The $5 man: the underground economic response to a large cigarette tax increase in New York City

What was the impact of tobacco taxes on smoking prevalence and coronary heart disease mortality in the United States -2005-2016, and did it vary by race and gender?

Tobacco taxes have reduced smoking and coronary heart disease (CHD) mortality, yet few studies have examined heterogeneity of these associations by race and gender. We constructed a yearly panel (2005-2016) that included age-adjusted cigarette smoking prevalence and CHD mortality rates across all 50 U.S. States and the District of Columbia using the Behavioral Risk Factor Surveillance System and Wide-ranging Online Data for Epidemiological Research. We examined associations between changes in total cigarette excise taxes (i.e., federal and state) and changes in smoking prevalence and CHD mortality, using linear regression models with state and year fixed effects. Each dollar of tobacco tax was associated with a reduction in age-adjusted smoking prevalence 1 year later of -0.4 [95% CIs: -0.6, -0.2] percentage points; and a relative reduction in the rate of CHD mortality 2 years later of -2.0% [95% CIs: -3.7%, -0.3%], or -5 deaths/100,000 in absolute terms. Associations between tobacco taxes and smoking prevalence were statistically significantly different by race and gender and were strongest among Black non-Hispanic women (-1.2 [95% CIs: -1.6, -0.8] percentage points). Associations between tobacco taxes and CHD mortality were not statistically significantly different by race and gender, but point estimates for percent changes were highest among Black non-Hispanic men (-2.9%) and Black non-Hispanic women (-3.5%) compared to White non-Hispanic men (-1.8%) and White non-Hispanic women (-1.5%). These findings suggest that tobacco taxation is an effective intervention for reducing smoking prevalence and CHD mortality among White and Black non-Hispanic populations in the United States.

Addressing lower-priced cigarette products through three-pronged comprehensive regulation on excise taxes, minimum price policies and restrictions on price promotions

The prices that smokers pay out-of-pocket for their tobacco products ultimately influence their smoking behaviour. Although cigarette excise taxes are arguably the best and most used policy to increase cigarette prices, taxes are only one component of retail cigarette prices. The persistence of lower-priced products, disproportionately purchased by lower-income smokers, in jurisdictions with high excise taxes is an Achilles heel for tobacco tax policy. When governments raise excise taxes, the tobacco industry responds. The industry reduces tax pass-through to minimise the price increases for lower-priced brands and offers price discounts to retailers and coupons to consumers. In addition, smokers who do not quit after tax increases may downshift brands, purchase in bulk or substitute lower-priced tobacco product types. This may be particularly true for price-sensitive smokers, including those with lower incomes. We propose that raising excise taxes will be more effective in reducing the persistence of lower-priced products and income-based smoking disparities when taxes are designed to raise prices frequently and substantially for all products and are combined with (a) minimum price laws and (b) bans on coupons, discounts and other promotions. In combination, these three complementary policies restrict the tobacco industry's ability to undermine the impact of higher excise taxes upon consumer prices. Very few jurisdictions have implemented comprehensive three-pronged tobacco price regulation, but doing so would likely address many of the limitations that come with a sole focus on raising excise taxes.

How Low-Income Smokers in New York Access Cheaper Cigarettes

PURPOSE

To understand the tobacco acquisition practices of low-income smokers in New York State in light of high cigarette prices due to high cigarette taxes.

DESIGN

Eight focus groups with low-income smokers were conducted in spring 2015 and 2016 (n = 74).

SETTING

New York City (NYC) and Buffalo, New York.

PARTICIPANTS

Low-income adults aged 18 to 65 who smoke cigarettes regularly.

METHOD

Qualitative analysis of focus group transcripts that explored differences and similarities by region. We used the interview guide-which covered the process of acquiring cigarettes and the impact of cigarette prices-as a framework for analysis to generate themes and subthemes (deductive coding). We also generated themes and subthemes that emerged during focus group discussions (inductive coding).

RESULTS

Some smokers in Western New York have switched to untaxed cigarettes from Native American reservations, whereas low-income smokers in NYC described convenient sources of bootlegged cigarettes (packs or loosies) in their local neighborhood stores, through acquaintances, or on the street. Familiarity with the retailer was key to accessing bootlegged cigarettes from retailers.

CONCLUSIONS

Smokers in this study could access cheaper cigarettes, which discouraged quit attempts and allowed them to continue smoking. The availability of lower priced cigarettes may attenuate public health efforts aimed at reducing smoking prevalence through price and tax increases.

"I'm gonna get me a loosie" Understanding single cigarette purchases by adult smokers in a disadvantaged section of New York City

This study seeks to update and expand our understanding of the perceptions and purchasing patterns of smokers of single cigarettes (‘loosies’) in disadvantaged urban areas. Semi-structured guides were used in thirteen focus groups with 67 self-identified adult smokers from the South Bronx section of New York City in summer 2013.

There is wide availability of single cigarettes in the South Bronx, with legitimate stores overwhelmingly being the preferred venue for purchases. Single cigarettes are sold at higher per-unit prices than illicit packs. However, buyers of single cigarettes can achieve cost savings compared to legal, fully taxed cigarette packs. Apart from cost-savings, smokers opt for single cigarettes to reduce their personal cigarette consumption. There is a general perception of market resilience despite law enforcement intervention. However, law enforcement has a limiting effect on access to single cigarettes outside of an individual smoker's immediate neighborhood.

The findings suggest that single cigarette sales are an important element of the illicit cigarette market in disadvantaged communities which should not be ignored in future research on the nature and extent of cigarette tax avoidance and evasion.

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Local stores are the preferred venue for single cigarette (loosie) purchases.

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Some smokers report buying loosies when lacking the funds for buying packs.

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Some smokers report buying loosies to control their smoking habit.

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Single cigarettes are an integral part of the selling of bootlegged cigarettes.

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Single cigarettes tend to cost more per unit than illicit packs but less than legal packs.

Cost-effectiveness of increasing the reach of smoking cessation interventions in Germany: results from the EQUIPTMOD

AIMS

To evaluate costs, effects and cost-effectiveness of increased reach of specific smoking cessation interventions in Germany.

DESIGN

A Markov-based state transition return on investment model (EQUIPTMOD) was used to evaluate current smoking cessation interventions as well as two prospective investment scenarios. A health-care perspective (extended to include out-of-pocket payments) with life-time horizon was considered. A probabilistic analysis was used to assess uncertainty concerning predicted estimates.

SETTING

Germany.

PARTICIPANTS

Cohort of current smoking population (18+ years) in Germany.

INTERVENTIONS

Interventions included group-based behavioural support, financial incentive programmes and varenicline. For prospective scenario 1 the reach of group-based behavioral support, financial incentive programme and varenicline was increased by 1% of yearly quit attempts (= 57 915 quit attempts), while prospective scenario 2 represented a higher reach, mirroring the levels observed in England.

MEASUREMENTS

EQUIPTMOD considered reach, intervention cost, number of quitters, quality-of-life years (QALYs) gained, cost-effectiveness and return on investment.

FINDINGS

The highest returns through reduction in smoking-related health-care costs were seen for the financial incentive programme (€2.71 per €1 invested), followed by that of group-based behavioural support (€1.63 per €1 invested), compared with no interventions. Varenicline had lower returns (€1.02 per €1 invested) than the other two interventions. At the population level, prospective scenario 1 led to 15 034 QALYs gained and €27 million cost-savings, compared with current investment. Intervention effects and reach contributed most to the uncertainty around the return-on-investment estimates. At a hypothetical willingness-to-pay threshold of only €5000, the probability of being cost-effective is approximately 75% for prospective scenario 1.

CONCLUSIONS

Increasing the reach of group-based behavioural support, financial incentives and varenicline for smoking cessation by just 1% of current annual quit attempts provides a strategy to German policymakers that improves the population's health outcomes and that may be considered cost-effective.

Rapid Assessment for Establishing Evidence of an Underground Cigarette Market in Oakland Chinatown: A Dual Approach

We conducted a preliminary study to rapidly assess (1) whether an underground cigarette market exists in the area known as Oakland Chinatown in Oakland, California; and if so, (2) who consumes untaxed cigarettes in this ethnic enclave to provide a basis for further investigation.

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.

Have higher cigarette taxes in the United States discouraged smoking? A review of data from 1999-2013

INTRODUCTION

Cigarette smoking continues to be a leading cause of preventable morbidity and premature death in the United States. This study examined the impact of federal and state cigarette excise taxes on adult smoking between 1999 and 2013.

METHODS

Data came from the National Health Interview Survey, Behavioural Risk Factor Surveillance System and Tax Burden on Tobacco. Analyses were done from 1999-2013, 2002-6 and 2009-13. Associations between cigarette taxes, prices and smoking were examined in several states based on cigarette tax: Missouri and Virginia (low tax), Florida, Nebraska and Nevada (median tax) and New York and Rhode Island (high tax).

RESULTS

Smoking declined nationally from 22.8% (1999) to 19.0% (2013) with rates falling from 25.7% to 20.5% in men and 21.5% to 15.3% in women. Annual cigarette consumption (in millions) declined from 432,758 to 280,534 and per capita consumption from 1,621 cigarettes (1999) to 894 cigarettes (2013). Smoking declined across age, gender, race/ethnicity, education and poverty level in 2009-13 compared to 2002-6 with large reductions in states with higher cigarette taxes. Negative correlations between cigarette tax and smoking, and positive correlations between cigarette tax and price, were seen.

CONCLUSIONS

Higher cigarette taxes appear to have had a negative impact on smoking in the US. Our data suggest that states with higher cigarette taxes have lower smoking rates than states with lower taxes. Tax measures are however implemented as part of a comprehensive tobacco control package and further research is needed to assess the relative contribution of cigarette tax on smoking reductions in the states examined.

Complexity and dynamism from an urban health perspective: a rationale for a system dynamics approach

In a variety of urban health frameworks, cities are conceptualized as complex and dynamic yet commonly used epidemiological methods have failed to address this complexity and dynamism head on due to their narrow problem definitions and linear analytical representations. Scholars from a variety of disciplines have also long conceptualized cities as systems, but few have modeled urban health issues as problems within a system. Systems thinking in general and system dynamics in particular are relatively new approaches in public health, but ones that hold immense promise as methodologies to model and analyze the complexity underlying urban processes to effectively inform policy actions in dynamic environments. This conceptual essay reviews the utility of applying the concepts, principles, and methods of systems thinking to the study of complex urban health phenomena as a complementary approach to standard epidemiological methods using specific examples and provides recommendations on how to better incorporate systems thinking methods in urban health research and practice.

Loose Cigarette Purchasing and Nondaily Smoking Among Young Adult Bar Patrons in New York City

OBJECTIVES

We examined loose cigarette (loosie) purchasing behavior among young adult (aged 18-26 years) smokers at bars in New York City and factors associated with purchase and use.

METHODS

Between June and December 2013, we conducted cross-sectional surveys (n = 1916) in randomly selected bars and nightclubs. Using multivariable logistic regression models, we examined associations of loose cigarette purchasing and use with smoking frequency, price, social norms, cessation behaviors, and demographics.

RESULTS

Forty-five percent (n = 621) of nondaily smokers and 57% (n = 133) of daily smokers had ever purchased a loosie; 15% of nondaily smokers and 4% of daily smokers reported that their last cigarette was a loosie. Nondaily smokers who never smoked daily were more likely than were daily smokers to have last smoked a loosie (odds ratio = 7.27; 95% confidence interval = 2.35, 22.48). Quitting behaviors and perceived approval of smoking were associated with ever purchasing and recently smoking loosies.

CONCLUSIONS

Loosie purchase and use is common among young adults, especially nondaily smokers. Smoking patterns and attitudes should be considered to reduce loose cigarette purchasing among young adults in New York City.

Development of measures assessing attitudes toward contraband tobacco among a web-based sample of smokers

BACKGROUND

As regulation of tobacco products tightens, there are concerns that illicit markets may develop to supply restricted products. However, there are few validated measures to assess attitudes or purchase intentions toward contraband tobacco (CT). As such, it is important to investigate individual level characteristics that are associated with the purchase and use of contraband tobacco.

METHODS

In May 2013, a pilot survey assessed attitudes, behaviors, and purchase intentions for contraband tobacco based on previous research regarding non-tobacco contraband. The survey was administered via Amazon Mechanical Turk, a crowdsourcing resource, among current smoking respondents in the United States and Canada. Structural equation modeling was used to evaluate the validity of the proposed model for understanding attitudes toward contraband tobacco.

RESULTS

CT purchasers were more likely to report norms supportive of counterfeit products, more intentions toward purchasing counterfeit products, a lowered risk associated with these products, and to have more favorable attitudes toward CT than those who had not purchased CT. Attitudes toward CT mediated the relationship between subjective norms and prior purchase with behavior intentions. Perceived risk had a significant direct effect on intentions and an indirect effect through attitudes toward CT. The structural model fit the data well and accounted for over half (53%) of the variance in attitudes toward tobacco.

CONCLUSIONS

Understanding the mechanisms associated with CT attitudes and purchase behaviors may provide insight for how to mitigate possible iatrogenic consequences of newly implemented regulations. The measures developed here elucidate some elements that influence attitudes and purchase intentions for CT and may inform policy efforts to curtail the development of illicit markets.

Out of view but in plain sight: the illegal sale of single cigarettes

The practice of selling single cigarettes (loosies) through an informal economy is prevalent in urban, low socioeconomic (low SES) communities. Although US state and federal laws make this practice illegal, it may be occurring more frequently with the recent increase in taxes on cigarettes. This investigation provides information concerning the illegal practice of selling single cigarettes to better understand this behavior and to inform intervention programs and policymakers. A total of 488 African American young adults were recruited and surveyed at two education and employment training programs in Baltimore City from 2005 to 2008. Fifty-one percent of the sample reported smoking cigarettes in the past month; only 3.7% of the sample were former smokers. Approximately 65% of respondents reported seeing single cigarettes sold daily on the street. Multivariate logistic regression modeling found that respondents who reported seeing single cigarettes sold on the street several times a week were more than two times as likely to be current smokers compared to participants who reported that they never or infrequently saw single cigarettes being sold, after controlling for demographics (OR = 2.16; p = 0.034). Tax increases have led to an overall reduction in cigarette smoking. However, smoking rates in urban, low SES communities and among young adults remain high. Attention and resources are needed to address the environmental, normative, and behavioral conditions influencing tobacco use and the disparities it causes. Addressing these factors would help reduce future health care costs and save lives.

Hookah smoking: behaviors and beliefs among young consumers in the United States

Hookah smoking is growing in popularity among college-age students in the United States. Community-based, semistructured, in-depth interviews were conducted with 20 college-age individuals who had used a hookah to smoke tobacco. A structured analysis of responses was conducted and framed in terms of the health belief model's four main constructs. Although hookah smokers were aware of the potential severity of tobacco-related illnesses, they did not express a perceived susceptibility to those illnesses. To the extent that cues to action exist with respect to hookah smoking, they generally serve to promote a risky behavior that is perceived to be largely social in nature.

'No-one actually goes to a shop and buys them do they?': attitudes and behaviours regarding illicit tobacco in a multiply disadvantaged community in England

AIMS

To explore attitudes towards, and experience of, illicit tobacco usage in a disadvantaged community against a backdrop of austerity and declining national trends in illicit tobacco use.

DESIGN

Qualitative study using 10 focus groups.

SETTING

Multiply disadvantaged community in Nottingham, United Kingdom.

PARTICIPANTS

Fifty-eight smokers, ex- and non-smokers aged 15-60 years.

MEASUREMENTS

Focus group topic guides.

FINDINGS

There was high awareness and use of illegal tobacco sources, with 'fag houses' (individuals selling cigarettes from their own homes) being particularly widespread. Rather than being regarded as marginal behaviour, buying illicit tobacco was perceived as commonplace, even where products were known to be counterfeit. Smokers' willingness to smoke inferior 'nasty' counterfeit products may be testament to their need for cheap nicotine. Illicit tobacco was seen to be of mutual benefit to both user (because of its low cost) and seller (because it provided income and support for the local economy). Illicit tobacco sellers were generally condoned, in contrast with the government, which was blamed for unfair tobacco taxation, attitudes possibly heightened by the recession. Easy access to illicit tobacco was seen to facilitate and sustain smoking, with the main concern being around underage smokers who were perceived to be able to buy cheap cigarettes without challenge.

CONCLUSIONS

National strategies to reduce illicit tobacco may have limited impact in communities during a recession and where illicit trade is part of the local culture and economy. There may be potential to influence illicit tobacco use by building on the ambivalence and unease expressed around selling to children.

Excise tax avoidance: the case of state cigarette taxes

We conduct an applied welfare economics analysis of cigarette tax avoidance. We develop an extension of the standard formula for the optimal Pigouvian corrective tax to incorporate the possibility that consumers avoid the tax by making purchases in nearby lower tax jurisdictions. To provide a key parameter for our formula, we estimate a structural endogenous switching regression model of border-crossing and cigarette prices. In illustrative calculations, we find that for many states, after taking into account tax avoidance the optimal tax is at least 20% smaller than the standard Pigouvian tax that simply internalizes external costs. Our empirical estimate that tax avoidance strongly responds to the price differential is the main reason for this result. We also use our results to examine the benefits of replacing avoidable state excise taxes with a harder-to-avoid federal excise tax on cigarettes.

The effectiveness of cigarette price and smoke-free homes on low-income smokers in the United States

OBJECTIVES

We examined the effectiveness of state cigarette price and smoke-free homes on smoking behaviors of low-income and high-income populations in the United States.

METHODS

We used the 2006-2007 Tobacco Use Supplement to the Current Population Survey. The primary outcomes were average daily cigarette consumption and successful quitting. We used multivariable regression to examine the association of cigarette price and smoke-free home policies on these outcomes.

RESULTS

High state cigarette price (pack price ≥ $4.50) was associated with lower consumption across all income levels. Although low-income individuals were least likely to adopt smoke-free homes, those who adopted them had consumption levels and successful quit rates that were similar to those among higher-income individuals. In multivariable analysis, both policies were independently associated with lower consumption, but only smoke-free homes were associated with sustained cessation at 90 days.

CONCLUSIONS

High cigarette prices and especially smoke-free homes have the potential to reduce smoking behaviors among low-income individuals. Interventions are needed to increase adoption of smoke-free homes among low-income populations to increase cessation rates and prevent relapse.

Ministers' perceptions of church-based programs to provide depression care for African Americans

African Americans, compared with white Americans, underutilize mental health services for major depressive disorder. Church-based programs are effective in reducing racial disparities in health; however, the literature on church-based programs for depression is limited. The purpose of this study was to explore ministers' perceptions about depression and the feasibility of utilizing the church to implement evidence-based assessments and psychotherapy for depression. From August 2011 to March 2012, data were collected from three focus groups conducted with adult ministers (n = 21) from a black mega-church in New York City. Using consensual qualitative research to analyze data, eight main domains emerged: definition of depression, identification of depression, causal factors, perceived responsibilities, limitations, assessment, group interpersonal psychotherapy, and stigma. A major finding was that ministers described depression within a context of vast suffering due to socioeconomic inequalities (e.g., financial strain and unstable housing) in many African American communities. Implementing evidence-based assessments and psychotherapy in a church was deemed feasible if principles of community-based participatory research were utilized and safeguards to protect participants' confidentiality were employed. In conclusion, ministers were enthusiastic about the possibility of implementing church-based programs for depression care and emphasized partnering with academic researchers throughout the implementation process. More research is needed to identify effective, multidisciplinary interventions that address social inequalities which contribute to racial disparities in depression treatment.

Cigarette price minimization strategies in the United States: price reductions and responsiveness to excise taxes

INTRODUCTION

Because cigarette price minimization strategies can provide substantial price reductions for individuals continuing their usual smoking behaviors following federal and state cigarette excise tax increases, we examined independent price reductions compensating for overlapping strategies. The possible availability of larger independent price reduction opportunities in states with higher cigarette excise taxes is explored.

METHODS

Regression analysis used the 2006-2007 Tobacco Use Supplement of the Current Population Survey (N = 26,826) to explore national and state-level independent price reductions that smokers obtained from purchasing cigarettes (a) by the carton, (b) in a state with a lower average after-tax cigarette price than in the state of residence, and (c) in "some other way," including online or in another country. Price reductions from these strategies are estimated jointly to compensate for known overlapping strategies.

RESULTS

Each strategy reduced the price of cigarettes by 64-94 cents per pack. These price reductions are 9%-22% lower than conventionally estimated results not compensating for overlapping strategies. Price reductions vary substantially by state. Following cigarette excise tax increases, the price reduction available from purchasing cigarettes by cartons increased. Additionally, the price reduction from purchasing cigarettes in a state with a lower average after-tax cigarette price is positively associated with state cigarette excise tax rates and border state cigarette excise tax rate differentials.

CONCLUSIONS

Findings from this large, nationally representative study of cigarette smokers suggest that price reductions are larger in states with higher cigarette excise taxes, and increase as cigarette excise taxes rise.

Cigarette price-minimization strategies by U.S. smokers

BACKGROUND

Smokers may react to cigarette excise tax increases by engaging in price-minimization strategies (i.e., finding ways to reduce the cost of cigarette smoking) rather than by quitting or reducing their cigarette use, thereby reducing the public health benefits of such tax increases.

PURPOSE

To evaluate the state and national prevalence of five common cigarette price-minimization strategies and the size of price reductions obtained from these strategies.

METHODS

Using data from the 2009-2010 National Adult Tobacco Survey, the prevalence of five common price-minimization strategies by type of strategy and by smoker's cigarette consumption level were estimated. The price reductions associated with these price-minimization strategies also were evaluated. Analyses took place in November 2012.

RESULTS

Approximately 55.4% of U.S. adult smokers used at least one of five price-minimization strategies in the previous year, with an average reduction of $1.27 per pack (22.0%). Results varied widely by state.

CONCLUSIONS

Cigarette price-minimization strategies are practiced widely among current smokers, and resulting price reductions are relatively large. Policies that decrease opportunities to effectively apply cigarette price-minimization strategies would increase the public health gains of cigarette excise tax increases.

The impact of cigarette excise tax increases on purchasing behaviors among New York city smokers

OBJECTIVES

We examined the relationship between cigarette excise tax increases and tax-avoidant purchasing behaviors among New York City adult smokers.

METHODS

We analyzed data from the city's annual Community Health Survey to assess changes in rates of tax avoidance over time (2003-2010) and smokers' responses to the 2008 state cigarette tax increase. Multivariable logistic regression analysis identified correlates of buying more cigarettes on the street in response to the increase.

RESULTS

After the 2002 tax increase, the percentage of smokers engaged in tax-avoidant behavior decreased with time from 30% in 2003 to 13% in 2007. Following the 2008 tax increase, 21% of smokers reported buying more cigarettes from another person on the street. Low-income, younger, Black, and Hispanic smokers were more likely than respondents with other sociodemographic characteristics to purchase more cigarettes on the street.

CONCLUSIONS

To maximize public health impact, cigarette tax increases should be paired with efforts to limit the flow of untaxed cigarettes entering jurisdictions with high cigarette pack prices.

Contraband tobacco on post-secondary campuses in Ontario, Canada: analysis of discarded cigarette butts

Background

No studies to date have assessed young adults’ use of First Nations/Native tobacco, a common form of contraband tobacco in Canada. This study examined the proportion of First Nations/Native cigarette butts discarded on post-secondary campuses in the province of Ontario, and potential differences between colleges and universities and across geographical regions.

Methods

In 2009, discarded cigarette butts were collected from high-traffic smoking locations at 12 universities and 13 colleges purposively selected to represent a variety of institutions from all 7 health service regions across Ontario. Cigarette butts were identified as First Nations/Native tobacco if they were: known First Nations/Native brands; had names not matching domestic and international legally-manufactured cigarettes; had no visible branding or logos.

Results

Of 36,355 butts collected, 14% (95% CI = 9.75–19.04) were First Nations/Native. Use of this tobacco was apparent on all campuses, accounting for as little as 2% to as much as 39% of cigarette consumption at a particular school. Proportions of First Nations/Native butts were not significantly higher on colleges (M = 17%) than universities (M = 12%), but were significantly higher in the North region.

Conclusions

The presence of cheap First Nations/Native (contraband) tobacco on post-secondary campuses suggests the need for regulation and public education strategies aimed to reduce its use. Strategies should account for regional variations, and convey messages that resonate with young adults. Care must be taken to present fair messages about First Nations/Native tobacco, and avoid positioning regulated tobacco as a healthier option than contraband.

Fiscal and policy implications of selling pipe tobacco for roll-your-own cigarettes in the United States

BACKGROUND

The Federal excise tax was increased for tobacco products on April 1, 2009. While excise tax rates prior to the increase were the same for roll-your-own (RYO) and pipe tobacco, the tax on pipe tobacco was $21.95 per pound less than the tax on RYO tobacco after the increase. Subsequently, tobacco manufacturers began labeling loose tobacco as pipe tobacco and marketing these products to RYO consumers at a lower price. Retailers refer to these products as "dual purpose" or "dual use" pipe tobacco.

METHODS

Data on tobacco tax collections comes from the Alcohol and Tobacco Tax and Trade Bureau. Joinpoint software was used to identify changes in sales trends. Estimates were generated for the amount of pipe tobacco sold for RYO use and for Federal and state tax revenue lost through August 2011.

RESULTS

Approximately 45 million pounds of pipe tobacco has been sold for RYO use from April 2009 to August 2011, lowering state and Federal revenue by over $1.3 billion.

CONCLUSIONS

Marketing pipe tobacco as "dual purpose" and selling it for RYO use provides an opportunity to avoid paying higher cigarette prices. This blunts the public health impact excise tax increases would otherwise have on reducing tobacco use through higher prices. Selling pipe tobacco for RYO use decreases state and Federal revenue and also avoids regulations on flavored tobacco, banned descriptors, prohibitions on shipping, and reporting requirements.

Personalized medicine and tobacco-related health disparities: is there a role for genetics?

Genetic testing has been proposed as a means to increase smoking cessation rates and thus reduce smoking prevalence. To understand how that might be practically possible, with appreciation of the current social context of tobacco use and dependence, we performed a contextual analysis of smoking-related genetics and smoking cessation. To provide added value, genetics would need to inform and improve existing interventions for smokers (including behavioral and pharmacological treatments). Pharmacogenetics offers the most promising potential, because it may improve the efficacy of medication-based smoking cessations strategies. All proven interventions for treating tobacco dependence, however, including simple cost-effective measures, such as quit lines and physician counseling, are underutilized. As tobacco use occurs disproportionately among disadvantaged populations, efforts to improve smokers' access to health care, and to the tools that are known to help them quit, represent the most promising approaches for reducing smoking prevalence within these groups. Similar considerations apply to other chronic diseases contributing to population-level health disparities. We conclude that although genetics offers increasing opportunities to tailor drug treatment, and may in some cases provide useful risk prediction, other methods of personalizing care are likely to yield greater benefit to populations experiencing health disparities related to tobacco use.

The role of antipsychotics in smoking and smoking cessation

Persons with severe and persistent mental illnesses, e.g. schizophrenia spectrum disorders and bipolar disorder, smoke at a much higher rate than the general population. Treatment options for schizophrenia spectrum disorders and bipolar disorder often include the first-generation (typical) and second-generation (atypical) antipsychotics, which have been shown to be effective in treating both psychotic and mood symptoms. This article reviews studies examining the relationship between antipsychotic medication and cigarette smoking. These studies suggest that in persons with schizophrenia and schizoaffective disorder, typical antipsychotics may increase basal smoking and decrease people's ability to stop smoking, whereas atypical antipsychotics decrease basal smoking and promote smoking cessation. However, we found that the data available were generally of moderate quality and from small studies, and that there were conflicting findings. The review also critically assesses a number of potential mechanisms for this effect: the use of smoking as a form of self-medication for the side effects of antipsychotics, the effect of antipsychotics on smoking-related cues and the effect of antipsychotics on the appreciation of the economic cost of smoking behaviour. Gaps in the research are noted and recommendations for further study are included. More study of this important issue is needed to clarify the effect of antipsychotics on smoking behaviours.

Best practice for prevention and treatment of cardiovascular disease through an equity lens: a review

BACKGROUND

Despite declining rates of cardiovascular disease (CVD) mortality in developed countries, lower socioeconomic groups continue to experience a greater burden of the disease. There are now many evidence-based treatments and prevention strategies for the management of CVD and it is essential that their impact on the more disadvantaged group is understood if socioeconomic inequalities in CVD are to be reduced.

AIMS

To determine whether key interventions for CVD prevention and treatment are effective among lower socioeconomic groups, to describe barriers to their effectiveness and the potential or actual impact of these interventions on the socioeconomic gradient in CVD.

METHODS

Interventions were selected from four stages of the CVD continuum. These included smoking reduction strategies, absolute risk assessment, cardiac rehabilitation, secondary prevention medications, and heart failure self-management programmes. Electronic searches were conducted using terms for each intervention combined with terms for socioeconomic status (SES).

RESULTS

Only limited evidence was found for the effectiveness of the selected interventions among lower SES groups and there was little exploration of socioeconomic-related barriers to their uptake. Some broad themes and key messages were identified. In the majority of findings examined, it was clear that the underlying material, social and environmental factors associated with disadvantage are a significant barrier to the effectiveness of interventions.

CONCLUSION

Opportunities to reduce socioeconomic inequalities occur at all stages of the CVD continuum. Despite this, current treatment and prevention strategies may be contributing to the widening socioeconomic-CVD gradient. Further research into the impact of best-practice interventions for CVD upon lower SES groups is required.

Socio-economic variation in price minimizing behaviors: findings from the International Tobacco Control (ITC) Four Country Survey

This paper examines how socio-economic status (SES) modifies how smokers adjust to changes in the price of tobacco products through utilization of multiple price minimizing techniques. Data come from the International Tobacco Control Policy Evaluation (ITC) Four Country Survey, nationally representative samples of adult smokers and includes respondents from Canada, the United States, the United Kingdom and Australia. Cross-sectional analyses were completed among 8,243 respondents (7,038 current smokers) from the survey wave conducted between October 2006 and February 2007. Analyses examined predictors of purchasing from low/untaxed sources, using discount cigarettes or roll-your-own (RYO) tobacco, purchasing cigarettes in cartons, and engaging in high levels of price and tax avoidance at last purchase. All analyses tested for interactions with SES and were weighted to account for changing and under-represented demographics. Relatively high levels of price and tax avoidance behaviors were present; 8% reported buying from low or untaxed source; 36% used discount or generic brands, 13.5% used RYO tobacco, 29% reported purchasing cartons, and 63% reported using at least one of these high price avoidance behaviors. Respondents categorized as having low SES were approximately 26% less likely to report using low or untaxed sources and 43% less likely to purchase tobacco by the carton. However, respondents with low SES were 85% more likely to report using discount brands/RYO compared to participants with higher SES. Overall, lower SES smokers were 25% more likely to engage in at least one or more tax avoidance behaviors compared to their higher SES counterparts. Price and tax avoidance behaviors are relatively common among smokers of all SES strata, but strategies differed with higher SES groups more likely to report traveling to a low-tax location to avoid paying higher prices, purchase duty free tobacco, and purchase by cartons instead of packs all of which were less commonly reported by low SES smokers. Because of the strategies lower SES respondents are more likely to use, reducing price differentials between discount and premium brands may have a greater impact on them, potentially increasing the likelihood of quitting.

Smokers of illicit tobacco report significantly worse health than other smokers

INTRODUCTION

The aim of this study was to ascertain whether the health of past and current smokers of illicit tobacco (chop-chop) differs from that of smokers of licit tobacco.

METHODS

The design was a telephone survey, stratified by state, using computer aided telephone interviewing, with households selected by random digit dialing from the telephone white pages. Setting was all Australian states and territories, 1,621 regular tobacco smokers aged 18+ years. Measures were social and personal characteristics of tobacco smokers, smoking histories and patterns, and health status (SF-8 and disability weights). Binary logistic regression was used to identify variables associated with current and lifetime chop-chop use.

RESULTS

Compared with licit-only tobacco smokers, current users of chop-chop had significantly greater odds of beginning smoking aged <16 years (odds ratio [OR] 1.65, 95% CI = 1.09-2.50), of reporting below-average social functioning (OR 1.61, 95% CI = 1.06-2.44), and of a measurable disability (OR 1.95, 95% CI = 1.08-3.51). Lifetime chop-chop users were relatively likely to be less than 45 years of age (OR 1.82, 95% CI = 1.38-2.39), report below-average mental health (OR 1.61, 95% CI = 1.22-2.13) and above-average bodily pain (OR 1.40, 95% CI = 1.06-1.85), smoke more than 120 cigarettes/week (OR 1.39, 95% CI = 1.06-1.83), and to have begun smoking aged <16 years (OR 1.33, 95% CI = 1.01-1.75).

DISCUSSION

Current and lifetime users of chop-chop report significantly worse health than smokers of licit tobacco. Investigation of how to communicate this finding to current and potential chop-chop smokers is warranted.

The association between DSM-IV nicotine dependence and stressful life events in the National Epidemiologic Survey on Alcohol and Related Conditions

BACKGROUND AND OBJECTIVES

Nicotine dependence (ND) is a pervasive public health concern and a leading cause of preventable mortality. Stressful life events (SLEs), which severely disrupt the lives of individuals experiencing such events, have been posited as correlates of persisting ND. While both ND and SLEs have been studied extensively in relation to other variables, there are few instances in which they have been investigated in concert.

METHODS

In this study, we use data on 18,013 smokers from the 2001-2002 data set of the National Epidemiological Survey on Alcohol and Related Conditions (NESARC, N = 43,093) to examine whether experiencing a SLE in the past 12 months was associated with meeting criteria for ND in the same past 12 months. Logistic regression analyses were conducted while accounting for a variety of covariates.

RESULTS

A majority of the SLEs were associated with past 12 month ND, even after controlling for poverty, psychiatric and substance use disorders, and a prior history of ND (odds-ratios 1.35-2.20). The rates of past 12 month ND were considerably greater in those experiencing more than one SLE.

CONCLUSIONS

While these data do not allow us to make causal interpretations, our results suggest an association between SLE and ND. Potentially, individuals experiencing SLEs may find it difficult to quit smoking; alternatively, directly or via correlated risks (e.g., living in a high risk neighborhood), smoking may increase the likelihood of exposure to SLEs.

Prevalence and correlates of purchasing contraband cigarettes on First Nations reserves in Ontario, Canada

AIMS

Non-First Nations people purchasing cigarettes on First Nations reserves do not pay applicable taxes. We estimated prevalence and identified correlates of purchasing contraband cigarettes on reserves; we also quantified the share of contraband purchased on reserves relative to reported total cigarette consumption and the associated financial impact on taxation revenue.

DESIGN

Data from the Ontario Tobacco Survey, a regionally stratified representative population telephone survey that over-samples smokers.

SETTING

Ontario, Canada.

PARTICIPANTS

A total of 1382 adult current smokers.

MEASUREMENTS

Reported status of purchasing cigarettes on reserves and the quantity of cigarettes bought on reserves. The prevalence of purchasing cigarettes on reserves was assessed with descriptive statistics. A two-part model was used to analyse correlates of having recently purchased contraband.

FINDINGS

A total of 25.8% reported recent purchasing and 11.5% reported usual purchasing. Heavy smoking, having no plans to quit and lower education were correlated with recent purchasing. Heavy smoking and not having plans to quit were also correlated with buying more packs of cigarettes on reserves. Contraband purchases on reserves accounted for 14.0% of the reported total cigarette consumption and resulted in an estimated tax loss of $122.2 million.

CONCLUSIONS

There was substantial purchasing of contraband cigarettes on reserves in Ontario, resulting in significant losses in tax revenues. The availability of these cheap cigarettes undermines the effectiveness of tobacco taxation to reduce smoking. Wherever indicated, governments should strengthen their contraband prevention and control measures, as recommended by the Framework Convention on Tobacco Control, to ensure that tobacco taxation achieves its intended health benefits and that tax revenues are protected.