Five in a row--reactions of smokers to tobacco tax increases: population-based cross-sectional studies in Germany 2001-2006

Gender differences in the price elasticity of demand for waterpipe and cigarette smoking in Lebanon, Jordan and Palestine: a volumetric choice experiment

OBJECTIVES

This study assessed the extent to which the elasticity of cigarette and waterpipe tobacco products differs between men and women. We also explored the levels of substitution and complementarity in tobacco products among men and women.

SETTING

The study examines tobacco elasticities in three Arab countries: Lebanon, Jordan and the West Bank of Palestine.

PARTICIPANTS

We used data from nationally representative surveys of adults aged ≥18 years in Lebanon (n=1680), Jordan (n=1925) and Palestine (n=1679). The proportion of women was 50.0% of the sample in Lebanon and Palestine, and 44.6% in Jordan.

PRIMARY AND SECONDARY OUTCOME MEASURES

A zero-inflated Poisson regression model estimated own-price and cross-price elasticities for two variations of cigarettes and five variations of waterpipe tobacco products. Elasticities were measured based on eight scenarios of prices.

RESULTS

Demand for waterpipe tobacco products was elastic for both men and women. The cross-price elasticities in the three countries indicate the existence of substitution between cigarettes and waterpipe products and by different varieties within each of the two tobacco products. Gender differences varied across the three countries whereby higher cross-price elasticities were observed for women in Jordan and Palestine. For example, the price elasticity for discount waterpipe was -1.4 and -0.6 for women and men in Jordan, respectively.

CONCLUSIONS

Results on the elasticity of demand for tobacco products and the existence of substitution between tobacco products reveal the higher responsiveness of men and women to changes in tobacco prices. This should be taken into consideration in tobacco control strategies particularly when reducing tobacco consumption via taxation policies.

Tobacco Price Increase and Successful Smoking Cessation for Two or More Years in Japan

INTRODUCTION

Assessing long-term smoking cessation after tobacco price increases is more valuable than short-term cessation as smokers often relapse after temporary cessation. We investigated whether tobacco price increases were associated with long-term smoking cessation and whether the association differed according to demographic, socioeconomic, and behavioral factors, using a national longitudinal survey of middle-aged individual-level data from 10 waves, every November from 2005 to 2014.

METHODS

Temporary and long-term at least 1 year (1y+) or 2 years (2y+) quitters were defined by smoking in any one wave and quitting in the subsequent two or three waves in a discrete-time design. November 2006 (after July 11% increase) and November 2010 (after October 37% increase) were used as proxy variables for price increases. Generalized estimating equation models adjusted for demographic, socioeconomic, and behavioral covariates, and analyses stratified by these covariates were performed to estimate the association between price increases and smoking cessation.

RESULTS

Of 43 630 smokers aged 50-65, 7.7%, 5.6%, and 5.2% of smokers quit temporarily, for at least 1 year and at least 2 years, respectively. 2y+ quitters significantly increased in November 2005-November 2008 (adjusted odds ratio = 1.23, 95% confidence interval: 1.06-1.43) and November 2009-November 2012 (adjusted odds ratio = 1.85, 95% confidence interval = 1.57-2.16). In stratified analyses, higher prices were associated with 2y+ quitters in all subgroups with some exceptions, including participants who smoked 21-30 cigarettes per day and those aged 60-65.

CONCLUSIONS

Increasing tobacco prices may be effective in promoting long-term smoking cessation in various subgroups among middle-aged Japanese adults.

IMPLICATIONS

Few longitudinal studies have examined the effect of a tobacco price increase on long-term smoking cessation. In a national longitudinal survey of middle-aged Japanese from 10 waves, the 37% tobacco price increase was found to be a trigger for successful smoking cessation for two or more years. Price increases were significantly associated with 2y+ smoking cessation in most demographic, behavioral, and socioeconomic subgroups. Results indicate that higher tobacco prices may be effective for long-term smoking cessation in almost all subgroups. Raising tobacco taxes and prices may be one of the most effective strategies for promoting long-term smoking cessation.

[Smoke-free Germany 2040: a discussion paper]

INTRODUCTION

A "smoke-free" society is assumed if less than 5 % of a population smoke. We predict when this goal could be reached in Germany. To reduce the proportion of smokers in the population, the World Health Organization recommends a bundle of measures (MPOWER) that should minimize both the supply of and the demand for tobacco. The current level of implementation of these recommendations in Germany is presented.

METHODS

A total of 21 representative cross-sectional surveys of the Drug Affinity Study and the Epidemiological Survey of Substance Abuse since 2000/2001 with adolescents and adults show the smoking behavior of the population until 2018. Per capita consumption of factory-built and self-made cigarettes during the same period is used as an objective data basis. Regression analyses are used to model the date at which less than 5 % of the German population smoke. A selective literature review is carried out to describe the implementation of the MPOWER program.

RESULTS

Before 2000 there was no trend in Germany towards non-smoking. After the implementation of various preventive measures such as price increases for tobacco products and the introduction of non-smoking protection laws, the spread of smoking among the population has steadily decreased since 2000. By 2018, the 5 % prevalence target among adolescents had almost been reached, as the relative proportion of adolescents who smoked fell by 20.9 percentage points to 6.6 %. The relative proportion of smoking in adult women fell by 12.1 percentage points to 18.5 %, the relative proportion of smoking in men by 14.8 percentage points to 24.2 %. Assuming a linear trend, the prevalence target of less than 5 % smoking adults can be reached by around 2043. Of the six recommended measures of the MPOWER program, Germany is currently only implementing the monitoring of tobacco consumption in society without compromises.

DISCUSSION

After various tobacco prevention measures were implemented, a trend towards non-smoking began in Germany. The continual price increase recommended by the World Health Organization, the further restriction of availability, the ban on all tobacco advertising and promotion, the support of smoking cessation as well as the education of the population appear to be necessary to reinforce this trend and to achieve the health policy goal of a smoke-free society in 2040.

Decrease in cross-border tobacco purchases despite intensification of antitobacco policies in France

BACKGROUND

Recently, France has intensified tobacco control policies which included gradual increase in tobacco product price and the introduction of plain packaging. However, there has been suggestion that cross-border tobacco purchases from neighbouring countries, with lower tobacco prices, will increase. We examine trends in cross-border tobacco purchases among smokers concurrent with the implementation of tobacco control measures between 2016 and 2017.

METHODS

Description des Perceptions, Images, et Comportements liés au Tabagisme is a two-wave cross-sectional national telephone survey of French adults aged 18-64 years, which recruited a total of 2167 smokers (2016: n=1238; 2017: n=929). Data were weighted to be representative of the French adult population. The association between study wave and cross-country tobacco purchases was examined across study waves using a multivariable logistic regression model (adjusted ORs: ORa (95% CI)).

RESULTS

Less than half (38.5%) of smokers declared cross-border tobacco purchases in the last year, which were mostly done on occasional basis: 22.6% purchased tobacco cross-border once or twice yearly. In 2017, as compared with 2016, cross-border tobacco purchases by French smokers decreased (ORa=0.81, 95% CI 0.68 to 0.98). Other factors associated with cross-border tobacco purchases included sex, and driving distance to a border.

CONCLUSION

In France, the increase in tobacco product price and the introduction of plain packaging did not contribute to increasing rates of out-of-country purchases of tobacco products, probably due to the overall decrease in smoking levels. However, a harmonisation of tobacco product prices and plain packaging policies across Europe might further improve tobacco control throughout the continent.

Availability and Use of Cheap Tobacco in the United Kingdom 2002-2014: Findings From the International Tobacco Control Project

Introduction

Raising tobacco prices is the most effective population-level intervention for reducing smoking, but this is undermined by the availability of cheap tobacco. This study monitors trends in cheap tobacco use among adult smokers in the United Kingdom between 2002 and 2014 via changes in product type, purchase source, and prices paid.

Methods

Weighted data from 10 waves of the International Tobacco Control policy evaluation study were used. This is a longitudinal cohort study of adult smokers with replenishment; 6169 participants provided 15812 responses. Analyses contrasted (1) product type: roll-your-own (RYO) tobacco, factory-made packs (FM-P), and factory-made cartons (FM-C); (2) purchase source: UK store-based sources (e.g., supermarkets and convenience stores) with non-UK/nonstore sources representing tax avoidance/evasion (e.g., outside the UK, duty free, and informal sellers); and (3) prices paid (inflation-adjusted to 2014 values). Generalized estimating equations tested linear changes over time.

Results

(1) RYO use increased significantly over time as FM decreased. (2) UK store-based sources constituted approximately 80% of purchases over time, with no significant increases in tax avoidance/evasion. (3) Median RYO prices were less than half that of FM, with FM-C cheaper than FM-P. Non-UK/nonstore sources were cheapest. Price increases of all three product types from UK store-based sources from 2002 to 2014 were statistically significant but not substantial. Wide (and increasing for FM-P) price ranges meant each product type could be purchased in 2014 at prices below their 2002 medians from UK store-based sources.

Conclusions

Options exist driving UK smokers to minimize their tobacco expenditure; smokers do so largely by purchasing cheap tobacco products from UK stores.

Implications

The effectiveness of price increases as a deterrent to smoking is being undermined by the availability of cheap tobacco such as roll-your-own tobacco and cartons of packs of factory-made cigarettes. Wide price ranges allowed smokers in 2014 to easily obtain cigarettes at prices comparable to 12 years prior, without resorting to tax avoidance or evasion. UK store-based sources accounted for 80% or more of all tobacco purchases between 2002 and 2014, suggesting little change in tax avoidance or evasion over time. There was a widening price range between the cheapest and most expensive factory-made cigarettes.

Analysis of tobacco industry pricing strategies in 23 European Union countries using commercial pricing data

Background

The tobacco industry (TI) can act to undermine the impact of tobacco tax increases by adopting various pricing strategies. Little is known about strategies used across the European Union (EU), except for the UK.

Aim

To examine pricing strategies adopted by the TI in the EU, and whether they differ by cigarette price segment, or between manufactured and roll-your-own (RYO) cigarettes.

Methods

This is a longitudinal analysis of commercial pricing data for manufactured and RYO cigarettes from 23 EU countries in 2006–2017. Price and revenue trends were explored. Linear regression estimated the average annual change in revenue, and linear fixed-effects panel regression models were used to explore the association between changes in median revenue (net of tax and adjusted for inflation) and tax increases in different price segments of manufactured cigarettes.

Results

Over the 11-year period price gaps were observed in all countries. The average annual adjusted median net revenue per pack increased in 19 of 23 countries for manufactured and RYO cigarettes. A tax increase was associated with a significant decrease of −€0.09 in adjusted median net revenue per pack (95% CI −0.16 to −0.03) in the cheap cigarette price segment, while no change was detected in the expensive cigarette price segment (−€0.05, 95% CI −0.11 to 0.01).

Conclusion

Across the EU, pricing strategies adopted by the TI maintained or increased price gaps and retained cheaper tobacco products in the market, diminishing the impact of tobacco tax increases. Further strengthening of tobacco taxation policy is needed to maximise public health impact.

From priority to endgame: the Region of Peel Living Tobacco-Free strategy

Tobacco use presents a tremendous burden on population health and remains the leading preventable cause of morbidity and mortality worldwide. Building on tobacco control successes to date, public health agencies are increasingly aligning with the international "Tobacco Endgame" initiative targeting decreases in tobacco use to less than 5% by the year 2025. The local implementation of this initiative follows a decade of work at Region of Peel-Public Health (RoP-PH), a local health department in Ontario, Canada, which made "Living Tobacco-Free" (LTF) a strategic priority in 2009 with a tactical framework encompassing Research, Protection, Prevention, and Cessation. This commentary provides an overview of the results observed by this local health department's decision to make LTF a strategic priority and discusses the department's next steps in developing a Theory of Change to systematically align continuing efforts to the call for a "Tobacco Endgame".

Examining quit attempts and successful quitting after recent cigarette tax increases

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

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.

Impact on Smoking Behavior of the New Zealand Annual Increase in Tobacco Tax: Data for the Fifth and Sixth Year of Increases

Introduction

New Zealand has implemented a series of seven annual increases in tobacco tax since 2010. All tax increases, except for the first in the series, were preannounced. It is unusual for governments to introduce small, persistent, and predictable increases in tobacco tax, and little is known about the impact of such a strategy. This paper evaluates the impact of the fifth and sixth annual increases.

Methods

Smokers' behaviors were self-reported during the 3-month period before, and the 3-month period after, the two annual increases. Responses to the two increases were analyzed separately, and generalized estimating equations models were used to control for sociodemographic variables, recent quit attempts, and the research design.

Results

Findings were consistent across years. The proportion of participants who made a smoking-related (54%-56% before and after each tax increase) or product-related change (fifth tax increase: 17%-19%; sixth tax increase: 21%-22%) did not significantly alter from before to after each tax increase. However, it should be noted that the proportion of participants making smoking-related changes was generally high, even prior to each increase. For example, before the 2015 tax increase, 1% reported quitting completely, 21% trying to quit, and 53% cutting down.

Conclusions

In New Zealand, with its series of annual tobacco tax increases since 2010, there were no significant changes in smoking- or product-related behavior associated with the fifth and sixth increases. Nevertheless, overall cessation-related activity was high, with a majority of participants reporting either quitting and/or cutting down recently.

Implications

Little is known about the impact of small, persistent, predictable tobacco tax increases on smoking behavior. This study evaluated the impact of the fifth (in 2014) and sixth (2015) tax increases in an annual series implemented in New Zealand. Although there were no detectable changes in smoking behaviors from before to after each tax increase, self-reported cessation-related activity was high overall (i.e., even prior to each increase). Given that there are multiple possible interpretations for these findings, more in-depth time-series analyses are needed to understand how such a tax strategy influences smoking behavior.

The relation between cigarette taxes and older adult smoking in Zhejiang and Gansu: what happened following the 2009 Chinese Tax adjustments?

Background

In May 2009, the Chinese government raised cigarette excise tax rates and adjusted standards for Grade A cigarettes and Grade B cigarettes. The present study aimed to examine the effects of the tax adjustments in 2009 on smoking behaviors and health outcomes among smokers aged above 45.

Methods

Data from the 2008 and 2012 China Health and Retirement Longitudinal Study of Zhejiang and Gansu provinces were used to estimate the influence of tax increase on the number of cigarettes smoked daily and health capital. The sample included 706 smokers who were 45 years old and older at the time of data collection in 2008. The sample group was surveyed again in 2012. The final sample size was 1366. Logit model was applied.

Results

Cigarette tax adjustment in 2009 resulted in the decrease in the likelihood of smoking 0–10 cigarettes per day by 1.06%; the increase in the likelihood of those smoking 11–20 cigarettes per day by 0.44%; and, those smoking 20 cigarettes or more by 0.63%; the decrease in the likelihood of good health by 0.47%; the increase in the prevalence of chronic disease by 1.34%.

Conclusions

The smoke tax adjustment in 2009 worsened individual unhealthy smoking behaviors and health outcomes. The proposed cigarette tax levied at the retail level can reduce the State Tobacco Monopoly Administration’s control overall and each price and increase the influence of the market on cigarette consumption in China.

Does smoke cross the border? Cigarette tax avoidance in France

This paper examines the impact on cigarette sales of the successive increases in cigarette prices in France from 2002 to 2004. Since the price differential between France and neighboring countries increased over the period in question, cross-border purchases became more financially attractive for smokers living near borders. Results from difference-in-differences estimates indicate that the decrease in cigarette sales observed in French border departments was around 20 % higher from 2004 to 2007 compared to non-border departments. The loss of fiscal revenue due to cross-border shopping since the tax increase amounts to 2 billion euros over the period 2002-2007. Our findings highlight the need for improved coordination of policies aimed at reducing tobacco consumption across European Union countries.

Changes to smoking habits and addiction following tobacco excise tax increases: a comparison of Māori, Pacific and New Zealand European smokers

OBJECTIVE

To compare changes in smoking habit and psychological addiction in Māori/Pacific and NZ European smokers in response to two annual excise tax increases from 2012 to 2014.

METHODS

Smokers from New Zealand cities completed questionnaires at three time points before and after two excise tax increases.

RESULTS

There were no significant differences in cigarettes per day or psychological addiction at baseline, but a linear decline in both measures was observed in Māori/Pacific and NZ European smokers. Cigarettes per day reduced at a greater rate for Māori/Pacific than NZ European smokers but dependence did not.

CONCLUSION

Results indicated that Māori/Pacific smokers' demand for cigarettes may be more price sensitive than NZ European smokers. Implications for Public Health: Tobacco excise tax may be particularly effective for Māori/Pacific smokers and may contribute to reductions in smoking-related health inequalities in NZ.

Smoking-related changes or brand switching? Smokers' anticipated responses to a large increase in Taiwan's Tobacco Health and Welfare Surcharge

OBJECTIVES

This study examines the impact on smokers' behaviour of a planned increase in the Health and Welfare Surcharge of Tobacco Products in Taiwan.

STUDY DESIGN

This study used a structured questionnaire to perform telephone interviews. Stratified random sampling was applied to interview current smokers aged 18-65 years in Taiwan.

METHODS

Based on nationwide survey data of smokers' responses to future increases in cigarette prices, this study used multinomial logistic regression to perform its analyses.

RESULTS

After the proposed increase in the Health and Welfare Surcharge of Tobacco Products, subsequent cigarette price increases would motivate nearly 30% of the smokers to adopt smoking-related changes and 10% to change to lower-priced brands.

CONCLUSIONS

The study suggests that a large increase in the Health and Welfare Surcharge of Tobacco Products would lead to considerable changes in smoking behaviour, which in turn would increase cessation rate at the population level.

Age- and Sex-Specific Trends in Lung Cancer Mortality over 62 Years in a Nation with a Low Effort in Cancer Prevention

BACKGROUND

A decrease in lung cancer mortality among females below 50 years of age has been reported for countries with significant tobacco control efforts. The aim of this study was to describe the lung cancer deaths, including the mortality rates and proportions among total deaths, for females and males by age at death in a country with a high smoking prevalence (Germany) over a time period of 62 years.

METHODS

The vital statistics data were analyzed using a joinpoint regression analysis stratified by age and sex. An age-period-cohort analysis was used to estimate the potential effects of sex and school education on mortality.

RESULTS

After an increase, lung cancer mortality among women aged 35-44 years remained stable from 1989 to 2009 and decreased by 10.8% per year from 2009 to 2013.

CONCLUSIONS

Lung cancer mortality among females aged 35-44 years has decreased. The potential reasons include an increase in the number of never smokers, following significant increases in school education since 1950, particularly among females.

Health, Health Inequality, and Cost Impacts of Annual Increases in Tobacco Tax: Multistate Life Table Modeling in New Zealand

BACKGROUND

Countries are increasingly considering how to reduce or even end tobacco consumption, and raising tobacco taxes is a potential strategy to achieve these goals. We estimated the impacts on health, health inequalities, and health system costs of ongoing tobacco tax increases (10% annually from 2011 to 2031, compared to no tax increases from 2011 ["business as usual," BAU]), in a country (New Zealand) with large ethnic inequalities in smoking-related and noncommunicable disease (NCD) burden.

METHODS AND FINDINGS

We modeled 16 tobacco-related diseases in parallel, using rich national data by sex, age, and ethnicity, to estimate undiscounted quality-adjusted life-years (QALYs) gained and net health system costs over the remaining life of the 2011 population (n = 4.4 million). A total of 260,000 (95% uncertainty interval [UI]: 155,000-419,000) QALYs were gained among the 2011 cohort exposed to annual tobacco tax increases, compared to BAU, and cost savings were US$2,550 million (95% UI: US$1,480 to US$4,000). QALY gains and cost savings took 50 y to peak, owing to such factors as the price sensitivity of youth and young adult smokers. The QALY gains per capita were 3.7 times greater for Māori (indigenous population) compared to non-Māori because of higher background smoking prevalence and price sensitivity in Māori. Health inequalities measured by differences in 45+ y-old standardized mortality rates between Māori and non-Māori were projected to be 2.31% (95% UI: 1.49% to 3.41%) less in 2041 with ongoing tax rises, compared to BAU. Percentage reductions in inequalities in 2041 were maximal for 45-64-y-old women (3.01%). As with all such modeling, there were limitations pertaining to the model structure and input parameters.

CONCLUSIONS

Ongoing tobacco tax increases deliver sizeable health gains and health sector cost savings and are likely to reduce health inequalities. However, if policy makers are to achieve more rapid reductions in the NCD burden and health inequalities, they will also need to complement tobacco tax increases with additional tobacco control interventions focused on cessation.

Quitting activity and tobacco brand switching: findings from the ITC-4 Country Survey

OBJECTIVE

Among Australian smokers, to examine associations between cigarette brand switching, quitting activity and possible causal directions by lagging the relationships in different directions.

METHODS

Current smokers from nine waves (2002 to early 2012) of the ITC-4 Country Survey Australian dataset were surveyed. Measures were brand switching, both brand family and product type (roll-your-own versus factory-made cigarettes) reported in adjacent waves, interest in quitting, recent quit attempts, and one month sustained abstinence.

RESULTS

Switching at one interval was unrelated to concurrent quit interest. Quit interest predicted switching at the following interval, but the effect disappeared once subsequent quit attempts were controlled for. Recent quit attempts more strongly predicted switching at concurrent (OR 1.34, 95%CI=1.18-1.52, p<0.001) and subsequent intervals (OR 1.31, 95%CI=1.12-1.53, p=0.001) than switching predicted quit attempts, with greater asymmetry when both types of switching were combined. One month sustained abstinence and switching were unrelated in the same interval; however, after controlling for concurrent switching and excluding type switchers, sustained abstinence predicted lower chance of switching at the following interval (OR=0.66, 95%CI=0.47-0.93, p=0.016).

CONCLUSIONS

The asymmetry suggests brand switching does not affect subsequent quitting.

IMPLICATIONS

Brand switching does not appear to interfere with quitting.

The use of legal, illegal and roll-your-own cigarettes to increasing tobacco excise taxes and comprehensive tobacco control policies: findings from the ITC Uruguay Survey

BACKGROUND

Little research has been done to examine whether smokers switch to illegal or roll-your-own (RYO) cigarettes in response to a change in their relative price.

OBJECTIVE

This paper explores how relative prices between three cigarette forms (manufactured legal, manufactured illegal and RYO cigarettes) are associated with the choice of one form over another after controlling for covariates, including sociodemographic characteristics, smokers' exposure to antismoking messaging, health warning labels and tobacco marketing.

METHODS

Generalised estimating equations were employed to analyse the association between the price ratio of two different cigarette forms and the usage of one form over the other.

FINDINGS

A 10% increase in the relative price ratio of legal to RYO cigarettes is associated with a 4.6% increase in the probability of consuming RYO cigarettes over manufactured legal cigarettes (p≤0.05). In addition, more exposure to antismoking messaging is associated with a lower odds of choosing RYO cigarettes over manufactured legal cigarettes (p≤0.05). Non-significant associations exist between the manufactured illegal to legal cigarette price ratios and choosing manufactured illegal cigarettes, suggesting that smokers do not switch to manufactured illegal cigarettes as prices of legal ones increase. However, these non-significant findings may be due to lack of variation in the price ratio measures. To improve the effectiveness of increased taxes and prices in reducing smoking, policymakers need to narrow price variability in the tobacco market. Moreover, increasing antismoking messaging reduces tax avoidance in the form of switching to cheaper RYO cigarettes in Uruguay.

Predicting decreases in smoking with a cigarette purchase task: evidence from an excise tax rise in New Zealand

BACKGROUND

Tobacco excise taxes are known to be effective in reducing smoking at the population level, but less research has examined how individual smokers respond to changes in tax policy. We ask whether price elasticities for individual smokers, derived from simulated demand curves obtained with a cigarette purchase task (CPT), can predict changes in smoking after a tax increase.

METHOD

Smokers (N=357) were recruited from four New Zealand cities and interviewed before and after a 10% tobacco excise tax increase.

RESULTS

Simulated demand curves from the CPT were curvilinear and well described by an exponential model. Smokers reported significant reductions in cigarettes/day and addiction scores at Wave 2 (n=226). Local elasticities derived from the demand curves significantly predicted decreases in cigarettes/day after controlling for covariates.

CONCLUSIONS

Elasticities from simulated demand curves can predict decreases in consumption for individual smokers after an excise tax increase. Understanding individual differences in tobacco demand curves may help to predict how different groups of smokers will respond to price increases.

How smokers may react to cigarette taxes and price increases in Brazil: data from a national survey

BACKGROUND

Despite being the third largest tobacco producer in the world, Brazil has developed a comprehensive tobacco control policy that includes a broad restriction on both advertising and smoking in indoor public places, compulsory pictorial warning labels, and a menthol cigarette ban. However, tax and pricing policies have been developed slowly and only very recently were stronger measures implemented. This study investigated the expected responses of smokers to hypothetical price increases in Brazil.

METHODS

We analyzed smokers' responses to hypothetical future price increases according to sociodemographic characteristics and smoking conditions in a multistage sample of Brazilian current cigarette smokers aged≥14 years (n=500). Logistic regression analysis was used to examine the relationship between possible responses and different predictors.

RESULTS

In most subgroups investigated, smokers most frequently said they would react to a hypothetical price increase by taking up alternatives that might have a positive impact on health, i.e., they would "try to stop smoking" (52.3%) or "smoke fewer cigarettes" (46.8%). However, a considerable percentage responded that they would use alternatives that would reduce the effect of price increases, such as the same brand with lower cost (48.1%). After controlling for sex age group (14-19, 20-39, 40-59, and ≥60 years), schooling level (≥9 versus ≤9 years), number of cigarettes per day (>20 versus ≤20), and stage of change for smoking cessation (precontemplation, contemplation, and preparation), lower levels of dependence were positively associated with the response "I would try to stop smoking" (odds ratio [OR], 2.19). Young age was associated with "I would decrease the number of cigarettes" (OR, 3.44). A low schooling level was strongly associated with all responses.

CONCLUSIONS

Taxes and prices increases have great potential to stimulate cessation or reduction of cigarette consumption further among two important vulnerable populations of smokers in Brazil: young smokers and those of low educational level. The results from the present study also suggest that seeking illegal products may reduce the impact of increased taxes, but does not eliminate it.

Sharp changes in tobacco products affordability and the dynamics of smoking prevalence in various social and income groups in Ukraine in 2008-2012

BACKGROUND

To curb the tobacco epidemic, successful implementation of tobacco control measures should take into account how specific demographic groups react to particular policies. In 2005-2010, Ukraine experienced a sharp decline in smoking prevalence. In 2008-2010, several excise tax hikes combined with the economic recession resulted in a sharp reduction of tobacco product affordability, but in 2011-2012 tax increases were rather moderate. The aim of the current research was to investigate how smoking prevalence in various gender, social and income groups in Ukraine changed in response to differing tobacco taxation policies in 2008-2012.

METHODS

The State Statistics Service of Ukraine annual household surveys among the population aged 12 years and older, which include questions about smoking, were used. The aggregate data from the annual household surveys datasets of 2008-2012 were analyzed.

RESULTS

The decline in general smoking prevalence was much steeper in 2008-2010 - 3.2 percentage points in two years, while in two subsequent years it constituted only 0.6 percentage points. Smoking prevalence declined in all age, social, and income groups in 2008-2010. However, in 2011-2012 smoking prevalence continued to decline mainly among young and poor people, while some older and more affluent smokers apparently relapsed to smoking.

CONCLUSIONS

Short-term and long-term price responsiveness of tobacco demand by socioeconomic status of population groups in low--and middle--income countries like Ukraine could be rather different for poor and more affluent people. Tobacco excise tax hikes have great potential in reducing smoking prevalence, especially in young and less affluent people, however they should also be supported by effective and available smoking cessation services.

The choice of discount brand cigarettes: a comparative analysis of International Tobacco Control surveys in Canada and the USA (2002-2005)

BACKGROUND

Increasing tobacco taxes to increase price is a proven tobacco control measure. This article investigates how smokers respond to tax and price increases in their choice of discount brand cigarettes versus premium brands.

OBJECTIVE

To estimate how increase in the tax rate can affect smokers' choice of discount brands versus premium brands.

METHODS

Using data from International Tobacco Control surveys in Canada and the USA, a logit model was constructed to estimate the probability of choosing discount brand cigarettes in response to its price changes relative to premium brands, controlling for individual-specific demographic and socioeconomic characteristics and regional effects. The self-reported price of an individual smoker is used in a random-effects regression model to impute price and to construct the price ratio for discount and premium brands for each smoker, which is used in the logit model.

FINDINGS

An increase in the ratio of price of discount brand cigarettes to the price of premium brands by 0.1 is associated with a decrease in the probability of choosing discount brands by 0.08 in Canada. No significant effect is observed in case of the USA.

CONCLUSIONS

The results of the model explain two phenomena: (1) the widened price differential between premium and discount brand cigarettes contributed to the increased share of discount brand cigarettes in Canada in contrast to a relatively steady share in the USA during 2002-2005 and (2) increasing the price ratio of discount brands to premium brands-which occurs with an increase in specific excise tax-may lead to upward shifting from discount to premium brands rather than to downward shifting. These results underscore the significance of studying the effectiveness of tax increases in reducing overall tobacco consumption, particularly for specific excise taxes.

Germany SimSmoke: the effect of tobacco control policies on future smoking prevalence and smoking-attributable deaths in Germany

INTRODUCTION

Although Germany has recently implemented some tobacco control policies, there is considerable scope to strengthen policies consistent with the MPOWER guidelines. This article describes the development of a simulation model projecting the effect of future tobacco control policies in Germany on smoking prevalence and associated premature mortality.

METHODS

Germany SimSmoke-an adapted version of the SimSmoke simulation model of tobacco control policy-uses population, smoking rates, and policy data for Germany. It assesses, individually and in combination, the effect of seven types of policies: taxes, smoke-free air laws, mass media campaigns, advertising bans, warning labels, cessation treatment, and youth access policies.

RESULTS

With a comprehensive set of policies, smoking prevalence within the first few years can be reduced by about 22.0% relative to the status quo and by 37.9% (40.5%) for males (females) in 30 years. By 2040, 39,548 deaths could be averted in that year alone. Without stronger policies, 700,000 additional smoking-attributable deaths (SADs) would occur in Germany over the next 30 years.

CONCLUSIONS

The model indicates that the consequences of inaction are considerable; without the implementation of a stronger set of policies, smoking prevalence rates will remain relatively stable, and SADs among women will continue to rise over a 30-year horizon. Significant inroads into reducing smoking prevalence and premature mortality can be achieved through strengthening tobacco control policies in line with MPOWER recommendations.

Trends in the prevalence of smoking in Portugal: a systematic review

Background

Understanding the dynamics of smoking at the population level is essential for the planning and evaluation of prevention and control measures. We aimed to describe trends in the prevalence of smoking in Portuguese adults by sex, age-group and birth cohort.

Methods

PubMed was searched from inception up to 2011. Linear regression was used to assess differences in prevalence estimates according to the type of population sampled, and to estimate time trends of smoking prevalence considering only the results of studies on nationally representative samples of the general population.

Results

Thirty eligible studies were identified. There were statistically significant differences in the prevalence estimates according to the types of population sampled in the original studies. Between 1987 and 2008, the prevalence of smoking increased significantly among women aged ≤ 70 years; the steepest increase was observed in those aged 31–50 and 51–70 years (from 4.6% and 0.1% in 1988, respectively, to 16.4% and 4.5% in 2008, respectively). The prevalence of smoking increased in all birth cohorts, except for those born before 1926. In the same period, among men, smoking decreased in all age-groups, with steepest declines in those aged ≤ 30 years (from 41.8% in 1988 to 28.8% in 2008) and those aged ≥ 71 years (from 15.1% in 1988 to 4.6% in 2008). The prevalence of smoking declined among men of all birth cohorts.

Conclusions

This study provides robust evidence to place Portuguese women at stage II and men at the later stages of the tobacco epidemic.

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

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

Adoption, reach and effectiveness of computer-based, practitioner delivered and combined smoking interventions in general medical practices: a three-arm cluster randomized trial

BACKGROUND

Brief advice for smoking patients has not been sufficiently integrated in routine care. Computer-based interventions emerged as a time saving option that might help to exhaust the potential population impact of the general practice setting.

METHOD

151 practices were randomly assigned to one of three intervention programs consisting in the delivery of: (1) brief advice by the practitioner; (2) individually tailored computer-generated letters; or (3) a combination of both interventions. We assessed three dimensions of population impact: (1) adoption, i.e., the rate of practices participating in the program; (2) reach, measured as the number of interventions provided within 7 months; (3) effectiveness, measured as smoking abstinence at 12-months follow-up.

RESULTS

Among the practices, 70% adopted the program with no significant differences across study groups. Treatment was provided to 3086 adult smokers. Negative binomial regression analysis revealed that the number of interventions provided was higher in practices allocated to the tailored letter and combination intervention groups by 215% (p<.01) and 127% (p=.02), respectively, compared to the brief advice intervention group. Among the patients who received the combination of both intervention, the odds of point abstinence from smoking was increased by 65% (p=.02) and 32% (p=.01) compared to the brief advice and tailored letters intervention respectively. Comparing the number of abstinent patients at follow-up revealed that the tailored letter and combination interventions were superior to the brief advice intervention.

CONCLUSIONS

Computer-based interventions alone or in addition to conventional practitioner-delivered advice can foster the participation of general medical practices in tobacco control.

Impact of the 2010 tobacco tax increase in Australia on short-term smoking cessation: a continuous tracking survey

OBJECTIVE

To use population-level data to monitor the impact on smoking cessation activity of the April 2010 Australian tobacco tax increase.

DESIGN AND SETTING

The Cancer Institute NSW [New South Wales] Tobacco Tracking Survey (CITTS) is a continuous tracking telephone survey conducting about 50 interviews per week. Data from February to September in 2009 and 2010 were analysed (ie, data on people who quit smoking in the 3 months before and 5 months after the tax increase in 2010 were compared, and quitting activity over the same period in 2009 was also analysed).

PARTICIPANTS

Adult smokers and smokers who had stopped smoking in the previous 12 months; 2009 (n = 1604); 2010 (n = 1699).

MAIN OUTCOME MEASURE

Recent quitting (defined as stopping smoking or trying to quit within a 1-month period).

RESULTS

22% of the sample reported that they had quit smoking in May 2010, compared with 13% in April 2010 and 12% in May 2009. Respondents interviewed in the 3 months after the tax increase (May-July) were significantly more likely to report quitting than those interviewed in the 3 months before the tax increase (odds ratio, 1.84; 95% CI, 1.26-2.69; P < 0.01). This increase in quitting activity was not sustained in the subsequent months (August-September).

CONCLUSIONS

The tobacco tax increase was associated with a short-term increase in the rate of smoking cessation among NSW adult smokers and recent quitters, suggesting that regular increases in tobacco tax may further encourage quitting activity.

Australian smokers' and recent quitters' responses to the increasing price of cigarettes in the context of a tobacco tax increase

AIMS

To track smokers' responses to the increasing price of cigarettes after a tax increase, and assess socio-demographic differences in responses.

DESIGN

The Cancer Institute NSW's Tobacco Tracking Survey (CITTS) is a continuous tracking telephone survey. Weekly data were collected between May and September 2010.

SETTINGS

New South Wales, Australia.

PARTICIPANTS

A total of 834 smokers and 163 recent quitters (quit in last 12 months).

MEASUREMENTS

Responses to the price increase included smoking-related changes (tried to quit, cut down) and product-related changes (changed to lower priced brands, started using loose tobacco, bought in bulk). Recent quitters were asked how much the increasing price of cigarettes influenced them to quit.

FINDINGS

Overall, 47.5% of smokers made smoking-related changes and 11.4% made product-related changes without making smoking-related changes. Multinomial logistic regressions showed that younger smokers (versus older) were more likely to make product-related changes and smoking-related changes in comparison to no changes. Low- or moderate-income smokers (versus high-income) were more likely to make smoking-related changes compared to no changes. Highly addicted smokers (versus low addicted) were more likely to make product-related changes and less likely to make smoking-related changes. The proportion of smokers making only product-related changes decreased with time, while smoking-related changes increased. Recent quitters who quit after the tax increase (versus before) were more likely to report that price influenced them.

CONCLUSIONS

The effect of increasing cigarette prices on smoking does not appear to be mitigated by using cheaper cigarette products or sources. These results support the use of higher cigarette prices to encourage smoking cessation.

Health decision making: lynchpin of evidence-based practice

Health decision making is both the lynchpin and the least developed aspect of evidence-based practice. The evidence-based practice process requires integrating the evidence with consideration of practical resources and patient preferences and doing so via a process that is genuinely collaborative. Yet, the literature is largely silent about how to accomplish integrative, shared decision making.

IMPLICATIONS

for evidence-based practice are discussed for 2 theories of clinician decision making (expected utility and fuzzy trace) and 2 theories of patient health decision making (transtheoretical model and reasoned action). Three suggestions are offered. First, it would be advantageous to have theory-based algorithms that weight and integrate the 3 data strands (evidence, resources, preferences) in different decisional contexts. Second, patients, not providers, make the decisions of greatest impact on public health, and those decisions are behavioral. Consequently, theory explicating how provider-patient collaboration can influence patient lifestyle decisions made miles from the provider's office is greatly needed. Third, although the preponderance of data on complex decisions supports a computational approach, such an approach to evidence-based practice is too impractical to be widely applied at present. More troublesomely, until patients come to trust decisions made computationally more than they trust their providers' intuitions, patient adherence will remain problematic. A good theory of integrative, collaborative health decision making remains needed.

Price increase causes fewer sales of factory-made cigarettes and higher sales of cheaper loose tobacco in Germany

Aim of this study is the analysis of the price responsiveness of demand for cigarettes and loose tobacco in Germany over the period 1991--2006. In this period the average consumption of all kinds of cigarettes per capita (German population > or = 15 years) declined from 634 pieces/quarter to 457pieces/quarter (-28%). Consumption of factory-made cigarettes decreased from about 545 pieces/quarter to 330 pieces/quarter in 2006 (-39%). In the same time consumption of self-made cigarettes increased from 89 pieces/quarter to 127 pieces/quarter (+42%). A one Euro Cent increase in price is associated with 28 cigarettes of all kinds consumed less per quarter. Data indicate that the different types of cigarettes are substitutes, e.g. there is evidence for a positive relationship between the price of factory-made cigarettes and the consumption of hand-made cigarettes. Thus, the increase in such consumption is rather driven by a positive cross-price effect of 17.01. Data indicate additionally an overall decrease in the cigarette consumption and a partial switch to cheaper loose tobacco. The availability of low-taxed loose tobacco may undermine the public health benefits of higher cigarette prices. Price differentials between tobacco products should be reduced in order to maximize the public health benefits of high cigarette prices.

Opinion on tobacco tax increase: factors associated with individuals' support in Germany

OBJECTIVES

To assess the opinion on tobacco tax increases in Germany.

DESIGN

Ten wave cross-sectional study with assessments before and after the tax increases.

SETTING

General population of Germany.

PARTICIPANTS

Ten representative samples from general population with a total number of 27,608 persons aged 14 and above were interviewed.

MAIN OUTCOME MEASURES

Opinion ("support", "disapprove", and "undetermined") before and after tobacco tax increases.

RESULTS

Thirty-nine percent of the sample supported the tobacco tax increases. Support was higher among non-smokers and subjects with higher levels of education. Data indicated an increase of support over time from 35% in 2002 to 42% in 2005 which was not affected by the amount of price increase.

CONCLUSIONS

The preliminary findings, that the amount of price increase did not affect the support of the general population in a negative way, and that support grew during a succession of tax increases, might be useful for legislators.