The crowding-out effects of tobacco and alcohol where expenditure shares are low: analyzing expenditure data for Taiwan

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.

Potential smoke-free dividend across local areas in England: a cross-sectional analysis

BACKGROUND

The value that might be added to local economies each year through the money that people who smoke tobacco would save if everyone quit smoking is called the 'smoke-free dividend'. This study aimed to estimate the value of the smoke-free dividend across local areas in England, and how it relates to the average income in those areas.

METHODS

The study was a cross-sectional descriptive analysis of tobacco expenditure from the Smoking Toolkit Study (STS) matched to income and smoking prevalence data for English local authorities. The STS sample was from 2014 to 2020 and comprised 18 721 adults who smoke cigarettes. Self-reported expenditure estimates from the STS were adjusted for under-reporting. This adjustment aimed to align the total expenditure estimate with figures derived from government tax receipts and national estimates of illicit tobacco use. The smoke-free dividend is calculated as 93% of spending on legal tobacco, which is the percentage estimated to leave the local economy, plus 100% of spending on illicit tobacco.

RESULTS

The total dividend in England is estimated to be £10.9 billion each year, which equates to £1776 per person who smokes or £246 per adult regardless of smoking status. The estimated dividend is greater in areas with lower average income, with a correlation coefficient of -0.521 (95% CI -0.629, -0.392) between the average income of local areas and the dividend per adult.

CONCLUSIONS

This study has estimated that local economies could gain a substantial dividend if everybody stopped smoking, which is larger in lower income areas, meaning that geographical economic inequalities could be reduced.

The Crowding-out Effect of Tobacco Expenditure on Health Expenditure: Evidence From a Lower-Middle-Income Country

INTRODUCTION

Poor people have remarkably lower health expenditures than rich people in Vietnam. According to the 2016 Vietnam Household Living Standard Survey (VHLSS), per capita health expenditure of the top quintile households is around 6 times higher than that of the bottom quintile households.

AIMS AND METHODS

We analyze economic inequalities in health expenditure using the concentration index approach and data from the VHLSS 2010-2016. Next, we use the instrumental-variable regression analysis to examine the crowding-out effect of tobacco expenditure on health expenditure. Finally, we use decomposition analysis to explore whether economic inequality in tobacco expenditure is associated with an economic inequality in health expenditure.

RESULTS

We find a crowding-out effect of tobacco expenditure on health expenditure of households. The share of health expenditure of households with tobacco spending is 0.78% lower than that of households without tobacco spending. It is estimated that a one-VND increase in tobacco expenditure results in a 0.18 Vietnamese Dong (VND) (95% CI: -0.30 to -0.06) decrease in health expenditure. There is a negative association between economic inequality in tobacco expenditure and economic inequality in health expenditure. This means that if the poor consume less tobacco, their expenditure on health can be increased, resulting in a decrease in inequality in health expenditure.

CONCLUSIONS

Findings from this study suggest that reducing tobacco expenditure could improve health care of the poor and reduce inequality in health care in Vietnam. Our study recommends that the government continuously increase the tobacco tax in order to effectively reduce tobacco consumption.

IMPLICATIONS

Empirical studies show mixed results on the effect of tobacco expenditure on health expenditure. We find a crowding-out effect of tobacco expenditure on health expenditure of poor households in Vietnam. It implies that if the poor reduce their expenditure on tobacco, economic inequality in health expenditure can be reduced. Our findings suggest that reducing tobacco consumption in poor households can increase their health expenditure, therefore, decreasing inequality in health expenditure. Different policies to reduce tobacco consumption such as tobacco taxation, smoke-free areas, and tobacco advertisement bans should be strengthened.

Recreational tobacco consumption and food insecurity among First Nations in Canada

OBJECTIVE

Crowding-out effects of tobacco consumption refers to the situation in which tobacco consumption reduces a household's spending on other commodities. In this paper, we test for the crowding-out effects of recreational tobacco consumption on food expenditures among on-reserve Indigenous communities in Canada.

METHODS

We use data from household expenditure surveys (N=469) to investigate tobacco consumption behaviour of on-reserve households of six First Nation communities in Canada. Using conditional Engel curves, we estimate the crowding-out effects of spending on tobacco on budget share of other expenditure categories with a focus on food expenditures.

RESULTS

Our analysis showed that crowding-out effects of consuming tobacco on consumption of goods and services are minimal with an estimated impact of -0.00004 on the budget share of food expenditures in the remaining budget excess of expenditures on tobacco. While crowding-out effects are not statistically significant in general, the budget share of store-bought food expenditures is significantly lower (i.e. 5%) among tobacco consumer households.

CONCLUSION

This study sheds new light on some of the indirect impacts of recreational tobacco use and Indigenous food insecurity in Canada. This study is the first attempt to test for crowding-out effects of tobacco consumption among Indigenous populations in Canada. Our findings are important and highlight areas for substantial improvements in health and well-being outcomes given the alarming rates of food insecurity experienced by Indigenous communities in Canada.

Crowding Out Effects of Alcohol Consumption Expenditure on Household Resource Allocation in Malawi

The study used Quasi maximum likelihood estimation (QMLE) on a nationally representative household level data set to estimate the effect of alcohol consumption expenditure on a set of expenditure proportions of other commodities. The results indicate that, the low-income, including the rural population, spent proportionately more on alcohol than their well-off and urban counterparts. Furthermore, the consumption of alcohol crowded-out expenditures on consumer non-durable (food and beverages), durable (housing) and essential services (education). The crowding out of these expenditures clearly has negative impacts on the wellbeing of individuals within households and communities through misallocated household resources. The strong, unequivocal message coming out of the results obtained in this study is that certainly for poorer countries alcohol consumption is inimical to household poverty reduction.

Implications of household tobacco and alcohol use on child health and women's welfare in six low and middle-income countries: An analysis from a gender perspective

OBJECTIVE

To study the implications of household tobacco and alcohol use on child health and women's welfare using a gender lens in Ethiopia, India, Indonesia, Jordan, Kenya, and Nigeria with varied geographical and cultural characteristics in the pattern of tobacco and alcohol use.

METHODS

We identified child health and women's welfare outcomes that may be impacted by tobacco and alcohol use, with a focus on the crowding-out effects on household resource allocation. For child health indicators, we focussed on engagement in preventative care, nutrition, and responses to acute illness. For women, we focused on access to resources for health-seeking and intimate partner violence (IPV). We used logistic regression to determine the association between household gender tobacco and/or alcohol use on child health and women's welfare, using data from six nationally-representative Demographic and Health Surveys, with each having a sample size of 5000-30,000 households and conducted after 2010.

RESULTS

Children in households where men and women use tobacco are significantly less likely to receive the full schedule of Diphtheria-Pertussis-Tetanus (DPT) vaccine in India, Indonesia, and Jordan (Odds ratio or OR; ORIndia = 0.67, p < 0.001; ORIndonesia = 0.55, p = 0.028; ORJordan = 0.45, p = 0.048), and all basic vaccinations as well as receive appropriate treatment for fever/diarrhoea in India and Indonesia (all basic vaccinations: ORIndia = 0.78, p < 0.001, ORIndonesia = 0.43, p = 0.009; treatment for fever/diarrhoea: ORIndia = 0.65, p < 0.001; ORIndonesia = 0.50, p = 0.038). In most countries, women are significantly more likely to experience IPV when their husband/partner uses tobacco and/or alcohol.

CONCLUSIONS

Across a diverse set of countries with varied cultural characteristics which affect the uptake and use of tobacco and alcohol, tobacco and alcohol use are associated with crowding-out of acute and preventative health-related behaviours and crowding-in of harmful behaviours. This has significant implications for tobacco and alcohol control programmes, and positions tobacco and alcohol control as central to human capital initiatives and in achieving health for all.

The effect of tobacco and alcohol consumption on poverty in the United Kingdom

BACKGROUND AND AIMS

Tobacco and alcohol use are major risk factors for premature mortality and morbidity. Tobacco and alcohol expenditure may also exacerbate poverty. This study aimed to estimate the financial impact of tobacco and alcohol consumption in low income households in the United Kingdom.

DESIGN

We undertook a cross-sectional study using a secondary dataset. A sample of 5031 households participated in the 2016-17 Living Costs and Food Survey. Measurements We measured the weekly household income and expenditure on tobacco and alcohol, and the proportion of households with expenditure on tobacco and alcohol overall, by income decile and in households in relative poverty (below 60% of the median household income). Estimates were extrapolated using population data to estimate the number of UK households, adults and children that would be classified as living in relative poverty on the basis of net income after subtracting tobacco or alcohol expenditure ('tobacco and alcohol expenditure-adjusted poverty').

FINDINGS

Spending on alcohol was more common in high income groups; 83% of households in the highest and 47% in the lowest income decile purchased alcohol. The reverse was true for tobacco, which was purchased by 8% and 24% of households in the highest and lowest income deciles respectively. Twenty-three percent of households in relative poverty purchased tobacco and 49% alcohol, with a median expenditure of £12.50 and £9.55 per week, respectively. A total of 320 000 households comprising 590 000 adults and 175 000 children were in alcohol expenditure-adjusted poverty, and 230 000 households, comprising 400 000 adults and 180 000 children in tobacco-expenditure adjusted poverty.

CONCLUSIONS

Tobacco and alcohol expenditure appear to exacerbate poverty in low income households in the United Kingdom. Hundreds of thousands of additional households would be defined as living in relative poverty based on their income after subtracting their tobacco and alcohol expenditure.

The effect of tobacco- and alcohol-control policies on household spending patterns in Kenya: An approach using matched difference in differences

This paper examines the effect of tobacco and alcohol control policies on tobacco and alcohol consumption patterns and the evolution of crowding-out effects on other household expenditure in Kenya. The current literature on crowding-out does not provide a defensible instrumental variable for a system of demand equations. This paper uses Matched Difference in Differences (MDID) as an alternative strategy and data from two nationally representative surveys in Kenya conducted ten years apart (2005/6 and 2015/16). We find that tobacco-control policies contributed to a decrease in the proportion of tobacco-consuming households between 2005 and 2015. Alcohol-control policies were only effective in reducing the proportion of alcohol-consuming households in the bottom quartile of the expenditure distribution. Overall, tobacco-consuming households spent less on education, communication, and some food items. Alcohol-consuming households also spent less on some food items, but expenditure on transportation was the only non-food item crowded out. Tobacco and alcohol control policies, when they result in reduced consumption of these products, can increase household expenditure on human capital development in the long run.

Price and expenditure elasticity of cigarette demand in El Salvador: a household-level analysis and simulation of a tax increase

BACKGROUND

In El Salvador, 8.8% of adults 15 years and older smoke cigarettes. Little is known about the sensitivity of cigarette consumption among the adults in El Salvador to tax and price increases and income growth.

METHODS

Elasticities are estimated using Deaton's Almost Ideal Demand System model applied to data from the National Household Income and Expenditure Survey 2005/2006 for the total population and separately for income groups. The estimates are then used to simulate the effects of a proposed change in tobacco tax policy on cigarette consumption and tax revenue.

FINDINGS

The estimated price elasticities (-0.77 for the total population) are within the range of price elasticity estimates available for low and middle-income countries. Given the estimated elasticities, a tobacco tax increase is expected to reduce the number of smokers (by almost 20%) and increase tobacco tax revenue (by more than 50%).

CONCLUSIONS

Increasing tobacco taxes has the potential to decrease consumption in El Salvador and raise fiscal revenues. The tobacco tax burden in El Salvador is one of the lowest in Latin America and the social costs of tobacco consumption largely exceed the tobacco tax revenues. An increase in tobacco tax could significantly decrease the number of smokers and reduce the burden of tobacco-related diseases and deaths.

The effect of tobacco expenditure on expenditure shares in South African households: A genetic matching approach

This paper examines whether tobacco expenditure leads to the crowding out or crowding in of different expenditure items in South Africa. We apply genetic matching to expenditure quartiles of the 2010/2011 South African Income and Expenditure Survey. Genetic matching is a more appealing approach for dealing with the endogeneity of tobacco expenditure that often plagues studies using systems of demand equations. Further, genetic matching provides transparent measures of covariate balance giving the analyst objective means of assessing match success. We find that the poorest tobacco consuming households in South Africa consistently allocate smaller budget shares towards food items than non-smoking households. Specifically, we find that dairy, fruits, nuts and oils are displaced in favour of tobacco expenditure in the two poorest quartiles. Unsurprisingly, food items are never displaced for households in the top two quartiles, given these households' greater access to resources. Like other studies in the literature, we find that tobacco expenditure consistently crowds-in alcohol across all quartiles confirming the strong complementarities between the two.

Expenditure on health care, tobacco, and alcohol: Evidence from household surveys in rural Puducherry

Background

Healthcare expenditures exacerbate poverty, with about 39 million people falling into poverty every year because of such expenditures. Tobacco and alcohol consumption in addition to harmful health impact have economic consequences at household level.

Aim

To evaluate healthcare, alcohol, and tobacco expenditures among households in rural Puducherry and their impact on household expenditure patterns.

Materials and Methods

A community-based cross-sectional analytical study was conducted in selected villages within 5 km of a medical college hospital in Puducherry from September 2016 to June 2017. Sociodemographic details and various household expenditures were obtained from 817 households with 3459 individuals. Data were analyzed using STATA (v14).

Results

Higher mean percentage of health expenditure was found among households with low socioeconomic status [17.7 (95% confidence interval (CI): 14-21.3)] and no health insurance schemes [13.4 (95% CI: 11.1-15.7)]. Households with low socioeconomic status [13.1 (95% CI: 7.5-18.7)] had higher tobacco-alcohol expenditure. Increased health expenditure among households was positively correlated with loan (r_s = 0.48). Increased alcohol-tobacco expenditure among households was negatively correlated with food (r_s= -0.52) and education (r_s= -0.70) expenditure.

Conclusion

Healthcare and alcohol-tobacco expenditure individually contributed to one-tenth of the household budget. Spending on healthcare, alcohol, and tobacco created significant negative influence on investment in human capital development.

Comparative analysis of diet and tobacco use among households in Bangladesh

INTRODUCTION

While studies from developed countries have reported dietary differences between tobacco users and non-users, less is known about the influence of tobacco on diet in developing countries where malnutrition is a major public health challenge.

METHODS

In this study we used the nationally representative Household Income Expenditure Survey 2010 from Bangladesh. Detailed household-level food consumption data including both ethnic and region-specific foods were collected over 14 days, consisting of 7 visits each collecting two days of dietary recall information.

RESULTS

Out of 12240 households, 2061 consumed smoking tobacco only (16.8%), 3284 consumed smokeless tobacco only (26.8%), and 3348 consumed both (27.4%). Overall, 71% of the households reported expenditure on tobacco (smoking and/or smokeless) and were considered any-tobacco use households. Our results indicate that after controlling for household expenditure, household size, household child to adult ratio, place of residence (urban/rural), and region fixed effects, any-tobacco households consumed significantly lower amounts (g/day) of milk and dairy products (β = -17.11, p<0.01) and oil/fat (β = -10.30, p<0.01) compared to tobacco non-use households (β: adjusted mean difference in food amount g/day/household). Conversely, consumption of cereal grains (β = 152.46, p<0.0001) and sugar (β = 8.16, p<0.0001) were significantly higher among any-tobacco households compared to non-tobacco households. We observed similar patterns for smoking-only, smokeless-only, and dual tobacco product households.

CONCLUSION

Evidence of dietary differences between tobacco-use and non-use households may play an important role in developing strategies to address poor diet and malnutrition among tobacco-use households in a developing country like Bangladesh. This study provides one of the first reports addressing diet in relation to tobacco use from a developing country, particularly using nationally representative data. The finding that tobacco-use households have poorer dietary consumption than non-use households suggests that it is important to address tobacco use in the context of nutrition and development programs in low-income environments.

The crowding-out effect of tobacco expenditure on household spending patterns in Bangladesh

BACKGROUND

Tobacco consumption constitutes a sizable portion of household consumption expenditure, which can lead to reduced expenditures on other basic commodities. This is known as the crowding-out effect. This study analyzes the crowding-out effect of tobacco consumption in Bangladesh, and the research findings have relevance for strengthening the tobacco control for improving health and well-being.

METHODS

We analyzed data from the Bangladesh Household Income and Expenditure Survey 2010 to examine the differences in consumption expenditure pattern between tobacco user and non-user households. We further categorize tobacco user households in three mutually exclusive groups of smoking-only, smokeless-only, and dual (both smoking and smokeless); and investigated the crowding-out effects for these subgroups. We compared the mean expenditure shares of different types of households, and then estimated the conditional Engel curves for various expenditure categories using Seemingly Unrelated Regression (SUR) method. Crowding-out was considered to have occurred if estimated coefficient of the tobacco use indicator was negative and statistically significant.

RESULTS

We find that tobacco user households on average allocated less in clothing, housing, education, energy, and transportation and communication compared to tobacco non-user households. The SUR estimates also confirmed crowding-out in these consumption categories. Mean expenditure share of food and medical expenditure of tobacco user households, however, are greater than those of tobacco non-user households. Albeit similar patterns observed for different tobacco user households, there were differences in magnitudes depending on the type of tobacco-use, rural-urban locations and economic status.

CONCLUSION

Policy measures that reduce tobacco use could reduce displacement of commodities by households with tobacco users, including those commodities that can contribute to human capital investments.

Relationship between smoking and health and education spending in Chile

Objective

To estimate the degree to which tobacco consumption is associated with spending on a set of goods and services in Chile, especially health and education, for the total population as well as for specific subgroups.

Methods

A seemingly unrelated regression equation system was used to estimate the statistical relationship between having tobacco expenditures and the budget share allocated to other items for the total population and for specific subgroups in Chile (eg, households within the bottom/top 33% by total expenditures). The use of household-level data allows for the control of a number of sociodemographic characteristics. The nationally representative 2012 Chilean Household Expenditure Survey was used for the analysis.

Results

Tobacco consumption is associated with lower budget shares allocated to healthcare, education and housing expenses, especially for poorer households. In the case of health, not consuming tobacco is related to higher health expenditures: up to 32% for the total population. Similarly, in the case of education, not consuming tobacco is statistically related to higher education expenditures: up to 16% for the total population. For all groups, tobacco consumption is also related to a significantly higher budget share allocated to alcoholic beverages.

Conclusions

The strong significant statistical relationship found between tobacco consumption and resources allocated to healthcare and education consumption may be indicative of the existence of a crowding out effect of tobacco. This effect, in turn, may increase the burden that the rest of society must bear for the increased healthcare that they require because of tobacco consumption.

Money Gone Up in Smoke: The Tobacco Use and Malnutrition Nexus in Bangladesh

BACKGROUND

The tobacco epidemic in Bangladesh is pervasive. Expenditures on tobacco may reduce money available for food in a country with a high malnutrition rate.

OBJECTIVES

The aims of the study are to quantify the opportunity costs of tobacco expenditure in terms of nutrition (ie, food energy) forgone and the potential improvements in the household level food-energy status if the money spent on tobacco were diverted for food consumption.

METHOD

We analyzed data from the 2010 Bangladesh Household Income and Expenditure Survey, a nationally representative survey conducted among 12,240 households. We present 2 analytical scenarios: (1) the lower-bound gain scenario entailing money spent on tobacco partially diverted to acquiring food according to households' food consumption share in total expenditures; and (2) the upper-bound gain scenario entailing money spent on tobacco diverted to acquiring food only. Age- and gender-based energy norms were used to identify food-energy deficient households. Data were analyzed by mutually exclusive smoking-only, smokeless-only, and dual-tobacco user households.

FINDINGS

On average, a smoking-only household could gain 269-497 kilocalories (kcal) daily under the lower-bound and upper-bound scenarios, respectively. The potential energy gains for smokeless-only and dual-tobacco user households ranged from 148-268 kcal and 508-924 kcal, respectively. Under these lower- and upper-bound estimates, the percentage of smoking-only user households that are malnourished declined significantly from the baseline rate of 38% to 33% and 29%, respectively. For the smokeless-only and dual-tobacco user households, there were 2-3 and 6-9 percentage point drops in the malnutrition prevalence rates. The tobacco expenditure shift could translate to an additional 4.6-7.7 million food-energy malnourished persons meeting their caloric requirements.

CONCLUSIONS

The findings suggest that tobacco use reduction could facilitate concomitant improvements in population-level nutrition status and may inform the development and refinement of tobacco prevention and control efforts in Bangladesh.

Tobacco use and household expenditures on food, education, and healthcare in low- and middle-income countries: a multilevel analysis

Background

The majority of one billion smokers worldwide live in low- and middle-income countries (LMICs) and the highest proportion of smokers in most of these countries belong to the lower socioeconomic groups. This study aimed to investigate the associations between tobacco use within households and expenditures on food, education, and healthcare in LMICs.

Methods

Using data from the World Health Survey, this cross-sectional study included a sample of 53,625 adult males aged <60 years from 40 LMICs. Multilevel, mixed-effects linear regression was used to determine the association between current tobacco use status of the main income provider (daily; occasional; no use) and three categories of (logged) household expenditures: food, education, and healthcare; controlling for age, level of education, household wealth quintile, marital status, urban–rural setting, country-level income group, and region.

Results

In the preferred random-slope models that controlled for covariates, daily tobacco use was associated with lower household expenditures on education and healthcare by 8.0 % (95 % confidence interval: −12.8 to –3.2 %) and 5.5 % (−10.7 to –0.3 %), respectively. The association between tobacco use and food expenditure was inconsistent across models.

Conclusions

Tobacco use in LMICs may have a negative influence on investment in human capital development. Addressing the tobacco use problem in LMICs could benefit not only the health and economic well-being of smokers and their immediate families but also long-run economic development at a societal level.

Socioeconomic implications of tobacco use in Ghana

INTRODUCTION

Country-level evidence from Africa on the prevalence of tobacco use and the role played by both demographic and socioeconomic factors, as influences on the use of tobacco products, is sparse. This paper analyzes the determinants of tobacco use in Ghana and explores the association between tobacco use and poverty in the country.

METHODS

Data from the 2008 Ghana Demographic and Health Survey, a nationally representative survey of households (n = 12,323), were used to generate descriptive statistics and characterize tobacco use in the country. A logistic regression model was used to evaluate the relationships between tobacco use and age, place of residence, region, education status, wealth, marital status, alcohol use, and whether the person has children. Unadjusted and adjusted odds ratios were calculated for tobacco users and nonusers on the likelihood of their purchase of selected commodities indicative of living standards.

RESULTS

Tobacco use was significantly higher among those living in poverty stricken regions, those with less education, lower levels of wealth, parents, and alcohol users. Tobacco use was significantly higher among men (7%) than women (0.4%), and it increased to a peak age of 41.4 years before it declined. Using tobacco was also associated with a lower likelihood of purchasing health insurance.

DISCUSSION

Tobacco use is inextricably related to poverty in Ghana. Policies should be formulated to target populations and regions with higher tobacco prevalence to combat both poverty and tobacco use simultaneously.

Association between concurrent alcohol and tobacco use and poverty

INTRODUCTION AND AIMS

The harm from alcohol and tobacco use in low- and middle-income countries includes substantial economic cost to the individual. Our aim was to describe the expenditure on concurrent alcohol and tobacco use in relation to family income in two districts in Sri Lanka.

DESIGN AND METHODS

A community-based cross-sectional study was carried out in two districts in Sri Lanka. We sampled 2684 men over 18 years of age using multistage cluster sampling. Cost of alcohol and cigarettes was calculated using the retail price for each brand and multiplying by the amount consumed.

RESULTS

Among current alcohol users 63.1% were also smokers. Among current smokers 61.9% were also using alcohol. Prevalence of concurrent alcohol and tobacco use in urban areas was 20.1% and in rural areas 14%. The two lowest income categories (<$US76 per month) spent more than 40% of their income on concurrent use while the next category ($US76-143 per month) spent 34.8% of their income on concurrent use.

DISCUSSION AND CONCLUSIONS

The poor spent less than those with higher income on alcohol and tobacco, but the expenditure constituted a much larger slice of their income thus compromising their ability to meet basic needs. In low-income countries, damaging economic consequences start at lower levels of alcohol and tobacco consumption and affect a significant proportion of the population. Defining risk levels and guidelines on safe limits based purely on individual health harm has, at best, little meaning in such settings.