Cigarette Affordability and Cigarette Consumption among Adult and Elderly Chinese Smokers: Evidence from A Longitudinal Study

As countries improve their cigarette tax policy, cigarette consumption declines

BACKGROUND

This study examines the association between the Tobacconomics cigarette tax scores and cigarette consumption in 97 countries during the period of 2014-2020.

METHODS

Data on countries' retail cigarette sales and overall cigarette tax scores from 2014 to 2020 are drawn from the proprietary Euromonitor International database and the Tobacconomics Cigarette Tax Scorecard (second edition). Information on countries' tobacco control environments and demographic characteristics is from the relevant years' WHO Report on the Global Tobacco Epidemic, and the World Bank's World Development Indicators database. Ordinary least squares regressions are employed to examine the link between countries' overall cigarette tax scores and cigarette consumption. All regressions control for countries' tobacco control environments, countries' demographic characteristics, year indicators and country fixed effects.

RESULTS

Each unit increase in the overall cigarette tax scores is significantly associated with a reduction of 9% in countries' per-capita cigarette consumption during 2014-2020. The reduction is more pronounced in low and middle-income countries (9%) than in high-income countries (6%). The modest improvement in scores from 2014 to 2020 is associated with a reduction of 3.27% in consumption, while consumption could have been reduced by 20.74% had countries implemented optimal tax policies that would earn the highest score of 5.

CONCLUSIONS

Our results provide evidence on the association between higher cigarette tax scores and lower cigarette consumption. To reduce tobacco consumption, governments must strive to implement all four components in the Cigarette Tax Scorecard at the highest level.

Decomposition and Comparative Analysis of the Prevalence of and Factors Associated With Smoking Between the Rural and Urban Elderly Population in China: A National Cross-Sectional Study

This study aimed to compare and analyse the differences in smoking prevalence, and knowledge, attitudes, and factors associated with smoking between the rural and urban elderly population in China. In total, 6,966 participants aged 60 and above were included in this study, which assessed their smoking-related knowledge, attitudes, and perceptions toward tobacco control. The Chi-square test and logistic regression model were used for statistical analysis, and the Fairlie model was used for decomposition analysis. The overall prevalence of smoking was 25.6%; the rate was much higher in men than in women (overall: OR = 26.234; urban: OR = 31.260; rural: OR = 23.889). The rate of correct responses to all questions on smoking problems was significantly higher among the urban elderly than the rural elderly. Further, 64.18% of the participants supported printing photos of the health hazards of smoking on the cover of cigarette packs, and the rural elderly were more supportive of this. Moreover, only 36.52% of the participants supported increasing taxation and retail price of cigarettes; the urban elderly showed more support for this. Rules about smoking at home also played an important role, especially for families where smoking was not allowed at home, but with exceptions to the rule; however, this factor was only meaningful in urban families (urban: OR = 0.117). Through the Fairlie decomposition analysis, gender (-1.62%), age (-2.03%), region (13.68%), knowing about e-cigarettes (5.17%), rules about smoking at home (3.95%), and smoking-related knowledge scores (42.85%) were found to be associated with rural-urban disparities. This study focused on the differences in smoking between urban and rural areas in China. Smoking among the urban elderly was significantly less prevalent compared with the rural population. Factors including education, region, and smoking-related knowledge need to be addressed to reduce the gap between urban and rural health hazards in China.

Percentage of income spent on tobacco and intention to quit: a cross-sectional analysis of the JASTIS 2020 study

BACKGROUND

Existing indicators for the ease of purchasing tobacco did not reflect the actual amount smoked and individual income, and did not assess heated tobacco products (HTPs). This study assessed the percentage of income spent on tobacco, including combustible cigarettes and/or HTPs, at the individual level and its relation to quit intention.

METHODS

An internet-based self-reported questionnaire survey was conducted in 2020 as a part of the Japan Society and New Tobacco Internet Survey. A total of 954 smokers aged 15-72 years were analyzed. We calculated the percentage of income spent on tobacco according to income levels. A high percentage implies that tobacco is not easy to purchase. The odds ratios for quit intention according to three categories of percentage of income spent on tobacco (<1%, 1-5%, >5%) were calculated by multivariable logistic regression.

RESULTS

The percentage of income spent on tobacco was higher as income level was lower, especially for dual cigarette and HTP users; the percentages in the lowest/highest income group were 7.1%/1.2% for exclusive combustible cigarette smokers; 6.5%/1.1% for exclusive HTPs users; and 9.2%/1.3% for dual users. The adjusted odds ratios (95% confidence intervals) of quit intention among the >5% of income spent on tobacco group compared with the <1% spent group were 0.43 (0.18-1.03) for exclusive combustible cigarette smokers, 0.71 (0.20-2.54) for exclusive HTPs users, and 0.11 (0.02-0.77) for dual users.

CONCLUSIONS

Higher tobacco expenditure was not associated with quit intention for all categories of tobacco product users, probably due to the low price of tobacco in Japan.

Assessing the Effects of a Tobacco Tax Reform on the Industry Price-Setting Strategy

In July 2020, the Executive Power submitted Bill no. 3887-2020 as the first step towards a wide reform of the Brazilian tax system. It will replace the current PIS/COFINS (charged on turnover of companies) by the CBS (a tax on goods and services), which includes a special regime for cigarettes. The novelty is that the specific cigarette tax will be charged on the highest retail price per cigarette brand across the country. This research simulates three scenarios that differ according to the price-setting strategy of the tobacco industry in reaction to the proposed tax reform. In all simulations, the tax reform would result in considerably higher cigarette prices, lower cigarette consumption, higher tax collection, and an implicit minimum price that is far above the current official price floor. Furthermore, the price dispersion and cross-border shopping across states would be reduced because prices and tax burden per brand would tend to be the same across the country due to the dominant price-setting strategy in the cigarette industry.

Effect of Message Approach and Image Size on Pictorial Health Warning Effectiveness on Cigarette Pack in Indonesia: A Mixed Factorial Experiment

Background: Cigarette consumption remains high and increasing in Indonesia. The government implemented a pictorial health warnings requirement of 40% cover of the pack (front and back) using fear appeal messages. Objective: Our study aims to assess the effectiveness of cigarette pictorial health warnings by message and size. Methods: We conducted a mixed factorial experiment online study using three messaging approaches (fear vs. guilt vs. financial loss) and two picture sizes (40% vs. 75%) among 209 smoking participants. Sociodemographic variables included gender, education, income, employment status, and marital status. Data analysis used a mixed model ANOVA to see the main effect and interaction effect on dependent variables. For subgroup analysis, we used t-test and one-way ANOVA. All analyzes were in SPSS 22. Results: We found significant differences in the three message types, in which fear and guilt have higher effectiveness than financial loss. By subgroup, the guilt message was more compelling among female smokers and married smokers. The financial loss message was effective among lower-income smokers. We found no difference in pictorial health warning effectiveness by image size, potentially because participants could zoom in/out the cigarette pack image on the screen. Conclusions: Our finding supports more diverse message types in pictorial health warnings in Indonesia and other countries.

Price, Income, and Affordability as the Determinants of Tobacco Consumption: A Practitioner's Guide to Tobacco Taxation

INTRODUCTION

Tobacco product prices and consumers' income are the two major economic determinants of tobacco demand. The affordability of tobacco products is dependent on the price of tobacco products relative to consumer income. Increase in tobacco tax is expected to lead to higher price, lower affordability, and reduced consumption. Price elasticity and affordability elasticity are used in analyzing the effect of tobacco tax increases on tobacco consumption and public health. The availability of both parameters raises the question of which one to apply in policy discussions.

AIMS AND METHODS

Using global data on cigarette consumption, price, income, and tobacco control measures for 169 countries over 2007-2016, this study estimated the price elasticity and affordability elasticity of cigarette consumption by country income classification using country-specific fixed effects model for panel data.

RESULTS

The estimates show that the restriction of equal strength of the effects of price and income changes on tobacco consumption maintained in affordability elasticity estimation is valid for low- and middle-income countries, while it is rejected for high-income countries.

CONCLUSIONS

Affordability elasticity may prove to be a useful parameter to explain and predict the sensitivity of consumers to tobacco tax and price policy changes under conditions of robust economic growth, which are more likely to be observed in countries with initial low- or middle-income setting. It can provide a reasonable benchmark for tobacco tax and price increase necessary to effectively reduce affordability and consumption of tobacco, which can form a basis for building systematic tax and price increases into the tobacco tax policy mechanism.

IMPLICATIONS

Price elasticity measures the sensitivity of consumers to changes in real prices, holding real income constant. Affordability elasticity measures the sensitivity of consumers to price changes adjusted for inflation and income changes. Existing scientific literature on tobacco demand abounds in both price and affordability elasticity estimates, without providing a clear explanation of the theoretical and policy implications of using one parameter over the other. By estimating and comparing price and affordability elasticities for high-income and low-and-middle-income countries separately, this article offers a guide to the practitioners in tobacco taxation for evaluating the effectiveness of tax-induced price increases on tobacco consumption.

Reasons why Chinese smokers prefer not to use electronic cigarettes

INTRODUCTION

China is the world’s largest e-cigarette manufacturer. It also has the world’s largest smoking population. Although smoking is strongly associated with e-cigarette use, the prevalence of e-cigarette use is low among Chinese smokers compared with smokers in countries such as the US and UK. This study aims to explore the reasons why Chinese smokers prefer not to use e-cigarettes.

METHODS

Cross-sectional data from the Tobacco Questions for Surveys (TQS) conducted in four large Chinese cities (Chengdu, Wuhan, Xiamen, and Xi’an) in 2017–2018 were analyzed. A multi-stage cluster sampling approach was applied to select a representative sample of adults for each city. Weighted percentages and 95% confidence intervals (CIs) were estimated for self-reported reasons why smokers in China had never tried e-cigarettes, in total and by demographic characteristics. Multivariate logistic regression models were used to examine the adjusted associations between the top reasons why smokers never tried e-cigarettes and demographic and socioeconomic characteristics.

RESULTS

The top three reasons that Chinese adult smokers reported for never having tried e-cigarettes were: ‘I do not want to quit smoking’ (35.35%), ‘I do not think they would help me quit or cut down’ (24.31%), and ‘I am not addicted to smoking and don't need help to quit’ (14.93%). Other prominent reasons included: ‘I am concerned they are not safe enough’, and ‘I do not want to substitute one addiction for another’. Generally, there were no statistically significant associations between reasons why smokers never tried e-cigarettes and demographic and socioeconomic characteristics.

CONCLUSIONS

Our results suggest that many Chinese smokers associate e-cigarette use with smoking cessation. Continued monitoring of smokers’ views, beliefs, and risk perceptions regarding e-cigarettes is warranted. Health education campaigns communicating the risks of e-cigarettes are also needed.

Association of state tobacco control policies with active smoking at the time of intervention for intermittent claudication

OBJECTIVE

Active smoking among patients undergoing interventions for intermittent claudication (IC) is associated with poor outcomes. Notwithstanding, current levels of active smoking in these patients are high. State-level tobacco control policies have been shown to reduce smoking in the general US population. We evaluated whether state cigarette taxes and 100% smoke-free workplace legislation are associated with active smoking among patients undergoing interventions for IC.

METHODS

We queried the Vascular Quality Initiative database for peripheral endovascular interventions, infrainguinal bypasses, and suprainguinal bypasses for IC. Active smoking at the time of intervention was defined as smoking within one month of intervention. We implemented difference-in-differences analysis to isolate changes in active smoking owing to cigarette taxes (adjusted for inflation) and implementation of smoke-free workplace legislation. The difference-in-differences models estimated the causal effects of tobacco policies by adjusting for concurrent temporal trends in active smoking unrelated to cigarette taxes or smoke-free workplace legislation. The models controlled for age, sex, race/ethnicity, insurance type, diabetes, chronic obstructive pulmonary disease, state, and year. We tested interactions of taxes with age and insurance.

RESULTS

Data were available for 59,847 patients undergoing interventions for IC in 25 states from 2011 to 2019. Across the study period, active smoking at the time of intervention decreased from 48% to 40%. Every $1.00 cigarette tax increase was associated with a 6-percentage point decrease in active smoking (95% confidence interval, -10 to -1 percentage points; P = .02), representing an 11% decrease relative to the baseline proportion of patients actively smoking. The effect of cigarettes taxes was greater in older patients and those on Medicare. Among patients aged 60 to 69 and 70 to 79 years, every $1.00 tax increase resulted in 14% and 21% reductions in active smoking relative to baseline subgroup prevalences of 53% and 29%, respectively (P < .05 for both); however, younger age groups were not affected by tax increases. Among insurance groups, only patients on Medicare exhibited a significant change in active smoking with every $1.00 tax increase (an 18% decrease relative to a 33% baseline prevalence; P = .01). The number of states implementing smoke-free workplace legislation increased from 9 to 14 by 2019; however, this policy was not significantly associated with active smoking prevalence. At follow-up (median, 12.9 months), $1.00 tax increases were still associated with decreased smoking prevalence (a 25% decrease relative to a 33% baseline prevalence; P < .001).

CONCLUSIONS

Cigarette tax increases seem to be an effective strategy to decrease active smoking among patients undergoing interventions for IC. Older patients and Medicare recipients are the most responsive to tax increases.

XGBoost-Based Framework for Smoking-Induced Noncommunicable Disease Prediction

Smoking-induced noncommunicable diseases (SiNCDs) have become a significant threat to public health and cause of death globally. In the last decade, numerous studies have been proposed using artificial intelligence techniques to predict the risk of developing SiNCDs. However, determining the most significant features and developing interpretable models are rather challenging in such systems. In this study, we propose an efficient extreme gradient boosting (XGBoost) based framework incorporated with the hybrid feature selection (HFS) method for SiNCDs prediction among the general population in South Korea and the United States. Initially, HFS is performed in three stages: (I) significant features are selected by t-test and chi-square test; (II) multicollinearity analysis serves to obtain dissimilar features; (III) final selection of best representative features is done based on least absolute shrinkage and selection operator (LASSO). Then, selected features are fed into the XGBoost predictive model. The experimental results show that our proposed model outperforms several existing baseline models. In addition, the proposed model also provides important features in order to enhance the interpretability of the SiNCDs prediction model. Consequently, the XGBoost based framework is expected to contribute for early diagnosis and prevention of the SiNCDs in public health concerns.

Use of Electronic Nicotine Delivery Systems (ENDS) in China: Evidence from Citywide Representative Surveys from Five Chinese Cities in 2018

China is the largest cigarette consuming country in the world. The emergence of electronic nicotine delivery systems (ENDS) in China may have important implications for the Chinese tobacco market. Unfortunately, research on ENDS in China, while growing, is still limited. This study was designed to examine the awareness and use of ENDS among adult urban residents in China. Data from five citywide representative surveys conducted in 2017–2018 were used. Percentages of residents who had ever heard of, ever used, or used ENDS in the past 30 days among all residents and smokers were estimated, in total and by demographic characteristics. Multiple logistic regression models were used to estimate the adjusted associations between awareness and use of ENDS and individual-level demographic characteristics and socioeconomic status (SES). Overall, 51.3% had ever heard, 4.8% ever used, and 0.9% used ENDS in the past 30 days. Men, young adults, those with high levels of education, and current smokers were more likely to be aware of and use ENDS. Among smokers, 67.8% had ever heard, 17.1% ever used, and 3.9% used ENDS in the past 30 days, respectively. Young adult smokers and smokers with high levels of education were more likely to be aware of and use ENDS. Our study results on ENDS awareness and use patterns and associated factors in China provide important evidence to inform research and policies related to ENDS manufacture, marketing, and sales in China.