Cigarette smoking by socioeconomic group, sex, and age: effects of price, income, and health publicity

The Impact of ChatGPT Exposure on User Interactions With a Motivational Interviewing Chatbot: Quasi-Experimental Study

Background

The worldwide introduction of ChatGPT in November 2022 may have changed how its users perceive and interact with other chatbots. This possibility may confound the comparison of responses to pre-ChatGPT and post-ChatGPT iterations of pre-existing chatbots, in turn affecting the direction of their evolution. Before the release of ChatGPT, we created a therapeutic chatbot, MIBot, whose goal is to use motivational interviewing to guide smokers toward making the decision to quit smoking. We were concerned that measurements going forward would not be comparable to those in the past, impacting the evaluation of future changes to the chatbot.

Objective

The aim of the study is to explore changes in how users interact with MIBot after the release of ChatGPT and examine the relationship between these changes and users' familiarity with ChatGPT.

Methods

We compared user interactions with MIBot prior to ChatGPT's release and 6 months after the release. Participants (N=143) were recruited through a web-based platform in November of 2022, prior to the release of ChatGPT, to converse with MIBot, in an experiment we refer to as MIBot (version 5.2). In May 2023, a set of (n=129) different participants were recruited to interact with the same version of MIBot and asked additional questions about their familiarity with ChatGPT, in the experiment called MIBot (version 5.2A). We used the Mann-Whitney U test to compare metrics between cohorts and Spearman rank correlation to assess relationships between familiarity with ChatGPT and other metrics within the MIBot (version 5.2A) cohort.

Results

In total, 83(64.3%) participants in the MIBot (version 5.2A) cohort had used ChatGPT, with 66 (51.2%) using it on a regular basis. Satisfaction with MIBot was significantly lower in the post-ChatGPT cohort (U=11,331.0; P=.001), driven by a decrease in perceived empathy as measured by the Average Consultation and Relational Empathy Measure (U=10,838.0; P=.01). Familiarity with ChatGPT was positively correlated with average response length (ρ=0.181; P=.04) and change in perceived importance of quitting smoking (ρ=0.296; P<.001).

Conclusions

The widespread reach of ChatGPT has changed how users interact with MIBot. Post-ChatGPT users are less satisfied with MIBot overall, particularly in terms of perceived empathy. However, users with greater familiarity with ChatGPT provide longer responses and demonstrated a greater increase in their perceived importance of quitting smoking after a session with MIBot. These findings suggest the need for chatbot developers to adapt to evolving user expectations in the era of advanced generative artificial intelligence.

Is the affordability of cigarettes associated with the prevalence of smoking and quitting at the regional level in Russia?

INTRODUCTION

Tobacco prices and income determine the affordability of cigarettes. Affordability in turn affects smoking prevalence. Both prices and incomes can vary widely across a large country. The aim of this paper is to find out whether there is an association between affordability of cigarettes and smoking/cessation prevalence across Russian regions. We assess the proportions of people who smoke and those who smoked and quit.

METHODS

We use microdata from a repeated survey on the living conditions of the Russian population that is representative at the regional level (2014, 2016, 2018, 2020, 2022, 77 regions). We aggregate the microdata by region and combine them with official macro data. Using descriptive and multivariable analyses, we identify factors that correlate with the prevalence of smoking and quitting in the regions.

RESULTS

A one per cent increase in real prices was associated with a 0.1% decrease in the smoking prevalence rate and with a 0.2% increase in quitting prevalence rate. A 1% decrease in real income is associated with a 0.5% increase in the proportion of those who quit. The more cigarettes that can be purchased for a daily per capita income, the higher the smoking prevalence rate and the lower the proportion of quitting, with affordability elasticities of 0.1 and -0.27 respectively.

CONCLUSIONS

Rising real prices, as well as reduced affordability of cigarettes not only reduce the proportion of people who smoke, but also increase the proportion of those who quit. In a country with a large geographical spread and high regional income inequality, tobacco taxes should be set at the regional level to eliminate significant differences in the affordability of cigarettes.

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.

How has Expenditure on Nicotine Products Changed in a Fast-Evolving Marketplace? A Representative Population Survey in England, 2018-2022

INTRODUCTION

In the last 5 years, there has been a dramatic shift in the types of nicotine products being purchased. This study aimed to estimate how much users spend on types of cigarettes and alternative nicotine products (e-cigarettes, nicotine replacement therapy (NRT), heated tobacco, and nicotine pouches) and describe changes between 2018 and 2022.

AIMS AND METHODS

Monthly representative cross-sectional survey in England. 10 323 adults who smoked cigarettes or used alternative nicotine reported their average weekly expenditure on these products, adjusted for inflation.

RESULTS

Smokers spent £20.49 [95% CI = 20.09-20.91] on cigarettes each week (£27.66 [26.84-28.50] and £15.96 [15.49-16.28] among those who mainly smoked manufactured and hand-rolled cigarettes, respectively), e-cigarette users spent £6.30 [5.99-6.55] (£8.41 [7.17-9.78], £6.42 [5.58-7.39], and £5.93 [5.64-6.30] among those who mainly used disposable, pod, and refillable devices, respectively), NRT users £6.11 [5.53-6.69], and heated tobacco users £13.87 [9.58-20.09]. Expenditure on cigarettes grew by 10% from September 2018 to July 2020, then fell by 10% from July 2020 to June 2022. These changes coincided with a 13% reduction in cigarette consumption and a 14% increase in the proportion mainly smoking hand-rolled cigarettes. Expenditure on e-cigarettes was stable between 2018 and late 2020, then rose by 31% up to mid-2022. Expenditure on NRT increased slowly in 2018-2020 (+4%) and more quickly thereafter (+20%).

CONCLUSIONS

Inflation-adjusted expenditure on cigarettes has fallen since 2020, such that the average smoker in England currently spends the same on cigarettes each week as in 2018. This has been achieved by smoking fewer cigarettes and switching to cheaper hand-rolled cigarettes. Expenditure on alternative nicotine has increased above inflation; users spent around a third more on these products in 2022 than between 2018-2020.

IMPLICATIONS

People in England continue to spend substantially more on smoking cigarettes than using alternative nicotine products. The average smoker in England spends around £13 a week (~£670 a year) more than people using only e-cigarettes or NRT. The average expenditure on manufactured cigarettes is double that of hand-rolled cigarettes.

Can decision field theory enhance our understanding of health-based choices? Evidence from risky health behaviors

Discrete choice models are almost exclusively estimated assuming random utility maximization (RUM) is the decision rule applied by individuals. Recent studies indicate alternative behavioral assumptions may be more appropriate in health. Decision field theory (DFT) is a psychological theory of decision-making, which has shown promise in transport research. This study introduces DFT to health economics, empirically comparing it to RUM and random regret minimization (RRM) in risky health settings, namely tobacco and vaccine choices. Model fit, parameter ratios, choice shares, and elasticities are compared between RUM, RRM and DFT. Test statistics for model differences are derived using bootstrap methods. Decision rule heterogeneity is investigated using latent class models, including novel latent class DFT models. Tobacco and vaccine choice data are better explained with DFT than with RUM or RRM. Parameter ratios, choice shares and elasticities differ significantly between models. Mixed results are found for the presence of decision rule heterogeneity. We conclude that DFT shows promise as a behavioral assumption that underpins the estimation of discrete choice models in health economics. The significant differences demonstrate that care should be taken when choosing a decision rule, but further evidence is needed for generalizability beyond risky health choices.

Effects of large financial incentives on motivation to quit smoking and on cigarette dependence

BACKGROUND

Financial incentives enhance long-term smoking cessation rates, but their effects on motivation to quit in those who fail to quit are not well documented.

AIM

To test the effects of large financial incentives on motivation to quit smoking and on cigarette dependence in smokers who failed to quit despite receiving incentives.

PARTICIPANTS

Low-income smokers in the general population in Geneva, Switzerland, in 2011-2013.

METHODS

A randomised controlled trial with follow-up after three, six and 18 months. Participants were assigned to receive either booklets plus access to a smoking cessation website (control group, n = 404), or the same intervention plus financial incentives (intervention group, n = 401). Incremental financial rewards, to a maximum of CHF 1500 (USD 1650, GBP 1000), were offered for biochemically verified smoking abstinence. No in-person counselling, telephone counselling, or medications were provided.

MEASUREMENTS

Intrinsic and extrinsic motivation to quit, intention to quit, cigarette dependence.

FINDINGS

In smokers at 6-month follow-up, intrinsic motivation decreased in the control group (-0.24 SD units, p < 0.001), extrinsic motivation increased in the intervention group (+0.35 SD units, p = 0.001), and twice as many participants in the intervention group (35 %) than in the control group (17 %, p < 0.001) said they intended to quit smoking in the next 30 days. Quit attempts were more frequent and their duration was longer in the intervention group than in the control group. The intervention had no impact on cigarette dependence scores.

CONCLUSIONS

Large financial incentives increased motivation to quit smoking in smokers who failed to quit smoking despite receiving incentives.

Prevalence and Factors Associated with Tobacco Smoking in a National Representative Sample of Zambian Adults: Data from the 2017 STEPS - NCDs Survey

BACKGROUND

There has been a reduction in tobacco smoking worldwide except in developing countries. Africa has the lowest prevalence of tobacco use in the world, however, the rising trends amidst the WHO FCTC implementation are worrisome as it is likely to increase the tobacco public health impact in the next decade. The study investigated factors associated with tobacco smoking among adults in Zambia.

METHODS

We used secondary data extracted from the 2017 STEPS - NCDs Survey. Logistic regression was used to obtain unadjusted (UOR) and adjusted odds ratios (AOR) at 95% confidence interval (CI).

RESULTS

Of the 4,301 adults who participated, 11.0% were current tobacco smokers (25.7% men and 2.27% women). Of these 75.6% and 11.9% drunk alcohol and had mental health problems, respectively. In multivariable analysis, factors significantly associated with increased odds of current tobacco smoking were older age groups of 45-59 years (AOR = 1.69; 95% CI: 1.17-2.43, p = 0.005) and 60-69 years (AOR = 2.22; 95% CI: 1.25-3.93, p = 0.006), alcohol consumption (AOR = 5.93; 95% CI: 4.44-7.91, p < 0.001), mental health problems (AOR = 2.08; 95% CI: 1.34-3.22, p = 0.001). On the other hand, female gender (AOR = 0.07; 95% CI: 0.05-0.10, p < 0.001), being diabetic (AOR = 0.52; 95% CI: 0.15-0.46, p = 0.026), education attainment; primary, secondary, and higher education (AOR = 0.65; 95% CI: 0.47-0.91, p = 0.012, AOR = 0.40; 95% CI: 0.29-0.55, p < 0.001 and AOR = 0.26; 95% CI: 0.15-0.46, p < 0.001), respectively, had reduced odds of tobacco smoking.

CONCLUSIONS

Our findings underscore the high prevalence of tobacco smoking particularly in uneducated males who consume alcohol and have mental health problems.  The mental health problems and alcohol consumption in this population need to be addressed in concert with smoking cessation strategies.

Can a conditional financial incentive (CFI) reduce socio-demographic inequalities in home-based HIV testing uptake? A secondary analysis of the HITS clinical trial intervention in rural South Africa

In sub-Saharan Africa, home-based HIV testing interventions are designed to reach sub-populations with low access to HIV testing such as men, younger or less educated people. Combining these interventions with conditional financial incentives (CFI) has been shown to be effective to increase testing uptake. CFI are effective for one-off health behaviour change but whether they operate differentially on different socio-demographic groups is less clear. Using data from the HITS trial in South Africa, we investigated whether a CFI was able to reduce existing home-based HIV testing uptake inequalities observed by socio-demographic groups. Residents aged ≥15 years in the study area were assigned to an intervention arm (16 clusters) or a control arm (29 clusters). In the intervention arm, individuals received a food voucher (∼3.5 US dollars) if they accepted to take a home-based HIV test. Testing uptake differences were considered for socio-demographic (sex, age, education, employment status, marital status, household asset index) and geographical (urban/rural living area, distance from clinic) characteristics. Among the 37,028 residents, 24,793 (9290 men, 15,503 women) were included in the analysis. CFI increased significantly testing uptake among men (39.2% vs 25.2%, p < 0.001) and women (45.9% vs 32.0%, p < 0.001) with similar absolute increase between men and women. Uptake was higher amongst the youngest or least educated individuals, and amongst single (vs in union) or unemployed men. Absolute uptake increase was also significantly higher amongst these groups resulting in increasing socio-demographic differentials for home-based HIV testing uptake. However, because these groups are known to have less access to other public HIV testing services, CFI could reduce inequalities for HIV testing access in our specific context. Although CFI significantly increased home-based HIV testing uptake, it did not do so differentially by socio-demographic group. Future interventions using CFI should make sure that the intervention alone does not increase existing health inequities.

Socio-economic deprivation and cancer incidence in England: Quantifying the role of smoking

BACKGROUND

More deprived populations typically experience higher cancer incidence rates and smoking prevalence compared to less deprived populations. We calculated the proportion of cancer cases attributable to smoking by socio-economic deprivation in England and estimated the impact smoking has on the deprivation gap for cancer incidence.

METHODS

Data for cancer incidence (2013-2017), smoking prevalence (2003-2007) and population estimates (2013-2017) were split by sex, age-group and deprivation quintile. Relative risk estimates from meta-analyses were used to estimate the population attributable fraction (PAF) for 15 cancer types associated with smoking. The deprivation gap was calculated using age-specific incidence rates by deprivation quintile.

RESULTS

Smoking-related cancer PAFs in England are 2.2 times larger in the most deprived quintile compared to the least deprived quintile (from 9.7% to 21.1%). If everyone had the same smoking prevalence as the least deprived quintile, 20% of the deprivation gap in cancer incidence could have been prevented. If nobody smoked, 61% of the deprivation gap could have been prevented.

CONCLUSIONS

The majority of the deprivation gap in cancer incidence could have been prevented in England between 2013-2017 if nobody had smoked. Policy makers should ensure that tobacco control policies reduce overall smoking prevalence by tackling smoking inequalities.

The Economics of Tobacco Regulation: A Comprehensive Review

Tobacco regulation has been a major component of health policy in the developed world since the UK Royal College of Physicians' and the US Surgeon General's reports in the 1960s. Such regulation, which has intensified in the past two decades, includes cigarette taxation, place-based smoking bans in areas ranging from bars and restaurants to workplaces, and regulations designed to make tobacco products less desirable. More recently, the availability of alternative products, most notably e-cigarettes, has increased dramatically, and these products are just starting to be regulated. Despite an extensive body of research on tobacco regulations, there remains substantial debate regarding their effectiveness, and ultimately, their impact on economic welfare. We provide the first comprehensive review of the state of research in the economics of tobacco regulation in two decades.

Smoking-related behaviour changes among Korean men after the 2015 tobacco price increase: assessing the implications for the tobacco endgame using a reconstructed retrospective cohort study

OBJECTIVES

To examine the effect of Korea's 2015 tax policy, discuss its effectiveness and limitations and present future directions for tax policy in the context of the tobacco endgame.

DESIGN

A retrospectively reconstructed cohort study.

SETTING

Korea, August 2014-October 2015.

PARTICIPANTS

The study examined 41,605 male smokers aged 19 years and older who participated in the 2015 Korea Community Health Survey.

MEASURES AND ANALYSIS

Binary and multinomial logistic regression was used to assess the impact of the tax policy on smoking-related behaviour. We adjusted for demographic and health-related variables.

RESULTS

Among 41,605 men who were smokers in 2014, 15,499 (35.85%, weighted) reported being affected by the price increase. Of all smokers, 1,772 (3.96%, weighted) reported quitting smoking because of the tobacco price increase. Others reduced their smoking amount (n=9,714, 22.48%, weighted) or made other changes such as switching brands (n=4,013, 9.41%, weighted). An additional 2,401 smokers (5.72%, weighted) quit smoking for reasons other than the tobacco price increase. Compared with those in the highest quintile of household income, the odds that those in the lowest quintile quit smoking due to the price increase were almost twice as high (OR=1.98, 95% CI 1.54 to 2.54).

CONCLUSIONS

Korea's 2015 tobacco price increase affected a significant number of smokers within a year, especially in the lowest income group, inducing some to quit or reduce their smoking amount. However, more smokers quit for reasons independent of the price change. Tax policy can effectively reduce smoking, but needs to be combined with other policies for optimal results.

Design and pilot evaluation of an evidence-based worksheet and clinician guide to facilitate nutrition counselling for patients with severe mental illness

BACKGROUND

Schizophrenia spectrum disorders (SSD) are severe, persistent mental illnesses resulting in considerable disability and premature mortality. Emerging evidence suggests that diet may be a modifiable risk factor in mental illness; however, use of nutritional counselling as a component of psychiatric clinical practice is limited. The objective of this project is the design and evaluate a worksheet and clinician guide for use in facilitating nutritional counseling in the context of existing mental health care.

METHODS

The worksheet and clinician guide were developed based on the results of a recent scoping review on the relationship between diet and mental health symptoms among individuals with SSD. A feedback process involved a focus group with psychiatrists and interviews with individuals with lived experience with psychosis. Participants were asked a series of structured and open-ended questions. Interviews were transcribed and data units were allocated to categories from an existing framework. The comments were used to guide modifications to the worksheet and clinician guide. A brief interview with all participants was completed to gather feedback on the final version.

RESULTS

Five psychiatrist participants and six participants with lived experience completed interviews. Participants provided positive comments related to the worksheet design, complexity and inclusion of interactive components. A novel theme emerged relating to the lack of nutritional counselling in psychiatric training and clinical practice. Many constructive comments were provided which resulted in meaningful revisions and improvements to the worksheet and clinician guide design and content. All participants were satisfied with the final versions.

CONCLUSIONS

A worksheet and clinician guide designed to facilitate nutritional counselling with individuals with SSD was found to be acceptable to all participants following a process of feedback and revision. Further research and dissemination efforts aimed at increasing the use of nutritional counselling in psychiatric practice are warranted.

Inequality-Reducing Effects of Tobacco Tax Increase: Accounting for Behavioral Response of Low-, Middle-, and High-Income Households in Serbia

While previous research has indicated that increasing tobacco excises is a crucial instrument for lowering tobacco demand, this policy has been criticized for its alleged regressive impact on the poor. However, this critique does not take into account the behavioral response, i.e., decrease in consumption that occurs after excises and prices increase. In this paper, we examine the effect of cigarettes' price increase on tobacco consumption, household expenditures, and tax burdens in three income groups and provide empirical arguments on the regressivity/progressivity effects of tobacco tax increase. Estimated elasticities indicate that all groups decrease their cigarettes demand with increasing prices, with demand decrease stronger for low- than for middle- and high-income households. Results further suggest that increasing tobacco excises (1) decreases tobacco expenditure of low-income households, which increases their productive consumption, such as on food, clothes, etc., and (2) redistributes the tobacco tax burden from low- to high-income households. Therefore, excise increase policies do not have an adverse effect on the position of the low-income households; on the contrary, they lower their cigarettes expenditure and their tax burden, while lower cigarettes consumption has an additional, positive effect on their health, which attenuates future inequalities.

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

BACKGROUND

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

METHODS AND FINDINGS

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

CONCLUSIONS

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

Written Advice Given by African American Smokers to Their Peers: Qualitative Study of Motivational Messages

BACKGROUND

Although African Americans have the lowest rates of smoking onset and progression to daily smoking, they are less likely to achieve long-term cessation. Interventions tailored to promote use of cessation resources in African American individuals who smoke are needed. In our past work, we demonstrated the effectiveness of a technology-assisted peer-written message intervention for increasing smoking cessation in non-Hispanic White smokers. In this formative study, we have adapted this intervention to be specific for African American smokers.

OBJECTIVE

We aimed to report on the qualitative analysis of messages written by African American current and former smokers for their peers in response to hypothetical scenarios of smokers facing cessation challenges.

METHODS

We recruited African American adult current and former smokers (n=41) via ResearchMatch between April 2017 and November 2017. We asked participants to write motivational messages for their peers in response to smoking-related hypothetical scenarios. We also collected data on sociodemographic factors and smoking characteristics. Thematic analysis was conducted to identify cessation strategies suggested by the study participants.

RESULTS

Among the study participants, 60% (25/41) were female. Additionally, more than half (23/41, 56%) were thinking about quitting, 29% (12/41) had set a quit date, and 27% (11/41) had used electronic cigarettes in the past 30 days. Themes derived from the qualitative analysis of peer-written messages were (1) behavioral strategies, (2) seeking help, (3) improvements in quality of life, (4) attitudes and expectations, and (5) mindfulness/religious or spiritual practices. Under the behavioral strategies theme, distraction strategies were the most frequently suggested strategies (referenced 84 times in the 318 messages), followed by use of evidence-based treatments/cessation strategies. Within the seeking help theme, subthemes included seeking help or support from family/friends or close social networks (referenced 56 times) and health care professionals (referenced 22 times). The most frequent subthemes that emerged from improvements in the quality of life theme included improving one's health (referenced 22 times) and quality of life (referenced 21 times). Subthemes that emerged from the attitude and expectations theme included practicing positive self-talk (referenced 27 times), autonomy/independence from the smoking habit (referenced six times), and financial cost of smoking (referenced five times). The two subthemes that emerged from the mindfulness/religious or spiritual practices theme were use of self-awareness techniques (referenced 36 times) and religious or spiritual practices to cope (referenced 13 times).

CONCLUSIONS

Our approach to adapt a prior peer-message intervention to African American smokers yielded a set of evidence-based messages that may be suitable for smokers at all phases of motivation to quit (ready to quit or not ready to quit). In future research, we plan to assess the impact of texting these messages to African American smokers in a smoking cessation trial.

Matched case-control data with a misclassified exposure: what can be done with instrumental variables?

Matched case-control studies are used for finding the association between a disease and an exposure after controlling the effect of important confounding variables. It is a known fact that the disease-exposure association parameter estimators are biased when the exposure is misclassified, and a matched case-control study is of no exception. Any bias correction method relies on validation data that contain the true exposure and the misclassified exposure value, and in turn the validation data help to estimate the misclassification probabilities. The question is what we can do when there are no validation data and no prior knowledge on the misclassification probabilities, but some instrumental variables are observed. To answer this unexplored and unanswered question, we propose two methods of reducing the exposure misclassification bias in the analysis of a matched case-control data when instrumental variables are measured for each subject of the study. The significance of these approaches is that the proposed methods are designed to work without any validation data that often are not available when the true exposure is impossible or too costly to measure. A simulation study explores different types of instrumental variable scenarios and investigates when the proposed methods work, and how much bias can be reduced. For the purpose of illustration, we apply the methods to a nested case-control data sampled from the 1989 US birth registry.

Effects of cigarette price increase on fresh food expenditures of low-income South Korean households that spend relatively more on cigarettes

On January 1, 2015, the cigarette tax in South Korea increased sharply. In this study, we analyzed how the fresh food expenditures of low-income smoking households that spend relatively more on cigarettes changed between 2014 and 2015 compared to their demographically comparable non-smoking counterparts. We conducted the analysis using a difference-in-differences analysis from which we derived expenditure differences between smoking households and non-smoking households and then examined whether the differences increased from 2014 to 2015. In deriving the differences, we utilized the nearest-matching method to ensure that, besides smoking status, the socio-demographics of the two groups were matched. We used data from the Household Income and Expenditure Survey of South Korea. The analysis showed that smoking households spent less on fruits and vegetables than non-smoking households and that this difference increased after the tax increase. The change was more remarkable in the poorest households that spent relatively more on cigarettes. This suggests that cigarette expenditures have a crowding out effect on fresh food expenditures for smoking households, with a significantly larger effect for households in the poorest group that spend more on cigarettes.

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.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS

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

Cost Effectiveness of Nutrition Policies on Processed Meat: Implications for Cancer Burden in the U.S

INTRODUCTION

Processed meats are associated with increased risk of colorectal and stomach cancers, but health and economic impacts of policies to discourage processed meats are not well established. This paper aims to evaluate the cost effectiveness of implementing tax and warning labels on processed meats.

METHODS

A probabilistic cohort-state transition model was developed in 2018, including lifetime and short-term horizons, healthcare, and societal perspectives, and 3% discount rates for costs and health outcomes. The model simulated 32 subgroups by age, gender, and race/ethnicity from the U.S. adult population and integrated nationally representative 2011-2014 data on processed meat consumption, with etiologic effects of processed meat consumption on cancer incidence, medical and indirect societal costs, and policy costs.

RESULTS

Over a lifetime, the 10% excise tax would prevent 77,000 cases of colorectal cancer (95% uncertainty interval=56,800, 107,000) and 12,500 cases of stomach cancer (95% uncertainty interval=6,880, 23,900), add 593,000 quality-adjusted life years (95% uncertainty interval=419,000, 827,000), and generate net savings of $2.7 billion from a societal perspective, including $1.1 billion healthcare costs saved. The warning label policy would avert 85,400 cases of colorectal cancer (95% uncertainty interval=56,600, 141,000) and 15,000 cases of stomach cancer (95% uncertainty interval=6,860, 34,500), and add 660,000 quality-adjusted life years (95% uncertainty interval=418,000, 1,070,000), with net savings of $4.5 billion from a societal perspective, including $1.3 billion healthcare costs saved. In subgroup analyses, greater health and economic benefits accrued to (1) younger subpopulations, (2) subpopulations with greater cancer risk, and (3) those with higher baseline processed meat consumption.

CONCLUSIONS

The model shows that implementing tax or warning labels on processed meats would be a cost-saving strategy with substantial health and economic benefits. The findings should encourage policy makers to consider nutrition-related policies to reduce cancer burden.

Socioeconomic Differences in Smoking and Cessation Across a Period of Rapid Economic Growth in an Upper-Middle-Income Country

INTRODUCTION

Higher smoking rates and lower cessation rates among the poor compared to the rich are evident in high-income countries. In low and middle-income countries (LMICs), many of which are in the early stages of tackling the tobacco epidemic, more knowledge is required of the socioeconomic inequalities in smoking. This is especially the case for upper-middle-income countries, where smoking prevalence is highest. This study examines trends in the socioeconomic gradient in smoking and cessation among adults across a period of rapid economic development in Malaysia, an LMIC with an upper-middle-income economy.

METHODS

The socioeconomic trends in smoking were analyzed using data from cross-sectional National Health and Morbidity Surveys for the years 1996, 2006, and 2011. Household per capita income was used as a measure of socioeconomic position. As a measure of inequality, the concentration index that quantified the degree of socioeconomic inequality in a health outcome was computed. Smoking was assessed in current and former smokers. The study population was examined by gender, region, and age group.

RESULTS

This study found a trend of an increasingly higher smoking prevalence among the poor and higher cessation rates among the rich. With the exception of younger women in Peninsular Malaysia, the socioeconomic gradient in current smoking is concentrated among the poor. For former smokers, especially men, distributions across the years were mostly concentrated among the rich.

CONCLUSION

It is important to ensure that health policies, programs, and interventions consider the potential impact of the socioeconomic patterning in smoking on equity in health.

IMPLICATIONS

Findings on the socioeconomic gradient in smoking and cessation from Malaysia across a period of rapid economic development will contribute to addressing the paucity of knowledge on the socioeconomic gradient of smoking and cessation in other progressing LMICs. This study provides evidence from an upper-middle-income country, of an increasing trend of smoking among the poor and an increasing trend of cessation rates among the rich, particularly for men. We found opposing trends for younger adult women in the more developed, Peninsular Malaysia. More rich young women were found to have taken up smoking compared to socioeconomically less advantaged young women.

Spatial distribution and correlates of smoking in Zambia

OBJECTIVE

The objective of the paper was to investigate the spatial distribution and correlates of tobacco smoking in various regions of Zambia.

METHODS

This paper adopts a cross-sectional study design. The study used data from the 2013/2014 Zambia Demographic Health Survey which is a nationwide health survey conducted in all the 10 provinces. A random sample of men and women from 15 920 households was successfully selected and interviewed. All women aged 15-49 and men aged 15-59 who were either permanent residents of the households or visitors present in the households on the night before the survey were eligible to be interviewed.

RESULTS

The results show that 8.2% and 11% of Zambians in urban and rural areas smoke, respectively. In urban areas, the risk of being a cigarette smoker was 2.31 (CI: 1.69 to 3.16) and 2.03 (CI: 1.36 to 3.02) times higher for the divorced and separated. However, the risk of being a cigarette smoker was lower for those with some formal education. In rural areas, the risk of being a cigarette smoker was lower for the married (relative risk ratios (RRR): 0.69, CI: 0.55 to 0.86) and those with a formal education. Nevertheless, in rural areas, the risk of being a pipe and other smoker was higher for those who were self-employed (RRR: 8.46, CI: 2.95 to 24.20) and with an occupation (RRR: 2.37, CI: 1.39 to 4.02) but was lower among women.

CONCLUSION

Tobacco smoking varies between and within regions as well as provinces. Therefore, interventions to curb smoking should target specific demographic, socioeconomic and cultural factors and how they are spatially distributed.

Socioeconomic inequalities in childhood-to-adulthood BMI tracking in three British birth cohorts

BACKGROUND

Body mass index (BMI) tracks from childhood-to-adulthood, but the extent to which this relationship varies across the distribution and according to socio-economic position (SEP) is unknown. We aimed to address this using data from three British cohort studies.

METHODS

We used data from: 1946 National Survey of Health and Development (NSHD, n = 2470); 1958 National Child Development Study (NCDS, n = 7747); 1970 British Cohort Study (BCS, n = 5323). BMI tracking between 11 and 42 years was estimated using quantile regression, with estimates reflecting correlation coefficients. SEP disparities in tracking were investigated using a derived SEP variable based on parental education reported in childhood. This SEP variable was then interacted with the 11-year BMI z-score.

RESULTS

In each cohort and sex, tracking was stronger at the upper end of the distribution of BMI at 42 years. For example, for men in the 1946 NSHD, the tracking estimate at the 10th quantile was 0.31 (0.20, 0.41), increasing to 0.71 (0.61, 0.82) at the 90th quantile. We observed no strong evidence of SEP inequalities in tracking in men in the 1946 and 1958 cohorts. In the 1970 cohort, however, we observed tentative evidence of stronger tracking in low SEP groups, particularly in women and at the higher end of the BMI distribution. For example, women in the 1970 cohort from low SEP backgrounds had tracking coefficients at the 50th, 70th, and 90th quantiles, which were 0.05 (-0.04; 0.15), 0.19 (0.06; 0.31), and 0.22 (0.02; 0.43) units higher, respectively, than children from high SEP groups.

CONCLUSION

Tracking was consistently stronger at the higher quantiles of the BMI distribution. We observed suggestive evidence for a pattern of greater BMI tracking in lower (compared to higher) SEP groups in the more recently born cohort, particularly in women and at the higher end of the BMI distribution.

The smoking epidemic across generations, genders, and educational groups: A matter of diffusion of innovations

This study determines whether the temporal variations in smoking habits across generations and genders and among groups with differing levels of education fit the pattern proposed by the theory of the diffusion of innovations (TDI) (Rogers, 2003). We focus on the Italian case and employ a pseudo-panel derived from repeated cross-sections of the annual household survey, "Aspects of Daily Life," that was part of the Multipurpose Survey carried out by the Italian National Statistical Office (ISTAT) for the period 1997 to 2012. The results confirm Rogers' TDI and show that smoking prevalence has declined over time and across age cohorts: Younger men of all educational levels and women with higher education are less likely to smoke than are those in other cohorts, while less-educated women who entered the smoking-diffusion process later than others are more likely to smoke. Hence, socio-economic differences in smoking continue to persist, especially for women. According to Rogers' TDI, smoking prevalence is expected to continue to decline, particularly among little-educated women.

Impact of tobacco control policies on smoking prevalence and quit ratios in 27 European Union countries from 2006 to 2014

BACKGROUND

Tobacco use is still highly prevalent in Europe, despite the tobacco control efforts made by the governments. The development of tobacco control policies varies substantially across countries. The Tobacco Control Scale (TCS) was introduced to quantify the implementation of tobacco control policies across European countries OBJECTIVE: To assess the midterm association of tobacco control policies on smoking prevalence and quit ratios among 27 European Union (EU) Member States (EU27).

METHODS

Ecological study. We used the TCS in EU27 in 2007 and the prevalence of tobacco and quit ratios data from the Eurobarometer survey (2006 (n=27 585) and 2014 (n=26 793)). We analysed the relationship between the TCS scores and smoking prevalence and quit ratios and their relative changes (between 2006 and 2014) by means of scatter plots and multiple linear regression models.

RESULTS

In EU27, countries with higher scores in the TCS, which indicates higher tobacco control efforts, have lower prevalence of smokers, higher quit ratios and higher relative decreases in their prevalence rates of smokers over the last decade. The correlation between TCS scores and smoking prevalence (rsp=-0.444; P=0.02) and between the relative changes in smoking prevalence (rsp=-0.415; P=0.03) was negative. A positive correlation was observed between TCS scores and quit ratios (rsp=0.373; P=0.06). The percentage of smoking prevalence explained by all TCS components was 28.9%.

CONCLUSION

EU27 should continue implementing comprehensive tobacco control policies as they are key for reducing the prevalence of smoking and an increase tobacco cessation rates in their population.

The association between cigarette affordability and consumption: An update

Objectives

This study calculates cigarette affordability for 78 countries worldwide from 2001 to 2014 using the Relative Income Price (RIP) ratio defined as the percentage of per capita GDP required to purchase 100 packs of cigarettes using the lowest price from Economist Intelligence Unit (EIU) database, examine the association between cigarette affordability and cigarette consumption, and calculate the affordability elasticity of demand.

Design and methods

RIP (2001–2014) was calculated for 16 low-income economies, 19 lower middle-income economies, 13 upper middle-income economies, and 30 high-income economies. Ordinary least square regressions were used to analyze the association between cigarette affordability and consumption.

Results

Per capita consumption continued to rise in low-income countries and decreased slightly in lower middle-income countries as the RIP of cigarette consistently declined in low- and lower middle-income economies from 2001 to 2014. The real cigarette prices continued to decline in low- and lower middle-income countries and continued to rise in upper middle- and high-income countries. Though cigarettes were more expensive in HICs than were in LMICs, cigarettes were more affordable in HICs than were in LMICs. The regression results show a 10% increase in the RIP of cigarettes led to a 2% decrease in per capita consumption. The affordability elasticity of demand differed significantly between HICs and LMICs. However, the effect of cigarette affordability on consumption has not changed over time.

Conclusions

To control the smoking epidemic, low- and lower middle-income countries should further increase cigarette prices. The rate of price increase should exceed the rate of economic growth and outpace the inflation rate to make cigarettes less affordable and thereby reducing tobacco use.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Social phenomena following the tobacco tax increase in South Korea: Lessons and policy implications

INTRODUCTION

This paper reviews the trial and error occurring before an increase in cigarette prices and the subsequent effects of this in South Korea. In addition, we introduce the social phenomena that occur as a result of an increase in tobacco tax, and propose effective strategies and principles that need to be taken into account before increasing cigarette prices.

METHODS

We compared changes to smoking rates before and after the increase in cigarette prices. To investigate the changes that occurred before South Korea’s increase in tobacco tax, we first analysed the state of cigarette consumption and then the change in smoking rates.

RESULTS

The increase in cigarette prices caused an immediate backlash from smokers, particularly low-income groups and those claiming tax inequality. In particular, the sales of electronic nicotine delivery systems (ENDS) increased dramatically and the lower price marketing of tobacco companies led to short-term market share increases. As expected, smoking rates in South Korea decreased. However, because the price increase was not sufficient to encourage widespread smoking cessation, the decrease in smoking rates was not significant.

CONCLUSIONS

Because the primary objective of the cigarette pricing policy was not designed to promote public health, by reducing smoking rates, it received public criticism. To avoid public criticism, the government must emphasize and convince the public that the primary objective of increasing cigarette prices is to protect public health through a decline in smoking rates. Ideally, health authorities should play a leading role in formulating tobacco tax policy.

Smoking Behavior among Jordanians: Physical, Psychological, Social, and Economic Reasons

OBJECTIVES

To highlight the physical, psychological, social, and economic reasons related to sex differences in smoking behaviors in Jordan.

METHODS

A cross-sectional questionnaire-based survey was conducted among Jordanian adult smokers.

RESULTS

Sex was a significant predictor of physical reasons related to smoking; when controlling for other factors (t₇₆₅ = 5.027; P < 0.001), women were more affected by physical factors than were men. In addition, work status was a significant predictor of physical reasons (t₇₆₅ = -2.563; P = 0.011), as was the price of cigarettes (t₇₆₅ = 2.224; P = 0.026). Age was a significant predictor of psychological reasons (t₇₆₅ = -3.092; P = 0.002): younger individuals were more likely to state psychological factors as their reason for smoking than were older individuals. Conversely, sex was a significant predictor (t₇₆₅ = 2.798; P = 0.005) of social reasons for smoking, with more men than women reporting social motivations.

CONCLUSIONS

Women were more likely to smoke for physical factors that are positively correlated with the price of cigarettes, rendering them less responsive to an increase in the price of cigarettes. Conversely, men were more likely to smoke for social reasons that are negatively correlated with the price of cigarettes; thus, men are more responsive to an increase in the price of cigarettes. Future public policies aiming to combat smoking in Jordan should consider sex differences in smoking behavior because one policy may not necessarily fit all.

Australia's $40 per pack cigarette tax plans: the need to consider equity

In May 2016, the Australian Government announced that it would implement annual increases in tobacco excise of 12.5% up to and including 2020, raising the cost of a pack of cigarettes to $A40. This increase will lead to Australia having one of the highest prices of cigarettes in the world. Increasing the cost of tobacco is considered by public health experts to be one of the most effective strategies to reduce tobacco use, and is generally well supported by the public. However, tobacco tax increases differentially impact various subgroups of the population. Based on a review of existing literature, this paper examines some of the potential (unintended) consequences of the tax to individual and family income; illicit trade; social stigma and opportunities for lobbying by the tobacco industry. In light of these considerations, we offer strategies that might be used by policymakers to mitigate potential harms. While this paper focuses on the impacts primarily on populations in Australia, the consequences and strategies offered may be useful to other countries implementing tobacco excise increases.

Smoking in chronic psychiatric illness: is it worth it?

The prevalence of smoking is higher among chronic psychiatric patients than the general population, in spite of their lower income. The purpose of this study was to calculate the percentage of income these patients spend on smoking and to discuss the relationship between smoking and chronic psychiatric disorders, in particular schizophrenia. Ninety-six smokers were included in the study. The mean percentage expenditure on smoking was 294% of income. We discuss why chronic psychiatric patients smoke so much, why they should not, and what factors may encourage them to quit.

The effects of a rise in cigarette price on cigarette consumption, tobacco taxation revenues, and of smoking-related deaths in 28 EU countries-- applying threshold regression modelling

BACKGROUND

European Union public healthcare expenditure on treating smoking and attributable diseases is estimated at over €25bn annually. The reduction of tobacco consumption has thus become one of the major social policies of the EU. This study investigates the effects of price hikes on cigarette consumption, tobacco tax revenues and smoking-caused deaths in 28 EU countries.

METHODS

Employing panel data for the years 2005 to 2014 from Euromonitor International, the World Bank and the World Health Organization, we used income as a threshold variable and applied threshold regression modelling to estimate the elasticity of cigarette prices and to simulate the effect of price fluctuations.

RESULTS

The results showed that there was an income threshold effect on cigarette prices in the 28 EU countries that had a gross national income (GNI) per capita lower than US$5418, with a maximum cigarette price elasticity of -1.227. The results of the simulated analysis showed that a rise of 10% in cigarette price would significantly reduce cigarette consumption as well the total death toll caused by smoking in all the observed countries, but would be most effective in Bulgaria and Romania, followed by Latvia and Poland. Additionally, an increase in the number of MPOWER tobacco control policies at the highest level of achievment would help reduce cigarette consumption.

CONCLUSIONS

It is recommended that all EU countries levy higher tobacco taxes to increase cigarette prices, and thus in effect reduce cigarette consumption. The subsequent increase in tobacco tax revenues would be instrumental in covering expenditures related to tobacco prevention and control programs.

Effects of Large Financial Incentives for Long-Term Smoking Cessation: A Randomized Trial

BACKGROUND

It is not known whether large financial incentives enhance long-term smoking cessation rates outside clinical or workplace settings.

OBJECTIVES

The goal of this study was to test whether large financial incentives improved long-term smoking cessation rates in low-income smokers, in a general population setting, without face-to-face or telephone counseling.

METHODS

This was a 2-arm, parallel group, individually randomized controlled trial, with follow-up after 3, 6, and 18 months. Participants were 805 low-income smokers enrolled between 2011 and 2013 from the general population in Geneva, Switzerland. We randomly assigned participants to receive either booklets plus access to a smoking cessation website (control group, n = 404), or the same intervention plus financial incentives (intervention group, n = 401). Incremental financial rewards, to a maximum of U.S. $1,650, were offered for biochemically verified abstinence at 1, 2, and 3 weeks, and 1, 3, and 6 months. No in-person counseling, telephone counseling, or medications were provided. The primary outcome was continuous abstinence between 6 months (end of incentives) and 18 months (12 months after the incentives ended), verified by expired carbon monoxide and salivary cotinine. We also assessed biochemically verified 7-day abstinence at 3, 6, and 18 months.

RESULTS

Rates of continuous abstinence between months 6 and 18 were 9.5% in the incentive group and 3.7% in the control group (p = 0.001). Rates of 7-day abstinence were higher in the incentive group than in the control group at 3 (54.9% vs. 11.9%; p < 0.001), 6 (44.6% vs. 11.1%; p < 0.001), and 18 months (18.2% vs. 11.4%; p = 0.006).

CONCLUSIONS

In low-income smokers who did not receive face-to-face or telephone smoking cessation counseling, large financial incentives increased long-term rates of smoking cessation. (Financial incentives for smoking cessation in low-income smokers; ISRCTN04019434).

Exploring Impacts of Taxes and Hospitality Bans on Cigarette Prices and Smoking Prevalence Using a Large Dataset of Cigarette Prices at Stores 2001-2011, USA

In the USA, little is known about local variation in retail cigarette prices; price variation explained by taxes, bans, and area-level socio-demographics, and whether taxes and hospitality bans have synergistic effects on smoking prevalence. Cigarette prices 2001–2011 from chain supermarkets and drug stores (n = 2973) were linked to state taxes (n = 41), state and county bar/restaurant smoking bans, and census block group socio-demographics. Hierarchical models explored effects of taxes and bans on retail cigarette prices as well as county smoking prevalence (daily, non-daily). There was wide variation in store-level cigarette prices in part due to differences in state excise taxes. Excise taxes were only partially passed onto consumers (after adjustment, $1 tax associated with $0.90 increase in price, p < 0.0001) and the pass-through was slightly higher in areas that had bans but did not differ by area-level socio-demographics. Bans were associated with a slight increase in cigarette price (after adjustment, $0.09 per-pack, p < 0.0001). Taxes and bans were associated with reduction in smoking prevalence and taxes had a stronger association when combined with bans, suggesting a synergistic effect. Given wide variation in store-level prices, and uneven state/county implementation of taxes and bans, more federal policies should be considered.

A Prospective Cohort Study of Cigarette Prices and Smoking Cessation in Older Smokers

Background: Cigarette price increases effectively prevent smoking initiation and reduce cigarette consumption among young smokers. However, the impact of cigarette prices on smoking cessation among older smokers is less clear, particularly for those aged 65 years and older, a group that is at highest risk of smoking-related disease and will almost double in the United States between 2012 and 2050.Methods: Biennial questionnaires administered between 1997 and 2013 assessed smoking status for 9,446 Cancer Prevention Study-II Nutrition Cohort participants who were ≥50 years old and lived in Washington, DC, and 48 states. For each interval between biennial questionnaires, change in price per pack and average price level per pack were calculated. The separate associations between these price variables and smoking cessation during the same time interval were determined.Results: In multivariable-adjusted models, each $1.00 price increase was associated with a 9% higher rate of quitting [rate ratio (RR) = 1.09; 95% confidence interval (CI), 1.04-1.14). Each $1.00 increase in average price was associated with a 6% higher rate of quitting (RR = 1.06; 95% CI, 1.02-1.10). The association with average price was strongest among smokers aged 65 years and older (RR = 1.07; 95% CI, 1.04-1.11) and, for price change, for smokers with no major prevalent disease (RR = 1.13; 95% CI, 1.07-1.19).Conclusions: These results suggest that increasing cigarette prices will promote quitting even among smokers aged 65 years and older.Impact: Increasing cigarette prices through higher taxes could reduce smoking rates among older adults and decrease risk of smoking-related cancers and diseases in this high-risk group. Cancer Epidemiol Biomarkers Prev; 26(7); 1071-7. ©2017 AACR.

Motivations for Smoking Cessation and the Impact of Regulatory Tax Increases Amongst Fathers within the Pacific Islands Families Study

Aims: To examine the prevalence of smoking, motivations for cessation, and impact of tobacco excise tax increases amongst a cohort of Pacific fathers at 11 years after the birth of their child.

Methods: Within the context of broader interviews, 723 Pacific fathers participating in the Pacific Islands Families (PIF) Study were surveyed about their smoking at the 11-year measurement point. Prevalence of smoking was calculated, alongside motivations to quit, and the impact of increases to the excise tax on tobacco.

Results: Smoking prevalence amongst Pacific fathers remains high (38%) at 11 years postpartum, although 81% of smokers disclosed interest in quitting smoking. The strongest motivation to quit smoking was their ‘own health’ (n = 185, 82%), followed by ‘the cost’ (n = 148, 66%), and the impact on ‘their child's health’ (n = 113, 50%). Among smokers, 12% (n = 31) had never attempted to quit, whereas 63% (n = 159) had made multiple attempts. Approximately 70% (n = 191) of smokers indicated the New Zealand Government-initiated tobacco excise tax increases caused them to reduce their tobacco consumption.

Conclusions: High smoking prevalence amongst this cohort raises serious concerns about the risks Pacific families and communities face from smoking. Maintaining a sustained series of tobacco excise tax increases, alongside the utilisation of information on key motivators for Pacific fathers to quit smoking, may prove more effective in supporting Pacific communities to achieve the New Zealand Government's Smokefree 2025 goal.

The effect of policies regulating tobacco consumption on smoking initiation and cessation in Spain: is it equal across socioeconomic groups?

Background

In Spain, the Law 28/2005, which came into effect on January 2006, was a turning point in smoking regulation and prevention, serving as a guarantee for the progress of future strategies in the direction marked by international organizations. It is expected that this regulatory policy should benefit relatively more to lower socioeconomic groups, thus contributing to a reduction in socioeconomic health inequalities. This research analyzes the effect of tobacco regulation in Spain, under Law 28/2005, on the initiation and cessation of tobacco consumption, and whether this effect has been unequal across distinct socioeconomic levels.

Methods

Micro-data from the National Health Survey in its 2006 and 2011 editions are used (study numbers: 4382 and 5389 respectively; inventory of statistical operations (ISO) code: 54009), with a sample size of approximately 24,000 households divided into 2,000 census areas. This allows individuals’ tobacco consumption records to be reconstructed over five years before the initiation of each survey, as well as identifying those individuals that started or stopped smoking. The methodology is based on “time to event analysis”. Cox’s proportional hazard models are adapted to show the effects of a set of explanatory variables on the conditional probability of change in tobacco consumption: initiation as a daily smoker by young people or the cessation of daily smoking by adults.

Results

Initiation rates among young people went from 25% (95% confidence interval (CI), 23–27) to 19% (95% CI, 17–21) following the implementation of the Law, and the change in cessation rates among smokers was even greater, with rates increasing from 12% (95% CI, 11–13) to 20% (95% CI, 19–21). However, this effect has not been equal by socioeconomic groups as shown by relative risks. Before the regulation policy, social class was not a statistically significant factor in the initiation of daily smoking (p > 0.05); however, following the implementation of the Law, young people belonging to social classes IV-V and VI had a relative risk of starting smoking 63% (p = 0.03) and 82% (p = 0.02) higher than young people of higher social classes I-II. On the other hand, lower social class also means a lower probability of smoking cessation; however, the relative risk of cessation for a smoker belonging to a household of social class VI (compared to classes I-II) went from 24% (p < 0.001) lower before the Law to 33% (p < 0.001) lower following the law’s implementation.

Conclusion

Law 28/2005 has been effective, as after its promulgation there has been a decrease in the rate of smoking initiation among young people and an increase in the rate of cessation among adult smokers. However, this effect has not been equal by socioeconomic groups, favoring relatively more to those individuals belonging to higher social classes.

No modifying effect of education level on the association between lifestyle behaviors and cardiovascular mortality: the Japan Collaborative Cohort Study

We examined the effect of education level on the association between healthy lifestyle behaviors and cardiovascular mortality in the Japanese population. A total of 42,647 community-based men and women aged 40-79 years were enrolled at baseline (1988-1990), followed through 2009. The components of the healthy lifestyle score included the intake of fruits, fish, and milk; body mass index; exercise; avoidance of smoking; moderate alcohol intake; and moderate sleep duration. During the 19.3 years of follow-up, 8,314 all-cause and 2,377 total cardiovascular mortality cases were noted. Inverse associations were observed between healthy lifestyle scores and total cardiovascular disease (CVD) for both the lower and higher education level groups. Multivariable hazard ratios (95% confidence interval) for CVD mortality from the highest to the lowest healthy lifestyle scores, and the population attributable fraction (95% CIs) without healthy lifestyle scores of 7-8 were 0.51 (0.33-0.52) and 42% (24-58%), and 0.38 (0.27-0.47) and 55% (36-69%) for the higher and lower education levels, respectively. Our findings suggest that the association between higher CVD mortality and lower education level can be explained by the individuals' lower adherence to a healthy lifestyle; hence, lifestyle modification would be beneficial for the prevention of cardiovascular mortality, irrespective of the education level.

Influence of Socioeconomic Factors, Gender and Indigenous Status on Smoking in Taiwan

The indigenous Austronesian minority of Taiwan is heavily affected by health disparities which may include suffering from a greater burden of the tobacco epidemic. While a lack of representative data has historically precluded an investigation of the differences in smoking between Taiwanese ethnicities, these data have recently become available through an annual population-based telephone survey conducted by the Health Promotion Administration, Ministry of Health and Welfare (previously known as the Bureau of Health Promotion (BHP), Department of Health). We used the BHP monitoring data to observe the prevalence of smoking and environmental tobacco smoke exposure among indigenous and non-indigenous Taiwanese surrounding a tobacco welfare tax increase in 2006, investigate ethnic differences in smoking prevalence and environmental tobacco smoke exposure each year between 2005 and 2008, and perform multiple logistic regression to estimate measures of association between potential risk factors and smoking status. Despite significant ethnic and gender differences in smoking prevalence, smoking status was not found to be significantly associated with ethnicity after controlling for socioeconomic and demographic factors.

Food and drink consumption among 1–5-year-old Los Angeles County children from households receiving dual SNAP and WIC v. only WIC benefits

Objective

The Supplemental Nutrition Assistance Program (SNAP) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) are two of the more well-known food assistance programmes in the USA. The current study describes food consumption patterns of children aged 1–5 years living in households dually enrolled in these two programmes v. households enrolled only in WIC.

Design

Food consumption and SNAP participation were assessed using data from the 2014 Survey of Los Angeles County (LAC) WIC Participants and the Follow-Up Survey of the same households that were also SNAP beneficiaries. Telephone interviews were conducted with WIC parents regarding each child’s (i.e. beneficiary’s) food consumption patterns. Follow-up interviews were conducted with those who reported receiving SNAP. Multivariable regression analyses were performed to assess the relationships between food and beverage consumption and dual v. single food assistance programme participation.

Setting

LAC, California.

Subjects

Children of WIC-enrolled households in LAC during 2014 (n 3248). This included a sub-sample of dual WIC- and SNAP-enrolled households (n 1295). Survey participants were the beneficiaries’ parents.

Results

Children from dually enrolled households consumed 1·03 (P&lt;0·05) and 1·04 (P&lt;0·01) more servings of fruits and vegetables daily respectively, 1·07 more sugar-sweetened beverages daily (P&lt;0·001) and ate sweets/sweetened foods 1·04 more times daily (P&lt;0·001) than children from households participating only in WIC.

Conclusions

Results suggest that SNAP+WIC enrolment is associated with increased consumption of both healthy foods and foods containing minimal nutritional value. Complementary nutrition education efforts across the two programmes may help beneficiaries maximize healthful food purchases with SNAP dollars.

Prevalence of Deleterious Oral Habits and Oral Mucosal Lesions among Fishermen Population of Mahe, South India

INTRODUCTION

Fishing is an occupation associated with uneven diet, strain, drunkenness, tobacco use, and deleterious habits. The physical state of laborers on a large scale will also be influenced by conditions at their work site. Oral mucosal lesions can occur as a result of infections, local shock or infuriation, systemic diseases, and uncontrolled usage of tobacco, betel quid, and alcohol. The aim of the present study is to assess the prevalence of deleterious oral habits and oral mucosal lesions among fishermen population of Mahe, South India.

MATERIALS AND METHODS

The study population consists of 362 fishermen aged between 15 and 54. The questionnaire consisted of questions on personal data, and information related to the subjects' oral habits were collected by the interview. The World Health Organization (WHO) Oral Health Assessment Form was designed for the assessment of oral mucosal lesions.

RESULTS

Among the 362 fishermen, 266 (73.48%) were males and 96 (26.52%) were females. The overall prevalence of smoking, alcohol consumption, and gutka chewing was found to be 24.3, 48.85, and 32.4% respectively. Smokeless tobacco (32.4%) was the most prevalent habit followed by smoking tobacco (24.3%). The prevalence of oral mucosal lesions was 14.9%. There is a statistically significant association between age groups and habits considered.

CONCLUSION

Findings of the present study suggest that oral health condition of the fisherfolk community was relatively poor, with high habit prevalence and oral mucosal lesions. This epi-demiological study has provided baseline data to plan further research in this area.

CLINICAL SIGNIFICANCE

Low socioeconomic status, strenuous working hours, inadequate diet and nutrition intake, stress, and use of tobacco and alcohol act as contributing factors for ill health and oral diseases. It is a challenging population to the clinician to identify and treat them.

Update on Performance in Tobacco Control: A Longitudinal Analysis of the Impact of Tobacco Control Policy and the US Adult Smoking Rate, 2011-2013

CONTEXT

Tobacco use remains the leading cause of preventable death in the United States. States and municipalities have instituted a variety of tobacco control measures (TCMs) to address the significant impact tobacco use has on population health. The American Lung Association annually grades state performance of tobacco control using the State of Tobacco Control grading framework.

OBJECTIVE

To gain an updated understanding of how recent efforts in tobacco control have impacted tobacco use across the United States, using yearly State of Tobacco Control TCM assessments.

DESIGN

The independent TCM variables of smoke-free air score, cessation score, excise tax, and percentage of recommended funding were selected from the American Lung Association State of Tobacco Control reports. Predictors of adult smoking rates were determined by a mixed-effects model.

SETTING/PARTICIPANTS

The 50 US states and District of Columbia.

MAIN OUTCOME MEASURE

Adult smoking rate in each state from 2011 to 2013.

RESULTS

The average adult smoking rate decreased significantly from 2011 to 2013 (21.3% [SD: 3.5] to 19.3% [SD: 3.5], P = .016). All forms of TCMs varied widely in implementation levels across states. Excise taxes (β = -.812, P = .006) and smoke-free air regulations (β = -.057, P = .008) were significant, negative predictors of adult smoking. Cessation services (β = .015, P = .46) did not have a measurable effect on adult smoking.

CONCLUSION

Tobacco control measures with the strongest influence on adult smoking include the state excise tax and state smoke-free air regulations. The lack of robust funding for tobacco cessation services across the majority of US states highlights an important shortfall in current tobacco control policy.

Potential Impact of Minimum Unit Pricing for Alcohol in Ireland: Evidence from the National Alcohol Diary Survey

AIM

One of the main provisions of the Irish Public Health (Alcohol) Bill is the introduction of a minimum unit price (MUP) for alcohol in Ireland, set at €1.00/standard drink. We sought to identify who will be most affected by the introduction of a MUP, examining the relationship between harmful alcohol consumption, personal income, place of purchase and price paid for alcohol.

METHOD

A nationally representative survey of 3187 respondents aged 18-75 years, completing a diary of their previous week's alcohol consumption. The primary outcome was purchasing alcohol at <€1.00/standard drink; secondary outcome was purchasing alcohol at <€1.00/standard drink off-sales. Primary exposures were harmful alcohol consumption (AUDIT-C > 5), low personal annual income (<€20,000) and place of purchase (off- or- on-sales).

RESULTS

One in seven respondents (14%) spent <€1.00/standard drink, with a median spend of 0.78/standard drink. High-risk drinkers (OR 1.56, 95% CI 1.09-2.23), men (OR 1.95, 95% CI 1.43-2.66), people on low income (OR 1.64, 95% CI 1.20-2.23) and those purchasing alcohol off-sales (OR 21.9, 95% CI 12.5-38.1) were most likely to report purchasing alcohol at <€1.00/standard drink. Forty-four per cent of alcohol consumed was purchased off-sales. Of those purchasing off-sales, 30% bought cheap alcohol. High-risk drinkers, men and those on low income were most likely to report paying < €1.00/standard drink off-sales.

CONCLUSION

Heavy drinkers, men and those on low income seek out the cheapest alcohol. The introduction of a MUP in Ireland is likely to target those suffering the greatest harm, and reduce alcohol-attributable mortality in Ireland. Further prospective studies are needed to monitor consumption trends and associated harms following the introduction of minimum unit pricing of alcohol.

Multiple Levels of Influence That Impact Youth Tobacco Use

OBJECTIVE

Multiple levels of influence interplay to impact youth tobacco use. We work towards understanding important policy and environmental strategies that are associated with youth tobacco use behaviors.

METHODS

We utilized data from participants of the Monitoring the Future (MTF) study and linked national data from multiple sources to assess correlates of youth tobacco use behaviors across individual, family, school, community, and state-level policy influences.

RESULTS

Higher cigarette prices had the strongest association with youth tobacco use behaviors. Demographic and socio-economic characteristics at the individual, familial, and community/school-levels were associated with youth tobacco use behaviors.

CONCLUSIONS

In the present study, we confirm that higher cigarette prices could help to reduce youth tobacco use behaviors. Several states are still lagging behind in terms of their low cigarette tax and they should enact tax policies to reduce youth tobacco use.

A Health Threat to Bystanders Living in the Homes of Smokers: How Smoke Toxins Deposited on Surfaces Can Cause Insulin Resistance

Thirdhand smoke (THS) is the accumulation of secondhand smoke on environmental surfaces. THS is found on the clothing and hair of smokers as well as on surfaces in homes and cars of smokers. Exposure occurs by ingestion, inhalation and dermal absorption. Children living in homes of smokers are at highest risk because they crawl on the floor, touch parents' clothing/hair and household objects. Using mice exposed to THS under conditions that mimic exposure of humans, we show that THS increases cellular oxidative stress by increasing superoxide dismutase (SOD) activity and hydrogen peroxide (H2O2) levels while reducing the activity of antioxidant enzymes catalase and glutathione peroxidase (GPx) that break down H2O2 into H2O and O2. This results in lipid peroxidation, protein nitrosylation and DNA damage. Consequences of these cell and molecular changes are hyperglycemia and insulinemia. Indeed, we found reduced levels of insulin receptor, PI3K, AKT, all important molecules in insulin signaling and glucose uptake by cells. To determine whether these effects on THS-induced insulin resistance are due to increase in oxidative stress, we treated mice exposed to THS with the antioxidants N-acetyl cysteine (NAC) and alpha-tocopherol (alpha-toc) and showed that the oxidative stress, the molecular damage, and the insulin resistance, were significantly reversed. Conversely, feeding the mice with chow that mimics "western diet", which is known to increase oxidative stress, while exposing the mice to THS, further increased the oxidative stress and aggravated hyperglycemia and insulinemia. In conclusion, THS exposure results in insulin resistance in the form of non-obese type II diabetes (NODII) through oxidative stress. If confirmed in humans, these studies could have a major impact on how people view exposure to environmental tobacco toxins, in particular to children, elderly and workers in environments where tobacco smoke has taken place.

Independent and Interactive Effects of Smoking Bans and Tobacco Taxes on a Cohort of US Young Adults

OBJECTIVES

We examined the mutual effects of smoking bans and taxes on smoking among a longitudinal cohort of young adults.

METHODS

We combined a repository of US tobacco policies at the state and local level with the nationally representative geocoded National Longitudinal Survey of Youth 1997 (2004-2011) from ages 19 to 31 years and Census data, to examine the impact of tobacco policies on any current and daily pack smoking. The analytic sample amounts to 19,668 observations among 4341 individuals within 487 cities.

RESULTS

For current smoking, we found significant effects for comprehensive smoking bans, but not excise taxes. We also found an interaction effect, with bans being most effective in locales with no or low taxes. For daily pack smoking, we found significant effects for taxes, but limited support for bans.

CONCLUSIONS

Social smoking among young adults is primarily inhibited by smoking bans, but excise taxes only deter such smoking in the absence of a ban. Heavy smokers are primarily deterred by taxes. Although both policies have an impact on young adult smoking behaviors, their dual presence does not intensify each policy's efficacy.

Cigarette Tax Increase and Infant Mortality

BACKGROUND AND OBJECTIVE

Maternal smoking increases the risk for preterm birth, low birth weight, and sudden infant death syndrome, which are all causes of infant mortality. Our objective was to evaluate if changes in cigarette taxes and prices over time in the United States were associated with a decrease in infant mortality.

METHODS

We compiled data for all states from 1999 to 2010. Time-series models were constructed by infant race for cigarette tax and price with infant mortality as the outcome, controlling for state per-capita income, educational attainment, time trend, and state random effects.

RESULTS

From 1999 through 2010, the mean overall state infant mortality rate in the United States decreased from 7.3 to 6.2 per 1000 live births, with decreases of 6.0 to 5.3 for non-Hispanic white and 14.3 to 11.3 for non-Hispanic African American infants (P < .001). Mean inflation-adjusted state and federal cigarette taxes increased from $0.84 to $2.37 per pack (P < .001). In multivariable regression models, we found that every $1 increase per pack in cigarette tax was associated with a change in infant deaths of -0.19 (95% confidence interval -0.33 to -0.05) per 1000 live births overall, including changes of -0.21 (-0.33 to -0.08) for non-Hispanic white infants and -0.46 (-0.90 to -0.01) for non-Hispanic African American infants. Models for cigarette price yielded similar findings.

CONCLUSIONS

Increases in cigarette taxes and prices are associated with decreases in infant mortality rates, with stronger impact for African American infants. Federal and state policymakers may consider increases in cigarette taxes as a primary prevention strategy for infant mortality.

Effectiveness of video- versus text-based computer-tailored smoking cessation interventions among smokers after one year

BACKGROUND

In western countries, smoking prevalence rates are high among smokers unmotivated to quit and those with a lower socioeconomic status (LSES). Multiple computer tailoring and the use of audio-visual aids may improve such interventions and increase cessation in LSES smokers. This study assessed the 12-month effectiveness of a video- and text-based computer-tailored intervention.

METHODS

A randomized controlled trial in the Netherlands was used in which smokers were allocated to the video-based condition (VC) (N=670), the text-based condition (TC) (N=708) or the control condition (CC) (brief generic text advice) (N=721). After 12months, self-reported prolonged abstinence was assessed and biochemically verified in respondents indicating to have quit smoking. Three analysis strategies were used to assess the effects: (1) multiple imputation (MI); (2) intention-to-treat (ITT); (3) complete case analysis (CC).

RESULTS

VC was more effective in prolonged abstinence compared to CC (odds ratio (OR)=1.90, p=.005) and the text-based condition (OR=1.71, p=.01). VC was furthermore more effective than TC. No differences were found for SES and motivational levels. Results were similar when using ITT and CC. For our secondary outcome seven-day point prevalence abstinence; however, neither VC (OR=1.17, p=.34) or TC (OR=0.91, p=.52) outperformed the CC.

CONCLUSION

The video-based computer-tailored intervention was effective in obtaining substantial long-term abstinence compared to the text-based version and a brief generic text advice.

Who pays the most cigarette tax in Turkey

BACKGROUND

Although higher taxation of tobacco products is considered the most cost-effective tobacco control policy, its negative impact on low-income groups is one of the arguments used against it.

OBJECTIVE

To investigate the impact of current excise taxes and the increases of excise taxes on tobacco and household expenditures by expenditure tertiles, and examine who pays excise taxes in general.

METHOD

Impacts of excise taxes on cigarettes are examined with a budgetary approach. We first estimate the price elasticity of cigarettes by expenditure tertiles using data from the 2003 Turkish Household Expenditure Survey, the most recent data set covering detailed tobacco product information relevant to our analysis. We then conduct a number of simulation analyses by increasing the excise taxes per pack of cigarettes and examine the impacts of these increases on household expenditures. Finally, as excise tax increases, we predict the total excise tax paid by households in different expenditure tertiles and compare the concentration curve of excise tax spending with the Lorenz curve showing the cumulative share of total household expenditures by expenditure tertiles. We estimate the progressivity coefficient that measures the area between the Lorenz and concentration curves.

RESULTS

The low-income group is found to be the most sensitive to tax and price increases. It spends a relatively higher share of the household expenditure on cigarettes compared with higher income groups. However, the results suggest a different outcome as excise tax increases; the share of household expenditures spent on cigarettes declines for all household tertiles but a significant reduction occurs on the lowest expenditure tertile, suggesting that increases in excise taxes are progressive. Furthermore, the highest expenditure tertile pays the highest excise tax among expenditure tertiles, and their share in total excise revenue increases as the excise tax per pack of cigarettes increases.

CONCLUSIONS

The poor smoking households benefit the most from increases in excise taxes; from a budgetary perspective, as they reduce their smoking consumption significantly, the share of their excise payment in total household expenditures declines. From a health perspective, they are likely to have more health benefits as their consumption reduces. Government revenues are also predicted to increase with increased excise taxes, and the government can allocate a part of these revenue increases on implementing and enforcing other tobacco control measures including cessation support and smoke-free environments.