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Evaluating smoking control policies in the e-cigarette era: a modelling study
  1. Thi Thanh Tra Doan,
  2. Ken Wei Tan,
  3. Borame Sue Lee Dickens,
  4. Yin Ai Lean,
  5. Qianyu Yang,
  6. Alex R Cook
  1. Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
  1. Correspondence to Alex R Cook, Saw Swee Hock School of Public Health, National University of Singapore, 119077, Singapore; ephcar{at}


Background In jurisdictions in which electronic cigarettes are currently prohibited, policy makers must weigh the potentially lower risk compared with conventional cigarettes against the risk of initiation of e-cigarettes among non-smokers.

Methods We simulated a synthetic population over a 50-year time horizon with an open cohort model using data from Singapore, a country where e-cigarettes are currently prohibited, and data from the USA, the UK and Japan. Using the smoking prevalence and the quality-adjusted life year gained calculated, we compared tobacco control policies without e-cigarettes—namely, raising the minimum legal age (MLA), introducing a smoke-free generation (SFG) and tax rises on tobacco consumption—with policies legalising e-cigarettes, either taking a laissez-faire approach or under some form of restriction. We also evaluated combinations of these policies.

Results Regardless of the country informing the transition probabilities to and from e-cigarette use in Singapore, a laissez-faire e-cigarette policy could reduce the smoking prevalence in the short term, but it is not as effective as other policies in the long term. The most effective single policies evaluated were SFG and aggressive tax rises; the most effective combination of policies considered was MLA plus moderate tax rises and e-cigarettes on prescription.

Conclusion Policy makers in jurisdictions in which e-cigarettes are not yet established may be advised not to prioritise e-cigarettes in their tobacco end-game strategy, unless their use can be restricted to current smokers seeking to quit.

  • electronic nicotine delivery devices
  • end game
  • public policy
  • taxation
  • denormalization

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  • TTTD and KWT contributed equally.

  • Contributors TTTD and KWT contributed to model building, data acquisition, analysis and drafting of the manuscript. ARC contributed to the conception of the model, interpretation of the results and drafting of the manuscript. BSLD, YAL and QY contributed to data acquisition and analysis.

  • Funding This work was supported by funding from Singapore’s Ministry of Health through the Population Health Metrics and Analytics programme and the National Medical Research Council’s Centre Grant Programme which funds the Singapore Population Health Improvement Centre (NMRC/CG/C026/2017_NUHS) and by Singapore’s National Research Foundation (grant NRF2017VSG-AT3DCM001-022).

  • Competing interests None declared.

  • Patient consent for publication Not required.

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

  • Data availability statement Data are available in a public, open access repository.

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