Effects of tobacco taxation and pricing on smoking behavior in high risk populations: a knowledge synthesis

A Scoping Review of Foci, Trends, and Gaps in Reviews of Tobacco Control Research

INTRODUCTION

The burden of disease associated with tobacco use has prompted a substantial increase in tobacco-related research, but the breadth of this literature has not been comprehensively examined. This review examines the nature of the research addressing the action areas in World Health Organization's Framework Convention on Tobacco Control (FCTC), the populations targeted and how equity-related concepts are integrated.

METHOD

A scoping review of published reviews addressing tobacco control within the primary prevention domain. We searched PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Educational Resources Information Centre, and PsycInfo from 2004 to 2018.

RESULTS

The scoping review of reviews offered a "birds-eye-view" of the tobacco control literature. Within the 681 reviews meeting inclusion criteria, there was a strong focus on smoking cessation targeting individuals; less attention has been given to product regulation, packaging, and labeling or sales to minors. Equity-related concepts were addressed in 167/681 (24.5%); few were focused on addressing inequity through structural and systemic root causes.

CONCLUSION

This analysis of foci, trends, and gaps in the research pursuant to the FCTC illustrated the particular action areas and populations most frequently addressed in tobacco control research. Further research is needed to address: (1) underlying social influences, (2) particular action areas and with specific populations, and (3) sustained tobacco use through the influence of novel marketing and product innovations by tobacco industry.

IMPLICATIONS

This scoping review of the breadth of tobacco control research reviews enables a better understanding of which action areas and target populations have been addressed in the research. Our findings alongside recommendations from other reviews suggest prioritizing further research to support policymaking and considering the role of the tobacco industry in circumventing tobacco control efforts. The large amount of research targeting individual cessation would suggest there is a need to move beyond a focus on individual choice and decontextualized behaviors. Also, given the majority of reviews that simply recognize or describe disparity, further research that integrates equity and targets various forms of social exclusion and discrimination is needed and may benefit from working in collaboration with communities where programs can be tailored to need and context.

Smoker motivations and predictors of smoking cessation: lessons from an inpatient smoking cessation programme

INTRODUCTION

Our study aimed to review the quit rates of smokers from our inpatient smoking cessation programme in relation to habits and sociodemographic factors, and also to explore the potential usefulness of electronic cigarettes (ECs) by reviewing smoking motivations.

METHODS

This was a retrospective study of patients recruited into our inpatient smoking cessation programme from June 2008 to June 2015. Sociodemographic factors and information on smoking habits were collected using a counsellor-administered questionnaire. Patients were given intensive counselling followed by a phone interview at one, three and six months to assess smoking status.

RESULTS

A total of 2,722 patients were enrolled. 27.6% of patients were abstinent at six months' follow-up. Patients who quit smoking were older, married, initiated smoking at a later age and had lower Fagerström Test for Nicotine Dependence scores. There was a trend towards successful quitting in those with higher education levels and Chinese ethnicity, but this was not statistically significant. Patients who planned to quit cold turkey and those who quit because of social pressures were more successful. Of the smoking motivations, only nicotine dependence was an independent predictor of smoking cessation.

CONCLUSION

Smoking motivations such as habitual use and psychological dependence did not influence quit rates and therefore do not support the use of ECs. Instead, a cold turkey method of quitting was shown in our study to contribute to cessation success. We recommend an increased focus on the use of pharmacologic aids as well as involvement of peer/spousal support to aid in such quit attempts.

Impact of tobacco control interventions on smoking initiation, cessation, and prevalence: a systematic review

This article investigates the effects of tobacco control policies on smoking initiation, cessation and prevalence by examining the papers published in the last 5 years. Twenty-one articles have been selected by two authors and sorted by four types of tobacco control: tobacco prices, anti-smoking campaigns for young people, mass media intervention and public smoking bans. Price/tax increase has deterrent effect on smoking initiation but does not promote smoking cessation; intervention on young people could reduce the smoking initiation if carried out at an early age and if acted on social skills and with peer-led approach, as opposed to restraining measures which hare generally easily circumvented by young people. The mass media campaigns showed positive effect on attempts to quit among smokers if carried forward over time and by involving multiple communication channels (TV, internet, radio). The bans in public have little effect on smoking cessation but could improve the overall well-being of non-smokers. Heterogeneous results have been described by different studies probably because of different research methodologies, cultural aspects and the really effective implementation of the rules for each country. In conclusion, comprehensive tobacco control interventions to reduce smoking prevalence and modify the smoking behavior are recommended. Moreover, the use of e-cigarettes and heat-not-burn (HnB) products, as possible helping tool for smoke cessation, currently remains controversial.

Public Policy to Promote Healthy Cardiovascular Lifestyles in Children

Health policy is an important component of prevention of cardiovascular disease (CVD) and promotion of health in childhood and adolescence, when major health behaviours are formed. Development of CVD-related health policy begins with continuous systematic collection, analysis, and interpretation of health-related data to establish the baseline prevalence of CV risk factors and behaviours. These findings allow identification of problems, initiation of focused research, and development of evidence-based interventions. Ultimately, these results inform development and implementation of population-level policies. This review focuses on CVD health-promotion policies in North American youth, for whom health surveillance is an ongoing part of public health policy, providing direct, objective, measurements of growth, lipids, blood pressure, physical activity and tobacco exposure for development of CV health research and policy. When national surveillance data identified significant risk of CVD in youth in the 1970s, major pediatric epidemiologic studies established the strong association between these risk factors and behaviours in childhood and the initiation and progression of atherosclerosis. This knowledge promoted development of the targeted public policies, which are reviewed in this paper. Public policy can directly and positively address cardiovascular health promotion in youth; the effective approach to smoking cessation exemplifies this. For more complex risk factors and behaviours, health policy can be a significant element in a comprehensive CV health promotion program.

CIGARETTE TAXES AND TEEN MARIJUANA USE

The spillover effect of cigarette taxes on youth marijuana use has been the subject of intense public debate. Opponents of cigarette taxes warn that tax hikes will cause youths to substitute toward marijuana. On the other hand, public health experts often claim that because tobacco is a "gateway" drug, higher cigarette taxes will deter youth marijuana use. Using data from the National and State Youth Risk Behavior Surveys (YRBS) for the period 1991-2017, we explore the relationship between state excise taxes on cigarettes and teen marijuana use. In general, our results fail to support either of the above hypotheses. Rather, we find little evidence to suggest that teen marijuana use is sensitive to changes in the state cigarette tax. This null result holds for the sample period where cigarette taxes are observed to have the largest effect on teen cigarette use and across a number of demographic groups in the data. Finally, we find preliminary evidence that the recent adoption of state e-cigarette taxes is associated with a reduction in youth marijuana use.

Effects of an 80% cigarette price increase on quit attempts, successful quitting and smoking intensity among Korean adult smokers: results from nationally representative longitudinal panel data

OBJECTIVES

South Korea implemented an unprecedented cigarette tax increase in 2015, raising its cigarette price by 80%. This study evaluated the extent to which the 2015 cigarette tax increase affected Korean adult smokers in terms of quit attempts, successful quitting and smoking intensity.

METHODS

Data were drawn from a nationally representative longitudinal study, the Korean Welfare Panel Study (waves 9-12, 2014-2017). Korean adults who smoked before the 2015 cigarette tax increase comprised the sample (n=2114). We used the multiple logistic regressions to examine factors of quit attempts and successful quitting and the generalised estimating equations to estimate changes in smoking intensity among continued smokers.

RESULTS

After the cigarette tax increase, 60.9% (n=1334) of baseline smokers attempted to quit and 34.7% of the attempters succeeded in quitting. The smokers aged ≥ 65 years and light smokers both attempted more (p<0.01) and succeeded more (p<0.05) in quitting than smokers aged 35-44 years and heavy smokers, respectively. The successful quitting was not significantly associated with income levels. Depressive symptoms, first cigarette use before age 19 and smoking a pack or more a day at baseline were associated with failures in quitting. Smoking intensity among continued smokers decreased after the cigarette tax increase (p<0.001), but such a decrease was not observed in light smokers, young smokers and high-income smokers.

CONCLUSION

The current study findings imply that the Korean government may consider implementing periodic increases in cigarette tax which should reflect the rate of inflation and income growth. Smoking cessation programmes need to address depressive symptoms.

Impact of tobacco tax increases and industry pricing on smoking behaviours and inequalities: a mixed-methods study

Background

Increasing tobacco prices through taxation is very effective for reducing smoking prevalence and inequalities. For optimum effect, understanding how the tobacco industry and smokers respond is essential. Tobacco taxation changes occurred in the UK over the study period, including annual increases, a shift in structure from ad valorem to specific taxation and relatively higher increases on roll-your-own tobacco than on factory-made cigarettes.

Objectives

Understanding tobacco industry pricing strategies in response to tax changes and the impact of tax on smokers’ behaviour, including tax evasion and avoidance, as well as the effect on smoking inequalities. Synthesising findings to inform how taxation can be improved as a public health intervention.

Design

Qualitative analysis and evidence synthesis (commercial and Nielsen data) and longitudinal and aggregate cross-sectional analyses (International Tobacco Control Policy Evaluation Project data).

Setting

The UK, from 2002 to 2016.

Data sources and participants

Data were from the tobacco industry commercial literature and retail tobacco sales data (Nielsen, New York, NY, USA). Participants were a longitudinal cohort (with replenishment) of smokers and ex-smokers from 10 surveys of the International Tobacco Control Policy Evaluation Project (around 1500 participants per survey).

Main outcome measures

(1) Tobacco industry pricing strategies, (2) sales volumes and prices by segments over time and (3) smokers’ behaviours, including products purchased, sources, brands, consumption, quit attempts, success and sociodemographic differences.

Review methods

Tobacco industry commercial literature was searched for mentions of tobacco products and price segments, with 517 articles extracted.

Results

The tobacco industry increased prices on top of tax increases (overshifting), particularly on premium products, and, recently, the tobacco industry overshifted more on cheap roll-your-own tobacco than on factory-made cigarettes. Increasingly, price rises were from industry revenue generation rather than tax. The tobacco industry raised prices gradually to soften impact; this was less possible with larger tax increases. Budget measures to reduce cheap product availability failed due to new cheap factory-made products, price marking and small packs. In 2014, smokers could buy factory-made (roll-your-own tobacco) cigarettes at real prices similar to 2002. Exclusive roll-your-own tobacco and mixed factory-made cigarettes and roll-your-own tobacco use increased, whereas exclusive factory-made cigarette use decreased, alongside increased cheap product use, rather than quitting. Quitting behaviours were associated with higher taxes. Smokers consumed fewer factory-made cigarettes and reduced roll-your-own tobacco weight over time. Apparent illicit purchasing did not increase. Disadvantaged and dependent smokers struggled with tobacco affordability and were more likely to smoke cheaper products, but disadvantage did not affect quit success.

Limitations

Different for each data set; triangulation increased confidence.

Conclusions

The tobacco industry overshifted taxes and increased revenues, even when tax increases were high. Therefore, tobacco taxes can be further increased to reduce price differentials and recoup public health costs. Government strategies on illicit tobacco appear effective. Large, sudden tax increases would reduce the industry’s ability to manipulate prices, decrease affordability and increase quitting behaviours. More disadvantaged, and dependent, smokers need more help with quitting.

Future work

Assessing the impact of tax changes made since 2014; changing how tax changes are introduced (e.g. sudden intermittent or smaller continuous); and tax changes on tobacco initiation.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 6. See the NIHR Journals Library website for further project information.

Standardised packaging, minimum excise tax, and RYO focussed tax rise implications for UK tobacco pricing

BACKGROUND

Standardised packaging for factory made (FM) and roll your own (RYO) tobacco was fully implemented in the UK in May 2017. Around the same time, several changes to the tax system were applied (a Minimum Excise Tax (MET) for FM products and tax increases weighted towards RYO products). The tobacco industry claims that standardised packaging will lower prices (a disincentive for quitting) by commoditising the product, yet had itself taken advantage of the previous tax regime to achieve large profits from premium brands while also keeping some products' prices relatively low. Here we evaluate the impact of standardised packaging, the MET and the RYO focussed tax changes on price and industry profitability.

METHODS AND FINDINGS

Nielsen electronic point of sale (EPOS) data (May 2015 to April 2018) were used to calculate real (inflation adjusted) monthly price per stick overall, by cigarette type (FM and RYO) and by seven market segments. Trend estimation, using additive mixed models, assessed weighted average price (weighted by volume of sales) and tobacco industry net revenue changes. The beginning and end of the data series were compared in terms of: (a) average monthly price growth, (b) average monthly net revenue growth, and (c) undershifting and overshifting patterns after tax changes. FM and RYO real prices changed little over the 3-year period-overall prices rose by about 1p per stick. There was no evidence of commoditisation with prices of all FM segments (but not RYO) rising faster after the implementation of standardised packaging than immediately beforehand. The prices of the cheapest FM brands rose with the implementation of the MET. RYO price increases did not close the gap to FM pricing levels despite RYO focussed tax increases. Tax changes following the implementation of standardised packaging and the MET were more widely and quickly passed on to smokers in the form of higher prices than the tax change pre-implementation. The main limitations are first that because we do not know the exact mechanism by which Nielsen scales up sample data to provide UK estimates, we could only use data for a set three year period during which the same adjustments are made. Second, the tax and standardised packaging events were sometimes too close in time to separate their consequences statistically. Third, tobacco prices may also be affected by external factors such as changes in smokers' disposable income or availability of electronic nicotine delivery systems.

CONCLUSIONS

There was no long-term lowering of tobacco prices after the implementation of standardised packaging as predicted by the industry. The introduction of the MET was successful in increasing the price of the cheapest FM cigarettes and narrowing the price gap between FM brands. The RYO tax increases were, however, insufficient to narrow the price gap between RYO and FM. Overall, undershifting became less extensive indicating that tobacco industry manipulation of the tax system which had previously kept cheap products available had declined. This suggests that standardised packaging and a MET will likely contribute to further declines in UK tobacco use.

Price smoking participation elasticity in Colombia: estimates by age and socioeconomic level

BACKGROUND

Tobacco prevalence in Colombia is small compared with other Latin America despite the nation's tobacco taxes being among the lowest in the region. However, tobacco taxes have increased several times during the last decade, and large increases in 2010 and 2016 impacted consumer prices.

OBJECTIVE

This paper aims to estimate the price smoking participation elasticity (PPE) in Colombia, with specific reference to regional increases in consumer prices after 2010 tax policy changes.

METHODS

The PPE is computed using logistic regression based on individual-level data from the National Psychoactive Substances Consumption Survey for 2008 and 2013. Our specific focus is state-level variation in Colombian cigarette prices between 2008 and 2013 induced by the tax hike in 2010.

RESULTS

The estimated PPE in Colombia is around -0.66 (p value=0.046). We find almost no differences across socioeconomic level, but price sensitivity was greater for women than men, and for relatively older individuals (ages 51-64).

CONCLUSIONS

PPE for Colombia is above estimates for comparable middle-income countries such as Mexico. As a result, current estimates for health gains of tax policies are likely to be underestimated. Moreover, in contrast with the literature, we find that the PPE for the youth (≤25 years) is lower than older age groups, and there is no evidence of a prominent socio-economic status (SES) gradient.

Positive Effects of the National Cigarette Price Increase Policy on Smoking Cessation in South Korea

Background

In January 2015, South Korea's government raised the cigarette tax, and the retail price of cigarettes abruptly increased by 80% compared to the previous year. This research aimed to determine the effect of this increase on smoking cessation among South Korean smokers.

Methods

We analyzed data collected by the 2013–2015 South Korea National Health and Nutrition Examination Survey of 15,203 South Koreans over 19 years old using regression analysis. We examined the recent non-smoking period of nonsmoking people, prepared according to the survey, and analyzed the recent smoking cessation ratio.

Results

Among smokers, from 2013 to 2014, the smoking cessation rate was 7.2%, and it increased to 9.9% in 2015 after the increase in the cigarette tax. In 2015, the recent smoking cessation rate was higher among people over the age of 60 (odds ratio [OR], 2.67) compared to those between the ages of 40 and 49. The recent smoking cessation rate was higher among people with below elementary education (OR, 2.28) and above university education (OR, 1.94) compared to high school, higher for those with apartments (OR, 1.74) compared to general type residences, and higher among those with a household income in the low-middle quartile (Q2) (OR, 2.32) compared to the highest quartile (Q4).

Conclusion

This innovative policy including increase in cigarette prices affected smoking cessation, and its impact varied by sub-group of smokers in South Korea.

Electronic Cigarette Themes on Twitter: Dissemination Patterns and Relations with Online News and Search Engine Queries in South Korea

This study examines multiple aspects of e-cigarette mentions on different online media channels during the announcement and implementation of a cigarette tax increase policy in South Korea. It consists of three parts. First, a Naive Bayes classifier was used to sort 59,147 tweets about e-cigarettes into five pre-designated themes - promotion, health, policy, product evaluation, and price - and to determine their relative prevalence. Second, social network analysis was used to identify the themes' dissemination patterns. Third, the themes were examined for their associations with e-cigarette mentions in two other media channels - online news articles (n = 580) and search engine queries (64 weeks of Google Trends data). Results show that the most prevalent tweet theme was product evaluation, and the theme with the largest increase during the data collection period was promotion. Promotion-themed tweets were the least connected with tweets about the other five themes, while health-themed tweets were the most connected. Finally, product evaluation-themed tweets exhibited the strongest correlation with search engine query count and had the largest explanatory power.

Rats choose high doses of nicotine in order to compensate for changes in its price and availability

Restricting when and where smoking can occur is a major focus of public health policies in Western countries. In conjunction with increased taxation, these approaches have contributed to a reduction in smoking uptake among adolescents, yet the consequences for established smokers are less clear. In order to further explore this relationship, we developed a novel animal model of restricted nicotine self-administration. Rats were trained to choose between three doses of nicotine (15, 30 and 60 μg/kg/infusion) under conditions where nicotine was (1) freely available at a low cost (20-second post-infusion time-out, fixed-ratio 1 [FR1]), (2) available under restricted access at a low cost (300-second post-infusion time-out, FR1), or (3) freely available at a high cost (20-second post-infusion time-out, FR5). We demonstrate that as access to nicotine is restricted or when cost increases, rats compensate for these changes by increasing their intake of the highest dose of nicotine available. This preference was impervious to treatment with the smoking cessation medication varenicline, but was reduced when the cost of the highest dose only was increased, or when nicotine was again made freely available at a low cost. These results provide the first evidence in rats that nicotine availability and cost influence nicotine choice independently of variations in nicotine and context exposure. They imply that established smokers may compensate for changes in the availability and cost of tobacco by increasing their rate of smoking when they are free to do so.

Youth smoking and anti-smoking policies in North Dakota: a system dynamics simulation study

BACKGROUND

The current study utilizes system dynamics to model the determinants of youth smoking and simulate effects of anti-smoking policies in the context of North Dakota, a state with one of the lowest cigarette tax rates in the USA.

METHODS

An explanatory model was built to replicate historical trends in the youth smoking rate. Three different policies were simulated: 1) an increase in cigarette excise taxes; 2) increased funding for CDC-recommended comprehensive tobacco control programs; and 3) enforcement of increased retailer compliance with age restrictions on cigarette sales.

RESULTS

The explanatory model successfully replicated historical trends in adolescent smoking behavior in North Dakota from 1992 to 2014. The policy model showed that increasing taxes to $2.20 per pack starting in 2015 was the most effective of the three policies, producing a 32.6% reduction in youth smoking rate by 2032. Other policies reduced smoking by a much lesser degree (7.0 and 3.2% for comprehensive tobacco control program funding and retailer compliance, respectively). The effects of each policy were additive.

CONCLUSIONS

System dynamics modeling suggests that increasing cigarette excise taxes are particularly effective at reducing adolescent smoking rates. More generally, system dynamics offers an important complement to conventional analysis of observational data.

A scoping review of men, masculinities, and smoking behavior: The importance of settings

Background: In many countries, smoking rates are higher among men than women, highlighting the importance of focusing on factors that influence smoking prevalence among men. Expressed masculinities occur within settings that can influence men’s perspectives and behaviours towards smoking.

Objectives: To provide an overview of key aspects of how masculinities underpin men’s behaviours regarding tobacco smoking.

Methods: The Health, Illness, Men and Masculinities framework was used to develop a synthesis of masculinities captured in published articles about men’s smoking behaviours. Five databases (PubMed, Medline Ovid, Embase, CINAHL and PsychINFO Ovid) and Google Scholar (up to April 2016) were searched using keywords derived from three concepts: men, smoking and health. In total, 351 articles that focused on smoking and used/implied masculinity concepts were identified. These underwent a two-stage screening process applying inclusion/exclusion criteria, first titles/abstracts and then full-text. Data from 45 selected articles were extracted and charted.

Results: Regions with high prevalence of smoking among men, such as South East Asia and the Western Pacific, had a disproportionate number of studies on masculinity and smoking, with less exploration of masculinity as a protective factor, especially for young people, and men-specific settings to support non-smoking behaviour.

Conclusions: Incorporating masculinity in future settings-based approaches to smoking-related health promotion programmes has the potential to reduce smoking prevalence among men.

Cigarette consumption estimates for 71 countries from 1970 to 2015: systematic collection of comparable data to facilitate quasi-experimental evaluations of national and global tobacco control interventions

OBJECTIVES

To collect, appraise, select, and report the best available national estimates of cigarette consumption since 1970.

DESIGN

Systematic collection of comparable data.

SETTING AND POPULATION

71 of 214 countries for which searches for national cigarette consumption data were conducted, representing over 95% of global cigarette consumption and 85% of the world's population.

MAIN OUTCOME MEASURES

Validated cigarette consumption data covering 1970-2015 were identified for 71 countries. Data quality appraisal was conducted by two research team members in duplicate, with greatest weight given to official government sources. All data were standardised into units of cigarettes consumed per year in each country, a detailed accounting of data quality and sourcing was prepared, and all collected data and metadata were made freely available in an open access dataset.

RESULTS

Cigarette consumption fell in most countries over the past three decades but trends in country specific consumption were highly variable. For example, China consumed 2.5 million metric tonnes (MMT) of cigarettes in 2013, more than Russia (0.36 MMT), the United States (0.28 MMT), Indonesia (0.28 MMT), Japan (0.20 MMT), and the next 35 highest consuming countries combined. The US and Japan achieved reductions of more than 0.1 MMT from a decade earlier, whereas Russian consumption plateaued, and Chinese and Indonesian consumption increased by 0.75 MMT and 0.1 MMT, respectively. These data generally concord with modelled country level data from the Institute for Health Metrics and Evaluation and have the additional advantage of not smoothing year-over-year discontinuities that are necessary for robust quasi-experimental impact evaluations.

CONCLUSIONS

Before this study, publicly available data on cigarette consumption have been limited; they have been inappropriate for quasi-experimental impact evaluations (modelled data), held privately by companies (proprietary data), or widely dispersed across many national statistical agencies and research organisations (disaggregated data). This new dataset confirms that cigarette consumption has decreased in most countries over the past three decades, but that secular country specific consumption trends are highly variable. The findings underscore the need for more robust processes in data reporting, ideally built into international legal instruments or other mandated processes. To monitor the impact of the WHO Framework Convention on Tobacco Control and other tobacco control interventions, data on national tobacco production, trade, and sales should be routinely collected and openly reported.

Socioeconomic factors associated with tobacco smoking among adult males in Sri Lanka

Background

Tobacco smoking is considered as a major public health issue worldwide. Reduction of tobacco usage has been one of the main government policies in Sri Lanka and the price of cigarettes has been raised several times in the last few years. The purpose of this study was to evaluate the socioeconomic factors associated with tobacco smoking among adult males in Sri Lanka.

Methods

A study was conducted in Gampaha district in Sri Lanka recruiting 365 tobacco smoking people and their spouses. Data regarding tobacco smoking were obtained using an interviewer administrated questionnaire.

Results

Frequency of tobacco smoking was negatively associated with the improvement of educational levels. Employment, monthly income, influence of friends, smoking frequency before price increment, weekly expenditure for smoking, low educational level and the age of first smoking exposure was significantly associated with tobacco smoking among smokers. According to the spouses, smoking frequency before price increment, weekly expenditure of the husbands of smoking and influence of friends, number on smoking friends, spouse’s employment and husband’s monthly income were factors associated with tobacco smoking of their husbands. In addition, smoking at home, at work places and at friend’s houses was significant with the frequency of daily smoking.

Conclusions

Increasing the price of tobacco products has no significant impact on smoking behaviors in Sri Lanka. The need for essential strategies to educate and motivate the smokers to stop smoking is required. Primary care health workers might play a major role in motivating smokers to quit smoking.

Impact of khat price increases on consumption behavior - price elasticity analysis

Background

The long border of Saudi Arabia with Yemen is the primary route for khat entry to the Kingdom. As of April 2015, the government of SA tightened the border, making it more difficult to import khat into the country. As a result, local user prices of khat probably increased due in part to higher supply costs and perhaps lower quantities. One anti-drug strategy is to increase consumption cost by increasing the price of supply. We aim in this study to measure the responsiveness of khat demand to price changes.

Methods

This study used a cross-sectional survey design. Two stage sampling was used to recruit 350 khat chewers from four selected primary healthcare centers in Jazan province (South western province of Saudi Arabia). The data were collected during the first quarter of 2017. This study used both contingent valuation and revealed preference methods to assess the impact of price increases on the purchasing of khat. Graphical analysis, paired-samples t-test, and one-way repeated measures analysis of variance (ANOVA) were used to assess the impact of price increases on khat consumption.

Results

The study results showed a significant decrease in khat consumption amount (t = 8.63, p ≤ 0.05), frequency (t = 30.42, p ≤ 0.05), and expenditure (t = 34.67, p ≤ 0.05) after the tightening of the Saudi–Yemeni border. Hence khat demand is price elastic. The price elasticity of khat demand in Jazan is estimated to be between − 2.38 and − 1.07. Therefore, each 1% increase in price is associated with 1–2% reduction in quantity demanded. This means khat chewers are relatively responsive to price changes (i.e., khat demand is price elastic). Repeated measures analysis of variance showed price increases significantly affect the quantity {F(4, 2.58) = 257, p ≤ 0.05, ηp² = 0.423} and frequency {F(4, 1.83) = 415, p ≤ 0.05, ηp² = 0.543} of khat chewing.

Conclusions

Increased prices for khat would significantly decrease demand. Accordingly, we recommend implementing law enforcement strategies focused on disrupting the khat supply chain to realize high prices and so discourage use, hence reducing the incidence of khat-related illnesses.

Smoking tobacco prevalence among college students in the Kingdom of Saudi Arabia: Systematic review and meta-analysis

INTRODUCTION

During the last two decades, several studies have been published regarding the prevalence of tobacco smoking among college students in the Kingdom of Saudi Arabia (KSA). This systematic review and meta-analysis is intended to determine and examine the smoking prevalence in Saudi college students from 2010-2018.

METHODS

PubMed, Science Direct, APA PsycNET, Web of Science, and CINAHL were used to search for published articles reporting the smoking prevalence among Saudi college students. After eliminating irrelevant articles, investigators independently assessed the quality of each article, based on Russell & Gregory guidelines. MetaXL software was used to calculate the pooled prevalence among included studies, using the IVhert model. Heterogeneity among the included studies was evaluated, using I2 statistic. Sensitivity analyses were conducted between male and female genders.

RESULTS

Of the 295 published articles, 29 articles used a cross-sectional design to determine smoking prevalence among Saudi college students. Most of the studies were conducted in Riyadh at health-science-related colleges; the rest were performed in different cities and colleges. The meta-analysis showed that the pooled estimate of smoking prevalence among college students in the KSA was 17% (95% CI: 11-23%). Saudi male students had a prevalence rate of 26% (95% CI: 24-29%), whereas for Saudi female students the prevalence was 5% (95% CI: 3-7%).

CONCLUSIONS

Smoking among Saudi college students was higher than in the majority of regional countries (e.g. Iran). Saudi male students had a higher smoking prevalence than Saudi female college students. Additionally, studies that reported a high prevalence targeted students in specific disciplines. Public health authorities in the KSA should develop a surveillance system that monitors the prevalence of tobacco smoking on campuses. A surveillance system of monitoring tobacco use among Saudi college students could be beneficial in determining the degree of the tobacco problem and in improving current tobacco control programs.

Public Policies to Reduce Sugary Drink Consumption in Children and Adolescents

Excess consumption of added sugars, especially from sugary drinks, poses a grave health threat to children and adolescents, disproportionately affecting children of minority and low-income communities. Public policies, such as those detailed in this statement, are needed to decrease child and adolescent consumption of added sugars and improve health.

Smoking related outcomes before and after implementation of tobacco-free grounds in residential substance use disorder treatment programs

BACKGROUND

This study examined the impact of a tobacco-free grounds (TFG) policy and the California $2.00/pack tobacco tax increase on tobacco use among individuals in residential substance use disorder (SUD) treatment.

METHODS

We conducted three cross-sectional surveys of clients enrolled in three residential SUD treatment programs. Wave 1 (Pre-TFG) included 190 clients, wave 2 (post-TFG and pre-tax increase) included 200 clients, and wave 3 (post-tax increase) included 201 clients. Demographic and tobacco-use characteristics were first compared between waves using bivariate comparisons. Regression models were used to compare each outcome with survey wave as the predictor, while adjusting for demographic characteristics and nesting of participants within programs.

RESULTS

Odds of clients being current smokers was lower (AOR = 0.43, 95%CI = 0.30,0.60) after implementation of TFG compared to baseline. Adjusted mean ratio (AMR) for cigarettes per day was lower post-TFG compared to baseline (AMR = 0.70, CI = 0.59, 0.83). There were no differences, across waves, in tobacco-related knowledge, attitudes, or services received by program clients, or use of nicotine replacement therapy. Increased cigarette taxation was not associated with reductions in client smoking.

CONCLUSION

Implementation of a TFG policy was associated with a lower prevalence of client smoking among individuals in residential SUD treatment. Increased state cigarette excise taxes were not associated with a further reduction in client smoking in the presence of TFG policies, though this may have been confounded by relaxing of the TFG policy. SUD treatment programs should promote TFG policies and increase tobacco cessation services for clients.

Cardiovascular and other risk factors among people who live in slums in Buenos Aires, Argentina

OBJECTIVES

Effective planning of health policies requires the availability of accurate data, representing the burden of disease and risks to the diverse components of society. In Argentina, health information comes from the national risk factors survey (NRFS), which characterises the distribution of different risk factors. However, the NRFS has never collected information from residents living in slums, despite slums representing 10% of the population. The objective of this survey was to characterise the prevalence of cardiovascular and other risk factors among the inhabitants of one of the largest slums in Buenos Aires (Villa 31) and compare it to data from the NRFS.

STUDY DESIGN

This was a cross-sectional study.

METHODS

A cross-sectional study was carried out in 400 slum households, using the same data structure as the NRFS. The survey obtained information about economic aspects, reproductive health, addictions and risk factors. All participants had their blood pressure, weight and height measured. A total of 406 people were interviewed and their data were compared with data from 32,365 people in the NRFS. All comparisons were made on the basis of age group.

RESULTS

A fair/poor self-perceived level of health (odds ratio [OR] 3.19, 95% confidence interval [CI]: 2.60-3.91), anxiety and moderate to severe depression (OR 5.44, 95% CI: 4.43-6.69), problem drinking (OR 10.01, 95% CI 8.08-12.40), self-reported hypertension (OR 1.26, 95% CI: 1.01-1.57), overweight (OR 1.26, 95% CI: 1.03-1.55) and obesity (OR 1.72, 95% CI: 1.38-2.15) were significantly higher in the slum population. In people aged 18-24 years, the prevalence of diabetes was triple the national average (OR 3.17, 95% CI: 1.26-7.98). For all evaluated conditions in this study, the inhabitants of the slum received significantly less treatment compared with participants from the NRFS.

CONCLUSIONS

The prevalence of cardiovascular and other risk factors in the slum population has a different distribution to that reported in the NRFS. These data suggest the need to establish specific policies for slum populations.

What public health strategies work to reduce the tobacco demand among young people? An umbrella review of systematic reviews and meta-analyses

OBJECTIVE

To perform an umbrella review of systematic reviews and meta-analyses of health policy and health promotion strategies to reduce the tobacco demand in adolescents, youth and young adults.

METHODS

Reviewers independently performed an electronic database search, reviewed titles and abstracts, assessed articles' eligibility for inclusion and quality, and extracted relevant data. Only systematic reviews and meta-analyses reporting data on tobacco policies and interventions focusing on individuals aged <25 years were included. The Framework Convention on Tobacco Control was used to guide data synthesis.

RESULTS

13 articles were included. Studies were of mixed quality with five studies ranked as critically low and seven as high quality. Overall, mixed results were found on the effectiveness for tobacco policies and interventions. Strategies such as increasing taxes on tobacco products were most promising.

CONCLUSION

Though data on a variety of measures to reduce smoking is available, conclusions concerning the effectiveness are inconclusive. Tobacco policies and interventions have the potential to reduce smoking, but conclusions are hampered due to both lack of high-quality trials and numerous biases in primary studies. Further high-quality research is required to examine the effectiveness of interventions and policies to reduce the tobacco demand in adolescents, youth and young adults.

The price of tobacco and its effects on smoking behaviors in Korea: The 2015 Korea Community Health Survey

This study investigated the effects of the price of tobacco on smoking behaviors in Korean adult smokers using a population-based survey. Current smokers or former smokers who quit smoking <1 year prior to the survey were selected from the data of 2015 Korea Community Health Survey (N = 45,686). The effects of the price of tobacco on smoking behaviors were measured. The major effects were defined as quitting, reducing smoking and using electronic cigarettes (e-cigarettes). Chi-square tests and multiple logistic regression analyses were performed. After tobacco prices increased, 3.8%, 22.8% and 5.4% of subjects quit, reduced smoking and switched to e-cigarettes. The adjusted odds ratio (aOR) for reducing smoking was significantly higher in subjects with a lower household income and lower education level than in those with a greater income and higher education level among current smokers. Subjects who started smoking at an older age, who smoked a smaller number of cigarettes smoked per day and who had been exposed to anti-smoking campaigns and anti-smoking information were more likely to reduce smoking after the price of tobacco increased. Younger subjects were less likely to reduce smoking, but they were more likely to use e-cigarettes after the price of tobacco increased. Low-income subjects were sensitive to increases in the price of tobacco. Additional strategies are required to change the smoking behaviors of heavy smokers. Future studies should investigate the long-term effects of increasing the price of tobacco, especially on younger adults, on smoking behaviors.

Correlates of Tobacco Use and Consumption Among Hospitalized Psychiatric Patients

Using a cross-sectional analysis, we assessed correlates of tobacco use and tobacco consumption from inpatient records (N = 2,060) from a state psychiatric hospital. We used multivariate logistic regression analyses to examine correlates of tobacco use in the total sample and multivariate linear regression to examine correlates of tobacco consumption among tobacco users. Tobacco-use associated variables in the total sample were being male, being White, lower education, having a substance-use disorder/treatment, having an externalizing or psychotic disorder, being from a rural county, being younger, and shorter length of hospital stay. Among tobacco users (n = 1,153), correlates of amount of tobacco consumption were being male; being White; lower education; having an internalizing, externalizing, and psychotic disorder; using cigarettes; and living in a county without a smoke-free policy. Psychiatric patients should be screened for specific associative variables as part of tobacco-use assessments. Future research may expand on the current findings to develop strategies to enhance tobacco treatment among psychiatric patients.

Smoking prevalence and trends among a U.S. national sample of women of reproductive age in rural versus urban settings

U.S. smoking prevalence is declining at a slower rate in rural than urban settings and contributing to regional health disparities. Cigarette smoking among women of reproductive age is particularly concerning due to the potential for serious maternal and infant adverse health effects should a smoker become pregnant. The aim of the present study was to examine whether this rural-urban disparity impacts women of reproductive age (ages 15-44) including pregnant women. Data came from the ten most recent years of the U.S. National Survey on Drug Use and Health (2007-2016). We estimated prevalence of current smoking and nicotine dependence among women categorized by rural-urban residence, pregnancy status, and trends using chi-square testing and multivariable modeling while adjusting for common risk factors for smoking. Despite overall decreasing trends in smoking prevalence, prevalence was higher among rural than urban women of reproductive age overall (χ2(1) = 579.33, p < .0001) and among non-pregnant (χ2(1) = 578.0, p < .0001) and pregnant (χ2(1) = 79.69, p < .0001) women examined separately. An interaction between residence and pregnancy status showed adjusted odds of smoking among urban pregnant compared to non-pregnant women (AOR = .58, [.53 -.63]) were lower than those among rural pregnant compared to non-pregnant women (AOR = 0.75, [.62 -.92]), consistent with greater pregnancy-related smoking cessation among urban pregnant women. Prevalence of nicotine dependence was also higher in rural than urban smokers overall (χ2(2) = 790.42, p < .0001) and among non-pregnant (χ2(2) = 790.58, p < .0001) and pregnant women examined separately (χ2(2) = 63.69, p < .0001), with no significant changes over time. Associations involving residence and pregnancy status remained significant in models adjusting for covariates (ps < 0.05). Results document greater prevalence of smoking and nicotine dependence and suggest less pregnancy-related quitting among rural compared to urban women, disparities that have potential for direct, multi-generational adverse health impacts.

How Do Waterpipe Smoking Establishments Attract Smokers? Implications for Policy

BACKGROUND

Given the unique social nature of waterpipe smoking, an important factor contributing to its popularity is the spread of waterpipe establishments.

OBJECTIVES

With a focus on implications for regulations, we conducted a qualitative assessment of customers' online reviews on Yelp.com to gain insight into their positive and negative perceptions about waterpipe establishments and products, and identify features that are most important to them.

METHODS

In June 2016, an online search of Yelp was conducted to identify waterpipe establishments in Miami, Florida. First, we collected information from the websites on establishments' characteristics and their marketing practices. Then we selected customers' waterpipe-related reviews and used an inductive qualitative method to code and identify key themes associated with positive and negative customers' experiences. Thematic analysis was completed upon reaching saturation. The final coding scheme consisted of 32 codes within eight themes.

RESULTS

The homepage of the establishment was used to promote special discounts and events, while the online waterpipe menu was used to promote the waterpipe products. Our thematic analysis indicated that the variety of flavored tobacco was the most rated positive factor to customers, while the low-quality charcoal and high price were the most negative factors. Conclusions/Importance: Waterpipe online advertisements and promotions should be monitored and restricted. The availability of flavored tobacco, innovative device/accessories, affordable pricing, and charcoal quality are important domains for waterpipe establishments policy/regulation. Regulatory framework for waterpipe establishments should address the complex context of waterpipe including the venue (i.e., physical, website, menu), the tobacco, the device/accessories, and charcoal.

Facilitators and barriers to smoking cessation among minority men using the behavioral-ecological model and Behavior Change Wheel: A concept mapping study

Background and aim

Universal smoking cessation strategies are not always successful for minorities, among whom smoking is highly prevalent despite high intention to quit. This study identifies facilitators for smoking cessation, as perceived by minority male smokers, that can inform a culturally appropriate national plan for smoking prevention and cessation.

Methods

We conducted in 2013 a three-stage study among Arab minority male current and former smokers (ages 18–64) in Israel, among whom smoking is very high: first, a Concept Mapping (CM) study with 102 and 202 participants in the brainstorming, and sorting and rating phases respectively. Second, we assigned clusters identified in the CM study to contingency levels using the Behavioral Ecological Model (BEM). Third, we classified clusters into intervention functions and policies using the Behavior Change Wheel (BCW).

Findings

The CM study revealed 58 barriers and facilitators for smoking prevention and cessation that were sorted into 11 clusters by the participants. These clusters were analogous to four BEM level contingency of smoking (social, institutional, community and individual). We classified it into two main policy categories, based on the BCW: 1- restructuring the socio-political environment of smoking through affirmative government's policies towards Arab minority in Israel, and 2-developing a culturally appropriate plan for smoking cessation in Arab local authorities including: raising awareness about tobacco hazards; enforcing anti-smoking laws; strengthening community institutional action; providing smoking cessation services; considering raising prices for tobacco products, addressing psychological sources of smoking in Arab men.

Conclusions

Our study revealed barriers, facilitators and contingencies of smoking prevention and cessation with two main policy action items among the Arab minority in Israel: changing the socio-political environment of smoking, and developing a culturally appropriate smoking prevention and cessation national plan. Our study framework can inform policies and culturally appropriate interventions for smoking prevention and cessation in other minorities.

Personal Income and Substance Use among Emerging Adults in the United States

BACKGROUND

Taxation and other policy measures have been implemented across the United States to curb the accessibility of substance use, especially among youth. While the inverse relationship between price and youth consumption is well known, available research on youth earned income and substance use is sparser, particularly among emerging adults.

OBJECTIVES

We examined the association between emerging adult past-year personal income and 30-day substance use.

METHODS

We analyzed data from Wave 5 (n = 2,202) of the NEXT Generation Health Study, an annual survey study administered to a nationally representative sample of emerging adults in the U.S. Wave 5 (mean age = 20.28 years, SE = 0.02 years) was administered during the 2013-2014 academic year. After grouping participants into five levels of self-reported, pre-tax personal income, we used binomial logistic regression to examine the association between personal income and cigarette smoking, marijuana use, alcohol use, and heavy episodic drinking (HED).

RESULTS

In unadjusted models, those at certain levels of higher past-year income were more likely to smoke cigarettes, consume alcohol, or engage in HED at least once in the past 30 days. Several associations remained significant after controlling for covariates. Most associations were no longer significant after including perceived peer norms as additional covariates. Personal income was not associated with 30-day marijuana use in unadjusted or adjusted models. Conclusions/Importance: Higher earned income may provide emerging adults greater economic access to cigarettes and alcohol, but the association might be partly attenuated by social factors, particularly perceived peer norms.

The effects of cigarette price and the amount of pocket money on youth smoking initiation and intensity in Canada

OBJECTIVES

To investigate the price and income elasticities of adolescent smoking initiation and intensity to determine the extent to which increased pocket money leads to greater smoking among youth, and whether higher taxes can mitigate this effect.

METHODS

We used the 2012/2013 Canadian Youth Smoking Survey including students in grades 7-12. The multivariable logistic regression was used to examine the probability of smoking initiation, and a linear regression to examine the smoking intensity determined by province-level prices of cigarettes, pocket money, and a vector of individual characteristics, including age, sex, race, and school-related and psychosocial factors.

RESULTS

Of respondents, 28.8% have tried cigarette smoking. More than 90% of these initiated smoking between age 9 and 17. Male smokers consumed a higher average number of whole cigarettes daily than did females. The price elasticity of smoking initiation and intensity for youth in the full sample were - 1.13 and - 1.02, respectively, which means that a 10% increase in price leads to an 11.3% reduction in initiation and a 10.2% reduction in intensity. The income elasticity of smoking initiation and intensity for youth in the full sample were 0.07 and 0.06, respectively, which means that a 10% increase in income leads to a 0.7% increase in initiation and a 0.6% increase in intensity.

CONCLUSION

Economic measures such as taxation that raise the price of cigarettes may be a useful policy tool to limit smoking initiation and intensity.

Does the Mexican sugar-sweetened beverage tax have a signaling effect? ENSANUT 2016

OBJECTIVE

To evaluate the potential signaling effect of the Mexican tax on sugar-sweetened beverages (SSBs) by analyzing the association between awareness of and opinions about its effectiveness with current consumption of taxed SSBs and with a self-reported change in consumption of SSBs since the implementation of the tax. We also examined the association between psychosocial and environmental determinants of SSB consumption with current consumption of taxed SSBs and with a reported change in consumption of SSBs.

METHODS

Cross-sectional analyses of survey and food-frequency questionnaire data from the Mexican National Health and Nutrition Survey 2016. Participants were Mexican adults (20-59 years, N = 6,650). Logistic regression was used to evaluate the probability of a person reporting a decrease in SSB consumption, given their awareness of the tax, opinion about its effectiveness, psychosocial (SSB health-related beliefs, self-efficacy, and liking of SSBs) and environmental (availability of potable water) determinants. Multiple linear regression analysis was utilized to examine the association between the aforementioned factors and current consumption of taxed SSBs.

RESULTS

Compared with adults not aware, adults who were aware of the SSB tax were more likely (OR = 1.30) to report a decrease in SSB consumption (p = .012). In urban areas, adults aware of the tax drank a significantly lower amount of taxed SSBs (-15.7%; p = .023) than those not aware. Self-efficacy and liking of SSBs were significantly associated with a reported decrease in consumption and with current consumption (p < .001), while health beliefs and availability of potable water were not significantly associated with either reported change in SSB consumption or current consumption of taxed SSBs.

CONCLUSIONS

Implementation of an SSB tax accompanied by highly visible campaigns may further influence the impact of taxes on SSBs consumption. Future public health and nutrition education campaigns designed to increase knowledge and enhance motivation should be complemented by programs to assist individuals develop self-efficacy and self-regulation skills.

Income disparities in smoking cessation and the diffusion of smoke-free homes among U.S. smokers: Results from two longitudinal surveys

Background

Lower rates of successful quitting among low-income populations in the United States may be from slower dissemination of smoke-free homes, a predictor of cessation.

Objectives

To explore the role of smoke-free homes in cessation behavior across income levels.

Participants

Current smokers who were ≥18 years and who participated in the longitudinal 2002–2003 (n = 2801) or 2010–2011 (n = 2723) Tobacco Use Supplements to the Current Population Survey.

Measurements

We categorized income as multiples of the federal poverty level (FPL) (<300% FPL versus ≥300% FPL). We examined the association of smoke-free homes with 1+day quit attempts and 30+days abstinence at 1-year follow-up. We then conducted a mediation analysis to examine the extent that smoke-free homes contributed to income disparities in 30+days abstinence.

Results

Between the two surveys, heavy smoking (≥ 1 pack/day) declined by 17%, and smoking prevalence declined by 15% among those with higher-incomes (>300%FPL). Although similar in 2002, the prevalence of smoke-free homes was 33% lower among individuals living <300% FPL than those living ≥300% FPL. Although the quit attempt rate was similar, the 30+days abstinence rate was higher in the 2010–11 cohort than in 2002–3 cohort (20.6% versus 15.5%, p<0.008). Whereas smoking ≥ 1 pack/ day was associated with lower odds of 30+days abstinence (Adjusted odds ratio [AOR] 0.7; 95% CI 0.5–0.9), having a higher income (AOR 1.9, 95% CI 1.4–2.6) and a smoke-free home (AOR 1.6, 95% CI 1.2–2.1) were associated with greater odds of 30+day abstinence. Differential changes in smoke-free homes across income groups between the two surveys contributed to 36% (95% CI 35.7–36.3) of the observed income disparity in 30+days abstinence.

Conclusions

Increasing the diffusion of smoke-free homes among low-income populations may attenuate at least a third of the income disparities in smoking cessation, highlighting the need for interventions to increase adoption of smoke-free homes among low-income households.

In-treatment cigarette demand among treatment-seeking smokers with depressive symptoms

INTRODUCTION

Despite previous evidence supporting the use of the Cigarette Purchase Task (CPT) as a valid tool for assessing smoking reinforcement, research assessing how environmental changes affect CPT performance is scarce.

AIMS

This study addressed for the first time the differential effect of treatment condition [Cognitive Behavioral Treatment (CBT) + Behavioral Activation (BA) versus CBT + BA + Contingency Management (CM)] on cigarette demand among treatment seeking smokers with depressive symptoms. It also sought to assess whether reductions in smoking consumption arranged over the course of an intervention for smoking cessation impact on in-treatment cigarette demand.

METHOD

Participants were 92 smokers with depressive symptoms from a randomized clinical trial that received eight weeks of either CBT + BA or CBT + BA + CM. Individuals completed the CPT 8 times; the first during the intake visit and the remaining 7 scheduled once a week in midweek sessions. Cotinine samples were collected in each session.

RESULTS

Participants receiving CBT + BA + CM showed higher reduction in cigarette demand across sessions than participants receiving CBT + BA, although this comparison was only significant for the intensity index (p = .004). Cotinine was positively related to cigarette demand (all p values < .001), although this association became less prominent across sessions. In-treatment cotinine decreases were associated with demand reductions (all p values < .001), but this association was not significant for elasticity.

CONCLUSIONS

Reductions in nicotine intake arranged over the course of an intervention for smoking cessation impact in-treatment cigarette demand.

Determinants of smokeless tobacco use in India

Non-communicable diseases (NCDs) contributes to more than 50 per cent disability adjusted life years (DALYs) in India; and tobacco contributes to 7·4 per cent of DALYs which is next to diet and high blood pressure. According to Global Burden of Disease (GBD) 2015, tobacco use contributed to 5.9 per cent out of total DALYs in India. Smokeless tobacco (SLT) consumption is a multifactorial process influenced by varied range of contextual factors i.e., social, environmental, psychological and the genetic factors which are linked to the tobacco use. The determinants associated with the SLT use are gender, educational level, wealth index (inverse association), urban-rural residence, socio-economic status and low tax. Taking the view from tobacco control programmes, there is a need to address determinants of SLT use with State level monitoring and socio-economic inequalities, progress and review of the taxation of the SLT use in India.

Longitudinal Associations of Local Cigarette Prices and Smoking Bans with Smoking Behavior in the Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Few studies have examined associations of geographically proximal cigarette prices with within-person changes in smoking outcomes or assessed interactions between cigarette prices and smoking bans.

METHODS

We linked neighborhood cigarette prices (inflation-adjusted) at chain supermarkets and drug stores and bar/restaurant smoking ban policies to cohort participants (632 smokers from the Multi-Ethnic Study of Atherosclerosis, 2001-2012, baseline mean age 58 years) using geocoded retailer and participant addresses. We used fixed-effects models to investigate associations of within-person changes in price and ban exposures with within-person changes in five smoking outcomes: current smoking, heavy (≥10 cigarettes) smoking, cessation, relapse, and intensity (average number of cigarettes smoked per day, natural log transformed). We assessed intensity associations among all smokers, and heavy (≥10 cigarettes per day) and light (<10) baseline smokers. Finally, we tested interactions between cigarette price and bans.

RESULTS

A $1 increase in price was associated with a 3% reduction in risk of current smoking (adjusted risk ratio [aRR]: 0.97; 95% confidence interval [CI] = 0.93, 1.0), a 7% reduction in risk of heavy smoking (aRR: 0.93; CI = 0.87, 0.99), a 20% increase in risk of smoking cessation (aRR: 1.2; CI = 0.99, 1.4), and a 35% reduction in the average number of cigarettes smoked per day by heavy baseline smokers (ratio of geometric means: 0.65; CI = 0.45, 0.93). We found no association between smoking bans and outcomes, and no evidence that price effects were modified by the presence of bans.

CONCLUSIONS

Results underscore the importance of local prices, but not hospitality smoking bans, in influencing older adults' smoking behaviors.

Disparities in cigarette smoking and use of other tobacco products in Minnesota, 2003-14

Background

Despite efforts to reduce disadvantages across society, widening health disparities have been observed in Minnesota. This research examined whether observed declines in state-wide smoking prevalence were experienced equally by all adults with varying educational attainment.

Methods

Serial cross-sectional data from the 2003, 2007, 2010 and 2014 Minnesota Adult Tobacco Survey (MATS) were analyzed. Weighted regression analyses for smoking status, time to first cigarette, cigarettes per day and non-cigarette other tobacco products (OTP) were conducted across education levels.

Results

Controlling for age and gender, a decreased rate of smoking among high and middle education groups was offset by an increase in the low education group. Dependence (time to first cigarette) was twice as high in the lowest education group compared to highest, yet dependence did not decline over time for any group. There was a decline in cigarettes per day in all education groups, but an increase in OTP use in the lowest and middle education groups.

Conclusions

Given existing smoking disparities, novel efforts are urgently needed. Complementing known population-level strategies with community and individual-level approaches will be necessary to eliminate the widening gap in smoking disparities and to end the burden of tobacco-related disease.

Attitudes and beliefs towards alcohol minimum pricing in Western Australia

Modelling data have provided good evidence to support the efficacy of a minimum pricing policy for alcoholic beverages as a means to reduce alcohol consumption and risky and harmful drinking. The aim of the present study was to investigate attitudes and beliefs towards a minimum price policy for alcohol among members of the general public in Western Australia (WA). The study also explored what factors might promote acceptance of the policy. Eleven focus groups, comprising participants from a broad range of backgrounds in WA, were conducted. Using a facilitator-administered semi-structured interview schedule participants discussed their beliefs about the policy and how its acceptability might be promoted. Transcriptions of discussions were analysed using qualitative inductive content analysis for emergent themes. Three major themes emerged: attitudes towards the policy, beliefs about effectiveness and strategies to increase acceptability. Participants expressed negative attitudes towards the policy and thought that it would lead to increased crime, drug use and financial strain. Participants identified the policy as unfair on disadvantaged groups, and suggested that individuals would find a way to procure alcohol regardless of minimum pricing policies. Suggestions to make the policy more acceptable included increasing alcohol education and directing the revenue towards alcohol reduction initiatives. Participants' negative views and perceived lack of effectiveness corroborate research conducted in the UK. Information and education campaigns aimed at reducing misunderstanding of the policy and highlighting its effectiveness may help to promote greater acceptability.

Financial Strain, Parental Smoking, and the Great Recession: An Analysis of the UK Millennium Cohort Study

Introduction

During the recent "Great Recession," many families in the United Kingdom experienced increased financial strain (FS). The aim of this study was to determine if increases in FS, occurring over the period of the "Great Recession," were associated with increased risks of persistent and relapsed tobacco use among parents.

Methods

We analyzed the Millennium Cohort Study, a longitudinal study of 18819 children born in the United Kingdom between 2000 and 2002. Surveys at 7 (T1, 2008) and 11 years (T2, 2012) spanned the "Great Recession." Three measures of increased FS were defined; "became income poor" (self-reported household income dropped below the "poverty line" between T1 and T2); "developed difficulty managing" (parental report of being "financially comfortable" at T1 and finding it "difficult to manage" at T2); "felt worse off" (parental report of feeling financially "worse off" at T2, compared to T1). Poisson regression was used to estimate risk ratios (RR), adjusted RRs (aRR), and 95% confidence intervals for three outcomes: "persistent tobacco use," "new reported tobacco use," and "relapsed tobacco use."

Results

Parents in households which "became income poor" over the period of the "Great Recession" were significantly more likely to report "persistent tobacco use" (aRR = 2.17 [1.83-2.57]) or "new reported tobacco use" (aRR = 1.72 [1.04-2.83]). Ninety-five percent of "new reported tobacco users" had evidence of prior tobacco use suggesting the majority were "relapsed tobacco users." Similar patterns were seen for those who "developed difficulty managing" and "felt worse off."

Conclusions

Increased tobacco use among financially strained families has the potential to widen inequalities and undermine the public health policies that have had positive impacts on tobacco consumption in the United Kingdom.

Implications

While several studies have shown that FS is associated with a higher prevalence of tobacco use, heavier smoking, and relapsed tobacco use, most of this work used cross-sectional data and none has focused on parents. We used longitudinal data from the UK Millennium Cohort Study, between 2008 and 2012, to examine the association between FS and parental smoking. We show that parents who experienced increased FS, over the period of the "Great Recession," were more likely to continue using tobacco or to relapse.

The Impact of Income and Taxation in a Price-Tiered Cigarette Market: findings from the ITC Bangladesh Surveys

BACKGROUND

Taxing tobacco is among the most effective measures of tobacco control. However, in a tiered market structure where multiple tiers of taxes coexist, the anticipated impact of tobacco taxes on consumption is complex. This paper investigates changing smoking behaviour in lieu of changing prices and changing income. The objective of the paper is to evaluate the effectiveness of change in prices (through taxes) and change in income in a price-tiered cigarette market.

METHOD

A panel dataset from the International Tobacco Control Bangladesh surveys is used for analysis. For preliminary analysis transition matrices are developed. Next, probit and multinomial logit regression models are used to identify the effects of changes in prices and changes in income along with other control variables.

FINDINGS

Transition matrices show significant movement of smokers across price tiers from one wave to another. Regression results show that higher income raises the probability to up-trade and decreases the probability to down-trade. Results also show that higher prices raises the probability to up-trade and reduces the probability to down-trade. Although not significant, there exists a negative relationship between the probability to down-trade and the probability to intend to quit.

CONCLUSION

It is evident from the results that a price-tiered market provides smokers more opportunities to accommodate their smoking behaviour when faced with price and income change. Therefore, tiered structure of the tax system should be replaced with uniform taxes. Moreover, overall cigarette taxes need to be raised to an extent so that it off-sets any positive effects of income growth.

Analysis of cigarette demand in Argentina: the impact of price changes on consumption and government revenues

Objective:

To estimate cigarette demand and to simulate a tax policy targeted to reduce tobacco consumption.

Materials and methods:

Demand was estimated using a vector error correction model. Simulation exercises present the impact of a tax increase on consumption and revenues.

Results:

Changes in real income and the real price of cigarettes affect the demand for cigarettes in Argentina. The long term price elasticity is 0.279 (a 10% increase in real prices reduces cigarette consumption by 2.79% per quarter) and the long term income elasticity is 0.411 (a 10% increase in real income raises consumption by 4.11% per quarter). Even in a conservative scenario, simulations show that increasing the price of cigarettes by 100% using excise taxes would maximize revenues and reduce cigarette consumption.

Conclusion:

There is sufficient room to increase taxes, reducing cigarette consumption, while still increasing tax revenues.

Factors Associated with Cigarette Smoking and Motivation to Quit among Street Food Sellers in Vietnam

Since 2013, smoke-free signs in public places, including in restaurants and food stores, have been introduced in Vietnam, aiming to prevent passive smoking. Although extensive research has been carried out on second-hand smoking among clients in public places (e.g., hospitals, restaurants) in Vietnam, no single study exists which captures the current practice of smoking among street food outlets. This study aims to estimate the prevalence of smoking and identify factors associated with smoking status and cessation motivation amongst food sellers in Vietnam. A cross-sectional study involving 1733 food providers at outlets was conducted in 29 districts in Hanoi capital, Vietnam, in 2015. The prevalence of smoking amongst food sellers was determined to be 8.5% (25% for men and 0.8% for women). The enforcement of the smoke-free policy remains modest, since only 7.9% observed outlets complied with the law, providing a room designated for smokers. Although approximately 80% of the participants were aware of the indoor smoke-free regulations in public places, such as restaurants and food stores, 40.2% of smokers reported no intention of quitting smoking. A percentage of 37.6% of current smokers reported that despite having intentions to quit, they did not receive any form of support for smoking cessation. Being male and having hazardous drinking habits and a poor quality of life were all factors that were significantly associated with smoking status. Additionally, having awareness of smoking’s adverse effects and being frequently supervised by the authority were associated with a greater motivation to quit. This study highlights the importance of an accompanying education and smoking cessation program in addition to the frequent inspection and reinforcement of smoke-free policy in food stores. This research extends on our knowledge of smoking prevalence and its factors related to smoking events and motivation to quit among street food outlets. Overall, this study strengthens the idea that more government efforts towards preventing passive smoking and smoking cessation education are necessary in restaurants and other street food outlets.

Changes in cigarette prices, affordability, and brand-tier consumption after a tobacco tax increase in Thailand: Evidence from the Global Adult Tobacco Surveys, 2009 and 2011

Despite the 2009 implementation of a tobacco tax increase in Thailand, smoking rates remained unchanged between 2009 and 2011. Prior evidence has linked cigarette tax increases to compensatory behaviours aimed at lowering the cost of smoking, such as switching to lower-priced cigarette brands. Using data from 2009 and 2011 Global Adult Tobacco Surveys in Thailand, we estimated unadjusted changes in cigarette prices paid, cigarette affordability, and consumption of cigarettes in three price categories classified as upper-, middle-, and lower-priced brand tiers (or price tertiles). We used ordered logit regression to analyse the correlates of price-tier choice and to estimate the change in price-tier consumption adjusted for demographic and region characteristics. Between 2009 and 2011, real cigarette prices increased, but the affordability of cigarettes remained unchanged overall. There was a significant reduction in the consumption of cigarette brands in the top price-tier overall, accompanied by increases in the consumption of brands in the bottom and middle price-tiers, depending on the region. Adjusted estimates from the logit models indicate that, on average, the proportion of smokers selecting brands from upper- and middle price-tiers decreased while consumption of lower price-tier brands increased during the study period. The estimated shifts in consumption from more expensive to less expensive cigarette brands and the overall lack of change in cigarette affordability in Thailand between 2009 and 2011 are both factors that may have contributed to the observed lack of change in smoking rates after the 2009 tax increase.

A population-based comparison of European and North American sinonasal cancer survival

OBJECTIVE

Sinonasal cancers (SNC) are rare, thus limiting previous prognostic studies on a multinational level. The aim of this study is to utilize two population-based datasets to compare prognoses for SNC between the United States (US) and Europe.

METHODS

The European Cancer Registry (EUROCARE) database and the United States National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database were searched to identify survival of patients diagnosed with SNC between 1990 and 2007. Relative survival (RS) data were stratified by age group, gender, geographic location, and diagnostic time period.

RESULTS

12,541 SNC cases were identified in EUROCARE, while SEER identified 4,312. Males comprised the majority in Europe (62.3%) and the US (58.3%). Most patients were over 55 years in Europe (77.0%) and the US (69.5%). Age over 75 was a statistically significant poor prognostic indicator for 5-year RS in the US (48.2%; 95% CI=[43.9, 52.4]) and Europe (38.5%; [34.7, 42.7]). Female gender imparted a favorable 5-year RS in all regions except in Central Europe. By region, the US had the highest 5-year RS (58.8%; [56.4, 61.1]) and Eastern Europe had the lowest 5-year RS (37.1%; [34.0, 40.6]). The aggregate European 5-year RS was 48.1% [46.4, 49.8].

CONCLUSION

SNC in Europe and the US most commonly affects males and individuals over the age of 55 years. Male gender and age over 75 are poor prognostic factors at 5 years. Five-year RS in the US is higher than the 5-year European aggregate RS.