The Impact of Restricting U.S. Cigarette Sales to State-Controlled Outlets on Tobacco-Related Mortality

INTRODUCTION: Smoking rates have declined markedly over the past several decades prompting discussion about new strategies to reach an "endgame" in tobacco control. An innovative endgame strategy is restricting cigarette sales to state-controlled outlets to reduce availability of cigarettes. In this study we estimate the impact of restricting cigarette sales to state-controlled outlets on tobacco-related mortality in four US states, Oregon, Pennsylvania, Vermont, and Virginia. METHODS: In each state, we used Monte Carlo simulation with repeated random sampling to estimate the number of reduced deaths over a 20-year period due to reduced cigarette consumption after cigarette sales are restricted to state-controlled outlets. Model estimates were informed by data on the number of annual deaths due to cigarette smoking from the Global Burden of Disease Study and estimates about sales, a proxy for consumption, and mortality risk from the literature. RESULTS: We estimated that over a 20-year period 366 (95% uncertainty interval [UI]: 169, 652), 1585 (95% UI: 735, 2773), 74 (95% UI: 34, 127), and 1064 (95% UI: 501, 1806) deaths due to cigarette smoking would be avoided in Oregon, Pennsylvania, Vermont and Virginia, respectively. CONCLUSIONS: Transitioning cigarette sales to state-controlled outlets appears to be a potent tobacco control strategy that may reduce tobacco-related mortality. Policy impact on mortality may be even greater if cigarette smoking prevalence is reduced more than we estimated. To reach an endgame, states should prioritize more aggressive tobacco control policies that limit the availability of cigarettes.