Abstract
BackgroundElectronic cigarettes (“e-cigarettes”) have altered tobacco smoking trends, and their impacts are controversial. Given their lower risk relative to combustible tobacco, e-cigarettes have potential for harm reduction. This study presents a simulation-based analysis of an e-cigarette harm reduction policy set in the USA.MethodsA system dynamics simulation model was constructed, with separate aging chains representing people in different stages of use (both of combustible cigarettes and e-cigarettes). These structures interact with a policy module to close the gap between actual (simulated) and goal numbers of individuals who smoke, chosen to reduce the tobacco-attributable death rate (i.e., mostly combustible cigarette-attributable, but conservatively allowing e-cigarette-attributable deaths) to that due to all accidents in the general population. The policy is two-fold, removing existing e-liquid flavor bans and providing an informational campaign promoting e-cigarettes as a lower-risk alternative. Realistic practical implementation challenges are modeled in the policy sector, including time delays, political resistance, and budgetary limitations. Effects of e-cigarettes on tobacco smoking occur through three mechanisms: (1) diversion from ever initiating smoking; (2) reducing progression to established smoking; and (3) increasing smoking cessation. An important unintended effect of possible death from e-cigarettes was conservatively included.ResultsThe base-case model replicated the historical exponential decline in smoking and the exponential increase in e-cigarette use since 2010. Simulations suggest tobacco smoking could be reduced to the goal level approximately 40 years after implementation. Implementation obstacles (time delays, political resistance, and budgetary constraints) could delay and weaken the effect of the policy by up to 62% in the worst case, relative to the ideal-case scenario; however, these discrepancies substantially decreased over time in dampened oscillations as negative feedback loops stabilize the system after the one-time “shock” introduced by policy changes.ConclusionsThe simulation suggests that the promotion of e-cigarettes as a harm-reduction policy is a viable strategy, given current evidence that e-cigarettes offset or divert from smoking. Given the strong effects of implementation challenges on policy effectiveness in the short term, accurately modeling such obstacles can usefully inform policy design. Ongoing research is needed, given continuing changes in e-cigarette use prevalence, new policies being enacted for e-cigarettes, and emerging evidence for substitution effects between combustible cigarettes and e-cigarettes.
Highlights
Smoking tobacco is a causal factor in a wide range of adverse health effects including cancers [1,2,3], cardiovascular disease [4], macular degeneration [5], birth defects [6], rheumatoid arthritis [7], inflammation [8], and impaired immune function [9], and exacerbates diabetes [10, 11]
The current study investigates the potential of a harm reduction policy of promoting e-cigarette use in order to divert those who currently smoke or would otherwise smoke away from combustible cigarettes, using system dynamics simulation modeling
Stock‐and‐flow diagram Based on the Causal loop diagram (CLD) above, a stock-and-flow diagram (Fig. 2) was constructed in Stella Architect, version 1.9.5 [49], which consists of “aging chains” for both combustible cigarette and e-cigarette use
Summary
Smoking tobacco is a causal factor in a wide range of adverse health effects including cancers [1,2,3], cardiovascular disease [4], macular degeneration [5], birth defects [6], rheumatoid arthritis [7], inflammation [8], and impaired immune function [9], and exacerbates diabetes [10, 11]. Combustible cigarettes seem to be becoming more harmful over time, at least for lung cancer: despite the declines in smoking prevalence, lung cancer incidence as well as mortality has increased among those who smoke, in adenocarcinoma. The increased cancer burden is speculated to be due to changes in the composition and processing of combustible cigarettes [12]. This increase in lung cancer rates runs counter to the decline in smoking prevalence over the last several decades. Electronic cigarettes (“e-cigarettes”) have altered tobacco smoking trends, and their impacts are controversial Given their lower risk relative to combustible tobacco, e-cigarettes have potential for harm reduction. This study presents a simulation-based analysis of an e-cigarette harm reduction policy set in the USA
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