# Development and validation of the Tobacco Use Individual-level Simulation and Tracking (TwIST) Model

## TL;DR

The TwIST Model simulates tobacco use in the US and predicts future smoking rates, showing that disparities and menthol cigarette use will persist.

## Contribution

The TwIST Model introduces an individual-based simulation for tracking tobacco use trends and disparities in the US adult population.

## Key findings

- Cigarette smoking rates are projected to decline from 12.4% in 2020 to 8.7% in 2050.
- Poverty is associated with 2.1–2.3 times higher smoking rates compared to those above the poverty line.
- Menthol cigarette use declines more slowly than non-menthol use, with a 21% vs. 38% reduction.

## Abstract

Simulation models of tobacco use behavior are useful analytic tools for projecting rates of tobacco use over time and identifying priority areas for intervention. This paper presents the Tobacco Use Individual-level Simulation and Tracking (TwIST) Model, an individual-based simulation model of tobacco use in the adult US population. We describe the model structure, data sources and parameters, and, in addition to future projections, compare modeled estimates of smoking prevalence to those from established surveys. The simulated population and model parameter estimates are informed by the Population Assessment of Tobacco and Health Study and other nationally representative datasets. To simulate tobacco use over time, we estimated 2nd order Markov models using multinomial logistic regression. To validate the model, we compared model estimates of tobacco use to data from three national surveys. The model estimates adult cigarette smoking rates will decline from a prevalence of 12.4% (95% uncertainty interval (95% UI): 12.2–12.8%) in 2020 to 9.6% (95% UI: 9.3–9.9%), 9.1% (95% UI: 8.9–9.4%), and 8.7% (95% UI: 8.5–9.0%) in 2030, 2040, and 2050, respectively. From 2020 through 2050, adults living in poverty are estimated to have a cigarette smoking rate 2.1–2.3 times higher than individuals living above the poverty line. The prevalence of menthol cigarette use will decline at a slower rate than the prevalence of non-menthol cigarette use (21% vs. 38% decline). Model projections of cigarette smoking prevalence typically fall within the 95% confidence intervals of prevalence estimates across three national surveys. Overall, the TwIST Model projects cigarette smoking prevalence rates that are similar to real-world estimates. If tobacco use continues based on current patterns, income-based disparities in smoking will persist and a growing proportion of individuals who smoke will use menthol cigarettes, which are known to be harder to quit.