.The total number of projected SADs for a specific year and the cumulative total for 2010-2040 are displayed in Table 3.
If tobacco control policies remain unchanged from their 2010 levels, as in the status quo scenario, male adult smoking is projected to fall from 34.6% in 2010 to 32.4% by 2020, to 29.5% by 2030, and to 27.5% by 2040.In the status quo scenario, female smoking prevalence is projected to fall from 23.1% in 2010 to 22.7% by 2020, to 21.3% by 2030, and to 18.7% by 2040.The estimated number of SADs in 2010 alone is 21,885 (16,110 males and 5,775 females).Male SADs are projected to increase until 2022, but then decline.Female SADs are 5,775 in 2010 and projected to increase by 3,122 per year by 2040.
Relative to the status quo, increasing excise taxes to 70% of the current price is projected to reduce smoking prevalence in relative terms by 5.1% for males and 4.8% for females in 2011.By 2040, smoking prevalence is projected to decline by 9.9% for males 8.7% for females.With the 70% tax, 1,042 lives are saved in the year 2040.Summing over

Discussion
We have applied population, smoking prevalence, and policy data for the Czech Republic and modified parameter values to the SimSmoke model.The model's projections are supported by validation in the CR and in countries with sufficient data to confirm predicted trends [11][12][13][14][15].
While some tobacco control policies have been implemented in recent years, the CR is still far from meeting the MPOWER targets.Using the SimSmoke model, we have projected that smoking prevalence can be decreased by as much as 22% on the short term, 35% by 20 years and almost 40% by 30 years.Because of the natural progression of tobaccorelated illnesses, reductions in smoking prevalence have a relatively small impact on SADs initially, but 5,873 deaths can be averted in 2040 alone.Without the complete set of MPOWER policies, 113,000 additional premature smoking related deaths will needlessly occur by 2040.
The smoking projections are based on 2002 Czech smoking prevalence data, but cessation rates are based on other countries due to gaps in the CR data.Data on the distribution of quitting-smokers can be used to gauge the impact of tobacco control policies, and further validate the model.With data on policies, the impact of new policies can be evaluated and the model updated.
Relative smoking risks estimates are based primarily on US studies.Notably, the SADs estimates are conservative in that they exclude deaths due to second-hand smoke exposure.
Uncertainty surrounding the effects of each policy varies [3].Many studies yield relatively consistent results for price.Many studies evaluate smoke-free air restrictions, but yield less consistent results.Less information is available on the impact of health warnings and treatment policies, or the interactive effects of policies.
SimSmoke results highlight the relative contribution of policies to reducing the tobacco health burden.Increasing cigarette taxes to 70% of price, stronger smoke-free air laws, a high intensity media campaign and a comprehensive treatment policy are each potent.When combined with strong youth access laws, stricter marketing bans and stronger warning labels, the smoking rate is projected to fall by 40% in relative terms and 113,000 deaths are averted by 2040.

2. 1 .
Population Model.Population (2002), mortality (2001), and fertility (2001) data by age and gender are from the Statistical Office of the Czech Statistical Agency.Projections from the model through 2010 showed a slight decline in population, consistent with estimates from the World Factbook [16].
(i) The Czech Republic has a weak tobacco control record.(ii) The Czech Republic has yet to ratify the WHO Framework Convention for Tobacco Control.(iii) This paper shows that the effect of implementing policies consistent with the Czech Republic has a weak tobacco control record.(iv) The smoking rate is projected to fall by 40% in relative terms and 113,000 deaths are averted by 2040.(v) Significant inroads to reducing smoking prevalence and premature mortality can be achieved through tax increases, a high intensity media campaign, a comprehensive cessation treatment program, strong health warnings, stronger smoke-free air laws and marketising bans, and well-enforced youth access laws.

Table 1 :
Policies, description, and effect sizes of the SimSmoke model.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 to be relative to the absence of any policy.They are based on literature reviews, advice of an expert panel, and model validation.

Table 2 :
15) SimSmoke projections of male smoking prevalence for ages15and older, Czech Republic, 2010-2040.(b) SimSmoke projections of female smoking prevalence for ages 15 and older, Czech Republic, 2010-2040.Measured relative to the status quo in the same year, that is, (SR p,t − SR Status quo,t )/SR Status quo,t , where SR p,t is the smoking rate in year t with policy p and SR Status quo,t is the smoking rate in year t under the status quo.Measured relative to the status quo in the same year, that is, (SR p,t − SR Status quo,t )/SR Status quo,t , where SR p,t is the smoking rate in year t with policy p and SR Status quo,t is the smoking rate in year t under the status quo.