TCORS: Center for the Assessment of Tobacco Regulations (CAsToR)

Research Project 3: Modeling the Impact of Tobacco Control Policies on Polytobacco Use and Associated Health Disparities

The tobacco market has become increasingly complex over the past decade, with new products recently introduced and others on the horizon. The increasing diversity of products will change the way people use tobacco and other nicotine-containing substances, including new combinations of polytobacco users. Little is known about how the evolving tobacco marketplace will shape the patterns of individual- and poly-tobacco use, their subsequent long-term health effects, and potential disparities by socioeconomic status (SES) and race/ethnicity. Because many products, including e-cigarettes, have only recently entered the market, long- term health outcome studies have not yet been conducted. In lieu of waiting decades for such data, simulation modeling can predict future health outcomes and provide insights into how different policies and regulations may affect disparities in consumption of polytobacco use and downstream health outcomes. Results from Aims 1 and 2 will provide evidence-based and expert-informed estimates of polytobacco use, potential policy impacts, and health outcomes by SES and race/ethnicity to inform the modeling in Aims 3 and 4, which will directly address disparities in long-term health consequences and policy impacts. Knowledge gained from this study will guide policy-makers’ decisions regarding which potential policies may be most effective in reducing downstream tobacco-related health disparities due to polytobacco use over time.


  • Aim 1: To determine disparities in polytobacco use by SES and race/ethnicity and to monitor changes over time in consumption patterns
  • Aim 2: To estimate the impact of tobacco control policies on patterns of tobacco and nicotine product use by SES and race/ethnicity
  • Aim 3: To determine downstream tobacco-related health disparities in all-cause mortality, cardiovascular mortality, and other health outcomes associated with individual- and poly-tobacco use
  • Aim 4: To model the impact of potential policies on tobacco-related health disparities associated with individual- and poly-tobacco use


  • Nancy Fleischer, PhD, MPH
    Nancy Fleischer, PhD, MPH
    University of Michigan
    Nancy Fleischer, PhD, MPH
    University of Michigan: Associate Professor of Epidemiology
    Position: Project Lead, Research Project 3 under TCORS 2.0
    Role: Co-Investigator
    Dr. Nancy Fleischer is Project Lead for Research Project 3 under TCORS 2.0 and a member of the CAsToR Steering Committee. Dr. Fleischer is an Associate Professor of Epidemiology at the University of Michigan. She is a social epidemiologist, whose research examines how the broader social and policy environments affect health and health disparities in the U.S. and around the world. Much of her research focuses on the role of tobacco control policies on health equity, including smoking behaviors, polytobacco use, and downstream health outcomes. More broadly, Dr. Fleischer is interested in the growing burden of non-communicable diseases globally, and the role tobacco plays in that growth.
  • David Levy, PhD
    David Levy, PhD
    Georgetown University
    David Levy, PhD
    Georgetown University: Professor, Georgetown University Medical Center
    Positions: Administrative (ADMIN) Core; CAsToR Principal Investigator; Research Project 1; Research Project 3
    Dr. David Levy is PI for CAsToR at Georgetown University. Dr. Levy received his PhD in Economics from UCLA (USA), and is currently a Professor of Oncology at Georgetown University. He has published over 250 articles, in renowned journals such as the American Economic Review, BMJ, AJPH, JAMA, The Lancet, Tobacco Control, and PLOS Medicine. He has been principal investigator of grants from the CDC, WHO, the National Cancer Institute, and Bloomberg/Gates Foundation. Dr. Levy currently oversees the design and development of the SimSmoke tobacco policy simulation model, for which he has developed models for over 40 countries covering 85% of the world’s population, and has recently developed models of smokeless tobacco and e-cigarette use. In addition to being a principal investigator on the TCORS grant, he is currently a principal investor on a National Cancer Institute grant with the International Tobacco Control Policy Evaluation Project (the ITC Project) in which he has developed models of e-cigarette use for Canada, England and France; and is a principal investigator on the National Cancer Institute CISNET Lung Group. He has recently published articles providing a public health framework for evaluating e-cigarettes and showing the potential benefits of e-cigarettes, as well as papers on the cigarette and e-cigarette markets.