Economic Impact of Tobacco Price Increases Through Taxation: A Community Guide Systematic Review

Identifying policy options to regulate high potency cannabis: A multiple stakeholder concept mapping study in Washington State, USA

BACKGROUND

Cannabis legalization in some U.S.A. states has catapulted the mass production of concentrates, with tetrahydrocannabinol (THC) concentrations ranging from 50-90%. A major public health concern is that these products will increase cannabis-related harms such as use disorders, psychotic symptoms, and accidental poisonings. This paper describes and contextualizes the results of a study requested by the WA State Legislature to understand perspectives of WA stakeholders on the topic.

METHODS

Concept Mapping (CM), a mixed-methods research approach that supports people-centered policy decisions was utilized. The goal of the study was to explore stakeholders' concern levels and support of policies to address the availability of high THC cannabis products. For analysis purposes, stakeholders were categorized into three groups: community, professionals, and cannabis advocates.

RESULTS

CM generated an inventory of policy ideas for regulating high-potency cannabis from a variety of stakeholders. Notably, stakeholders from community and professional groups supported environmental policy changes such as such as taxation, increasing minimum age for high concentration cannabis products, and advertising prohibition. Meanwhile, cannabis advocates (mostly industry actors) opposed taxation per THC content, proposed lowering taxes, and supported policies with low population impact such as educating parents, teachers, and youth.

CONCLUSION

Support for regulating high concentration THC products varied by stakeholder group. Consistent with how other health compromising industries have historically acted, cannabis industry stakeholders rejected regulation of their products. Future studies should explore non-cannabis industry stakeholders' willingness to work towards minimizing the influence of the cannabis industry in policy development processes to assure public health regulations prevail.

Economic research in waterpipe tobacco smoking: reflections on data, demand, taxes, equity and health modelling

Economic evaluation of tobacco control policies is common in high-income settings and mainly focuses on cigarette smoking. Evidence suggests that increasing the excise tax of tobacco products is a consistently effective tool for reducing tobacco use and is an efficient mechanism for increasing government revenues. However, less research has been conducted in low/middle-income countries where other tobacco forms are common. This paper presents insights from our work on the economics of waterpipe tobacco smoking conducted in the Eastern Mediterranean Region where waterpipe smoking originated and is highly prevalent. The specific areas related to economics of waterpipe smoking considered herein are: price elasticity, taxation, government revenue, expenditure and healthcare costs. This paper aims to provide practical guidance for researchers investigating the economics of waterpipe tobacco with potential implications for other novel tobacco products. We present lessons learnt across five thematic areas: data, demand, taxes, equity and health modelling. We also highlight knowledge gaps to be addressed in future research. Research implications include designing comprehensive assessment tools that investigate heterogeneity in waterpipe smoking patterns; accounting for cross-price elasticity of demand with other tobacco products; exploring the change in waterpipe tobacco smoking in response to a tax increase and analysing the equity impact of waterpipe tobacco control interventions.

Impact of the Spanish smoke-free laws on cigarette sales by brands, 2000-2021: Evidence from a club convergence approach

INTRODUCTION

In January 2006, the Spanish government enacted a tobacco control law that banned the advertising, promotion and sponsorship of tobacco. In January 2011, further legislation on this matter was adopted to provide a more restrictive specification of the ban. In this study, we analyze the effect produced on cigarette sales by these two prohibitions. We address this problem using a cluster time-series analysis to test whether the sales of cigarettes by brands have been homogenized with the prohibition of advertising, promotion, and sponsorship.

METHODS

The data source used was the official data on legal sales of cigarettes by brands in Spain, from January 2005 to December 2021 (excluding the Canary Islands and the Autonomous Communities of the cities of Ceuta and Melilla). To achieve our objective, we used log(t) test statistics to check if there is global convergence in the three selected periods according to the regulatory changes that have occurred in Spain (2005-2021, 2005-2010 and 2011-2021). Second, once absolute convergence is rejected, we applied a clustering algorithm to test for the existence of subgroup convergence.

RESULTS

The cigarette brands that have been marketed during the period 2005-2021 (n=40), can only be grouped into three groups according to the behavior of their sales. When we focus on the period 2005-2010 (n=74), cigarette brands are grouped into five groups according to their sales behavior. Finally, the cigarette brands marketed during the period 2011-2021 (n=67) are grouped into three groups according to the temporal evolution of their sales. These results suggest a greater homogenization of cigarette sales after the application of the law of January 2011.

CONCLUSIONS

Act 42/2010 (total ban on tobacco advertising, promotion, and sponsorship actions) was associated with greater homogenization of cigarette sales than the application of Act 28/2005 (partial ban). This finding supports what is established in the previous literature that indicates that Act 42/2010 provided a more restrictive specification of the ban than Act 28/2005.

Price Promotions of E-Liquid Products Sold in Online Stores

Background: Retailer price promotions are an important marketing strategy to attract consumers. However, there is scarce evidence on how retail price promotions are being implemented by e-cigarette online stores, particularly for e-liquid products that are not often found in brick-and-mortar stores and sold in lower prices compared to other types of e-cigarettes. Objectives: We collect data on e-liquid price-promotion activities from online stores using web scraping. From February to May 2021, we scraped the price promotion data of over 14,000 e-liquid products, from five popular online vape shops that sell nationwide in the US. We present descriptive analyses of price promotion on those products, assess price promotion practices in online stores, and discuss components of the final purchase price paid by online customers. Findings: Of the 14,000 e-liquid products and over, 13,326 (92.36%) were on sale, and each online store on average offered discounts from 9.20% to 47.53% for these products. The distribution of the after-discount price was largely similar across the five stores, and there is evidence that each store had adopted different price-promotion strategies. Conclusion: Despite low prices, price promotions are common for e-liquid products, which may undermine the effect of e-cigarette pricing policies such as excise tax that are designed to raise e-cigarette prices.

A qualitative study on retailer experiences with Philadelphia's sweetened beverage tax

The Philadelphia Beverage Tax was implemented on January 1, 2017 for some sugar- and artificially-sweetened beverages. Few qualitative studies have assessed retailers' reactions to beverage taxes. We aimed to understand food retailers' knowledge and attitudes about the Philadelphia beverage tax and how they responded to it with the goal of informing the framing and implementation of beverage taxes in other interested jurisdictions. Researchers conducted semi-structured interviews with retailers within Philadelphia before (n = 15) and after (n = 11) the Philadelphia Beverage Tax was implemented. Purposeful sampling was used to recruit participants with different store locations and customer base characteristics. A priori codes based on the interview guide were used to organize data, and analytic memos were developed and reviewed to identify themes that emerged within the data using a grounded theory approach. Five themes emerged: (a) concerns about the tax purpose, amount, and use of revenue; (b) concerns about the tax's impact on finances and business operations; (c) business strategies implemented to lessen financial burden of the tax; (d) perceptions of customer responses to the tax based on income; and (e) confusion around tax implementation. Results highlighted ways to improve implementation. Retailers in Philadelphia implemented various strategies to offset negative effects on taxed beverage sales. Cities implementing a beverage tax would benefit from investment in educational outreach and support to business owners prior to tax implementation and ensure transparency in how tax revenue will be spent.

Cancer Groundshot: Building a Robust Cancer Control Platform in Addition To Launching the Cancer Moonshot

Cancer Groundshot is a philosophy that calls for prioritization of strategies in global cancer control. The underlying principle of Cancer Groundshot is that one must ensure access to interventions that are already proven to work before focusing on the development of new interventions. In this article, we discuss the philosophy of Cancer Groundshot as it pertains to priorities in cancer care and research in low- and middle-income countries and the utility of technology in addressing global cancer disparities; we also address disparities seen in high-income countries. The oncology community needs to realign our priorities and focus on improving access to high-value cancer control strategies, rather than allocating resources primarily to the development of technologies that provide only marginal gains at a high cost. There are several "low-hanging fruit" actions that will improve access to quality cancer care in low- and middle-income countries and in high-income countries. Worldwide, cancer morbidity and mortality can be averted by implementing highly effective, low-cost interventions that are already known to work, rather than investing in the development of resource-intensive interventions to which most patients will not have access (i.e., we can use Cancer Groundshot to first save more lives before we focus on the "moonshots").

Impact of tobacco price and taxation on affordability and consumption of tobacco products in the South-East Asia Region: A systematic review

INTRODUCTION

The objective of the review was to study the impact of tobacco taxes or prices on affordability and/or consumption of tobacco products in WHO South-East Asia Region (SEAR) countries, overall and by socioeconomic status; and change in consumption of one tobacco product for a given change in price/tax on another tobacco product.

METHODS

The searches were made in five databases (Medline, Embase, Cinahl, EconLit, Tobacconomics) using keywords such as 'tobacco', 'tax', 'price', 'impact' with their synonyms. Additionally, the first 100 articles through google search and e-reports from targeted sources were also reviewed. Studies illustrating the impact of prices/taxes on consumption/affordability of tobacco products in SEAR, in English and with no limitation on year, were included in the review. After two steps of screening, data from 28 studies were extracted using a structured and pre-tested data extraction form.

RESULTS

Of the 28 studies, 12 studies reported an inverse association between price and consumption/affordability, while 11 studies reported no or positive association between price and consumption/affordability of tobacco products. Five studies had unclear interpretations. The majority of studies estimated that the less affluent group were more price responsive compared to the more affluent group. Some studies indicated increased consumption of one product in response to price rise of another product, although, the findings were inconsistent.

CONCLUSIONS

The findings of our review support the use of tobacco tax and price measures as effective tools to address the tobacco epidemic. Our findings, however, also emphasize the importance of increasing tobacco product taxes and prices sufficiently to outweigh the effects of income growth, in order for the measures to be effective in reducing the affordability and consumption of tobacco products.

Cost-effectiveness analysis of the 2019 cigarette excise tax reform in the Philippines

In this past decade alone, the Philippines has made major strides in increasing the price of cigarettes. This study estimated the cost-effectiveness of the most recent cigarette price increase of about 29% brought about by Republic Act (RA) 11346 in 2019. A static or a single cohort model was populated with locally-sourced inputs whenever possible. Public payer and societal perspectives were taken wherein the former only considered direct costs and tax revenue gained earmarked for the health sector while the latter adds indirect costs in the form of productivity losses. A 7% discount rate was applied. Increasing the price of cigarettes by about 29% was found to prevent about 1961 tobacco-related deaths which translate to about 34,571 disability adjusted life years (DALYs) saved. Savings incurred from hospitalizations prevented and additional excise tax revenues for health was about USD 367 Million. But when productivity losses averted due to the lives saved and the higher cost of hospitalizations were accounted for in the societal perspective, the excise tax reform yielded USD 415 Million net gain. It would save the public payer USD 10,612 per DALY averted while society at large stand to save USD 11,955 per DALY averted. Tax increases like RA 11346 yield significant revenue that can be used towards public health programs.

E-cigarette and cigarette purchasing among young adults before and after implementation of California's tobacco 21 policy

BACKGROUND

Tobacco 21 (T21) laws, which raise the minimum legal age of sale of tobacco products to 21, have been proposed and implemented in states and cities across the USA. However, limited data are available on the effect of T21 laws on youth tobacco purchasing behaviours and access to tobacco products.

METHODS

Participants in a population-based prospective cohort in southern California completed questionnaires before (n=1609, age=18-19 y) and after (n=1502, age=19-20 y) T21 was implemented in California (June 2016). We examined the prevalence of past 30-day cigarette and e-cigarette use, and among past 30-day users, purchase location of tobacco products before (pre-) versus after (post-) T21. We also examined whether, post-T21, participants were refused purchase of tobacco products due to their age, and the perceived relative ease of purchasing cigarettes and e-cigarettes (vs pre-T21).

RESULTS

Negligible changes in cigarette and e-cigarette use were observed pre-T21 versus post-T21. At both time points, the majority of past 30-day users purchased cigarettes from gas stations and e-cigarettes from vape shops. Post-T21, the proportion of participants who reported purchasing cigarettes at gas stations decreased. Post-T21, most past 30-day cigarette or e-cigarette users were not refused purchase of cigarettes (65.4%) or e-cigarettes (82.0%) in the past 30 days, despite being under 21; half of the participants felt it was harder to purchase cigarettes (54.3%) and e-cigarettes (43.6%) post-T21.

CONCLUSION

Post-T21, few participants were refused purchase of any tobacco product, despite the illegality of such sales. Better enforcement of T21 is needed to improve the efficacy of T21 legislation.

Message framing to inform cancer prevention pricing interventions in the UK and USA: a factorial experiment, 2019

OBJECTIVES

To advance understanding of how message framing can be used to maximise public support across different pricing policies for alcohol, tobacco and sugary drinks/foods that prevent consumption of cancer-causing products.

DESIGN

We designed a 3×4×3 randomised factorial experiment to test responses to messages with three pricing policies, four message frames and three products.

SETTING

Online survey panel (Qualtrics) in 2019.

PARTICIPANTS

Adults (N=1850) from the UK and USA.

INTERVENTIONS

Participants randomly viewed one of 36 separate messages that varied by pricing policy (increasing taxes, getting rid of price discounts, getting rid of low-cost products), four frames and product (alcohol, tobacco, sugary drinks/foods).

PRIMARY AND SECONDARY OUTCOME MEASURES

We assessed the relationship between the message characteristics and four dependent variables. Three were related to policy support: (1) increasing taxes on the product mentioned in the message, (2) getting rid of price discounts and special offers on the product mentioned in the message and (3) getting rid of low-cost versions of the product mentioned in the message. One was related to reactance, a psychological response to having one's freedom limited.

RESULTS

We found no effect for pricing policy in the message. Frames regarding children and reducing cancer risk moderated some outcomes, showing promise for real-world use. We found differences in support by product and reactance with greatest support and least reactance for tobacco policies, less support and more reactance for alcohol policies, and the least support and most reactance for sugary drinks/foods policies.

CONCLUSIONS

Cancer prevention efforts using policy interventions can be informed by the message framing literature. Our results offer insights for cancer prevention advocacy efforts across the UK and USA and highlight that tax versus non-tax approaches to increasing the cost of cancer-causing products result in similar responses from consumers.

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.

Price and income elasticities of demand for cigarette consumption: what is the association of price and economic activity with cigarette consumption in Spain from 1957 to 2016?

OBJECTIVES

Extensive empirical and theoretical studies have been devoted to analyzing the relationship between tobacco and income. The price and income elasticities of demand for cigarette consumption are the main focus of studies in this body of literature. However, few empirical studies exist that analyze how economic growth affects the cigarette market, and no one has studied the effects of economic expansions and recessions. Spain, as in the other countries of the European Union, has suffered a strong recession since 2008. Therefore, this article aims to detect if income elasticity takes different values in economic growth and recession and, in addition, to check whether price elasticity in Spain is consistent with previous studies.

STUDY DESIGN

This is an observational epidemiological study.

METHODS

In this article, the price and income elasticities of demand for cigarette consumption are measured for the Spanish cigarette market using time series data from 1957 to 2016 and by applying a non-linear autoregressive dynamics lag model. The novel specification proposed in this study is the determination of the possible effects of asymmetries in the economic shocks on cigarette consumption.

RESULTS

Our results reveal that cigarette consumption maintains a notable asymmetric relationship. In particular, our results show that in expansion shocks, cigarette consumption increases (a 10% economic growth is associated with a 4.05% increase in cigarette consumption), whereas in recession shocks, cigarette consumption decreases dramatically, with a more pronounced pattern in recession phases than in expansion phases (a 10% economic decline is associated with a 58.16% decrease in cigarette consumption). On the other hand, price elasticity maintains the same behavior shown in the previous literature (a 10% price increase is associated with a 2% decrease in cigarette consumption).

CONCLUSIONS

Higher cigarette prices are associated with decreased smoking. In addition, the economic recession helps in decreasing cigarette consumption. Therefore, it is strongly recommended that tax authorities have our results in mind before establishing health policies. If the authorities do not, it is possible that they will not obtain the expected results in terms of decreased tobacco consumption.

The Price Elasticity of Cigarettes: New Evidence From Spanish Regions, 2002–2016

Introduction

There is an agreement in the literature that tobacco price elasticity is around −0.4 for given location. Furthermore, works only focus separately, on the temporal dimension or the spatial dimension, however, there are studies that show the existence of spillovers between different geographical areas due to the spatial dependence in tobacco consumption. The novelty of this study is the measurement of the effect that neighboring regions have on the price elasticity of cigarettes.

Aims and Methods

This study simultaneously analyzed, first, a dynamic spatial model used to measure the price elasticity of cigarettes in the short term and long term of the 47 provinces that make up the Spanish territory, detailing the influence of neighbors. Second, given the spatial arrangement of the elasticities observed in the provinces, we can detect behaviors typical of large-scale illicit trade and cross-border purchasing since geographical location can be an important factor in smuggling, and politicians should take this into account when making price policies.

Results

Results reveal that the consumption of the regions is influenced by the consumption of the neighboring regions in the same period. The price elasticity of cigarettes in the long term exceeds in many cases, in absolute value, unity. This result is novel because tobacco has historically been treated as an inelastic demand good. Finally, we found that the regions that are most sensitive to price are those bordering France and Gibraltar or tourist regions, demonstrating the effect that smuggling has on the behavior of the regions.

Conclusions

These results are important because the price in Spain is set by the central government and fiscal policies regarding the price of tobacco can have different effects in different regions. This study has shown that the consumption of cigarettes is influenced by the neighboring regions and also measured different sensitivities for each region. Regional cooperation in tobacco control policies may have better effects than the elaborated policies based on historical information.

Implications

Policy makers should consider that tobacco could be an elastic good in the long term and that cooperation between countries in terms of price differential should be taken to avoid tobacco smuggling. The allocation of resources to control smoking should consider the special dependence shown in this report. Also, academics should account for spatial dependence to measure tobacco consumption instead of temporal analysis.

Increases in Cigarette Consumption and Decreases in Smoking Intensity When Nondaily Smokers Are Provided With Free Cigarettes

Introduction

Studies testing novel tobacco products often provide participants with free product and assess consumption. Some, but not all, studies find that providing free cigarettes increases smoking. We tested changes in smoking when free cigarettes were provided to nondaily, intermittent smokers, who constitute one-third of US adult smokers.

Methods

Cigarette consumption was assessed by Time-Line Follow-Back in 235 intermittent smokers for two 2-week periods: when providing their own cigarettes and when provided own-brand cigarettes for free. Smoking topography and carbon monoxide boost were assessed for one cigarette at the end of each period.

Results

Cigarette consumption increased significantly, by 66% (from 1.98 to 3.28 cigarettes per day), when cigarettes were available for free; both the number of days the subjects smoked and the number of cigarettes on those days increased. The increases were significantly greater among African Americans, those Fagerström Tobacco Nicotine Dependence scores >0, those with incomes less than US $25,000 per year, those who engaged in greater conscious restraint of smoking, and for smokers of menthol cigarettes, or "longs." Smoking intensity (smoke volume, by topography) and carbon monoxide boost decreased significantly when cigarettes were provided for free.

Conclusions

Providing intermittent smokers with free cigarettes substantially increased their smoking while decreasing smoking intensity. The increases in smoking varied according to multiple individual and cigarette-type differences. These phenomena may complicate interpretation of studies that compare consumption of a free test product with cigarette consumption or constituent exposure when smokers are providing their own cigarettes. They also suggest that cigarette cost and variations in low-level dependence and in smoking restraint are factors in nondaily smoking.

Implications

The study shows that providing nondaily smokers with free cigarettes increases cigarette consumption, but does differentially for different subgroups and cigarette types, while also decreasing smoking intensity. This suggests the value of using free-cigarette baseline data in studies where interventions provide free cigarettes.

What do cost-effective health behaviour-change interventions contain? A comparison of six domains

OBJECTIVES

To help implement behaviour change interventions (BCIs) in practice it is important to be able to characterize their key components. This study compared broad features of cost-effective BCIs that addressed smoking, diet, physical activity, alcohol and sexual health. It also assessed the association of these with the magnitude of the cost-effectiveness estimates.

METHODS

A content analysis of 79 interventions based on 338 intervention descriptions was conducted, using the Behaviour Change Wheel (BCW) to classify intervention content in terms of intervention functions, and the BCT taxonomy to identify and categorise component Behaviour Change Techniques (BCT). Regression analysis identified the association of these with upper (pessimistic) and lower (optimistic) cost-effectiveness estimates.

RESULTS

The most and least common functions and BCT clusters were education (82.3%) and shaping knowledge (79.7%), and coercion (3.8%) and covert learning (2.5%). Smoking interventions contained the largest ([Formula: see text] = 12) number of BCTs and were most cost-effective. Several other factors were associated with worse (coercionfunction βupper = 36551.24; shaping knowledgeBCT βlower = 2427.78; comparison of outcomesBCT βupper = 9067.32; repetition and substitutionBCT βupper = 7172.47) and better (modellingfunction βlower = -2905.3; environmental restructuringfunction βupper = -8646.28; reward and threatBCT βupper = -5577.59) cost-effectiveness (p<0.05).

DISCUSSION

Cost-effective BCIs rely heavily on education with smoking interventions exhibiting the most comprehensive range of BCTs. Providing an example to aspire to, restructuring the environment and rewarding positive behaviour may be associated with greater cost-effectiveness.

National Cancer Societies and their public statements on alcohol consumption and cancer risk

BACKGROUND AND AIMS

Studies have shown that alcohol consumption is a risk factor for oral, pharyngeal, laryngeal, esophageal, liver, colon, rectal and breast cancer. It would therefore be expected that cancer prevention organizations would incorporate these facts into their public stance on the consumption of alcohol. The aims of this study were to: (1) assess how national cancer societies in developed English-speaking countries [i.e. English-speaking countries belonging to the Organization for Economic Co-operation and Development (OECD)] communicate alcohol-related cancer risk to the public and (2) compare whether these organization's advocacy of increased alcohol taxes is in line with their advocacy of tobacco tax increases to reduce cancer risk.

METHODS

We searched the websites of the following national cancer organizations for all statements related to the relationship between alcohol consumption and cancer risk: Cancer Council Australia, Canadian Cancer Society, Irish Cancer Society, Cancer Society New Zealand, Cancer Research UK and the American Cancer Society. A categorical system was developed to code the qualitative data for health statements, alcohol consumption recommendations, and tax policy recommendations. Websites were analyzed in March of 2017.

RESULTS

All organizations, with the exception of the American Cancer Society and Canadian Cancer Society, state that alcohol is a group 1 carcinogen and that even low-level alcohol consumption increases risk for some cancers. Additionally, while the American Cancer Society supports increasing tobacco taxes through its cancer action network, it has not advocated for increased alcohol taxes in relation to support for tobacco tax increases.

CONCLUSION

Analysis in 2017 of the websites for national cancer societies in Australia, Canada, Ireland, New Zealand, the United Kingdom and the United States-including Cancer Council Australia, the Canadian Cancer Society, the Irish Cancer Society, Cancer Society New Zealand, Cancer Research UK and the American Cancer Society-shows that only the American Cancer Society and Canadian Cancer Society websites fail to state that alcohol is a group 1 carcinogen and can cause cancer at low doses, and that there is no safe threshold for cancer risk.

Estimates of effectiveness and reach for 'return on investment' modelling of smoking cessation interventions using data from England

BACKGROUND AND AIMS

Estimating 'return on investment' (ROI) from smoking cessation interventions requires reach and effectiveness parameters for interventions for use in economic models such as the EQUIPT ROI tool (http://roi.equipt.eu). This paper describes the derivation of these parameter estimates for England that can be adapted to create ROI models for use by other countries.

METHODS

Estimates were derived for interventions in terms of their reach and effectiveness in: (1) promoting quit attempts and (2) improving the success of quit attempts (abstinence for at least 12 months). The sources were systematic reviews of efficacy supplemented by individual effectiveness evaluations and national surveys.

FINDINGS

Quit attempt rates were estimated to be increased by the following percentages (with reach in parentheses): 20% by tax increases raising the cost of smoking 5% above the cost of living index (100%); 10% by enforced comprehensive indoor public smoking bans (100%); 3% by mass media campaigns achieving 400 gross rating points (100%); 40% by brief opportunistic physician advice (21%); and 110% by use of a licensed nicotine product to reduce cigarette consumption (12%). Quit success rates were estimated to be increased by the following ratios: 60% by single-form nicotine replacement therapy (NRT) (5%); 114% by NRT patch plus a faster-acting NRT (2%);124% by prescribed varenicline (5%); 60% by bupropion (1%); 100% by nortriptyline (0%), 10) 298% by cytisine (0%); 40% by individual face-to-face behavioural support (2%); 37% by telephone support (0.5%); 88% by group behavioural support (1%); 63% by text messaging (0.5%); and 19% by printed self-help materials (1%). There was insufficient evidence to obtain reliable, country-specific estimates for interventions such as websites, smartphone applications and e-cigarettes.

CONCLUSIONS

Tax increases, indoor smoking bans, brief opportunistic physician advice and use of nicotine replacement therapy (NRT) for smoking reduction can all increase population quit attempt rates. Quit success rates can be increased by provision of NRT, varenicline, bupropion, nortriptyline, cytisine and behavioural support delivered through a variety of modalities. Parameter estimates for the effectiveness and reach of these interventions can contribute to return on investment estimates in support of national or regional policy decisions.

Cigarette tax rates, behavioral disengagement, and quit ratios among daily smokers

Cigarette taxation is an economics-based policy associated with increased population-level quit ratios. However, the estimated effects of tax increase on smoking behavior vary substantially, underscoring the need to identify moderating variables. We examined whether behavioral disengagement - the tendency to abandon goals when experiencing stress - modified the association between cigarette taxes and daily smoking behavior. We connected state-level cigarette tax rate data with individual-level behavioral data, including a national sample of 725 US adults who smoked daily at baseline and reported follow-up data approximately 10 years later, and 376 who were resampled a third time after another 10 years. Analyses involved multilevel logistic regression (with time as a nested variable and anonymized state codes as a grouping variable), where current smoking status (dichotomous) was regressed on behavioral disengagement, state-level cigarette tax at baseline and current time, and the interaction between disengagement and current tax. Consistent with hypotheses, tax rate interacted with disengagement (OR=0.95, 95% CI=0.90,0.99, p=.0255): Among those one SD above the mean for disengagement, tax rate was unassociated with quit ratio (OR=0.99, 95% CI=0.85,1.16, p=.6975). However, among those one SD below the mean, tax rate was significantly associated with higher quit ratio (OR=1.22, 95% CI=1.04,1.43, p=.0163). Our data suggest the possibility that cigarette taxes may be more effective in facilitating cessation among smokers low in behavioral disengagement or when accompanied by interventions that reduce stress or maintain goal pursuit. Identifying psychological moderators of policy effectiveness holds promise for improving policy design and targeting.

The role of travel distance and price promotions in tobacco product purchase quantity

INTRODUCTION

Rural Americans are particularly vulnerable to tobacco price reducing promotions are known to be directed to and used by vulnerable populations. Tobacco purchasing decisions, such as unit quantity purchased, may vary by rurality, by price promotion use, and possibly by the interaction between the two. Purchase decisions are likely to affect tobacco use behavior. Therefore, explanation of variation in tobacco purchase quantity by factors associated with rural vulnerability and factors that fall under the regulatory scope of the Tobacco Control Act (TCA) of 2009 could be of value to regulatory proposals intended to equitably benefit public health.

METHODS

Our sample included 54 combustible tobacco users (298 purchase events) and 27 smokeless tobacco users (112 purchase events), who were asked to report all tobacco purchases on a smartphone application. We used an ecological momentary assessment methodology to collect data about tobacco users' purchasing patterns, including products, quantity purchased, and use of price promotions. A parent cohort study provided relevant data for home-outlet distance calculation and covariates. Our analysis examined associations between our outcome-purchase quantity per purchase event-and distance from participant's home to the nearest outlet, whether a price reducing promotion was used, and the interaction of these two factors.

RESULTS

Combustible users showed an increased cigarette pack purchase quantity if they lived further from an outlet and used a price promotion (i.e., an interaction effect; RR = 1.70, 95% CI [1.11, 2.62]). Smokeless users purchased more units of snuff when they used price promotions (RR = 1.81, 95% CI [1.02, 3.20]).

CONCLUSIONS

Regulatory action that imposes restrictions on the availability or use of price promotions could alter the purchasing behavior of rural Americans in such a way that makes it easier to reduce tobacco use or quit. Such action would also restrict flexibility in the price of tobacco products, which is known as a powerful tobacco control lever.

Projecting the effects of tobacco control policies in the USA through microsimulation: a study protocol

INTRODUCTION

Smoking remains the leading cause of preventable death in the USA but can be reduced through policy interventions. Computational models of smoking can provide estimates of the projected impact of tobacco control policies and can be used to inform public health decision making. We outline a protocol for simulating the effects of tobacco policies on population health outcomes.

METHODS AND ANALYSIS

We extend the Smoking History Generator (SHG), a microsimulation model based on data from the National Health Interview Surveys, to evaluate the effects of tobacco control policies on projections of smoking prevalence and mortality in the USA. The SHG simulates individual life trajectories including smoking initiation, cessation and mortality. We illustrate the application of the SHG policy module for four types of tobacco control policies at the national and state levels: smoke-free air laws, cigarette taxes, increasing tobacco control programme expenditures and raising the minimum age of legal access to tobacco. Smoking initiation and cessation rates are modified by age, birth cohort, gender and years since policy implementation. Initiation and cessation rate modifiers are adjusted for differences across age groups and the level of existing policy coverage. Smoking prevalence, the number of population deaths avoided, and life-years gained are calculated for each policy scenario at the national and state levels. The model only considers direct individual benefits through reduced smoking and does not consider benefits through reduced exposure to secondhand smoke.

ETHICS AND DISSEMINATION

A web-based interface is being developed to integrate the results of the simulations into a format that allows the user to explore the projected effects of tobacco control policies in the USA. Usability testing is being conducted in which experts provide feedback on the interface. Development of this tool is under way, and a publicly accessible website is available at http://www.tobaccopolicyeffects.org.

The impact of a federal cigarette minimum pack price policy on cigarette use in the USA

BACKGROUND

Increasing cigarette prices reduce cigarette use. The US Food and Drug Administration has the authority to regulate the sale and promotion-and therefore the price-of tobacco products.

OBJECTIVE

To examine the potential effect of federal minimum price regulation on the sales of cigarettes in the USA.

METHOD

We used yearly state-level data from the Tax Burden on Tobacco and other sources to model per capita cigarette sales as a function of price. We used the fitted model to compare the status quo sales with counterfactual scenarios in which a federal minimum price was set. The minimum price scenarios ranged from $0 to $12.

RESULTS

The estimated price effect in our model was comparable with that found in the literature. Our counterfactual analyses suggested that the impact of a minimum price requirement could range from a minimal effect at the $4 level to a reduction of 5.7 billion packs sold per year and 10 million smokers at the $10 level.

CONCLUSION

A federal minimum price policy has the potential to greatly benefit tobacco control and public health by uniformly increasing the price of cigarettes and by eliminating many price-reducing strategies currently available to both sellers and consumers.

Tobacco retail policy landscape: a longitudinal survey of US states

Background

There are ∼380 000 tobacco retailers in the USA, where the largest tobacco companies spend almost $9 billion a year to promote their products. No systematic survey has been conducted of state-level activities to regulate the retail environment, thus little is known about what policies are being planned, proposed or implemented.

Methods

This longitudinal study is the first US survey of state tobacco control programmes (TCPs) about retail policy activities. Surveyed in 2012 and 2014, programme managers (n=46) reported activities in multiple domains: e-cigarettes, retailer density and licensing, non-tax price increases, product placement, advertising and promotion, health warnings and other approaches. Policy activities were reported in one of five levels: no formal activity, planning or advocating, policy was proposed, policy was enacted or policy was implemented. Overall and domain-specific activity scores were calculated for each state.

Results

The average retail policy activity almost doubled between 2012 and 2014. States with the largest increase in scores included: Minnesota, which established a fee-based tobacco retail licensing system and banned self-service for e-cigarettes and all other tobacco products (OTP); Oregon, Kansas and Maine, all of which banned self-service for OTP; and West Virginia, which banned some types of flavoured OTP.

Conclusions

Retail policy activities in US states increased dramatically in a short time. Given what is known about the impact of the retail environment on tobacco use by youth and adults, state and local TCPs may want diversify policy priorities by implementing retail policies alongside tax and smoke-free air laws.

Comparing projected impacts of cigarette floor price and excise tax policies on socioeconomic disparities in smoking

Background

About half of all US states have cigarette minimum price laws (MPLs) that require a per cent mark-up on prices, but research suggests they may not be very effective in raising prices. An alternative type of MPL sets a floor price below which packs cannot be sold, and may be more promising. This new type of MPL policy has only been implemented in 1 city, therefore its benefits relative to excise taxes is difficult to assess.

Methods

We constructed a set of possible state floor price MPL options, and matched them to possible state excise tax hikes designed to produce similar average price increases. Using self-reported price and cigarette consumption data from 23 521 participants in the 2010–2011 Tobacco Use Supplement of the Current Population Survey, we projected changes in pack prices and cigarette consumption following implementation of each paired MPL and tax option, for lower and higher income groups.

Results

We project that state MPLs set at the average reported pack price would raise prices by $0.33 and reduce cigarette consumption by about 4%; a tax with a similar average price effect would reduce consumption by 2.3%. MPLs and taxes that raise average prices by more than $2.00 would reduce consumption by 15.9% and 13.5%, respectively. In all models, we project that MPLs will reduce income-based smoking disparities more than their comparable excise taxes.

Conclusions

Floor price cigarette MPLs set at or above what consumers currently report paying could reduce both tobacco use and socioeconomic disparities in smoking.

Limited indications of tax stamp discordance and counterfeiting on cigarette packs purchased in tobacco retailers, 97 counties, USA, 2012

Increasing the per-unit cost of tobacco products is one of the strongest interventions for tobacco control. In jurisdictions with higher taxes in the U.S., however, cigarette pack litter studies show a substantial proportion of littered packs lack the appropriate tax stamp. More limited but still present counterfeiting also exists. We sought to examine the role of tobacco retailers as a source for untaxed and counterfeit products. Data collectors purchased Newport Green (menthol) or Marlboro Red cigarette packs in a national probability-based sample of tobacco retailers (in 97 counties) from June–October 2012. They made no effort to buy counterfeit or untaxed cigarettes. In this cross-sectional study, we assessed the presence, tax authority, and type (low-tech thermal vs. encrypted) of cigarette pack tax stamps; concordance of tax stamps with where the pack was purchased; and, for Marlboro cigarettes, publicly available visible indicators of counterfeiting. We purchased 2147 packs of which 2033 had tax stamps. Packs missing stamps were in states that do not require them. We found very limited discordance between store location and tax stamp(s) (< 1%). However, a substantial minority of cigarette packs had damaged tax stamps (13%). This occurred entirely with low-tech tax stamps and was not identified with encrypted tax stamps. We found no clear evidence of counterfeit products. Almost all tax stamps matched the location of purchase. Litter studies may be picking up legal tax avoidance instead of illegal tax evasion or, alternatively, purchase of illicit products requires special request by the purchaser.

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This study purchased 2147 cigarette packs in 97 U.S. counties.

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No clear indicators of cigarette counterfeiting were found.

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Virtually all packs had the correct tax stamp affixed.

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Inspection protocols for illicit cigarettes should consider real-world behaviors.

Cessation-related information, motivation, and behavioral skills in smokers living with HIV

There is a need for new, targeted smoking cessation interventions for smokers living with HIV. The Information-Motivation-Behavioral Skills (IMB) model has been applied effectively to HIV-related health behaviors and was used in this qualitative study to elicit factors that could lead to the development of innovative and successful cessation interventions for this population. Twenty individuals who smoked from two clinics providing care to people living with HIV participated in open-ended interviews, responding to questions covering the domains of the IMB model, as applied to smokers living with HIV. Participants were enrolled from a larger survey cohort to recruit into groups based on the impact of HIV diagnosis on smoking as well as attempting to enroll a mix of demographics characteristics. Interviews were recorded, transcribed, coded and thematically analyzed using a grounded theory qualitative approach. Interviews continued until thematic saturation was reached. Major themes included: Presence of knowledge deficits regarding HIV-specific health risks of smoking; use of smoking for emotional regulation, where many reported close contacts who smoke and concern with the effect of cessation on their social networks; Use of smoking cessation aids or a telephone-based wellness intervention were acceptable to most. Providing HIV-specific information in cessation advice is of the utmost importance for clinicians caring for smokers living with HIV, as this theme was noted consistently as a potential motivator to quit. Innovative and effective interventions must account for the social aspect of smoking and address other methods of emotional regulation in this population.

A 14-year longitudinal study of the impact of clean indoor air legislation on state smoking prevalence, USA, 1997-2010

While clean indoor air legislation at the state level is an evidence-based recommendation, only limited evidence exists regarding the impact of clean indoor air policies on state smoking prevalence. Using state smoking prevalence data from 1997 to 2010, a repeated measures observational analysis assessed the association between clean indoor air policies (i.e., workplace, restaurant, and bar) and state smoking prevalence while controlling for state cigarette taxes and year. The impacts from the number of previous years with any clean indoor air policy, the number of policies in effect during the current year, and the number of policies in effect the previous year were analyzed. Findings indicate a smoking prevalence predicted decrease of 0.13 percentage points (p=0.03) for each additional year one or more clean indoor air policies were in effect, a predicted decrease of 0.12 percentage points (p=0.09) for each policy in effect in the current year, and a predicted decrease of 0.22 percentage points (p=0.01) for each policy in effect in the previous year on the subsequent year. Clean indoor air policies show measurable associations with reductions in smoking prevalence within a year of implementation above and beyond taxes and time trends. Further efforts are needed to diffuse clean indoor air policies across states and provinces that have not yet adopted such policies.

Appetite self-regulation: Environmental and policy influences on eating behaviors

OBJECTIVE

Appetite regulation is influenced by the environment, and the environment is shaped by food-related policies. This review summarizes the environment and policy research portion of an NIH Workshop (Bethesda, MD, 2015) titled "Self-Regulation of Appetite-It's Complicated."

METHODS

In this paper, we begin by making the case for why policy is an important tool in efforts to improve nutrition, and we introduce an ecological framework that illustrates the multiple layers that influence what people eat. We describe the state of the science on how policies influence behavior in several key areas: the federal food programs, schools, child care, food and beverage pricing, marketing to youth, behavioral economics, and changing defaults. Next, we propose novel approaches for multidisciplinary prevention and intervention strategies to promote breastfeeding, and examine interactions between psychology and the environment.

RESULTS

Policy and environmental change are the most distal influences on individual-level appetite regulation, yet these strategies can reach many people at once by changing the environment in which food choices are made. We note the need for more research to understand compensatory behavior, reactance, and how to effectively change social norms.

CONCLUSIONS

To move forward, we need a more sophisticated understanding of how individual psychological and biological factors interact with the environment and policy influences.

Prices for Tobacco and Nontobacco Products in Pharmacies Versus Other Stores: Results From Retail Marketing Surveillance in California and in the United States

OBJECTIVES

To examine disparities in the price of tobacco and nontobacco products in pharmacies compared with other types of stores.

METHODS

We recorded the prices of Marlboro, Newport, the cheapest cigarettes, and bottled water in a random sample of licensed tobacco retailers (n = 579) in California in 2014. We collected comparable data from retailers (n = 2603) in school enrollment zones for representative samples of US 8th, 10th, and 12th graders in 2012. Ordinary least squares regressions modeled pretax prices as a function of store type and neighborhood demographics.

RESULTS

In both studies, the cheapest cigarettes cost significantly less in pharmacies than other stores; the average estimated difference was $0.47 to $1.19 less in California. We observed similar patterns for premium-brand cigarettes. Conversely, bottled water cost significantly more in pharmacies than elsewhere. Newport cost less in areas with higher proportions of African Americans; other cigarette prices were related to neighborhood income and age. Neighborhood demographics were not related to water prices.

CONCLUSIONS

Compared with other stores, pharmacies charged customers less for cigarettes and more for bottled water. State and local policies to promote tobacco-free pharmacies would eliminate an important source of discounted cigarettes.

Revisiting the Rise of Electronic Nicotine Delivery Systems Using Search Query Surveillance

INTRODUCTION

Public perceptions of electronic nicotine delivery systems (ENDS) remain poorly understood because surveys are too costly to regularly implement and, when implemented, there are long delays between data collection and dissemination. Search query surveillance has bridged some of these gaps. Herein, ENDS' popularity in the U.S. is reassessed using Google searches.

METHODS

ENDS searches originating in the U.S. from January 2009 through January 2015 were disaggregated by terms focused on e-cigarette (e.g., e-cig) versus vaping (e.g., vapers); their geolocation (e.g., state); the aggregate tobacco control measures corresponding to their geolocation (e.g., clean indoor air laws); and by terms that indicated the searcher's potential interest (e.g., buy e-cigs likely indicates shopping)-all analyzed in 2015.

RESULTS

ENDS searches are rapidly increasing in the U.S., with 8,498,000 searches during 2014 alone. Increasingly, searches are shifting from e-cigarette- to vaping-focused terms, especially in coastal states and states where anti-smoking norms are stronger. For example, nationally, e-cigarette searches declined 9% (95% CI=1%, 16%) during 2014 compared with 2013, whereas vaping searches increased 136% (95% CI=97%, 186%), even surpassing e-cigarette searches. Additionally, the percentage of ENDS searches related to shopping (e.g., vape shop) nearly doubled in 2014, whereas searches related to health concerns (e.g., vaping risks) or cessation (e.g., quit smoking with e-cigs) were rare and declined in 2014.

CONCLUSIONS

ENDS popularity is rapidly growing and evolving. These findings could inform survey questionnaire development for follow-up investigation and immediately guide policy debates about how the public perceives the health risks or cessation benefits of ENDS.