Tobacco Endgame Simulation Modelling: Assessing the Impact of Policy Changes on Smoking Prevalence in 2035
Round 1
Reviewer 1 Report
Intro: Suggest defining 'less than 5 by 35' earlier in the introduction as it is not clear until the end.
Line 76 should read "...costs to society detailed above..."
Materials & Methods: Line 94 should read "...each Tobacco Endgame strategy..."
Suggest adding some clarity as to how the changes to the SimSmoke parameters serve as a valid proxy measure. For those who are unfamiliar with Ontario's SimSmoke, this was not immediately evident.
Line 123 should read "...younger than 19 who might be..."
Line 167, suggest finessing "$2016"
Discussion: Same comment in the abstract, it might be helpful to present these findings as decreases from the status quo (e.g., 12.9%-10.1% = 2.8% as the independent impact of increased taxation).
Sentence covering lines 304-306 reads a little strangely, consider revising.
Author Response
Response to reviewers:
Intro:
- Suggest defining 'less than 5 by 35' earlier in the introduction as it is not clear until the end.
Response: “Less than 5 by 35” was defined in line 43-46 as “In October 2016, a Tobacco Endgame for Canada Summit was convened with over 80 experts, researchers, government officials, advocates, and health professionals in attendance to discuss possible strategies to the target goal “less than 5 by 35”- to achieve less than 5% smoking prevalence by 2035.”
- Line 76 should read "...costs to society detailed above..."
Response: Typographical error was revised as requested.
Materials & Methods:
- Line 94 should read "...each Tobacco Endgame strategy..."
Response: Typographical error was revised as requested.
- Suggest adding some clarity as to how the changes to the SimSmoke parameters serve as a valid proxy measure. For those who are unfamiliar with Ontario's SimSmoke, this was not immediately evident.
Response: We attempted to clarify how the model was adapted. The appropriate section now reads (line 95):
“]. Each policy parameter in the model is accorded an effect size developed for the SIMSMOKE model based on literature reviews and expert panel. These existing parameters were then either maximized to represent full implementation of the intervention or the parameter effect sizes themselves were adapted according the new assumptions. Modifications were made to the Ontario SimSmoke policy levels or policy effect sizes to assess the impact of each Tobacco Endgame strategy on smoking prevalence in Ontario between 2019 and 2035. The following representent the changes in the SIMSMOKE model to represent the effect of the endgame scenarios.
To simulate the impact of plain packaging, the comprehensive marketing ban (both direct and indirect) policy level in Ontario SimSmoke was increased to 90% (up from 25%) as a proxy measure for plain packaging in which the package itself was assumed to be the primary method of direct consumer marketing in Ontario..
Free cessation services were modeled adapting two parameters in Ontario SimSmoke. The first parameter incorporated free cessation services (pharmacotherapy and behavioural therapy) in all primary care and hospital settings,. The second parameter expanded the number of settings offering free cessation to also include offices of health professionals, community and ‘other.’ Free cessation services are currently limited in Ontario.
Analyses conducted by Chaiton, Mecredy and Cohen [19] identified an increased risk of relapse among smokers who resided within 500m from a tobacco outlet (Hazard ratio: 1.41) compared to those who lived further away. As a proxy measure for decreasing the number of outlets selling tobacco products, the policy effect sizes in Ontario SimSmoke for the five cessation treatment policies (treatment availability, treatment access, quitlines, quitlines with treatment access, and brief interventions) were increased by a value of 1.41.
Price elasticities were doubled in the Ontario SimSmoke model to assess the impact of increased tobacco taxes on smoking prevalence. Specifically, the policy effects were increased to -0.6 for youth less than 18 years (60% reduction in smoking), -0.4 for young adults aged 18 to 24 (40% reduction in smoking), -0.3 for adults aged 25 to 34 years (30% reduction in smoking) and -0.2 for adults aged 35 years or more (20% reduction in smoking).”
- Line 123 should read "...younger than 19 who might be..."
Response: Typographical error was revised as requested.
- Line 167, suggest finessing "$2016"
Response: We have edited this to read “2016 dollars”
Discussion:
- Same comment in the abstract, it might be helpful to present these findings as decreases from the status quo (e.g., 12.9%-10.1% = 2.8% as the independent impact of increased taxation).
Response: Thank you. We have revised the abstract and discussion (Line 270) to include these as decreases.
“Increasing the tobacco taxes had the greatest independent predicted decrease in smoking prevalence by the year 2035 (2.8%), followed by increased the minimum age for legal purchase to 21 years (2.4%) and decreasing the number of tobacco outlets (1.5%).”
- Sentence covering lines 304-306 reads a little strangely, consider revising.
Response: Lines 303-306 were revised as “Our approach does not address the issue of tax avoidance such as brand switching. Because governments in Canada rely entirely on tobacco specific excise taxes and not on specific ad valorem taxes, which differs between brands of tobacco products.”
Reviewer 2 Report
The article “Tobacco Endgame Simulation Modelling: Assessing the impact of policy changes on smoking prevalence in 2035” is an interesting research article where the authors try to analyze the possible impact of five potential Tobacco endgame strategies on smoking prevalence in Ontario by 2035. The study is worthwhile because the authors did not limit their analysis to the cumulative results; instead, they gave also details on the effect of each strategy considered alone.
The article is well written, and the exposure of the results is clear and effective, even for readers who are not so accustomed to the analysis of projection models.
However, the manuscript could be improved with some revisions, mainly concerning the clarification of some terms in order to make the paper clearer and more readable.
In conclusion, I will recommend publishing the article, once implemented with the revisions suggested.
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However, I suggest considering some revisions:
Line 45: the authors should better contextualize and clarify the meaning and the implication of the target goal “less than 5 by 35”;
Line 75-78: the authors might consider rephrasing the sentence, which results in a bit cumbersome and not sufficiently clear;
Table 2: the authors should check the presence of a possible misprint in the second line of the first column (“policies”)
Line 290: in order to better contextualize and value the importance of the Tobacco Endgame strategies, it would be appreciable if the authors could report esteem of the economic savings in terms of health care and social cost.
Line 301: the authors should consider specifying the meaning of “Harmonised Sales Tax (HST)” for non-Canadian readers.
General consideration: the authors might consider discussing the potential impact of other factors not considered in the models, such as, for example, the use of the e-cigarette.
Author Response
Reviewer 2
- Line 45: the authors should better contextualize and clarify the meaning and the implication of the target goal “less than 5 by 35”;
Response: “Less than 5 by 35” was clarified in line 43-46 as “In October 2016, a Tobacco Endgame for Canada Summit was convened with over 80 experts, researchers, government officials, advocates, and health professionals in attendance to discuss possible strategies to the target goal “less than 5 by 35”- to achieve less than 5% smoking prevalence by 2035.”
- Line 75-78: the authors might consider rephrasing the sentence, which results in a bit cumbersome and not sufficiently clear.
Response: Line 75-78 were revised as “Irrespective of the substantial cost savings gained from reductions in health care spending and reductions in indirect costs to society detailed above, there might be minimal changes in government revenue during the period of transition to “less than 5”, if increased tax rates are a component of an endgame strategy.”
- Table 2: the authors should check the presence of a possible misprint in the second line of the first column (“policies”)
Response: Typographical error in Table 1, second line of first column, was revised as “Status Quo Policiesa” where superscript “a” represents a footnote.
- Line 290: in order to better contextualize and value the importance of the Tobacco Endgame strategies, it would be appreciable if the authors could report esteem of the economic savings in terms of health care and social cost.
Response: We have revised the sentence at line 290 to include the reference to the total estimated cost of tobacco use in Canada.
“The analysis shows that with a sensible taxation policy, fiscal cost impact over the period of implementation is minimal compared to the health care and social costs of tobacco which currently are estimated at $16 billion per year [27].”
- Line 301: the authors should consider specifying the meaning of “Harmonised Sales Tax (HST)” for non-Canadian readers.
Response: In line 304, the meaning of HST was specified and revised as “Our approach examines the effect of changes in tobacco excise rates on tobacco excise revenue and not on harmonized sales tax (HST) which is a non-tobacco specific tax applicable on any taxable supplies in Canada, as ex-smokers and continuing smokers that reduce their consumption will very likely divert their spending towards goods and services that are also subject to HST.”
General consideration: the authors might consider discussing the potential impact of other factors not considered in the models, such as, for example, the use of the e-cigarette.
Response:
More broadly, the Endgame potential intervention here are only a possible subset of innovative strategies that could change the landscape of tobacco control. For instance, this study does not consider the role of e-cigarettes, reduced nicotine, or structural changes to the tobacco industry. These other interventions may have a greater impact on smoking prevalence or health burden than the intervention set considered here.
