RESEARCH AND PRACTICE
Application of a System Dynamics Model to Inform Investment
in Smoking Cessation Services in New Zealand
Martin I. Tobias, MBBCh, Robert Y. Cavana, PhD, and Ashley Bloomfield, MBChB, MPH
Tobacco use peaked in New Zealand around
1970. Smoking prevalence (daily plus non-
daily) among adults has since declined from
approximately 35% to 21%, and tobacco
consumption has fallen from approximately
3000 cigarette equivalents per person-year to
1000.1 For the past decade, smoking rates
among youths have declined yearly across all
social and ethnic groups.2 Nevertheless, tobacco
use remains the leading preventable cause of
mortality, accounting for almost 1 in 5 deaths
annually, or approximately 4200 from active
smoking and 300 from secondhand smoke
exposure in 2006.1
Clearly, much remains to be done, but New
Zealand already enjoys one of the world’s most
comprehensive tobacco control programs and
is compliant with the mandates of the World
Health Organization’s Framework Convention
on Tobacco Control, ratified in 2003.3 New
Zealand’s tobacco control program comprises
comprehensive legislation for smoke-free envi-
ronments, including restaurants and bars; taxes
on tobacco products amounting to approxi-
mately 70% of total price; a total advertising and
sponsorship ban (although retail tobacco displays
remain); a comprehensive countermarketing
strategy, including regular media campaigns; and
provision of smoking cessation services, includ-
ing a national telephone quit line and heavily
subsidized nicotine replacement therapy (NRT).3
The tobacco control program is supported
by a sophisticated monitoring program; since
2006, the government has conducted a dedi-
cated annual population-based survey, the New
Zealand Tobacco Use Survey (NZTUS).4 The
2006 NZTUS estimated that 44% of smokers
currently attempted to quit at least once each
year, although at least 70% said they would like
to quit. However, only 20% of quit attempts
were assisted, usually with NRT and multisession
behavioral support,5 limiting the likelihood of
long-term success. The survey thus identified
smoking cessation as an outstanding opportu-
nity for further improving tobacco control. A
1274 | Research and Practice | Peer Reviewed | Tobias et al.
Objectives. We estimated the long-term effects of smoking cessation in-
terventions to inform government decision-making regarding investment in
tobacco control.
Methods. We extracted data from the 2006 New Zealand Tobacco Use Survey
and other sources and developed a system dynamics model with the iThink
computer simulation package. The model derived estimates of population
cessation rates from smoking behaviors and applied these over a 50-year period,
from 2001 to 2051, under business-as-usual and enhanced cessation interven-
tion scenarios.
Results. The model predicted larger effects by 2051 with the enhanced
cessation than with the business-as-usual scenario, including: an 11% greater
decline in adult current smoking prevalence (9 versus 10 per 100 people), 16%
greater decline in per capita tobacco consumption (370 versus 440 cigarette
equivalents per year), and 11% greater reduction in tobacco-attributable mor-
tality (3000 versus 3300 deaths per year).
Conclusions. The model generated reliable estimates of the effects on health
and on tobacco use of interventions designed to enhance smoking cessation.
These results informed a decision announced in May 2007 to increase funding
for smoking cessation by NZ $42 million over 4 years. (Am J Public Health. 2010;
100:1274–1281. doi:10.2105/AJPH.2009.171165)
major increase in funding for cessation was smoking13; a Markovian computer simulation
announced by the government in its May 2007 model developed in the United States for ana-
budget.6 lyzing tobacco-related policies14–18; SimSmoke,
Tobacco use and control can be thought of a computer simulation model that assesses the
as a complex system containing emergent effects of a broad array of public policies related
properties, feedback loops, and nonlinear dy- to tobacco control19,20; dynamic modeling work
namics. Traditional epidemiological methods at the University of Michigan related to US
deal with complexity by breaking the issue tobacco policy and smoking objectives21–23; and
down into parts simple enough to be controlled a system dynamics study at the New Zealand
(randomized controlled trials) or observed Customs Service that analyzed public policy
(cohort or case–control studies). System dy- issues related to the collection of tobacco excise
namics, by contrast, deals with complexity by duties.24
abstracting the key elements of the system and We estimated the health effects of enhanced
simulating their dynamic interrelationships cessation with the assistance of a system dy-
(with multiple differential equations) over namics model,25 developed to guide the New
time.7–11 System dynamics is widely regarded Zealand tobacco control community in the for-
as a suitable method for analyzing complex mulation and evaluation of the dynamic conse-
tobacco policy issues and complex public health quences of tobacco control policies.
issues in general.12
Previous dynamic simulation studies related METHODS
to tobacco policy include system dynamics
modeling work at the Massachusetts Institute of The structure of our system dynamics model
Technology around 1980 on the effects of is shown in Figure 1; the model is fully described
American Journal of Public Health | July 2010, Vol 100, No. 7
 RESEARCH AND PRACTICE

elsewhere.25 We constructed the model with
the iThink software package version 9.0,26 and it
is available from M. I.T. or R. Y.C. The model
comprises a population aging chain that simu-
lates the New Zealand population over a 50-year
period (from 2001 to 2051) by age, period, and
cohort, stratified by smoking status.
The main input variables were smoking
initiation and net quit rates derived from the
2006 NZTUS5 and quitting effectiveness data
from a Cochrane review27; NZTUS data on
smoking intensity (which affects both tobacco
consumption and, after a 10-year delay, smoking
mortality hazard ratios); average tobacco weight
per factory-made and roll-your-own cigarette
and ratio of factory-made to roll-your-own ciga-
rettes smoked (all derived from the 2006
NZTUS); mortality hazard ratios for current
smokers (dependent on duration and intensity of
smoking), ex-smokers (dependent on elapsed
time since quitting), and nonsmokers exposed to
secondhand smoke (derived from the New Zea-
land Census–Mortality Study)28; and demo-
graphic data from Statistics New Zealand (in-
cluding fertility and household composition
data). We also included peer and parent feed-
back on smoking initiation by adolescents in the
model; we derived values for these parameters
from a national cross-sectional survey of year 10
(14-year-old) students.29 The main output vari-
ables were current smoking prevalence, tobacco
consumption, and tobacco-attributable mortality.
Calibrating and Testing the System
Dynamics Model
We subjected the model to appropriate
verification and validation tests.30 First, we
calibrated the model by checking that the base
case reproduced current prevalence (2001–
2004) by age, tobacco consumption, and tobacco
attributable-mortality; this process involved mi-
nor tweaking of initiation and quit rates.
We then checked the population projections
generated by the model to 2051 (4.89 million
people) against the national population pro-
jections published by Statistics New Zealand
(series 5, medium fertility, medium mortality,
10 000 per year net migration assumptions).31
We adjusted for net migration flows (5.48
million – 0.5 million =4.98 million), confirming
that our model was reflecting feasible population
dynamics and projections for New Zealand over
the simulation period (2001–2051).
We validated the model by verifying that (1)
the business-as-usual scenario (usual scenario)
reproduced recent trends in current smoking
prevalence, tobacco consumption, and tobacco-
attributable mortality; (2) prevalence increased
if relative risk of mortality related to smoking
decreased; (3) prevalence, consumption, and

Note. AS = adult smoker; R1 = peer feedback; R2 = parental feedback; XS = ex-smoker; YS = youth smoker. Boxes represent population stocks; arrows with valve symbols represent physical flows;
cloud symbols represent births and deaths; single-line arrows represent causal links; circles represent other factors and influences; hexagons indicate tobacco control policies. The actual model is
structured into 10-year age groups rather than in youths and adults. Tobacco control policies in general can influence smoking initiation rates and excess mortality risks, as well as quitting
behaviors and smoking intensity (the parameters affected by smoking cessation policies).
FIGURE 1—Causal structure of the New Zealand tobacco system dynamics model.

July 2010, Vol 100, No. 7 | American Journal of Public Health Tobias et al. | Peer Reviewed | Research and Practice | 1275

tobacco-attributable mortality behaved appro-
priately if initiation and quit rates changed; (4)
smoking prevalence among youths changed
appropriately if parental or peer feedback in-
fluences changed; and (5) mortality attribut-
able to secondhand smoke changed appropri-
ately if living arrangements changed.
These experiments and the structure of the
model were discussed extensively with subject
matter experts in New Zealand, lending the
model additional validity. In addition, the
policy and scenario experiments described in
our previous research demonstrated the val-
idity (and suitability) of the New Zealand
tobacco system dynamics model for policy
analysis.25 These policy experiments included
fiscal strategies involving less affordable ciga-
rettes (through raising the excise tax rate on
tobacco products), harm minimization strategies
involving either less addictive cigarettes or less
toxic cigarettes, and combinations of these strat-
egies.
New Zealand Tobacco Use Survey
The NZTUS is an annual survey, with the
first wave fielded in 2006. The survey uses
a stratified multistage design with an areal
(census meshblock) frame to generate a nation-
ally representative sample of youths and adults
aged 15 to 64 years. The final sample size
was 5703, corresponding to an overall res-
ponse rate of approximately 75.4%. The
questionnaire (derived from the Canadian To-
bacco Use Monitoring Survey instrument and
validated for the New Zealand population by
the University of Auckland) was administered
through computer-assisted personal interviews
by trained interviewers in the respondents’
own homes. The survey was approved by the
Multi Regional Ethics Committee. More detail
on the NZTUS is reported elsewhere.5
In the New Zealand tobacco system dy-
namics model, net quit rates were provided for
each age group (i.e., cessation rate minus re-
lapse rate). The population actual cessation (net
quit) rate (Q) depended on the proportion of
smokers who made 1 or more quit attempts per
year (C), defined as abstaining for a week or
more; the proportion of quit attempts that were
assisted (A), defined as multisession behavioral
support plus NRT, bupropion, or varenicline;
and the proportion of quitters who relapsed (R),
defined as less than 6 months of abstinence.
1276 | Research and Practice | Peer Reviewed | Tobias et al.
RESEARCH AND PRACTICE
We further defined the short-term unassisted
quitting success rate as S and the rate ratio
Sassisted/Sunassisted as E.
Figure 2 shows that
ð1Þ Q ¼ ½C  A  E  S  ð12RÞ
1 ½C  ð12AÞ  S  ð12RÞ:
Simplifying equation 1 yielded the following
model for Q:
ð2Þ Q ¼ C  S  ð12RÞ  ½A  ðE21Þ 1 1:
Age-specific population cessation (net quit)
rates could then be estimated with equation 2,
taking age-specific estimates for quitting and
relapsing behaviors (C, A, and R) from surveys,
along with values for short-term unassisted
quitting success rate and effectiveness of as-
sistance from randomized controlled trials.
Feasible change in quitting behaviors. A review
of what other countries, in particular the United
States, had already achieved suggested that
a feasible change in quit attempts (proportion
of smokers making at least 1 quit attempt per
year) for New Zealand would be an approxi-
mately 14% increase, that is, from 44% to
50%.32 The US experience also indicated that
the proportion of quit attempts that were assisted
could be increased by approximately 36% in
Note. C = proportion of smokers who made 1 or more quit attempts per year; A = proportion of quit attempts that were
assisted; R = proportion of quitters who relapsed; S = short-term unassisted quitting success rate; E = rate ratio Sassisted/
Sunassisted.
FIGURE 2—Smoking cessation tree diagram.
American Journal of Public Health | July 2010, Vol 100, No. 7
New Zealand, from 22% to 30%. Both these
changes should be achievable within 5 years of
implementation, allowing for both administrative
and behavioral lags.
Although the evidence for effectiveness of
relapse prevention is unclear, a decline in the
proportion of quitters who relapse within 6
months from 48% to 45% over a 5-year period
would be feasible, if long-term use of NRT and
varenicline was permitted (and subsidized)
and if visual cues relating to smoking (e.g.,
visibility of cigarette displays in retail outlets)
were reduced.33
Although effectiveness of assistance could
increase (from 2.0 to perhaps 3.0) with wider
use of varenicline in combination with NRT or
through discovery of new drugs, over a rela-
tively short simulation horizon we assumed the
ratio of assisted to unassisted quit attempts to
be stable at 2.0 (assistance doubles the chance
of successfully quitting, at least in the short
term). Similarly, we held the unassisted quitting
success rate stable at 0.07 (7% of quit attempts
are successful in the short term, without assis-
tance).27 The recalculated rate for the net quit
rates in equation 2 implied that the population
cessation (net quit) rate at each age would
increase by approximately 25% if these changes
in quitting and relapsing behaviors took place.

Feasible change in smoking intensity. Cessa-
tion enhancement policies can be expected to
affect smoking intensity as well as the net quit
rate. That is, in response to the intervention,
some current smokers may cut down rather
than quit altogether. In the absence of relevant
data from the NZTUS or other New Zealand
sources, we estimated from US studies that
average smoking intensity could decline by up
to 5% within 5 years of program implementa-
tion.34
Simulations
For the usual scenario, we assumed a con-
tinuing decline in initiation rates of 2% per
year and an increase in population smoking
cessation rates (net quit rates) at all ages of
1% per year from the base year (2001); we
based these assumptions on historical trends
in smoking prevalence and limited survey
evidence of trends in these rates.1 Average
smoking intensity was assumed to remain
stable at 12 cigarette equivalents per day; we
derived this base year estimate from survey data1
and Statistics New Zealand annual tobacco
returns.
The proposed intervention package aims to
trigger quit attempts through a media campaign
and by further reducing cigarette affordability
(including equalizing the excise tax on roll-
your-own and factory-made cigarettes); to in-
crease the chances of short-term quitting suc-
cess by widening access to NRT, bupropion,
and varenicline, to be achieved by extending
the national quit line and by improving smok-
ing cessation services in the primary health
care setting through training and incentives;
and to reduce the risk of late relapse through
provision of long-term NRT and varenicline
and by reducing cues that could trigger relapse,
for example, by promoting establishment of
more healthy environments, such as smoke-
free homes and cars, and by reducing visibility
of cigarette displays in retail outlets.
For the enhanced cessation scenario, we
assumed that initiation rates would be un-
affected at first (they should fall later as
a result of peer group and parent feedback
loops), but more smokers would quit as a re-
sult of the intervention and others would cut
down. We further assumed that the incre-
mental effect on net quit rates and on smok-
ing intensity would begin in 2011 (3 years
July 2010, Vol 100, No. 7 | American Journal of Public Health
RESEARCH AND PRACTICE
after introduction of the policy) and progress
steadily to reach full effect by 2016, reflecting
both administrative delays in implementing
the intervention package and behavioral re-
sponse lags, after which the rates of change in
these parameters would revert to those in the
usual scenario.
We entered into the model the net quit rates
shown in equation 2, derived from our as-
sumptions about feasible changes in quit at-
tempts, proportion of assisted attempts, and
relapse rates, which yielded an average annual
percentage change of 5% in net quit rates at all
ages during the peak change years of 2011 to
2016 (in the usual scenario, the change would
be only 1%). Calculations taking into account
our assumptions about the impact of the in-
tervention on average smoking intensity per
smoker predicted a 1% average annual reduc-
tion in smoking intensity during the same
period (i.e., from 12 cigarette equivalents per
day in 2011 to 11.4 cigarette equivalents per
day in 2016).
Sensitivity Tests
Because several behavioral parameters in
the model were estimated with less certainty
than we could achieve with the demographic
and other epidemiological parameters, we
conducted multivariate sensitivity analysis
with these parameters: initial smoking initia-
tion rate, peer and adult feedback effects on
initiation, and initial net quit rates for each age
group.
We changed the base case values of these
parameters by plus or minus 10% to represent
the range of uncertainty in these estimates. We
constructed an optimistic case by changing all
the behavioral parameters in a favorable di-
rection (which would result in lower future
smoking prevalence in New Zealand) and
a pessimistic case by changing all these pa-
rameters simultaneously in an unfavorable di-
rection. We then simulated the model for both
the usual scenario and enhanced cessation
scenario under the base, optimistic, and pessi-
mistic cases.
RESULTS
Our model was relatively insensitive to
variation in behavioral parameter values
through their plausible ranges (Table 1). For
Tobias et al. | Peer Reviewed | Research and Practice | 1277
example, by the simulation horizon (2051),
smoking prevalence under the usual scenario
was projected to be 8.1% (optimistic case),
10.1% (base case), and 11.9% (pessimistic
case), a range of approximately 40%. We
found similar ranges for the enhanced cessa-
tion scenario and for all main model output
variables.
Smoking Prevalence and Per Capita
Tobacco Consumption
Current smoking prevalence (daily plus
nondaily) was predicted to decline over the
simulation period under both the usual and
enhanced cessation scenarios (Figure 3).
However, the rate of decline would be faster
with the intervention, reflecting higher net
quit rates. The sensitivity analysis indicated
that smoking prevalence by the end of the
simulation horizon (2051) under the usual
scenario is likely to be in the range of 8% to
12%, with a base case estimate of 9%. The
range would be 7% to 11% under the en-
hanced cessation scenario (Table 1). In each
case, prevalence would be approximately 11%
lower under the enhanced cessation than the
under the usual scenario by the simulation
horizon.
The difference between the usual and
enhanced cessation scenarios was predicted
to be greater for per capita tobacco con-
sumption than for prevalence, reflecting the
assumption that some smokers will cut down
(reduce smoking intensity) and others will
quit (Figure 3). By 2051, per capita tobacco
consumption was projected to be approxi-
mately 15% to 17% lower under the en-
hanced cessation scenario (290–440 ciga-
rette equivalents per year) than under the
usual scenario (360–520 cigarette equiva-
lents per year). The base case estimate was
approximately 370 cigarette equivalents per
year for the enhanced cessation scenario and
440 cigarette equivalents per year for the
usual scenario.
Tobacco-Attributable Mortality
The absolute burden of excess mortality
attributable to tobacco use reflects both
smoking behavior patterns and demographic
forces affecting the size and age structure of
the population. Under the usual scenario, this
burden would initially increase and then fall
 RESEARCH AND PRACTICE

TABLE 1—Key Projections of the New Zealand Tobacco Policy Model for the Business-as-Usual and Enhanced
Cessation Scenarios for 2001–2051

Smoking Prevalence Tobacco Consumption Tobacco-Attributable Mortality

Rate, No./100 Per Capita, Cigarette Total, Rate, No./100 000
Year Scenario People or % No. or % Equivalents/Year or % Tons/Year or % People or % No./Year or %

Base casea
2001 Initial values 22.7 744 000 996 3 259 110 4 260
2006 Business as usual 21.8 739 000 955 3 239 113 4 537
2011 Business as usual 20.7 721 000 905 3 160 112 4 616

2031 Business as usual 14.8 576 000 648 2 524 88 3 971

Enhanced cessation 13.8 538 000 575 2 240 81 3 684
Difference 1.0 38 73 284 7.0 287
Percentage difference 6.8% 6.6% 11.3% 11.3% 8.0% 7.2%

2051 Business as usual 10.1 431 000 443 1 887 68 3 338

Enhanced cessation 9.0 383 000 374 1 594 60 2 964
Difference 1.1 38 69 293 8.0 374
Percentage difference 10.9% 6.6% 15.6% 15.5% 11.8% 11.2%

Optimistic caseb
2031 Business as usual 12.8 500 000 562 2 192 83 3 776
Enhanced cessation 11.6 454 000 485 1 891 76 3 441
Difference 1.2 38 77 301 7.0 335
Percentage difference 9.4% 6.6% 13.7% 13.7% 8.4% 8.9%

2051 Business as usual 8.1 346 000 356 1 518 64 3 115

Enhanced cessation 7.1 302 000 294 1 256 55 2 709
Difference 1.0 38 62 262 9.0 406
Percentage difference 12.3% 6.6% 17.4% 17.3% 14.1% 13.0%

Pessimistic casec
2031 Business as usual 16.5 642 000 723 2 812 92 4 170
Enhanced cessation 15.3 597 000 638 2 484 84 3 814
Difference 1.2 38 85 328 8.0 356
Percentage difference 7.3% 6.6% 11.8% 11.7% 8.7% 8.5%

2051 Business as usual 11.9 504 000 520 2 209 73 3 582

Enhanced cessation 10.6 450 000 440 1 873 64 3 151
Difference 1.3 38 80 336 9.0 431
Percentage difference 10.9% 6.6% 15.4% 15.2% 12.3% 12.0%

Note. The business-as-usual scenario reproduced recent trends in current smoking prevalence, tobacco consumption, and tobacco-attributable mortality. The enhanced cessation scenario
estimated the effects of a proposed intervention package aiming to trigger more quit attempts, and increase short- and long-term quitting success rates.
a
Smoking prevalence in 2001 to 2004.
b
All behavioral parameters were changed to be 10% more favorable (e.g., greater decrease in smoking prevalence).
c
All behavioral parameters were changed to be 10% less favorable (e.g., smaller decrease in smoking prevalence).

slowly. Under the enhanced cessation sce- combined effects of quitting and cutting 3580 (for both active and passive smoking
nario, the early rise would be the same as in down. effects) under the usual scenario. However,
the usual scenario, but the subsequent decline By 2051, the annual tobacco death toll was under the enhanced cessation scenario, the
would be greater (Figure 3), reflecting the projected to decline to between 3120 and reduction would be greater—to between 2710

1278 | Research and Practice | Peer Reviewed | Tobias et al. American Journal of Public Health | July 2010, Vol 100, No. 7

Note. The base case represents smoking prevalence in 2001 to 2004.
FIGURE 3—New Zealand tobacco system dynamics model base case projections for
business-as-usual (BAU) and enhanced cessation (EC) simulations for (a) smoking
prevalence, (b) per-capita tobacco consumption, and (c) tobacco attributable mortality
count: 2001–2051.
and 3150 deaths per year. The base case
estimate was approximately 3340 for the usual
scenario and approximately 3000 for the
enhanced cessation intervention, an 11% dif-
ference.
The cumulative saving in lives over the
35 years following full implementation of
the intervention (i.e., 2016–2051) was pro-
jected to be approximately 9000 lives, or an
average of approximately 260 fewer deaths
per year. The reduction in excess mortality
would begin almost immediately, although
few deaths would be avoided in the first few
July 2010, Vol 100, No. 7 | American Journal of Public Health
RESEARCH AND PRACTICE
years. Annual deaths avoided would total
nearly 300 after 15 years and approximately
350 after 20 years. Thereafter, this figure
would stabilize at approximately 350 to 370
per year.
DISCUSSION
Our model estimated that an enhanced
cessation package could have substantial ef-
fects on tobacco use and associated harms.
The main focus of the intervention should be
on increasing quit attempts, rather than on
Tobias et al. | Peer Reviewed | Research and Practice | 1279
increasing the proportion of attempts that are
NRT assisted, because the former has much
greater impact on population cessation rates
than does the latter (as can be seen by
substituting numerical values for the parame-
ters in equation 2). Hence, the modeled
intervention aimed primarily at increasing
the quit attempt rate and secondarily at in-
creasing the proportion of quit attempts that
are assisted and at reducing late relapses. We
also modeled anticipated effects on smoking
intensity.
In total, the model estimated that feasible
changes in quitting behaviors and smoking
intensity (in response to the intervention) could
reduce tobacco-attributable mortality by up to
11% more than under business-as-usual con-
ditions within 35 years. This corresponds to an
(additional) annual average saving of approxi-
mately 200 lives per year during the first 20
years after implementation, with more than
350 deaths avoided per year by 2051. The
reduced mortality projected for the enhanced
cessation scenario represents a health impact
almost equivalent to the current annual road
death toll in New Zealand (approximately 400
road traffic deaths per year on average in the
middle of the first decade of this century).
The effect on smoking prevalence would be
similar (approximately 11%–12% fewer adult
daily and nondaily smokers than under the
usual scenario by the simulation horizon),
and per capita tobacco consumption declines
would be relatively larger (approximately
15%–17%), reflecting the combined effect of
quitting and cutting down.
Limitations
Our model was carefully calibrated to ensure
that it reproduced New Zealand tobacco epi-
demiology and was validated with a range of
system dynamics tests (e.g., whether the model
responded appropriately as different input
parameter values were changed) and by having
the model’s structure and parameters carefully
reviewed by subject matter experts. Neverthe-
less, our model—like any model—had several
limitations. In particular, the model was age
structured but not differentiated by gender,
ethnicity, or socioeconomic position, so social
inequalities (other than age and cohort differ-
ences) in response to the enhanced cessation
intervention could not be investigated. Health

effects were captured by mortality only and so
were not comprehensive.
Our model did not include net migration
flows, because these are only a small propor-
tion of total population and are difficult to
predict. The model as currently structured also
did not capture all relevant dimensions of
industry behavior or tobacco control. Finally,
New Zealand data could not be found for
some model parameters, necessitating use of
data derived from other (albeit similar) popu-
lations.
In addition to these limitations of the model
and data, the estimates were also affected by
our assumptions about the effectiveness and
coverage of the planned intervention and the
dynamics of the usual scenario. Enhancement
of other aspects of the tobacco control pro-
gram is ongoing, including consideration of
new regulatory measures, such as banning
retail tobacco displays and retailer licensing.
This source of uncertainty could be addressed
by further sensitivity analysis. Instead we
chose to model only 1 intervention and 1 usual
scenario (under optimistic, base case, and
pessimistic assumptions); we considered these
the most likely, at least in the short term.
This approach is more comprehensible for
policymakers who may act on the model’s
projections, and it reflects the reality that it is
not the accuracy of either scenario that mat-
ters in absolute terms, but rather the differ-
ence between them. However, because the
assumptions are fully transparent, different
scenarios can easily be run to test the potential
impact of new or enhanced tobacco control
measures.
Conclusions
Our model generated reasonably reliable
estimates of the impact on health and on
tobacco use of interventions designed to en-
hance smoking cessation. The results were
used by 1 author (A. B.) during the 2007
annual government budget process to provide
supporting evidence for a cabinet paper pro-
posing additional investment in cessation ser-
vices in New Zealand. The government de-
cided to invest an additional NZ $42 million in
smoking cessation services over 4 years from
July 2007, representing a 30% increase in the
annual budget for tobacco control over this
period.
1280 | Research and Practice | Peer Reviewed | Tobias et al.
RESEARCH AND PRACTICE
Our simulation represents a relatively sim-
ple and straightforward application of the
model; it involved exogenous change in only 2
model parameters (quit rates and smoking
intensity) in response to policy changes. Other
behavioral change estimates, such as reduc-
tions in adolescent smoking initiation rates,
were based on feedback processes built into
the model. The full value of system dynamics
models, however, is revealed when multiple
interventions affecting multiple model pa-
rameters are simulated.
Our relatively simple application of the
model has served to increase awareness
among policymakers of the dynamics of to-
bacco control. It also illustrated for policy-
makers how data (estimates) from a survey can
be entered into a mathematical model to
generate projections that can guide policy. The
model is now available to support tobacco
control policy in New Zealand by providing
a learning experience for policy advisers and
epidemiologists; helping to frame and evaluate
policy options; and identifying where data
collection systems may need to be enhanced to
provide key empirical data required to run
policy experiments in the virtual world of the
model. j
About the Authors
Martin I. Tobias and Ashley Bloomfield are with the New
Zealand Ministry of Health, Wellington. Robert Y. Cavana
is with the Victoria Management School, Victoria Univer-
sity of Wellington.
Correspondence should be sent to Martin I. Tobias,
Ministry of Health, PO Box 5013, Wellington, New
Zealand (e-mail: martin_tobias@moh.govt.nz). Reprints
can be ordered at http://www.ajph.org by clicking on the
‘‘Reprints/Eprints’’ link.
This article was accepted November 17, 2009.
Contributors
M. I. Tobias contributed to originating and designing the
study, building the system dynamics model, deriving the
data to run the model, and drafting and revising the
article. R. Y. Cavana contributed to the study design, led
the building of the model, and contributed to drafting
and revising the article. A. Bloomfield contributed to
originating and designing the study, interpreting the
model output, and revising the article.
Acknowledgments
We appreciate the assistance of Emmanuel Jo, Ministry of
Health, with the smoking intensity equations and Li-Chia
Yeh, Ministry of Health, with survey data for the
parameters in the model. We also acknowledge the very
useful comments from 2 anonymous reviewers.
American Journal of Public Health | July 2010, Vol 100, No. 7
Note. This article is published with the approval of the
deputy director-general of health, Health and Disability
Systems Strategy Directorate, New Zealand Ministry of
Health. However, opinions expressed are ours and do not
necessarily reflect the policy advice of the ministry.
Human Participant Protection
No protocol approval was needed for this study because
only secondary data were used.
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