Article Text

Download PDFPDF
Impact of five tobacco endgame strategies on future smoking prevalence, population health and health system costs: two modelling studies to inform the tobacco endgame
  1. Frederieke S van der Deen1,
  2. Nick Wilson1,
  3. Christine L Cleghorn1,
  4. Giorgi Kvizhinadze1,
  5. Linda J Cobiac1,2,
  6. Nhung Nghiem1,
  7. Tony Blakely1,2
  1. 1 Burden of Disease Epidemiology, Equity and Cost Effectiveness Programme (BODE3), University of Otago, Wellington, New Zealand
  2. 2 Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
  1. Correspondence to Frederieke S van der Deen, Burden of Disease Epidemiology, Equity and Cost Effectiveness Programme (BODE), University of Otago, 23 Mein Street, Newtown, Wellington 6242, New Zealand; frederieke.vanderdeen{at}


Objective There is growing international interest in advancing ‘the tobacco endgame’. We use New Zealand (Smokefree goal for 2025) as a case study to model the impacts on smoking prevalence (SP), health gains (quality-adjusted life-years (QALYs)) and cost savings of (1) 10% annual tobacco tax increases, (2) a tobacco-free generation (TFG), (3) a substantial outlet reduction strategy, (4) a sinking lid on tobacco supply and (5) a combination of 1, 2 and 3.

Methods Two models were used: (1) a dynamic population forecasting model for SP and (2) a closed cohort (population alive in 2011) multistate life table model (including 16 tobacco-related diseases) for health gains and costs.

Results All selected tobacco endgame strategies were associated with reductions in SP by 2025, down from 34.7%/14.1% for Māori (indigenous population)/non-Māori in 2011 to 16.0%/6.8% for tax increases; 11.2%/5.6% for the TFG; 17.8%/7.3% for the outlet reduction; 0% for the sinking lid; and 9.3%/4.8% for the combined strategy. Major health gains accrued over the remainder of the 2011 population’s lives ranging from 28 900 QALYs (95% Uncertainty Interval (UI)): 16 500 to 48 200; outlet reduction) to 282 000 QALYs (95%UI: 189 000 to 405 000; sinking lid) compared with business-as-usual (3% discounting). 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).

Conclusions Implementing endgame strategies is needed to achieve tobacco endgame targets and reduce inequalities in smoking. Given such strategies are new, modelling studies provide provisional information on what approaches may be best.

  • tobacco endgame
  • simulation model
  • smoking prevalence
  • QALYs
  • health system costs

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Contributors FSvdD led the writing, intervention specification, adaptation of the established models, analyses and extraction and interpretation of the results. LJC and TB conceived the core aspects of the modelling approach for the BODE3 tobacco forecasting model and the BODE3 multi-state life-table model, but with design contributions from FSvdD for the first model, and from CLC, GK, FSvdD, NN and NW for the latter model. All authors provided advice during analyses, and contributed towards the interpretation of results and drafting of the paper. All authors approved the final manuscript.

  • Funding FSvdD is supported by a University of Otago Doctoral Postgraduate Publishing Bursary. NW, CLC, GK, LJC, NN and TB are supported by the BODE3 Programme which is studying the effectiveness and cost-effectiveness of various health sector interventions and receives funding support from the Health Research Council of New Zealand (Grant number 10/248).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Correction notice This paper has been amended since it was published Online First. Owing to a scripting error, some of the publisher names in the references were replaced with ’BMJ Publishing Group'. This only affected the full text version, not the PDF. We have since corrected these errors and the correct publishers have been inserted into the references.