title: The Brazil SimSmoke policy simulation model: the effect of strong tobacco control policies on smoking prevalence and smoking-attributable deaths in a middle income nation.
abstract: BACKGROUND
  Brazil has reduced its smoking rate by about 50% in the last 20 y. During that time period, strong tobacco control policies were implemented. This paper estimates the effect of these stricter policies on smoking prevalence and associated premature mortality, and the effect that additional policies may have.
  
  
  RESULTS
  The model was developed using the SimSmoke tobacco control policy model. Using policy, population, and smoking data for Brazil, the model assesses the effect on premature deaths of cigarette taxes, smoke-free air laws, mass media campaigns, marketing restrictions, packaging requirements, cessation treatment programs, and youth access restrictions. We estimate the effect of past policies relative to a counterfactual of policies kept to 1989 levels, and the effect of stricter future policies. Male and female smoking prevalence in Brazil have fallen by about half since 1989, which represents a 46% (lower and upper bounds: 28%-66%) relative reduction compared to the 2010 prevalence under the counterfactual scenario of policies held to 1989 levels. Almost half of that 46% reduction is explained by price increases, 14% by smoke-free air laws, 14% by marketing restrictions, 8% by health warnings, 6% by mass media campaigns, and 10% by cessation treatment programs. As a result of the past policies, a total of almost 420,000 (260,000-715,000) deaths had been averted by 2010, increasing to almost 7 million (4.5 million-10.3 million) deaths projected by 2050. Comparing future implementation of a set of stricter policies to a scenario with 2010 policies held constant, smoking prevalence by 2050 could be reduced by another 39% (29%-54%), and 1.3 million (0.9 million-2.0 million) out of 9 million future premature deaths could be averted.
  
  
  CONCLUSIONS
  Brazil provides one of the outstanding public health success stories in reducing deaths due to smoking, and serves as a model for other low and middle income nations. However, a set of stricter policies could further reduce smoking and save many additional lives. Please see later in the article for the Editors' Summary.
authors.affiliation: Population Sciences, Department of Oncology, Georgetown University, Washington DC, USA. dl777@georgetown.edu
authors.forename: David
authors.initials: D
authors.lastname: Levy
authors.forename: Liz Maria
authors.initials: LM
authors.lastname: de Almeida
authors.forename: Andre
authors.initials: A
authors.lastname: Szklo
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001938:Brazil / Q000453:epidemiology; D003198:Computer Simulation; D005260:Female; D033161:Government Regulation; D006291:Health Policy / Q000331:legislation & jurisprudence*; D006801:Humans; D008297:Male; D008875:Middle Aged; D008962:Models, Theoretical; D061213:Mortality, Premature; D015995:Prevalence; D012621:Seasons; D012907:Smoking / Q000009:adverse effects / Q000453:epidemiology* / Q000331:legislation & jurisprudence* / Q000639:trends; D055815:Young Adult