The Association Between State Value-Added Taxes and Tobacco Use in India-Evidence From GATS and TCP India Survey

Evolution of tobacco control in India: a narrative review of the legislative and regulatory approach

Tobacco is the only consumer product that kills half its users yearly. The challenges posed by tobacco control are limitless especially in a country like India where in addition to smoked forms, other smokeless forms of tobacco are also highly prevalent. Apart from being a health hazard tobacco is also a great environmental hazard. Policies for controlling tobacco use also include policy to prevent people from second hand smoke, which is aimed at improvement of air quality. According to the National Non-Communicable Disease Monitoring Survey, 2017-18, daily tobacco use was 32.8% in adults (18-69 years) and 3.1% in adolescents (15-17 years). Overall reduction in tobacco users by 8.1 Million was seen from GATS-1 to GATS-2, and prevalence amongst youth decreased from 18.4 to 12.4%. GYTS-4 (2019) revealed that 8.5% of students, 9.6% of boys and 7.4% of girls-currently used any tobacco products. This makes tobacco control a priority in India. Tobacco control consists of different approaches such as educational, healthcare, legislative, regulatory and fiscal. In the present article we traverse nearly five decades and decode the evolution of legislative, regulatory and fiscal approaches to Tobacco Control in India. A critical evaluation of all these approaches is described in the format of the MPOWER strategy for Tobacco Control which stands for Monitoring Tobacco use, Preventing people from Second Hand Smoke, Offering help to quit, Waring regarding ill effects of tobacco, Enforcing bans and Raising taxes on tobacco products.

Lung Cancer Management in Low and Middle-Income Countries

Lung cancer is an increasing problem in the developing world due to rising trends in smoking, high incidence of air pollution, lack of awareness and screening, delayed presentation, and diagnosis at the advanced stage. Even after diagnosis, there are disparities in access to health care facilities and inequitable distribution of resources and treatment options. In addition, the shortage of trained personnel and infrastructure adds to the challenges faced by patients with lung cancer in these regions. A multi-pronged effort targeting tobacco cessation, health promotion and awareness, capacity building, and value-based care are the need of the hour.

Poor implementation of tobacco control measures and lack of education influences the intention to quit tobacco: a structural equation modelling approach

BACKGROUND

Tobacco consumption remains a public health issue and is one of the major causes of death in India. This study presents a validated conceptual model to assess the interaction between education, perceived application of tobacco control measures, type of tobacco and their effects on the intention to quit tobacco. Additionally, the direct and mediating roles of tobacco use -frequency, -duration, and -dependency on the intention to quit is also investigated.

METHODS

An analytical cross-sectional study was carried out, and data from tobacco users of six randomly selected states in India was collected via face-to-face interviews. Structural equation modeling (SEM) was performed using R v 3.6.3 to test the model fit and to explore the association between tobacco control measures and the intention to quit tobacco.

RESULTS

From 1962 tobacco users, 43.7% wanted to quit tobacco immediately. Tambakoo (57.7%) was the most common type of tobacco used and 68.9% said that minors could buy tobacco. Findings from SEM showed that that one standard deviation (SD) increase in the perceived application of tobacco control measures is directly associated with a 0.181 SD increase in the intention to quit tobacco (B = 0.181, P < 0.001), and this effect was partially mediated by frequency of tobacco consumption (B = 0.06, P < 0.05). Also, a better education level was associated with a higher intention to quit tobacco (B = 0.14, P < 0.001).

CONCLUSIONS

To conclude, the application of tobacco control measures and a better education level may positively affect the intention to quit tobacco. The frequency of tobacco use and the number of influencers play an essential role in deciding to quit. In future, longitudinal studies are recommended to further substantiate the evidence.

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.

Understanding low mobilization for non-communicable diseases among people living with NCDs: A qualitative study on hypertension in urban South India

There is low civil society mobilization for NCD policies in low- and middle-income countries (LMICs) despite a growing NCD burden. While existing research explains low mobilization largely through constraints such as inadequate funding and capacity at the organizational level, we explore the issue from the perspective of people living with NCDs and ask how lay understandings of hypertension may inform potential mobilization for multisectoral policy actions by people living with hypertension. To explore this question, we develop a theoretical framework that casts mobilization as a function of people's recognition of disease importance, attribution of NCD risk factors to government policies, beliefs about who bears responsibility for NCD prevention and management, and beliefs around efficacy of multisectoral policies. We present findings from 45 semi-structured interviews with people living with hypertension in a qualitative study in Chennai, India. Our thematic analysis reveals that respondents can dedicate limited time and resources to actions around hypertension. People living with hypertension also strongly internalize responsibility for developing and managing their condition and focus primarily on achieving lifestyle changes. Instead of demanding multisectoral policy action around hypertension, respondents recommend that government actions focus on measures that enable their lifestyle changes, such as increasing awareness and health care capacities, and express doubts about the efficacy of government policies. Our findings expand existing theories around mobilization by revealing how people's own understanding of their illness, its risk factors and their underlying drivers, as well as their perception of challenges in NCD policy making can present barriers to mobilization around multisectoral policies. Theory on health social movements would benefit from a deeper integration of individual perspectives and a closer consideration of the specific challenges of living with NCDs given the local context.

Burden, prevention and control of tobacco consumption in Nepal: a narrative review of existing evidence

Tobacco consumption is one of the major public health problems in the world. Annually, 27 100 premature deaths are attributed to tobacco-related diseases in Nepal. Despite enacting different policies and strategies, the prevalence of tobacco consumption is still high. This study aims to synthesize prevalence, factors associated with its consumption and the policy initiatives for prevention and control in Nepal. This review includes peer-reviewed studies retrieved from two databases (PubMed and EMBASE) and published from 2000 to 2018, and policy initiatives on tobacco prevention and regulations in Nepal. A total of 32 studies and 5 policy documents were reviewed. Findings suggest that tobacco consumption was higher among men, illiterates, older people, people living in rural and mountainous areas and those who initiated smoking as adolescents. Peer pressure and parental/family smoking were major contributing factors for tobacco initiation. Policy analysis showed that low excise tax, weak monitoring mechanisms, poor compliance to bans on the advertisement and promotion of tobacco, smoke-free zones and insufficient programs on tobacco cessation were the major factors behind weak implementation of tobacco-control policies. Hence, targeted and high-risk group tobacco-cessation interventions, increasing taxation and strict policy implementation are crucial for effective tobacco prevention and control in Nepal.

Designing an Optimum Fiscal Policy for Tobacco to Maximise the Tax Revenue, Social Savings and the Net Monetary Benefits in Sri Lanka

BACKGROUND

Fiscal policy targeting tobacco control is identified as the most effective strategy for rapid control of tobacco use. An optimum fiscal policy to estimate the percentage taxation that will maximise the government tax revenue, social savings and the net monetary benefit has not been empirically designed before in Sri Lanka.

METHODS

A model was developed using Microsoft Excel 2016, utilizing up-to-date published evidence on the cigarette sales, current fiscal policy, social cost of tobacco use, consumer response and the price elasticity of cigarettes. Univariate estimates on the expected revenue from tobacco tax, average annual social savings and the net monetary benefit were predicted for different levels of tobacco taxation. A deterministic sensitivity analysis was performed covering all possibilities. The percentage taxation maximizing the government tax revenue and the net monetary benefit were identified.

RESULTS

It was estimated that a further 30% tax increase from the 2019 baseline will generate approximately LKR 3544 million per year of additional tax revenue for the government while saving LKR 28 069 million per annum as social savings. A fiscal elevation of 50% will produce identical annual tax revenue to that of 2018, while securing a social saving of more than LKR 47 600 million per annum. The maximum net monetary benefit is achievable at an overnight tax increase of 90% from the baseline, however with a short-term compromise in tax revenue.

CONCLUSION

The well-defined thresholds take tobacco taxation advocacy in Sri Lanka a step forward and will assist the government in taking an informed decision on its fiscal policy for cigarettes.

Impact of India's National Tobacco Control Programme on bidi and cigarette consumption: a difference-in-differences analysis

Background

Despite the importance of decreasing tobacco use to achieve mortality reduction targets of the Sustainable Development Goals in low-income and middle-income countries (LMICs), evaluations of tobacco control programmes in these settings are scarce. We assessed the impacts of India’s National Tobacco Control Programme (NTCP), as implemented in 42 districts during 2007–2009, on household-reported consumption of bidis and cigarettes.

Methods

Secondary analysis of cross-sectional data from nationally representative Household Consumer Expenditure Surveys (1999–2000; 2004–2005 and 2011–2012). Outcomes were: any bidi/cigarette consumption in the household and monthly consumption of bidi/cigarette sticks per person. A difference-in-differences two-part model was used to compare changes in bidi/cigarette consumption between NTCP intervention and control districts, adjusting for sociodemographic characteristics and time-based heterogeneity.

Findings

There was an overall decline in household-reported bidi and cigarette consumption between 1999–2000 and 2011–2012. However, compared with control districts, NTCP districts had no significantly different reductions in the proportions of households reporting bidi (adjusted OR (AOR): 1.03, 95% CI: 0.84 to 1.28) or cigarette (AOR: 1.01 to 95% CI: 0.82 to 1.26) consumption, or for the monthly per person consumption of bidi (adjusted coefficient: 0.07, 95% CI: −0.13 to 0.28) or cigarette (adjusted coefficient: −0.002, 95% CI: −0.26 to 0.26) sticks among bidi/cigarette consuming households.

Interpretation

Our findings indicate that early implementation of the NTCP may not have produced reductions in tobacco use reflecting generally poor performance against the Framework Convention for Tobacco Control objectives in India. This study highlights the importance of strengthening the implementation and enforcement of tobacco control policies in LMICs to achieve national and international child health and premature NCD mortality reduction targets.

Association between tobacco prices and smoking onset: evidence from the TCP India Survey

BACKGROUND

Tobacco use is prevalent among youth and adults in India. However, direct evidence on how increasing taxes or prices affect tobacco use onset is scarce.

OBJECTIVE

To analyse the associations between cigarette and bidi prices and smoking onset in India, and how these associations differ by socioeconomic status.

METHODOLOGY

The Wave 1 of the Tobacco Control Policy Evaluation India Survey by the International Tobacco Control Project contains information on the age at smoking onset for cigarettes and bidis. Using this information, data were expanded to a yearly pseudo-panel dataset that tracked respondents at risk of smoking onset from 1998 to 2011. The associations between bidi prices and bidi smoking onset, between cigarette prices and cigarette smoking onset, and between bidi and cigarette prices and any smoking onset were examined using a discrete-time hazard model with a logit link function. Stratified analyses were conducted to examine the difference in these associations by rural versus urban division.

RESULTS

We found that higher bidi prices were significantly associated with a lowered hazard of bidi smoking onset (OR 0.42, 95% CI 0.35 to 0.51). Higher cigarette prices were significantly (OR 0.87, 95% CI 0.83 to 0.92) associated with a lowered hazard of cigarette smoking onset among urban residents, but this association was non-significant when SEs were clustered at the state level. In addition, the association between increasing bidis prices and lowered hazards of bidi smoking onset was greater for urban residents than for rural ones (p<0.01).

CONCLUSIONS

Under the new regime of a central goods and service system, policymakers may need to raise the prices of tobacco products sufficiently to curb smoking onset.

Price elasticity of demand of non-cigarette tobacco products: a systematic review and meta-analysis

OBJECTIVE

To systematically review the price elasticity of demand of non-cigarette tobacco products.

DATA SOURCES

Medline, Embase, EconLit and the Web of Science without language or time restrictions.

STUDY SELECTION

Two reviewers screened title and abstracts, then full texts, independently and in duplicate. We based eligibility criteria on study design (interventional or observational), population (individuals or communities without geographic restrictions), intervention (price change) and outcome (change in demand).

DATA EXTRACTION

We abstracted data on study features, outcome measures, statistical approach, and single best own- and cross-price elasticity estimates with respect to cigarettes. We conducted a random effects meta-analysis for estimates of similar product, outcome and country income level. For other studies we reported median elasticities by product and country income level.

DATA SYNTHESIS

We analysed 36 studies from 15 countries yielding 125 elasticity estimates. A 10% price increase would reduce demand by: 8.3% for cigars (95% CI 2.9 to 13.8), 6.4% for roll your owns (95% CI 4.3 to 8.4), 5.7% for bidis (95% CI 4.3 to 7.1) and 2.1% for smokeless tobacco (95% CI -0.6 to 4.8). Median price elasticities for all ten products were also negative. Results from few studies that examined cross-price elasticity suggested a positive substitution effect between cigarette and non-cigarette tobacco products.

CONCLUSIONS

There is sufficient evidence in support of the effectiveness of price increases to reduce consumption of non-cigarette tobacco products as it is for cigarettes. Positive substitutability between cigarette and non-cigarette tobacco products suggest that tax and price increases need to be simultaneous and comparable across all tobacco products.