Taxation reduces social disparities in adult smoking prevalence

Impact of tobacco spending on intrahousehold resource allocation in Montenegro

BACKGROUND

The main goal of this study is to estimate the crowding out impact of tobacco expenditures on the household budget allocation to other mutually exclusive commodity groups in Montenegro.

METHODOLOGY

The analysis uses the Household Budget Survey data from 2005 to 2017 to estimate a system of Engel curves using a three-stage least squares approach. As the tobacco expenditure variable is endogenous to budget shares on other consumption items, instrumental variables were included to obtain consistent estimates.

RESULTS

Overall, the results confirm the existence of the crowding out effect of tobacco spending on various commodities, such as some food items (eg, cereals, fruits and vegetables and dairy products), clothing, housing and utilities, education and recreation while a positive effect of tobacco consumption was estimated on budget shares on bars and restaurants, alcohol, coffee and sugary drinks. These results are consistent throughout the income groups of households. The estimates indicate that an increase in tobacco expenditures leads to reduction in budget shares on essential goods, which is likely to have negative impacts on the household living standard.

CONCLUSIONS

Tobacco expenditure crowds out household spending on necessities, especially in case of the poorest households, thus increasing inequality, hampering human capital development and potentially causing long-term adverse effects on the households in Montenegro. Our results are similar to evidence from other low and middle-income countries. This paper contributes to the analysis of the crowding out effect of tobacco consumption, which was conducted for the first time in Montenegro.

Inequality of the crowding-out effect of tobacco expenditure in Colombia

In recent decades, policy initiatives involving increases in the tobacco tax have increased pressure on budget allocations in poor households. In this study, we examine this issue in the context of the expansion of the social welfare state that has taken place over the last two decades in several emerging economies. This study explores the case of Colombia between 1997 and 2011. In this period, the budget share of the poorest expenditure quintile devoted to tobacco products of smokers' households doubled. We analyse the differences between the poorest and richest quintiles concerning the changes in budget shares, fixing a reference population over time to avoid demographic composition confounders. We find no evidence of crowding-out of education or healthcare expenditures. This is likely to be the result of free universal access to health insurance and basic education for the poor. For higher-income households, tobacco crowds out expenditures on entertainment, leisure activities, and luxury expenditures. This finding should reassure policymakers who are keen to impose tobacco taxes as an element of their public health policy.

Exploring the Link between Altitude of Residence and Smoking Patterns in the United States

INTRODUCTION

Smoking-related diseases affect 16 million Americans, causing approximately 480,000 deaths annually. The prevalence of cigarette smoking varies regionally across the United States, and previous research indicates that regional rates of smoking-related diseases demonstrate a negative association with altitude. The purpose of this study was to determine the relationship between altitude and the prevalence of cigarette smoking by county (N = 3106) in the United States. We hypothesized that smoking prevalence among adults would be negatively associated with mean county altitude.

METHODS

A multivariate linear regression was performed to examine the relationship between county-level mean altitude and county smoking rate. Covariates were individually correlated with 2020 smoking data, and significant associations were included in the final model.

RESULTS

The multivariate linear regression indicated that the county-level smoking rates are significantly reduced at high altitudes (p < 0.001). The model accounted for 89.5% of the variance in smoking prevalence, and for each 1000-foot increase in altitude above sea level, smoking rates decreased by 0.143%. Based on multivariate linear regression, the following variables remained independently and significantly associated: race, sex, educational attainment, socioeconomic status, unemployment, physical inactivity, drinking behavior, mental distress, and tobacco taxation.

CONCLUSIONS

Our results indicate that smoking rates are negatively associated with altitude, which may suggest that altitude affects the pharmacokinetics, pharmacodynamics, and mechanistic pathways involved in cigarette use. Further research is needed to explore the relationship between altitude and smoking and how altitude may serve as a protective factor in the acquisition and maintenance of tobacco use disorders.

Linking health and finance ministries to improve taxes on unhealthy products

The World Health Organization recommends economic measures such as taxes on tobacco, alcohol and unhealthy foods and beverages as part of a comprehensive strategy for prevention of noncommunicable diseases. However, progress in adopting these so-called health taxes has been hampered, in part, by different approaches and perceptions of key issues in different sectors of government. Health promotion is the responsibility of health policy-makers, while taxation is the mandate of finance ministries. Thus, strengthening cooperation between health and finance policy-makers is central to the successful adoption and implementation of effective health taxes. In this paper we identify the shared concerns of finance and health policy-makers about health taxes with the aim of enabling more effective cross-sector cooperation towards both additional financing for health systems and changes in unhealthy behaviours. For example, new approaches to supporting health taxation include the growing priority for health-system financing due to the growing burden of noncommunicable diseases, and the need to address the health and economic damage due to the coronavirus disease 2019 pandemic. As a result, high-level efforts to achieve progress on health taxes are gaining momentum and represent important progress towards using the combined expertise of health and finance policy-makers.

Percentage of income spent on tobacco and intention to quit: a cross-sectional analysis of the JASTIS 2020 study

BACKGROUND

Existing indicators for the ease of purchasing tobacco did not reflect the actual amount smoked and individual income, and did not assess heated tobacco products (HTPs). This study assessed the percentage of income spent on tobacco, including combustible cigarettes and/or HTPs, at the individual level and its relation to quit intention.

METHODS

An internet-based self-reported questionnaire survey was conducted in 2020 as a part of the Japan Society and New Tobacco Internet Survey. A total of 954 smokers aged 15-72 years were analyzed. We calculated the percentage of income spent on tobacco according to income levels. A high percentage implies that tobacco is not easy to purchase. The odds ratios for quit intention according to three categories of percentage of income spent on tobacco (<1%, 1-5%, >5%) were calculated by multivariable logistic regression.

RESULTS

The percentage of income spent on tobacco was higher as income level was lower, especially for dual cigarette and HTP users; the percentages in the lowest/highest income group were 7.1%/1.2% for exclusive combustible cigarette smokers; 6.5%/1.1% for exclusive HTPs users; and 9.2%/1.3% for dual users. The adjusted odds ratios (95% confidence intervals) of quit intention among the >5% of income spent on tobacco group compared with the <1% spent group were 0.43 (0.18-1.03) for exclusive combustible cigarette smokers, 0.71 (0.20-2.54) for exclusive HTPs users, and 0.11 (0.02-0.77) for dual users.

CONCLUSIONS

Higher tobacco expenditure was not associated with quit intention for all categories of tobacco product users, probably due to the low price of tobacco in Japan.

The impact of cigarette prices on smoking participation and tobacco expenditure in Vietnam

Vietnam is one of countries with the highest number of smokers in the world and the high smoking prevalence among men in the region. Although the real cigarette prices increased by around 4% during the 2010-2015 period, the prevalence of daily cigarette smoking among men decreased slightly from 31.3% to 30.7% during this period. This raises the question of whether cigarette consumption is sensitive to price. In this study, we estimated the effect of cigarette prices on smoking participation and tobacco expenditure in Vietnam. We found that a one-percent increase in the real cigarette price reduced the probability of cigarette smoking among males by 0.08 percentage points (95% CI from -0.06 to -0.10), equivalent to the price elasticity of the smoking prevalence at -0.26 (95% CI from -0.16% to -0.33%). Using this estimate, we predict that if the cigarette price is increased by 10%, the daily cigarette smoking prevalence among men would decrease from 30.7% to 29.9% and the number of male smokers would decline by around 270 thousand. Higher cigarette prices also reduced per capita tobacco expenditure of households. A one-percent increase in the cigarette price decreased per capita expenditure on tobacco consumption expenditure of households by 0.43 percent (the 95% CI from -0.029 to 0.822). This finding suggests that raising tobacco taxes and prices can be an effective measure to reduce tobacco use.

Exploring indigenous perspectives on tobacco tax: how some Māori families are responding in Aotearoa New Zealand

OBJECTIVE

High smoking prevalence rates, combined with a steep tax on tobacco and lower household income, mean that 5% of Māori (indigenous) whānau (family unit) expenditure in New Zealand is on tobacco. This paper outlines whānau perceptions of, and behavioural responses to, increasing tobacco tax.

METHODS

This qualitative study was informed by the Kaupapa Māori theory and used a simplified interpretive phenomenological analysis thematic hybrid methodology. A semistructured, open-ended interview guide was designed and used in one-off focus group interviews.

SETTING AND PARTICIPANTS

Interviews were separately conducted with each of 15 whānau units. A total of 72 participants, most of whom were smokers, took part in the interviews carried out in two geographical regions: one rural/provincial and one urban.

RESULTS

Whānau were concerned about the rising cost of tobacco. However, this concern had not generally translated into quit attempts. Whānau had instead developed innovative tobacco-related practices. Working collectively within their whānau, they were able to continue to smoke, although in a modified fashion, despite the rising costs of tobacco. Whānau thereby resisted the intended outcome of the government's tobacco tax which is to reduce rates of smoking prevalence.

CONCLUSION

In the face of significant government disinvestment in New Zealand tobacco control over the last 10 years, hypothecated taxes should be used to scale up Māori-specific cessation and uptake prevention programmes, supporting authentic Māori partnerships for endgame solutions including restricting the availability and appeal of tobacco.

Questioning the regressivity of tobacco taxes: a distributional accounting impact model of increased tobacco taxation

BACKGROUND

Tobacco taxes, as with other 'sin taxes', are generally regarded as a highly cost-effective mechanism to reduce consumption but are often considered by policymakers to be regressive, undermining efforts to fully implement them at levels recommended by the WHO due to concerns of fairness. We aim to demonstrate whether there are circumstances in which the impacts of additional tobacco taxes are not regressive, using a standard income-share accounting definition of tax burden.

METHODS AND FINDINGS

We apply mathematical modelling and explore the hypothetical distributions in the net change in tobacco taxes and cigarette expenditures by income group, following an increase in tobacco taxation. The hypothetical distribution per income group of additional taxes and cigarette expenditures borne by individuals following tobacco tax hikes was calculated with respect to a selection of parameters including: the change in the retail price of cigarettes, the price elasticity of demand for tobacco, smoking prevalence, cigarette consumption and individual income. We determine the range of hypothetical parameter values for which increased tobacco taxation should not be considered to penalise the poorest income groups when examining marginal cigarette consumption expenditures and using an accounting definition of tax burden.

CONCLUSIONS

Our findings question the doctrine that tobacco taxes are uniformly regressive from a standard income-share accounting view and point to the importance of the specific features of tax policy to shape a progressive approach to tobacco taxation: tobacco tax increases are less likely to be regressive when accompanied by a broad framework of demand-side measures that enhance the capacity of low-income smokers to quit tobacco use.

Tobacco Taxation and Its Prospective Impact on Disparities in Smoking Initiation and Progression Among Young Adults

PURPOSE

Limited research exists on tobacco taxes and cigarette smoking initiation and progression, particularly across different sociodemographic groups in young adulthood. This project examines how cigarette pack price in late adolescence prospectively relates to smoking initiation and progression by 21 years of age, focusing on differences across demographics.

METHODS

Data are from the longitudinal Monitoring the Future project (2001-2017). Monitoring the Future examines drug use behaviors with nationally representative samples of 12th graders annually. Subsamples of 12th graders are followed up longitudinally. We examined past 30-day cigarette smoking among baseline never smokers (N = 9,232) and daily smoking among youths who were not daily cigarette smokers at baseline (N = 15,141). Using logistic regression, we examined state-level cigarette pack price at a modal age of 18 years and smoking at follow-up ages 19-20 years; we used interaction terms to assess differences across sociodemographic groups (by gender, race/ethnicity, and parental education).

RESULTS

For each dollar increase in price at baseline, the odds of initiation by age 19-20 years were reduced by 12% (adjusted odds ratio = .88; 95% confidence interval = .78, .99) and the odds of progression to daily smoking were reduced by 16% (adjusted odds ratio = .84; 95% confidence interval = .76, .92). After adjusting for multiple testing, for both outcomes there were no statistically significant interactions between price and demographics.

CONCLUSIONS

Cigarette prices in late adolescence were associated with a prospective reduction in cigarette smoking initiation and progression among young adults, with limited differences across sociodemographic characteristics. Higher cigarette prices can prevent smoking initiation and progression; however, complementary interventions are needed to reduce initiation and progression among subgroups disproportionately affected by tobacco.

Longitudinal Associations of Cigarette Prices With Smoking Cessation: The Coronary Artery Risk Development in Young Adults Study

INTRODUCTION

Few studies have used longitudinal cohort data to examine associations of cigarette prices with smoking cessation or whether price sensitivity varies by income or education. This study examines these associations in a multicenter US cohort and explores whether associations vary by education and income.

METHODS

Longitudinal data from baseline daily cigarette smokers aged 18-30 years in the Coronary Artery Risk Development in Young Adults study were linked to inflation-adjusted cigarette carton prices from the Council for Community and Economic Research Cost of Living Index based on residential address at baseline and in years 7, 10, and 15 (1985-2001). Multivariable Cox models estimated hazard ratios (HRs) of first (any) smoking cessation and sustained smoking cessation (no relapse) associated with each $1 increase in time-dependent cigarette price over 15 years of follow-up. Models were adjusted for sociodemographic, health-related, and policy covariates. We assessed effect modification by education and household income.

RESULTS

Among 1489 participants, a $1.00 higher cigarette carton price was associated with a 16% higher likelihood of first smoking cessation (HR = 1.16, 95% CI = 1.11 to 1.21) and an 8% higher likelihood of sustained smoking cessation (HR = 1.08, 95% CI = 1.02 to 1.14). Associations were strongest among participants with lower income for first cessation, and among those with higher income for sustained cessation. Associations were strongest for participants with less than a high school degree for both outcomes.

CONCLUSIONS

Results suggest higher cigarette prices promote smoking cessation among young to middle-aged adults, and that price sensitivity may differ by socioeconomic status.

IMPLICATIONS

Few studies have examined longitudinal associations of cigarette prices with smoking cessation, and findings are mixed on whether price sensitivity varies by education or income. In a cohort of US adult daily smokers, cigarette prices were associated with greater likelihood of both a first cessation and sustained cessation. Price associations with first cessation were stronger among low-income smokers, but associations with sustained cessation were stronger among high-income smokers. Results suggest that although higher cigarette prices may promote short-term smoking cessation among smokers at all income levels, additional supports may be needed to facilitate sustained smoking cessation among low-income smokers.

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.

Indexation of Tobacco Excise and Customs Duty and Smoking Prevalence Among Australian Adults, 2001-2010: A Serial Cross-sectional Study

INTRODUCTION

Australia's excise and customs duty on tobacco has been automatically increased biannually since 1984. Increases in duty on par with inflation ensured that tobacco stayed at least as costly as other goods. This would be expected to maintain, rather than drive down, smoking prevalence. We examined the association between smoking prevalence and duty over a 10-year period.

METHODS

Using monthly data from five Australian capital cities, collected from March 2001 to March 2010 among Australians aged at least 18 years, multiple linear regression modeled associations between smoking prevalence and the two components (duty and non-duty) of the recommended retail price of an average packet of cigarettes, adjusting for policy covariates.

RESULTS

Prevalence declined from 23.6% in March 2001 to 17.0% in March 2010 [absolute difference 6.6%; 95% confidence interval (CI) = 6.5 to 6.8]. Duty increased from $0.2026 to $0.2622 per cigarette over the same period. In the adjusted model, a 1-cent increase in the duty component of price was not associated with changes in prevalence (0.019; 95% CI = -0.035 to 0.028). Increased non-duty component of price was associated with a decline in prevalence (-0.027; 95% CI = -0.052 to -0.002). This effect was stronger when changes in income were controlled for.

CONCLUSIONS

In line with expectations, inflation-adjusted duty was not associated with changes in smoking prevalence, but it may have prevented upward pressure on prevalence that increasing affordability could have exerted. Frequent increases in duty greater than the growth in both wages and goods would more effectively reduce smoking than regular indexation.

IMPLICATIONS

Few countries inflation-adjusted excise duty to ensure that tobacco products do not become more affordable; however, Australia experienced a decade of inflation adjustment alone, enabling the impact of this policy to be studied. This study shows that inflation-adjusted duty likely did prevent tobacco becoming more affordable and that indexation was associated with declines in smoking when tobacco companies over-shifted the duty rises (ie, increased price over and above duty rises).The study also suggests that frequent increases in taxation that exceed both wage growth and increases in costliness of other goods are needed to prompt increased rates of quitting.

Examining quit attempts and successful quitting after recent cigarette tax increases

As cigarette smoking rates decline, an important policy question is whether increasing cigarette taxes will continue to encourage smoking cessation. We tested this question following recent tobacco tax increases. Data were from the Minnesota Adult Tobacco Survey, a serial cross-sectional telephone survey conducted statewide, and was limited to past-year cigarette smokers in 2010 (n = 1029) and 2014 (n = 1382). Weighted estimates were calculated of the prevalence of past year smokers, smokers who attempted to quit smoking, and those who successfully quit by demographics, tobacco use, use of evidence-based cessation assistance to quit, and smoker perceptions of the tax increases. Among past year smokers, almost 60% reported a quit attempt in both years, 12.8% successfully quit in 2010 and 15.6% in 2014. Although older age, daily smoking, mean cigarettes per day, and more days of e-cigarette use, were associated with quit attempts in unadjusted models, only the perceived tax increase effect (AOR = 8.9; 95% CI 6.3-12.5) and low nicotine dependence (AOR = 1.9, 95% CI 1.3-2.7) were associated with making a quit attempt in adjusted models. Successful 12-month quits were predicted by college education (AOR = 3.2, 95% CI 1.3-7.8), the use of cessation support (AOR = 2.1, 95% CI 1.3-3.6), and reporting the tax increase helped maintain a quit (AOR = 12.3, 95% CI 7.5-20.1). These findings suggest that a large tax increase is effective in promoting quitting even in the presence of strong tobacco control measures such as indoor smoking bans and other smoking restrictions, mass media campaigns, and universal access to cessation support.

Tobacco-attributable burden of cancer according to socioeconomic position in France

Smoking is a major preventable cause of cancers and is increasingly concentrated among the most deprived individuals leading to increasing socioeconomic inequalities in the incidence of cancers linked to smoking. We aimed to estimate the tobacco-attributable cancer burden according to socioeconomic position in France. The analysis was restricted to cancer sites for which tobacco smoking was recognized as a risk factor. Cancer cases by sex, age group and European Deprivation Index (EDI) among people aged 30-74 between 2006 and 2009 were obtained from cancer registries covering ∼20% of the French population. The tobacco-attributable burden of cancer according to EDI was estimated applying the population attributable fraction (PAF) computed with the Peto-Lopez method. The PAF increased from 56% in the least deprived EDI quintile to 70% in the most deprived EDI quintile among men and from 26% to 38% among women. In total, 28% of the excess cancer cases in the four most deprived EDI quintiles in men and 43% in women could be prevented if smoking in these 4 EDI quintiles was similar to that of the least deprived EDI quintile. A substantial smoking-attributable burden of cancer by socioeconomic position was observed in France. The results highlight the need for policies reducing tobacco consumption. More comprehensive interventions integrating the various dimensions of health determinants and proportionate according to socioeconomic position may essentially contribute to the reduction of socioeconomic inequalities in cancer.

Socioeconomic status and cigarette expenditure among US households: results from 2010 to 2015 Consumer Expenditure Survey

OBJECTIVES

To examine (1) the association between household socioeconomic status (SES) and whether a household spends money on cigarettes and (2) socioeconomic variations in proportion of total household expenditure spent on cigarettes among smoking households.

METHODS

We pooled data from six consecutive years, 2010-2015, of the Consumer Expenditure Interview Survey. The interviews involved a structured questionnaire about household income, demographics and expenditures including expenditure on cigarettes. Households that reported cigarette expenditure in the previous 3 months were distinguished as smoking households. SES indicators were household poverty status, education and occupation of the head of household. Logistic regression was used to assess the association of household smoking status with SES. Fractional logistic regression was used to assess the association of cigarette expenditure as a proportion of total household expenditure with SES. The analysis sample size was 39 218.

RESULTS

The probability of spending money on cigarettes was higher among lower SES households. Households in poverty compared with those above 300% of poverty threshold had 1.86 (95% CI 1.61 to 2.16), households headed by a person with less than high school education compared with those headed by a person with at least a bachelor's degree had 3.37 (95% CI 2.92 to 3.89) and households headed by a blue-collar work compared with those headed by a person in a managerial occupation had 1.45 (95% CI 1.26 to 1.66) higher odds of spending money on cigarettes. Similarly, the proportion of total household expenditure spent on cigarettes was higher among lower SES smoking households.

CONCLUSION

Lower SES households are more likely to spend money on cigarettes and spend a larger proportion of their total expenditure on cigarettes. We recommend strategies effective in reducing smoking among low SES smokers.

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.

Modelling the implications of reducing smoking prevalence: the benefits of increasing the UK tobacco duty escalator to public health and economic outcomes

INTRODUCTION

Taxing tobacco is one of the most effective ways to reduce smoking prevalence, mitigate its devastating consequential health harms and progress towards a tobacco-free society. This study modelled the health and economic impacts of increasing the existing cigarette tobacco duty escalator (TDE) in the UK from the current 2% above consumer price inflation to 5%.

METHODS

A two-stage modelling process was used. First, a non-linear multivariate regression model was fitted to cross-sectional smoking data, creating longitudinal projections from 2015 to 2035. Second, these projections were used to predict the future incidence, prevalence and cost of 17 smoking-related diseases using a Monte Carlo microsimulation approach. A sustained increase in the duty escalator was evaluated against a baseline of continuing historical smoking trends and the existing duty escalator.

RESULTS

A sustained increase in the TDE is projected to reduce adult smoking prevalence to 6% in 2035, from 10% in a baseline scenario. After increasing the TDE, only 65% of female and 60% of male would-be smokers would actually be smoking in 2035. The intervention is projected to avoid around 75 200 new cases of smoking-related diseases between 2015 and 2035. In 2035 alone, £49 m in National Health Service and social care costs and £192 m in societal premature mortality and morbidity costs are projected to be avoided.

CONCLUSION

Increasing the UK TDE to 5% above inflation could effectively reduce smoking prevalence, prevent diseases and avoid healthcare costs. It would deliver substantial progress towards a tobacco-free society and should be implemented by the UK Government with urgency.

Behavioral change in response to a statewide tobacco tax increase and differences across socioeconomic status

BACKGROUND

Tobacco use is a leading behavioral risk factor for morbidity and mortality, and the tobacco epidemic disproportionately affects low-socioeconomic status (SES) populations. Taxation is effective for reducing cigarette use, and it is an effective population-based policy for reducing SES-related tobacco disparities. However, progress in implementing cigarette excise taxes has stalled across the United States, and there is a dearth of research on the full spectrum of behavioral shifts that result from taxes, particularly among low-SES populations. This project documents the impact of Minnesota's $1.75 cigarette tax increase implemented in 2013.

METHODS

Data come from the 2014 Minnesota Adult Tobacco Survey. Descriptive analyses and Latent Class Analysis (LCA) were used to provide a typology of the tax impact.

RESULTS

From the LCA, six classes were identified, and 42% of respondents were classified as reporting action-oriented behavioral change related to the tax-8% reported sustained smoking abstinence. We found differential behavior change across levels of SES. Low-SES and medium/high-SES individuals were equally likely to report complete tobacco cessation, but the prevalence of daily smokers who reported action-oriented behavior without sustained cessation was nearly double for low-SES individuals.

CONCLUSIONS

Smokers report a range of behavioral changes in response to cigarette taxes, with differences across SES. The majority of smokers, and particularly low-SES smokers, report behavioral steps toward quitting or achieving sustained tobacco cessation in response to cigarette taxes. Complementary population-based programs geared toward assisting individuals, especially low-SES individuals, to achieve continuous tobacco cessation could increase the reach and effectiveness of cigarette taxes.

Tobacco policy reform and population-wide antismoking activities in Australia: the impact on smoking during pregnancy

Introduction

This study examined the impact of antismoking activities targeting the general population and an advertising campaign targeting smoking during pregnancy on the prevalence of smoking during pregnancy in New South Wales (NSW), Australia.

Methods

Monthly prevalence of smoking during pregnancy was calculated using linked health records for all pregnancies resulting in a birth (800 619) in NSW from 2003 to 2011. Segmented regression of interrupted time series data assessed the effects of the extension of the ban on smoking in enclosed public places to include licensed premises (evaluated in combination with the mandating of graphic warnings on cigarette packs), television advertisements targeting smoking in the general population, print and online magazine advertisements targeting smoking during pregnancy and increased tobacco tax. Analyses were conducted for all pregnancies, and for the population stratified by maternal age, parity and socioeconomic status. Further analyses adjusted for the effect of the Baby Bonus maternity payment.

Results

Prevalence of smoking during pregnancy decreased from 2003 to 2011 overall (0.39% per month), and for all strata examined. For pregnancies overall, none of the evaluated initiatives was associated with a change in the trend of smoking during pregnancy. Significant changes associated with increased tobacco tax and the extension of the smoking ban (in combination with graphic warnings) were found in some strata.

Conclusions

The declining prevalence of smoking during pregnancy between 2003 and 2011, while encouraging, does not appear to be directly related to general population antismoking activities or a pregnancy-specific campaign undertaken in this period.

Contrasting temporal trends in lung cancer incidence by socioeconomic status among women in New South Wales, Australia, 1985-2009

OBJECTIVE

We examined long-term trends in lung cancer incidence for women by socioeconomic groups in New South Wales (NSW), Australia.

METHODS

Data on lung cancer incidence for women were extracted from the NSW Cancer Registry database. We divided the study cohort into five quintiles according to an area-based index of education and occupation (IEO) and calculated annual age-standardised incidence rates by IEO quintile for the period 1985-2009. The age-standardised incidence ratio (SIR) was estimated for IEO quintiles and 5-year period of diagnosis using the highest IEO quintile as the reference.

RESULTS

Overall, lung cancer incidence for women aged 25-69 years increased gradually from 19.8 per 100,000 in 1985 to 25.7 per 100,000 in 2009. The trends by IEO quintile were somewhat comparable from 1985 through to 1995, but from then on rates remained relatively stable for women residing in the highest quintile while increasing for women residing in the remaining four quintiles. Consequently, the SIR for all four of the lower IEO quintiles increased significantly over the 25-year period. For example, the SIR in the lowest IEO quintile increased from 1.16 (95% CI, 0.99-1.37) during 1985-1989 to 1.70 (95% CI, 1.50-1.93) during 2005-2009. The corresponding estimates for women aged 70 years or older showed no clear pattern of socioeconomic gradient.

CONCLUSION

The increasing gap in lung cancer incidence between women in the highest socioeconomic group and all others suggests that there is a continued need for the broad implementation of tobacco control interventions, so that smoking prevalence is reduced across all segments of the population and the subsequent benefits are shared more equitably across all demographic groups.

A qualitative analysis of low income smokers' responses to tobacco excise tax increases

BACKGROUND

While increasing the excise tax applied to tobacco products reduces consumption and smoking prevalence, it may also cause hardship among smokers who do not quit. We explored how smokers living on a low income respond to increasing tobacco excise taxes.

METHODS

Using a social justice perspective, we explored the increasing costs of tobacco with a sample of 27 adult smokers who live below the poverty line (i.e., with an income less than 60% of the median New Zealand income). Face-to-face interviews were conducted in Dunedin, New Zealand, a city with marked income differences, and were undertaken shortly after a further tobacco excise tax increase. The interview guide explored participants' smoking practices, their perceptions of excise tax as a strategy to reduce smoking prevalence, and the strategies they used to manage their tobacco needs.

RESULTS

We identified three key themes: depriving the poor; tobacco as a precious commodity, and desperation. While many participants described smoking as a pleasure or coping mechanism, they also saw it as a burden that they struggled to manage. Despite trying to quit, most had failed to become smokefree and felt victimised by a punitive policy system that coerced change without supporting it. They managed financial pressure by reducing their tobacco consumption but also used increasingly desperate measures, including recycling waste tobacco; participants reported feeling demeaned by measures they saw as their only option.

CONCLUSION

Providing intensive cessation support for lower income smokers could avoid further alienating a group already experiencing considerable disadvantage.

A Review of Trends in Indigenous Australian Tobacco Research (From 2004 to 2013), its Associated Outputs and Evidence of Research Translation

INTRODUCTION

Smoking prevalence among Indigenous Australians nationally (45%) is more than double that of other Australians but ranges up to 82% in remote communities, causing significant health disparities. This paper examines trends in peer-reviewed research outputs related to Indigenous Australian tobacco control over the past decade and describes their research translation potential and alignment with national and jurisdictional policy priorities.

METHODS

Systematic searches of electronic databases were conducted: Medline, CINAHL, Cochrane Systematic Reviews, PsychInfo, and Australian HealthInfoNET for English-language peer-reviewed publications (2004-2013) primarily focusing on Indigenous Australian tobacco use. Publications were categorized by types, topics, and geographic location. Following established procedures, "reviews" and "commentaries" were distinguished from "original research," the latter further classified as "measurement," "descriptive," or "intervention" studies. Research translation categories used were: "synthesis," "dissemination," "exchange," and "application."

RESULTS

The majority of 78 publications meeting selection criteria focused on cessation treatment (28%), monitoring and prevalence (24%) and passive smoking (13%). "Original research" was mostly "descriptive/epidemiologic" (81%) with few "intervention" studies (9%). Many studies were in remote communities. Components of research translation were identified in 50% of the publications with little evidence of dissemination strategies.

CONCLUSION

Remote community populations are an area of great need. However, generally it is disappointing that since 2004, few intervention studies are available to guide efforts to reduce tobacco-related health disparities. Stronger and more immediate alignment of policy with research that contributes to the evidence-base is required together with more systematic use of research dissemination translation strategies to better match evidence with priorities which may develop rapidly over time.

A política antitabagismo e a variação dos gastos das famílias brasileiras com cigarro: resultados das Pesquisas de Orçamentos Familiares, 2002/2003 e 2008/2009

O estudo teve como objetivo descrever a evolução dos gastos com cigarro das famílias brasileiras e seu peso sobre a renda dessas no período de 2002-2009. Foram utilizados dados da Pesquisa de Orçamentos Familiares (POF) de 2002/2003 e 2008/2009. Foi realizada correção dos valores mediante o Índice de Preços ao Consumidor Amplo (IPCA). A proporção de famílias que tiveram gastos com cigarro reduziu de 23,5% para 18,2%, no período estudado, mas o valor do gasto aumentou de R$ 55,36 para R$ 59,45. O gasto foi maior à medida que aumentavam a renda e a escolaridade do chefe das famílias. As famílias com maior renda concentram a maior parte desses gastos, apesar da redução de sua contribuição no gasto total com cigarro. O comprometimento da renda na aquisição de cigarros foi de 5,2% no primeiro e de 1,2% no último quinto de renda. A política antitabagismo logrou êxitos na redução da prevalência do tabagismo no Brasil. Porém, medidas econômicas ainda são importantes no contexto nacional, tendo em vista que a parcela da renda e da despesa das famílias comprometida com cigarro apresentou redução.

Trends and socioeconomic differences in roll-your-own tobacco use: findings from the ITC Europe Surveys

OBJECTIVES

To examine if exclusive Roll-Your-Own (RYO) tobacco use relative to factory-made (FM) cigarette use has been rising over time, to determine the extent to which economic motives and perceptions that RYO cigarettes are less harmful act as primary motivations for use, and to examine the association of income and education with the level of RYO tobacco use among smokers in four European countries.

METHODS

Data were obtained from the International Tobacco Control (ITC) Europe Surveys, and a cohort sample of 7070 smokers from the Netherlands, Germany, France and UK were interviewed between June 2006 and December 2012. Generalised estimating equations (GEE) were used to assess trends in RYO use, and whether RYO consumption varied by socioeconomic variables.

RESULTS

Exclusive RYO use over the study period has increased significantly in the UK from 26.4% in 2007 to 32.7% in 2010 (p<0.001); France from 12.2% in 2006 to 19.1% in 2012 (p<0.001); and Germany from 12.7% in 2007 to 18.6% in 2011 (p=0.031), with increased borderline significantly in the Netherlands (31.7% to 34.3%, p=0.052), from 2008 to 2010. Over three-quarters of users in each of the study countries indicated that lower price was a reason why they smoked RYO. Just over a fourth of smokers in the UK, less than a fifth in France, and around a tenth in Germany and the Netherlands believed that RYO is healthier. Compared with exclusive FM users, exclusive RYO users were more likely to have lower incomes and lower education.

CONCLUSIONS

Effective tobacco tax regulation is needed in the European Union and elsewhere to eliminate or reduce the price advantage of RYO tobacco. Additional health messages are also required to correct the misperception that RYO tobacco is healthier than FM cigarettes.

Are lower income smokers more price sensitive?: the evidence from Korean cigarette tax increases

BACKGROUND

The cigarette excise taxes and the price of a typical pack of cigarettes in Korea have not increased since 2005, and effective tax rate as a fraction of price and real price of cigarettes have both been falling. As smoking prevalence is higher among lower income people than among higher income people in Korea, the regressivity of cigarette excise taxes is often cited as a barrier to tobacco tax and price policy. While studies in several other high-income countries have shown that higher income individuals are less price sensitive, few studies have examined the differential impact of cigarette tax increases by income group in Korea. Most of the Korean literature has estimated the demand for cigarettes using time-series aggregate sales data or household level survey data, which record household cigarette expenditures rather than individual cigarette consumption. Studies using survey data often lack time-series variation and estimate cigarette demand using household expenditure data, while studies using time-series aggregate sales data lack cross-sectional variation.

OBJECTIVE

I examine differences in the effects of cigarette price on the cigarette consumption of various income groups using individual-level cigarette consumption records from the Korea National Health and Nutrition Examination Survey (KHNNES). I also analyse the implications of cigarette taxes and price increases on the relative tax burdens of different income groups.

DESIGN

I use pooled data from the KNHNES for the 1998-2011 period to estimate the price elasticity of cigarette consumption of four income groups. Treating cigarette consumption as a latent variable, I employ an econometric procedure that corrects for non-random sample selection, or the fact that some non-smokers might have smoked at a low enough price, and estimate the price elasticity of cigarette consumption by income group. The estimated price elasticities include the responsiveness of potential smokers as well as current smokers.

RESULTS

Lower income Korean smokers are more responsive to changes in the price of cigarettes. While the overall price elasticity of cigarettes is estimated to be -0.425, the price elasticity of the lowest income quartile is estimated to be -0.812, whereas that of the highest income quartile is estimated to be -0.325.

CONCLUSIONS

The estimated price elasticities of different income groups imply that the cigarette tax and price increases in Korea would reduce smoking more in those with lower incomes. For a given price increase, the percentage reduction in cigarette consumption among smokers in the lowest income quartile is 2.5 times greater than among smokers in the top income quartile. The simulated tax burdens of different income groups show that the additional burden of a tax increase and the associated price rise is largely borne by higher income smokers.

Time series analysis of the impact of tobacco control policies on smoking prevalence among Australian adults, 2001-2011

OBJECTIVE

To determine the impact of tobacco control policies and mass media campaigns on smoking prevalence in Australian adults.

METHODS

Data for calculating the average monthly prevalence of smoking between January 2001 and June 2011 were obtained via structured interviews of randomly sampled adults aged 18 years or older from Australia's five largest capital cities (monthly mean number of adults interviewed: 2375). The influence on smoking prevalence was estimated for increased tobacco taxes; strengthened smoke-free laws; increased monthly population exposure to televised tobacco control mass media campaigns and pharmaceutical company advertising for nicotine replacement therapy (NRT), using gross ratings points; monthly sales of NRT, bupropion and varenicline; and introduction of graphic health warnings on cigarette packs. Autoregressive integrated moving average (ARIMA) models were used to examine the influence of these interventions on smoking prevalence.

FINDINGS

The mean smoking prevalence for the study period was 19.9% (standard deviation: 2.0%), with a drop from 23.6% (in January 2001) to 17.3% (in June 2011). The best-fitting model showed that stronger smoke-free laws, tobacco price increases and greater exposure to mass media campaigns independently explained 76% of the decrease in smoking prevalence from February 2002 to June 2011.

CONCLUSION

Increased tobacco taxation, more comprehensive smoke-free laws and increased investment in mass media campaigns played a substantial role in reducing smoking prevalence among Australian adults between 2001 and 2011.

Equity impact of population-level interventions and policies to reduce smoking in adults: a systematic review

BACKGROUND AND AIMS

There is strong evidence about which tobacco control policies reduce smoking. However, their equity impact is uncertain. The aim was to assess the effectiveness of population-level interventions/policies to reduce socioeconomic inequalities in adult smoking.

METHODS

Systematic review of studies of population-level interventions/policies reporting smoking-related outcomes in adults of lower compared to higher socioeconomic status (SES). References were screened and independently checked. Studies were quality assessed. Results are presented in a narrative synthesis. Equity impact was assessed as: positive (reduced inequality), neutral (no difference by SES), negative (increased inequality), mixed (equity impact varied) or unclear.

RESULTS

117 studies of 130 interventions/policies were included: smokefree (44); price/tax (27); mass media campaigns (30); advertising controls (9); cessation support (9); settings-based interventions (7); multiple policies (4). The distribution of equity effects was: 33 positive, 36 neutral, 38 negative, 6 mixed, 17 unclear. Most neutral equity studies benefited all SES groups. Fourteen price/tax studies were equity positive. Voluntary, regional and partial smokefree policies were more likely to be equity negative than national, comprehensive smokefree policies. Mass media campaigns had inconsistent equity effects. Cigarette marketing controls were equity positive or neutral. Targeted national smoking cessation services can be equity positive by achieving higher reach among low SES, compensating for lower quit rates.

CONCLUSIONS

Few studies have assessed the equity impact of tobacco control policy/interventions. Price/tax increases had the most consistent positive equity impact. More research is needed to strengthen the evidence-base for reducing smoking inequalities and to develop effective equity-orientated tobacco control strategies.

A cross-sectional survey of experts' opinions about the relative effectiveness of tobacco control strategies for the general population versus disadvantaged groups: what do we choose in the absence of evidence?

BACKGROUND

There is a clear disparity in smoking rates according to social disadvantage. In the absence of sufficiently robust data regarding effective strategies for reducing smoking prevalence in disadvantaged populations, understanding the views of tobacco control experts can assist with funding decisions and research agendas.

METHODS

A web-based cross-sectional survey was conducted with 192 respondents (response rate 65%) sampled from the Australian and New Zealand Tobacco Control Contacts list and a literature search. Respondents were asked to indicate whether a number of tobacco control strategies were perceived to be effective for each of: the general population; Aboriginal and Torres Strait Islander people; those with a low income; and people with a mental illness.

RESULTS

A high proportion of respondents indicated that mass media and increased tobacco taxation (84% and 89% respectively) were effective for the general population. Significantly lower proportions reported these two strategies were effective for sub-populations, particularly Aboriginal and Torres Strait Islanders (58% and 63% respectively, p's < .0001). Subsidised medication was the only strategy associated with a greater proportion of respondents perceiving it to be effective in disadvantaged sub-populations compared to the general population. Tailored quit programs and culturally relevant programs were nominated as additional effective strategies for disadvantaged populations.

CONCLUSIONS

Views about subsidised medications in particular, suggest the need for robust cost-effectiveness data relevant to disadvantaged groups to avoid wastage of scarce tobacco control resources. Strategies perceived to be effective for disadvantaged populations such as tailored or culturally relevant programs require rigorous evaluation so that potential adoption of these approaches is evidence-based.

Smoking and the potential for reduction of inequalities in mortality in Europe

Socioeconomic inequalities in health and mortality remain a widely recognized problem. Countries with smaller inequalities in smoking have smaller inequalities in mortality, and smoking plays an important part in the explanation of inequalities in some countries. We identify the potential for reducing inequalities in all-cause and smoking-related mortality in 19 European populations, by applying different scenarios of smoking exposure. Smoking prevalence information and mortality data come from 19 European populations. Prevalence rates are mostly taken from National Health Surveys conducted around the year 2000. Mortality rates are based on country-specific longitudinal or cross-sectional datasets. Relative risks come from the Cancer Prevention Study II. Besides all-cause mortality we analyze several smoking-related cancers and chronic obstructive pulmonary disease/asthma. We use a newly-developed tool to quantify the changes in population health potentially resulting from modifying the population distribution of exposure to smoking. This tool is based on the epidemiological measure of the population attributable fraction, and estimates the impact of scenario-based distributions of smoking on educational inequalities in mortality. The potential reduction of relative inequality in all-cause mortality between those with high and low education amounts up to 26 % for men and 32 % for women. More than half of the relative inequality may be reduced for some causes of death, often in countries of Northern Europe and in Britain. Patterns of potential reduction in inequality differ by country or region and sex, suggesting that the priority given to smoking as an entry-point for tackling health inequalities should differ between countries.

Minnesota smokers' perceived helpfulness of 2009 federal tobacco tax increase in assisting smoking cessation: a prospective cohort study

BACKGROUND

The cost of cigarettes has been cited as a motivating factor for smokers to quit smoking, and a cigarette tax increase is an effective way to increase the cost of cigarettes. Scholars have suggested that smokers may see cigarette tax increases as commitment devices to help them quit smoking. Little is known about whether smokers actually think cigarette tax increases help them quit, and whether this perception predicts subsequent smoking cessation behaviors. We used data from the Minnesota Adult Tobacco Survey Cohort Study collected after the 2009 federal tobacco tax increase to answer these questions.

METHODS

In 2009, 727 smokers were asked whether they thought the federal tobacco tax increase helped them to: (1) think about quitting, (2) cut down on cigarettes, and (3) make a quit attempt. We also collected data on demographics, number of cigarette price-minimizing strategies used, and cigarette consumption. In 2010, we assessed if these smokers had made a quit attempt, had cut down on their cigarette consumption, and had stopped smoking. Logistic regression models were used to assess the characteristics associated with the perceptions that the tax increase was helpful in assisting smoking cessation, and the association between these perceptions in 2009 and cessation behaviors in 2010.

RESULTS

Overall, 65% of the sample thought that the 2009 tax increase helped them think about quitting, 47% thought it helped them cut down on cigarettes, and 29% thought it helped them make a quit attempt. Lower education, lower income, lower cigarette consumption, and using more cigarette price-minimizing strategies were associated with the perceptions that the tax increase was helpful in assisting smoking cessation (p < 0.05). Smokers who perceived the tax increase as helpful in assisting smoking cessation were more likely than those who did not perceive the tax increase as helpful to report making a quit attempt in 2010 (p < 0.05).

CONCLUSIONS

A significant proportion of smokers in our sample thought the 2009 federal tobacco tax increase was helpful in assisting smoking cessation, particularly among smokers of lower socio-economic status. Health communication interventions to promote cigarette tax increases as an opportunity for smoking cessation may further assist quit attempts.

The effectiveness of cigarette price and smoke-free homes on low-income smokers in the United States

OBJECTIVES

We examined the effectiveness of state cigarette price and smoke-free homes on smoking behaviors of low-income and high-income populations in the United States.

METHODS

We used the 2006-2007 Tobacco Use Supplement to the Current Population Survey. The primary outcomes were average daily cigarette consumption and successful quitting. We used multivariable regression to examine the association of cigarette price and smoke-free home policies on these outcomes.

RESULTS

High state cigarette price (pack price ≥ $4.50) was associated with lower consumption across all income levels. Although low-income individuals were least likely to adopt smoke-free homes, those who adopted them had consumption levels and successful quit rates that were similar to those among higher-income individuals. In multivariable analysis, both policies were independently associated with lower consumption, but only smoke-free homes were associated with sustained cessation at 90 days.

CONCLUSIONS

High cigarette prices and especially smoke-free homes have the potential to reduce smoking behaviors among low-income individuals. Interventions are needed to increase adoption of smoke-free homes among low-income populations to increase cessation rates and prevent relapse.

A store cohort study of compliance with a point-of-sale cigarette display ban in Melbourne, Australia

INTRODUCTION

This study aimed to evaluate compliance with legislation which restricted cigarette displays in retail outlets, and to assess prevalence of pro- and anti-tobacco elements in stores pre- and post-legislation. METHODS Three audits of 302 stores in Melbourne, Australia by trained observers who gathered information on point-of-sale tobacco displays 2-3 months before and 3-4 and 11-12 months after the enactment of new restrictions.

RESULTS

Between the first and second audits, nine stores stopped selling tobacco and three stores had either shut down or were closed for renovations. Of the remaining 290 stores, 94.1% observed the full ban on cigarette package visibility, while new restrictions on price board size and new requirements for graphic health warnings were followed in 85.9% and 67.2% of stores, respectively. Between the second and third audits, another seven stores ended tobacco sales and two stores closed. In Audit 3, 89.7% of the remaining 281 stores complied with price board restrictions, and 82.2% of stores followed requirements for graphic health warnings. Overall, the prevalence of anti-tobacco signage increased and pro-tobacco features decreased between audits for every store type and neighborhood socio-economic status.

CONCLUSIONS

Tobacco retailers were almost universally compliant with placing cigarettes out of sight and a substantial majority were compliant with regulations on price board size and display of graphic health warnings, demonstrating that such legislation can be implemented successfully.

Cigarette smoking among Korean international college students in the United States

OBJECTIVE AND PARTICIPANTS

This study explored (1) the prevalence of cigarette smoking among South Korean international college students in the United States, (2) differences in smoking between on- and off-campus living arrangements, and (3) predictors of an increase in smoking over time in the United States

METHODS

An online survey was completed by 1,201 students at 52 4-year US universities (34% response rate).

RESULTS

The overall smoking prevalence was 43.5%. The smoking rate (29.0%) of female students was higher than that (4%) of female college students in South Korea. Sex, living place, living situation, length of stay as a student in the United States, home smoking rules, campus-wide tobacco-free policies, and levels of acculturative stress, anxiety, and depression were significantly associated with an increase in smoking (p < .05).

CONCLUSIONS

Given the high smoking prevalence among the South Korean students on US college campuses, targeted prevention efforts for these students may be warranted.

Impact and perceptions of tobacco tax increase in remote Australian Aboriginal communities

INTRODUCTION

We sought to assess the impact of a 25% tax excise rise on tobacco sales in Aboriginal communities in remote Australia and to explore local perceptions about tobacco tax rises and their impact.

METHODS

Tobacco sales data were collected from 18 stores in small remote Aboriginal communities from October 2009 to December 2010. Sales in the 7 months before and after the tax increase were compared. Interviews were conducted with 54 informants in 6 communities.

RESULTS

There was a nonsignificant 2.2% average reduction (95% CI = -5 to 10) in total tobacco sold in a store in the 7 months after the price increase compared with the 7 months before the price increase, with a large variation across the 18 stores. The magnitude of this apparent impact may have been reduced by seasonal effects. There were increased demands to share cigarettes, with a perception that there was increased reliance on those with more disposable income to purchase cigarettes for other smokers. The main reasons given for not quitting or reducing smoking were dependence, the normative nature of smoking, and the lack of support to quit. All Aboriginal interviewees supported price increases as important in reducing smoking.

CONCLUSIONS

The wide confidence interval around our estimated reduction in consumption means that the tax increase could have either been associated or not with a reduction in consumption. Future excise rises are supported but should be carefully monitored in Australian Indigenous populations.

Perceived price sensitivity by ethnicity and smoking frequency among California Hispanic and non-Hispanic white smokers

OBJECTIVES

Little is currently known about price sensitivity across ethnic groups as well as for non-daily smokers. To address this issue, this study compared perceived price sensitivity across smoking status (daily and non-daily) and within ethnicity (Hispanic and non-Hispanic White) in a recent representative population survey of California smokers.

METHODS

This study employed data from the 2008 California Tobacco Survey (CTS), a large population-based random-digit-dialed telephone survey. Participants were 1,777 non-Hispanic White and 450 Hispanic respondents who had smoked at least 100 cigarettes and currently smoked daily or on some days.

RESULTS

Differences in perceived price sensitivity were found by ethnicity when controlling for age, gender, and cigarette consumption. Comparisons across ethnic groups indicated that Hispanic smokers, in general, have more price-sensitive perceptions than non-Hispanic White smokers. However, daily versus non-daily status had no effect on price sensitivity when controlling for cigarette quantity.

CONCLUSIONS

These findings indicate that pricing increases may be differentially influential for Hispanic compared with non-Hispanic White smokers across smoking status categories.

The consequences of high cigarette excise taxes for low-income smokers

BACKGROUND

To illustrate the burden of high cigarette excise taxes on low-income smokers.

METHODOLOGY/PRINCIPAL FINDINGS

Using data from the New York and national Adult Tobacco Surveys from 2010-2011, we estimated how smoking prevalence, daily cigarette consumption, and share of annual income spent on cigarettes vary by annual income (less than $30,000; $30,000-$59,999; and more than $60,000). The 2010-2011 sample includes 7,536 adults and 1,294 smokers from New York and 3,777 adults and 748 smokers nationally. Overall, smoking prevalence is lower in New York (16.1%) than nationally (22.2%) and is strongly associated with income in New York and nationally (P<.001). Smoking prevalence ranges from 12.2% to 33.7% nationally and from 10.1% to 24.3% from the highest to lowest income group. In 2010-2011, the lowest income group spent 23.6% of annual household income on cigarettes in New York (up from 11.6% in 2003-2004) and 14.2% nationally. Daily cigarette consumption is not related to income.

CONCLUSIONS/SIGNIFICANCE

Although high cigarette taxes are an effective method for reducing cigarette smoking, they can impose a significant financial burden on low-income smokers.

Cigarette prices, cigarette expenditure and smoking-induced deprivation: findings from the International Tobacco Control Mexico survey

AIM

Mexico implemented annual tax increases between 2009 and 2011. We examined among current smokers the association of price paid per cigarette and daily cigarette expenditure with smoking-induced deprivation (SID) and whether the association of price or expenditure with SID varies by income.

METHODS

We used data (n=2410) from three waves of the International Tobacco Control Mexico survey (ie, 2008, 2010, 2011) and employed logistic regression to estimate the association of price paid per cigarette and daily cigarette expenditure with the probability of SID ('In the last 6 months, have you spent money on cigarettes that you knew would be better spent on household essentials like food?').

RESULTS

Price paid per cigarette increased from Mex$1.24 in 2008, to Mex$1.36 in 2010, to Mex$1.64 in 2011. Daily cigarette expenditure increased from Mex$6.9, to Mex$7.6 and to Mex$8.4 in the 3 years. There was no evidence of an association between price and SID. However, higher expenditure was associated with a higher probability of SID. There was no evidence that the association of price or expenditure with SID varied by income.

CONCLUSION

Tax increases in Mexico have resulted in smokers paying more and spending more for their cigarettes. Those with higher cigarette expenditure experience more SID, with no evidence that poorer smokers are more affected.

The long-term decline of adult tobacco use in Victoria: changes in smoking initiation and quitting over a quarter of a century of tobacco control

OBJECTIVE

To examine changes in regular smoking prevalence among demographic and socioeconomic groups of Victorian adults from 1984 to 2008.

METHODS

Data were drawn from face-to-face and telephone surveys of randomly sampled Victorians conducted annually from 1984 to 2008.

RESULTS

Regular smoking in Victoria declined from 33.2% in 1984 to 15.5% in 2008, a relative decline of 53%. This change was largely accounted for by significant drops in 'ever smoking' among 18-29 year olds (from 59% to 35%, a relative decline of 41%) and by increased quitting among those aged 30 and older (from a quit proportion [% of those ever smoked who have quit] of 37% to 61% among 30-49 year olds, a relative increase of 64%; and from 53% to 79% among 50+ years, an increase of 48%). Over time, smoking prevalence became more similar between males and females. Regular smoking declined significantly across all socioeconomic status (SES) groups. Victorians living in low SES areas experienced the greatest relative increase in quit proportions of 75% (from 34% to 60%), helping to reduce the gap between low and higher SES groups in terms of smoking prevalence.

CONCLUSIONS

Regular smoking in Victoria has declined substantially across all demographic groups. Victorians are taking up smoking at much lower levels than 25 years ago, while quit proportions have more than doubled.

IMPLICATIONS

The continuation and extension of comprehensive, multi-level approaches to tobacco control is likely to be required for the maintenance of the downward trend in smoking.

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

Background. Policymakers need estimates of the impact of tobacco control (TC) policies to set priorities and targets for reducing tobacco use. We systematically reviewed the independent effects of TC policies on smoking behavior. Methods. We searched MEDLINE (through January 2012) and EMBASE and other databases through February 2009, looking for studies published after 1989 in any language that assessed the effects of each TC intervention on smoking prevalence, initiation, cessation, or price participation elasticity. Paired reviewers extracted data from studies that isolated the impact of a single TC intervention. Findings. We included 84 studies. The strength of evidence quantifying the independent effect on smoking prevalence was high for increasing tobacco prices and moderate for smoking bans in public places and antitobacco mass media campaigns. Limited direct evidence was available to quantify the effects of health warning labels and bans on advertising and sponsorship. Studies were too heterogeneous to pool effect estimates. Interpretations. We found evidence of an independent effect for several TC policies on smoking prevalence. However, we could not derive precise estimates of the effects across different settings because of variability in the characteristics of the intervention, level of policy enforcement, and underlying tobacco control environment.

Cigarette smoking, illicit drug use, and routes of administration among heroin and cocaine users

Cigarette smoking is ubiquitous among illicit drug users. Some have speculated that this may be partially due to similarities in the route of administration. However, research examining the relationship between cigarette smoking and routes of administration of illicit drugs is limited. To address this gap, we investigated sociodemographic and drug use factors associated with cigarette smoking among cocaine and heroin users in the Baltimore, Maryland community (N=576). Regular and heavy cigarette smokers were more likely to be White, have a history of a prior marriage, and have a lower education level. Regular smoking of marijuana and crack was associated with cigarette smoking, but not heavy cigarette smoking. Injection use was more common among heavy cigarette smokers. In particular, regular cigarette smokers were more likely to have a lifetime history of regularly injecting heroin. Optimal prevention and treatment outcomes can only occur through a comprehensive understanding of the interrelations between different substances of abuse.

Tobacco use among married women in Nepal: the role of women's empowerment

This study documented the prevalence and correlates of tobacco use among women of reproductive age in Nepal using nationally representative data. We utilized the 2006 Nepal Demographic and Health Survey that interviewed 10,793 women and 4,397 men. We analyzed the couple's data or households (N = 2,600) in which both husband and wife were interviewed. We examined the effects of women's empowerment-measured by education, employment, intra-household decisions, and age-on their tobacco use controlling for other individual and household characteristics. Women's empowerment had mixed effects on tobacco use. While women's education was inversely associated with their tobacco use, their age, employment and ability to make intra-household mobility decisions were positively associated with smoking. Women with primary and beyond primary education were 48 and 92 % less likely to smoke compared to women with no education, respectively. Tobacco use among women increased dramatically with age from 8 % in teen years to 42 % in their forties. A 1 year increase in age increased the odds of tobacco use by 6 %. Women whose husbands smoked were twice as likely to smoke. Nepal should not only restrict tobacco use in public places by implementing its Tobacco Control and Regulatory Act of 2010 but also focus on encouraging smoke-free homes by increasing awareness about the health consequences of tobacco use and secondhand smoke among populations most likely to smoke that include nearly all men, employed women, women with low levels of education, women whose spouses smoke and those who are 30 and above in age. Additionally, a long term goal should be to ensure at least 5th grade of education for all girls.

The influence of neighbourhood disadvantage on smoking cessation and its contribution to inequalities in smoking status

INTRODUCTION AND AIMS

Individual smokers from disadvantaged backgrounds are less likely to quit, which contributes to widening inequalities in smoking. Residents of disadvantaged neighbourhoods are more likely to smoke, and neighbourhood inequalities in smoking may also be widening because of neighbourhood differences in rates of cessation. This study examined the association between neighbourhood disadvantage and smoking cessation and its relationship with neighbourhood inequalities in smoking.

DESIGN AND METHODS

A multilevel longitudinal study of mid-aged (40-67 years) residents (n = 6915) of Brisbane, Australia, who lived in the same neighbourhoods (n = 200) in 2007 and 2009. Neighbourhood inequalities in cessation and smoking were analysed using multilevel logistic regression and Markov chain Monte Carlo simulation.

RESULTS

After adjustment for individual-level socioeconomic factors, the probability of quitting smoking between 2007 and 2009 was lower for residents of disadvantaged neighbourhoods (9.0-12.8%) than their counterparts in more advantaged neighbourhoods (20.7-22.5%). These inequalities in cessation manifested in widening inequalities in smoking: in 2007 the between-neighbourhood variance in rates of smoking was 0.242 (P ≤ 0.001) and in 2009 it was 0.260 (P ≤ 0.001). In 2007, residents of the most disadvantaged neighbourhoods were 88% (OR 1.88, 95% credible intervals (CrI) 1.41-2.49) more likely to smoke than residents in the least disadvantaged neighbourhoods: the corresponding difference in 2009 was 98% (OR 1.98, 95% CrI 1.48-2.66).

CONCLUSION

Fundamentally, social and economic inequalities at the neighbourhood and individual levels cause smoking and cessation inequalities. Reducing these inequalities will require comprehensive, well-funded and targeted tobacco control efforts and equity-based policies that address the social and economic determinants of smoking.

The effects of Arkansas master settlement spending on disparities in smoking

OBJECTIVES

We assessed the effect of Master Settlement Agreement (MSA) spending on smoking disparities in Arkansas, which distinguished itself from other states by investing all of its MSA funds in health-related programs.

METHODS

In 1996-2009 data from the Behavioral Risk Factor Surveillance System, we specified multivariate logistic models to examine gender and racial/ethnic disparities in smoking rates within Arkansas (a pre-post analysis) and between Arkansas and its 6 neighboring states.

RESULTS

Before the MSA programs started in 2001, male Arkansans smoked more than did female Arkansans (P < .05). After the programs, smoking declined significantly among men (but not women), eliminating the gender disparity by 2009. Smoking among men in Arkansas also declined more than it did in neighboring states (P < .05). Hispanics showed a greater decline in smoking than did non-Hispanic Whites in Arkansas (but not in neighboring states). In 2001, Hispanic Arkansans smoked more than did non-Hispanic Whites (P < .05); by 2009, Hispanic Arkansans smoked significantly less than did non-Hispanic Whites (P < .05).

CONCLUSIONS

MSA-funded programs were more effective in some segments of the Arkansas population than in others. Policymakers should consider targeting future MSA tobacco control programs to populations most resistant to change.

Tobacco expenditure, smoking-induced deprivation and financial stress: results from the International Tobacco Control (ITC) Four-Country Survey

INTRODUCTION AND AIMS

While higher tobacco prices lead to a reduction in smoking prevalence, there is a concern that paying more for cigarettes can lead to excess financial burden. Our primary aim was to examine the association of daily cigarette expenditure with smoking-induced deprivation (SID) and financial stress (FS).

DESIGN AND METHODS

We used data from wave 7 (2008-2009) of the International Tobacco Control (ITC) Four-Country Survey which is a survey of smokers in Canada, the USA, the UK and Australia (n = 5887). Logistic regressions were used to assess the association of daily cigarette expenditure with SID and FS.

RESULTS

In multivariate analyses, a one standard deviation increase in daily cigarette expenditure was associated with an increase of 24% (P = 0.004) in the probability of experiencing SID. While we found no association between daily cigarette expenditure and FS, we found that SID is a strong predictor of FS (odds ratio 6.25; P < 0.001). This suggests that cigarette expenditure indirectly affects FS through SID. Results showed no evidence of an interaction between cigarette expenditure and income or education in their effect on SID or FS.

CONCLUSIONS

Our results imply that spending more on tobacco may result in SID but surprisingly has no direct effect on FS. While most smokers may be adjusting their incomes and consumption to minimise FS, some fail to do so occasionally as indexed by the SID measure. Future studies need to prospectively examine the effect of increased tobacco expenditure on financial burden of smokers.

Interventions to increase smoking cessation at the population level: how much progress has been made in the last two decades?

This paper reviews the literature on smoking cessation interventions, with a focus on the last 20 years (1991 to 2010). These two decades witnessed major development in a wide range of cessation interventions, from pharmacotherapy to tobacco price increases. It was expected that these interventions would work conjointly to increase the cessation rate on the population level. This paper examines population data from the USA, from 1991 to 2010, using the National Health Interview Surveys. Results indicate there is no consistent trend of increase in the population cessation rate over the last two decades. Various explanations are presented for this lack of improvement, and the key concept of impact = effectiveness × reach is critically examined. Finally, it suggests that the field of cessation has focused so much on developing and promoting interventions to improve smokers' odds of success that it has largely neglected to investigate how to get more smokers to try to quit and to try more frequently. Future research should examine whether increasing the rate of quit attempts would be key to improving the population cessation rate.