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Estimated Public Health Gains From German Smokers Switching to Reduced-Risk Alternatives: Results From Population Health Impact Modelling

Romana Rytsar
Romana Rytsar
, 
Smilja Djurdjevic
Smilja Djurdjevic
, 
Alexander K. Nussbaum
Alexander K. Nussbaum
, 
Ashok Kaul
Ashok Kaul
, 
Emanuel Bennewitz
Emanuel Bennewitz
, 
Peter N. Lee
Peter N. Lee
 and 
John S. Fry
John S. Fry
   | May 05, 2022
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Published Online: May 05, 2022
Page range: 35 - 51
Received: May 27, 2021
Accepted: Mar 01, 2022
DOI: https://doi.org/10.2478/cttr-2022-0004
Keywords
© 2022 Romana Rytsar et al., published by Sciendo
This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Figure 1

Comparison of Null Scenario and derived estimates of current smoker prevalence.
Comparison of Null Scenario and derived estimates of current smoker prevalence.

Figure 2

Product usage in the Conversion Scenario. Abbreviations used: ECig = e-cigarettes; HnB = heat-not-burn;
Product usage in the Conversion Scenario. Abbreviations used: ECig = e-cigarettes; HnB = heat-not-burn;

Figure 3

DDs in the Conversion Scenario over the whole follow-up period. Abbreviations used: COPD = chronic obstructive pulmonary disease; IHD = ischaemic heart disease; LC = lung cancer;
DDs in the Conversion Scenario over the whole follow-up period. Abbreviations used: COPD = chronic obstructive pulmonary disease; IHD = ischaemic heart disease; LC = lung cancer;

Figure 4

YLS by Scenario over the whole follow-up period.See Table 2 for a description of the scenarios.
YLS by Scenario over the whole follow-up period.See Table 2 for a description of the scenarios.

Assumed relative risk for continued smoking and quitting half-life by disease for Germany.

Age (years) LC COPD Stroke IHD
Relative risk Any 8.68 3.31 – –
to 54 – – 2.48 3.38
55–64 – – 2.13 2.32
65–74 – – 1.39 1.70
75–79 – – 1.06 1.27
Half-life Any – 13.32 4.78 –
to 49 6.98 – – 1.47
50–59 10.39 – – 5.22
60–69 10.60 – – 7.48
70–79 12.99 – – 13.77

Years of life saved (thousands) by age 75 over the whole follow-up period in Germany.

Men Women
Scenario LC IHD Stroke COPD All four diseases LC IHD Stroke COPD All four diseases
1 Complete cessation 520 1,329 213 98 2,160 292 258 118 52 720
2 Complete switch to RRPs (HnBs) 357 943 160 74 1,534 203 189 89 40 521
3 Complete switch to RRPs (50% HnBs; 50% ECigs) 412 1,077 180 83 1,752 233 213 99 44 589
4 Conservative Scenario 83 241 43 20 387 42 43 21 10 116
5 Dynamic Scenario 134 379 68 31 612 67 68 33 15 183
6 Conversion Scenario 161 461 80 37 739 84 84 40 18 226
7 Full Conversion Scenario 176 506 86 39 807 90 89 43 19 241

Drop in deaths in Germany over the whole follow-up period for the seven Alternative Scenarios.

Drop in deaths % Drop in deaths
Sex/Scenario LC IHD Stroke COPD All four diseases LC IHD Stroke COPD All four diseases
Men
1 Complete cessation 48,092 83,798 15,429 14,166 161,485 13.38 45.26 46.06 16.48 24.32
2 Complete switch to RRPs (HnBs) 34,148 61,591 11,783 10,820 118,342 9.50 33.27 35.17 12.59 17.82
3 Complete switch to RRPs (50% HnBs; 50% ECigs) 38,967 69,431 13,111 12,038 133,547 10.84 37.50 39.14 14.01 20.11
4 Conservative Scenario 8,316 16,144 3,286 2,969 30,714 2.31 8.72 9.81 3.46 4.63
5 Dynamic Scenario 13,437 25,533 5,136 4,680 48,785 3.74 13.79 15.33 5.44 7.35
6 Conversion Scenario 15,950 30,276 6,004 5,425 57,655 4.44 16.35 17.92 6.31 8.68
7 Full Conversion Scenario 17,210 32,734 6,431 5,777 62,153 4.79 17.68 19.20 6.72 9.36
Women
1 Complete cessation 23,231 18,101 7,345 6,487 55,165 22.01 45.20 50.02 23.22 29.31
2 Complete switch to RRPs (HnBs) 16,617 13,670 5,649 5,000 40,936 15.74 34.14 38.47 17.89 21.75
3 Complete switch to RRPs (50% HnBs; 50% ECigs) 18,882 15,245 6,261 5,534 45,923 17.89 38.07 42.64 19.81 24.40
4 Conservative Scenario 3,476 3,089 1,369 1,169 9,104 3.29 7.71 9.32 4.19 4.84
5 Dynamic Scenario 5,605 4,934 2,141 1,859 14,540 5.31 12.32 14.58 6.66 7.72
6 Conversion Scenario 7,014 6,035 2,616 2,277 17,942 6.64 15.07 17.81 8.15 9.53
7 Full Conversion Scenario 7,530 6,404 2,783 2,424 19,140 7.13 15.99 18.95 8.67 10.17

Yearly transition probabilities (per million) in the Null Scenario for Germany.

Period (years) Initiation (PNC) Quitting (PCF) Re-initiation (PFC)
Age Men Women Men Women Men Women
1–5 10–14 50,351 40,762 28,960 17,309 13,903 8,308
15–19 67,051 77,814 46,165 82,605 22,164 39,653
20–24 8,903 35,760 16,045 58,582 7,701 28,119
25–29 6,699 8,653 24,172 37,175 11,602 17,840
30–34 2,637 4,288 30,186 30,128 14,495 14,459
35–39 0 0 26,610 9,641 12,765 4,634
40–44 0 0 23,808 18,902 11,424 3,080
45–49 0 0 27,218 19,232 9,796 1,559
50–54 0 0 36,677 25,626 5,291 1,032
55–59 0 0 40,739 33,146 2,912 684
60–64 0 0 40,265 40,970 1,427 420
65–69 0 0 55,101 26,610 960 264
70–74 0 0 90,546 223,260 684 192
75–79 0 0 90,546 223,260 684 192
6–10 10–14 42,977 35,249 24,477 26,200 11,756 12,575
15–19 63,577 60,793 57,559 83,602 27,628 40,127
20–24 6,174 23,515 11,626 60,079 5,578 28,832
25–29 14,672 11,436 38,461 51,426 18,454 24,676
30–34 3,953 5,649 35,122 29,264 16,860 14,045
35–39 0 0 22,246 10,770 10,675 5,172
40–44 0 0 20,917 25,907 9,558 3,104
45–49 0 0 27,066 27,745 7,200 1,667
50–54 0 0 43,070 31,795 5,172 960
55–59 0 0 48,060 32,086 2,888 684
60–64 0 0 46,430 39,282 2,529 420
65–69 0 0 67,962 47,417 1,858 252
70–74 0 0 55,785 177,670 1,367 180
75–79 0 0 55,785 177,670 1,367 180
11+ 10–14 34,053 24,583 21,858 42,274 10,497 20,281
15–19 64,469 54,133 72,396 106,963 34,750 51,335
20–24 3,869 9,165 6,914 53,403 3,319 25,626
25–29 22,974 13,772 57,718 70,086 27,698 33,646
30–34 5,948 6,783 42,366 24,888 20,328 11,946
35–39 0 0 17,321 11,079 8,308 5,315
40–44 0 0 18,489 36,711 7,152 4,407
45–49 0 0 30,676 35,749 4,574 2,792
50–54 0 0 49,103 35,458 3,678 2,170
55–59 0 0 54,714 28,960 2,050 1,655
60–64 0 0 51,438 32,040 1,954 876
65–69 0 0 87,902 27,523 1,631 492
70–74 0 0 18,737 63,915 432 372
75–79 0 0 18,737 63,915 684 192

The Alternative Scenarios.

Scenario Number Name Summary description and comments
Extreme Scenarios
1 Complete cessation In 1995, all current cigarette smokers immediately stop smoking. There is no further initiation or re-initiation of cigarettes, HnB, or ECig use.
2 Complete switch to RRPs (HnBs) In 1995, all current cigarette smokers immediately switch to HnBs. The subsequent initiation, re-initiation, and quitting rates are as in the Null Scenario, but only involve transfers in or out of HnBs.
3 Complete switch to RRPs (50% HnBs and 50% ECigs) In 1995, all current cigarette smokers immediately switch to either HnBs or ECigs with equal probability. The subsequent rates are as in the Null Scenario, but only involve transfers involving the new products.
Pragmatic Scenarios
HnB: The market share in 2005 is 9% of that in 1995 for cigarette smoking, with 67% exclusive users.ECig: The market share in 2005 is 27% of that in 1995 for cigarette smoking, with 40% exclusive users.The calculated target distributions for 2005 are:
Never Cig only HnB only ECig only Multiple use Former use
4 Conservative Scenario Men 35.46 24.22 2.28 4.09 7.25 26.70
Women 60.56 15.64 1.47 2.64 4.68 15.01
Note: Multiple (product) users currently use at least one of the three products, while former (product) users have used at least one of the products, but do not currently use an).
The sum of the TPs for initiation and the sum of the TPs for re-initiation are the same as that for the Null Scenario. Each quitting TP is as for the Null Scenario. The difference between the four Pragmatic Scenarios only relates to the rates of switching among the three products.
The market shares in 2005 increase to 15.5% for HnBs and 36.4% for ECigs. The proportions of exclusive users are as in the Conservative Scenario.The calculated target distributions for 2005 are:
Never Cig only HnB only ECig only Multiple use Former use
5 Dynamic Scenario Men 35.46 18.20 3.93 5.51 10.20 26.70
Women 60.56 11.75 2.54 3.56 6.59 15.01
The rates of switching from exclusive cigarette smoking are increased from those in the Conservative Scenario.
The same as the Dynamic Scenario, except that the proportions of exclusive users rise to 84% for both RRPs.The calculated target distributions for 2005 are:
6 Conversion Scenario Never Cig only HnB only ECig only Multiple use Former use
Men 35.46 18.20 4.93 11.57 3.14 26.70
Women 60.56 11.75 3.18 7.47 2.03 15.01
Relative to the Dynamic Scenario, all 12 possible rates of switching vary, except those of switching from exclusive use of one RRP to exclusive use of the other.
The same as the Dynamic Scenario, except that the proportions of exclusive users rise to 100% for both RRPs.The calculated target distributions for 2005 are:
7 Full Conversion Scenario Men 35.46 18.20 5.87 13.87 0.00 26.70
Women 60.56 11.75 3.79 8.89 0.00 15.01
The comment for the Conversion Scenario applies here as well.
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