Challenges and way forward for implementation of sugar taxation in the Middle East and North Africa (MENA)

BACKGROUND

Over consumption of added sugar beyond the World Health Organization (WHO) recommended level of 10% of daily energy intake has well-established negative health consequences including oral diseases. However, the average consumption of added sugar in the Middle East and North Africa region (MENA-World Bank's regional classification) is 70% higher than the WHO recommended level. Imposing taxes on added sugar has been proposed by the WHO to decrease its consumption. Yet, only 21.6% of the total MENA population are covered by taxation policies targeting added sugar.

CHALLENGES

Well-recognized challenges for the implementation of sugar taxation in MENA include the tactics used by the food and beverage industry to block these type of policies. However, there are also other unfamiliar hurdles specific to MENA. Historically, there have been incidents of protest and riots partially sparked by increased price of basic commodities, including sugar, in MENA countries. This may affect the readiness of policy makers in the region to impose added sugar taxes. In addition, there are also cultural, lifestyle and consumption behavioural barriers to implementing added sugar taxation. Ultra-processed foods and sugar-sweetened-beverages (SSBs) rich in added sugar are perceived by many in MENA as essential treats regardless of their health risks. Furthermore, some countries even provide subsidies for added sugar. Also, (oral) healthcare providers generally do not engage in policy advocacy mainly due to limited training on health policy.

WAYS FORWARD

Here, we discuss these challenges and suggest some ways forward such as (1) support from a health-oriented political leadership, (2) raising public awareness about the health risks of over consumption of sugar, (3) transparency during the policy-cycle development process, (4) providing a free and safe environment for a community dialogue around the proposed policy, (5) training of (oral) healthcare professionals on science communication and policy advocacy in local lay language/dialect, ideally evidence informed from local/regional studies, (6) selecting the appropriate political window of opportunity to introduce a sugar tax policy, and (7) clear and strict conflict of interest regulations to limit the influence of commercial players on health policy.

National taxation on sugar-sweetened beverages and its association with overweight, obesity, and diabetes

BACKGROUND

Consumption of sugar-sweetened beverages (SSBs) has been linked to several adverse health outcomes, thus many countries introduced taxation to reduce it.

OBJECTIVES

To summarize national SSB taxation laws and to assess their association with obesity, overweight and diabetes.

METHODS

We conducted a systematic scoping review up to January 2022 on PubMed, Web of Science, Embase, and Google Search to identify taxes on SSBs. An interrupted time series analysis (ITSA) was conducted on 17 countries with taxation implemented in 2013 or before to evaluate the level and slope modifications in the rate of change of standardized prevalence rates of overweight, obesity, and diabetes. Random-effects meta-regression was used to assess whether year of entry into force of the law, national income, and tax design affected observed results.

RESULTS

We included 76 tax laws issued between 1940 and 2020 by 43 countries, which were heterogeneous in terms of tax design, amount, and taxed products. Among children and adolescents, ITSA showed level or slope reduction for prevalence of overweight and obesity in 5 (Brazil, Samoa, Palau, Panama, Tonga) and 6 (El Salvador, Uruguay, Nauru, Norway, Palau, Tonga) countries out of 17, respectively. No clear pattern of modification of results according to investigated factors emerged from the meta-regression analysis.

CONCLUSIONS

Taxation is highly heterogeneous across countries in terms of products and design, which might influence its effectiveness. Our findings provide some evidence regarding a deceleration of the increasing prevalence rates of overweight and obesity among children occurring in some countries following introduction of taxation. PROSPERO registration number: CRD42021233309.

Menstrual Products: Attitudes About Taxation and Safety

Background: This study explored factors associated with the differences between women and men in attitudes, norms, and the support of taxation of menstrual products (MPs) and menstrual-adjacent products. It also investigated the use of these products in women. Methods: Young adults from 18 to 30 years of age were recruited via social media, listserve emails, and flyers placed throughout a university campus. Following cognitive interviewing, a survey investigated attitudes, beliefs, and behaviors associated with MPs. Results: Individuals self-identified as men or women. Women (n = 154) had more positive general attitudes, less positive safety attitudes, and less support for taxation of MPs than men (n = 43). Regression analyses indicated that factors, such as race, age, attitudes, norms, and taxation, were associated with product use. Conclusions: Attitudes about safety and taxation differ for men and women. Tax policies and attitude-shifting interventions need to be tailored to their audience, and our study can inform that effort.

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.

Cigarette prices and smoking among adults in eight sub-Saharan African countries: evidence from the Global Adult Tobacco Survey

BACKGROUND

Despite growing concern over tobacco use in sub-Saharan Africa, evidence on the association between cigarette prices and adult smoking behaviour in the region is limited.

OBJECTIVES

To provide new evidence on the association between cigarette prices and adult smoking in eight sub-Saharan African countries.

METHODS

The analysis uses data from 51 270 individuals taken from the Global Adult Tobacco Survey, which was conducted in eight African countries during 2012-2018. The relationship between prices and smoking is estimated using probit models for smoking participation and generalised linear models for conditional cigarette demand.

RESULTS

Higher prices are significantly associated with lower cigarette demand across African countries. The estimated price elasticity of participation is -0.362 (95% CI -0.547 to -0.177). The price elasticity of conditional cigarette demand is -0.133 (95% CI -0.194 to -0.072) for people who have just started smoking. The estimated total price elasticity of cigarette demand by new adult smokers is -0.495. The absolute value of the conditional demand elasticity becomes smaller by 0.004 units for each additional year that a person smokes. For the average smoker in the sample, with a smoking duration of 18.07 years, the total elasticity estimate is -0.422.

CONCLUSIONS

Higher cigarette prices significantly decrease the likelihood of smoking and decrease the intensity of cigarette consumption among African adults. Increases in the excise tax that increase the retail price of cigarettes will play an important role in reducing adult tobacco use on the continent. Governments are encouraged to increase excise taxes to improve public health.

Going 'Super Value' in New Zealand: cigarette pricing strategies during a period of sustained annual excise tax increases

BACKGROUND

Between 2010 and 2020, the New Zealand (NZ) Government increased tobacco excise tax by inflation plus 10% each year. We reviewed market structure changes and examined whether NZ tobacco companies shifted excise tax increases to maintain the affordability of lower priced cigarette brands.

METHODS

We cluster-analysed market data that tobacco companies supply to the NZ Ministry of Health, created four price partitions and examined the size and share of these over time. For each partition, we analysed cigarette brand numbers and market share, calculated the volume-weighted real stick price for each year and compared this price across different price partitions. We calculated the net real retail price (price before tax) for each price partition and compared these prices before and after plain packaging took effect.

RESULTS

The number and market share of Super Value and Budget brands increased, while those of Everyday and Premium brands decreased. Differences between the price of Premium and Super Value brands increased, as did the net retail price difference for these partitions. Following plain packaging's implementation, Super Value brand numbers more than doubled; contrary to industry predictions, the price difference between these and higher priced brands did not narrow.

CONCLUSIONS

Between 2010 and 2020, NZ tobacco companies introduced more Super Value cigarette brands and shifted excise tax increases to reduce the impact these had on low-priced brands. Setting a minimum retail price for cigarettes could curtail tobacco companies' ability to undermine tobacco taxation policies designed to reduce smoking.

Improving estimates of the illicit cigarette trade through collaboration: lessons from two studies of Malaysia

This paper critically analyses contrasting estimates of Malaysia's illicit cigarette trade in 2011, 2015 and 2019 by Bui et al and Koya et al who previously produced independent estimates at about the same time using tax gap analysis. Collaboration between the two authors' teams emerged due to the discrepancies in their results, generating this paper to explore the methodological issues identified and hence produce revised estimates of the rate of illicit. Key issues identified were: Bui et al's assessment of legally imported cigarettes impacting all years; their exclusion of ad valorem duty affecting the 2011 and 2015 estimates; Koya et al overlooked the value of cigarettes for export market in their ad valorem calculation and used the sales value of imported tobacco/tobacco products, not just cigarettes, both of which impact estimates for 2011 and 2015. Recalculations using Koya et al's consumption data reveal that in 2019, illicit cigarettes accounted for about 70% of the market, which is higher than Bui et al's estimate (38%) but slightly lower than Koya et al's (72%). For 2011 and 2015 where ad valorem applied, the corrected estimates show a share of the illicit cigarette market of approximately 41.1% and 52.7%, respectively, differing from Bui et al's 0% in 2011 and 29.6% in 2015, and Koya et al's 51% in 2011 and 55% in 2015. This paper provides essential lessons for addressing methodological issues between authors' teams and updated estimates of Malaysia's illicit cigarette trade, verifying that Malaysia faces a substantial illicit cigarette trade problem.

Tobacco industry pricing strategies for single cigarettes and multistick packs after excise tax increases in Colombia

INTRODUCTION

Taxes on tobacco products are an efficient way of reducing consumption. However, they are only effective if passed on to consumers with higher prices. This study aims to examine tobacco industry (TI) pricing strategies in response to tax increases, and whether they differ by price segments or presentation (packs or individual sticks) in Colombia. This is the first such academic study in Latin America and the first anywhere to include the market for single sticks.

METHODS

Using data on cigarette pricing/taxation from a survey of smokers (2016-2017) and official government data on pricing (2007-2019), the TI's pricing strategies were examined, split by brand, price segments, different sized packs and single cigarettes.

RESULTS

The TI employed targeted pricing strategies in Colombia: differentially shifting taxes; and launching new brands/brand variants. The industry overshifted taxes when increases were smaller and predictable, but used undershifting more when there was a larger increase in 2017, after which it mostly overshifted on budget and premium (but undershifted mid-priced) brands. The prices for single sticks increased more than the tax increase in 2017 when their consumption also increased.

CONCLUSION

The pricing strategies identified suggest excise taxes can be increased further, particularly the specific component, to reduce the price gap between brand segments. Brands should be restricted to a single variant along with prohibitions on launching new brands/brand variants. Lastly, since the pricing of single sticks does not match the pattern of packs, more monitoring of their sales and distribution is required, especially since they promote consumption and hinder effective implementation of tobacco tax policies.

Economic research in waterpipe tobacco smoking: reflections on data, demand, taxes, equity and health modelling

Economic evaluation of tobacco control policies is common in high-income settings and mainly focuses on cigarette smoking. Evidence suggests that increasing the excise tax of tobacco products is a consistently effective tool for reducing tobacco use and is an efficient mechanism for increasing government revenues. However, less research has been conducted in low/middle-income countries where other tobacco forms are common. This paper presents insights from our work on the economics of waterpipe tobacco smoking conducted in the Eastern Mediterranean Region where waterpipe smoking originated and is highly prevalent. The specific areas related to economics of waterpipe smoking considered herein are: price elasticity, taxation, government revenue, expenditure and healthcare costs. This paper aims to provide practical guidance for researchers investigating the economics of waterpipe tobacco with potential implications for other novel tobacco products. We present lessons learnt across five thematic areas: data, demand, taxes, equity and health modelling. We also highlight knowledge gaps to be addressed in future research. Research implications include designing comprehensive assessment tools that investigate heterogeneity in waterpipe smoking patterns; accounting for cross-price elasticity of demand with other tobacco products; exploring the change in waterpipe tobacco smoking in response to a tax increase and analysing the equity impact of waterpipe tobacco control interventions.

The effect of cigarette and e-cigarette taxes on prescriptions for smoking cessation medications

OBJECTIVE

To test the effect of cigarette and e-cigarette taxes on prescriptions for smoking cessation medications.

DATA SOURCE

Symphony Health, IDV all-payer prescription claims data for the United States over the period 2009-2017. Prescription fills for smoking cessation products were provided at the patient's age, patient's sex, brand/generic, payment type, year, and quarter levels.

STUDY DESIGN

We study the effect of state-level cigarette and e-cigarette tax rates on prescriptions for smoking cessation medications using two-way fixed effect modified difference-in-differences regressions. We also use a multiperiod difference-in-differences estimator robust to bias from dynamic and heterogeneous treatment effects with a staggered policy rollout.

DATA COLLECTION/EXTRACTION METHODS

We use fills for Chantix, Zyban, and their generics, as well as Food and Drug Administration-approved nicotine replacement therapies that are paid for by insurance.

PRINCIPAL FINDINGS

We observe no statistically significant change in prescription fills following an increase in the e-cigarette tax rate, though we are unable to rule out potentially large effects. However, following a $1.00 increase in the cigarette tax rate, we observe a 1052 increase in prescription fills per 100,000 adults (95% CI: 57, 2046; 4.2% increase). The effect of cigarette taxes on prescription fills was particularly large for 18-34 year-olds.

CONCLUSIONS

Our findings suggest that, during a period when e-cigarettes are widely available, cigarette tax increases remain effective in increasing use of these medications, but e-cigarette taxes do not increase use of these medications.

Procedural fairness and the resilience of health financing reforms in Ukraine

In 2017, Ukraine's Parliament passed legislation establishing a single health benefit package for the entire population called the Programme of Medical Guarantees,‎ financed through general taxes and administered by a single national purchasing agency. This legislation was in line with key principles for financing universal health coverage. However, health professionals and some policymakers have been critical of elements of the reform, including its reliance on general taxes as the source of funding. Using qualitative methods and drawing on deliberative democratic theory and criteria for procedural fairness, this study argues that the acceptance and sustainability of these reforms could have been strengthened by making the decision-making process fairer. It suggests that three factors limited the extent of stakeholders' participation in this process: first, a perception among reformers that fast-paced decision-making was required because there was only a short political window for much needed reforms; second, a lack of trust among reformers in the motives, representativeness, and knowledge of some stakeholders; and third, an under-appreciation of the importance of dialogic engagement with the public. These findings highlight a profound challenge for policymakers. In retrospect, some of those involved in the reform's design and implementation believe that a more meaningful engagement with the public and stakeholders who opposed the reform might have strengthened its legitimacy and durability. At the same time, the study shows how difficult it is to have an inclusive process in settings where some actors may be driven by unconstrained self-interest or lack the capacity to be representative or knowledgeable interlocutors. It suggests that investments in deliberative capital (the attitudes and behaviours that facilitate good deliberation) and in civil society capacity may help overcome this difficulty.

No smoking gun: tobacco taxation and smuggling in Sierra Leone

OBJECTIVE

To evaluate the common industry claim that higher tobacco taxation leads to higher levels of smuggling, particularly in a limited state capacity setting.

DESIGN

This paper evaluates the effects of a tobacco tax increase in Sierra Leone on smuggling by using gap analyses. Its models are based on multiple rounds of the Demographic and Health Survey and customs data as well as newly collected data on cigarette prices.

RESULTS

The paper shows that despite a substantial increase in cigarette taxation, and despite the absence of other formal tobacco control policies, smuggling has not increased in Sierra Leone. Its primary model shows a decrease in cigarette smuggling by 16.74% following the tax increase, alongside a decrease in cigarette consumption more widely and an increase in tax revenue.

CONCLUSIONS

By presenting a low income and lower enforcement capacity case study, this paper provides novel and critical evidence to the debate on the tax-smuggling link. Furthermore, it points to new questions on how states in these contexts can limit cigarette smuggling.

Estimating own-price and cross-price elasticity of cigarette consumption by price tiers in Bangladesh

OBJECTIVES

The overall price elasticity of cigarette consumption in Bangladesh has been studied extensively. The estimates of price elasticity by price tiers are not available in the existing literature.

METHODS

Using cohort data of nearly 6000 individuals from the International Tobacco Control Bangladesh survey, this study estimated the own-price and cross-price elasticity and income elasticity of cigarette demand by price tiers in Bangladesh. The elasticity was estimated in three stages of consumer decisions: whether to smoke, which brand to smoke and finally, how many cigarettes to smoke per day. The decision to smoke cigarettes and the choice of cigarette brands were modelled using instrumental variable probability regression. The cigarette consumption per day was modelled using seemingly unrelated regression.

RESULTS

The price elasticity of cigarette smoking prevalence with respect to the price of low-price cigarettes is -0.0487. The total elasticity for low-price cigarette consumption with respect to its own price is -0.1678. The own-price elasticity of smoking intensity of high-priced brands is -0.2512. The cross-price elasticity of low-price cigarette consumption with respect to high-price brand prices is 0.2643. The income elasticity of smoking prevalence overall is 0.0564. The income elasticity of daily consumption of low-price cigarettes is -0.1934 and for high-price cigarettes, it is 1.4044. The total income elasticity is 1.4608 for high-price cigarettes.

CONCLUSION

A cigarette tax policy that raises the prices of both low-price and high-price brands-but increases prices in the low-price tier at a faster rate than in the high-price tier and increases prices of all brands at a pace faster than income growth-can effectively reduce cigarette consumption in Bangladesh.

JEL CODES

H29, L66, I18.

Cask wine: Describing drinking patterns associated with Australia's cheapest alcohol

INTRODUCTION

In Australia, cask wine is the cheapest alcoholic beverage available, offering the lowest price per standard drink. Despite this, there is little research on the contextual correlates of cask wine consumption. Therefore, the current study aims to describe how cask wine consumption has changed over the last decade. Then, through comparisons between cask and bottled wine, how prices, typical drinking locations, and patterns of consumption differ between the beverages.

METHODS

Cross-sectional data was drawn from two sources. Four waves of the National Drug Strategy Household Survey were used (2010, 2013, 2016 and 2019) in order to examine consumption trends over time. The International Alcohol Control study (2013) in Australia was additionally used to explore pricing and consumption trends in greater detail.

RESULTS

Cask wine was considerably cheaper than other forms of wine at $0.54 per standard drink (95% confidence interval [CI] 0.45-0.62, p < 0.05). Consumption trends associated with cask wine differed from that of bottled wine, being consumed almost entirely at home and in significantly greater quantity (standard drinks per day 7.8, 95% CI 6.25-9.26, p < 0.05). Among the heaviest drinkers, 13% (95% CI 7.2-18.8, p < 0.05) consumed cask wine as their main drink, compared to 5% (95% CI 3.76-6.24, p < 0.05) consuming bottled wine.

CONCLUSIONS

Cask wine drinkers are disproportionately more likely to consume higher amounts of alcohol, paying less per drink doing so compared to bottled wine drinkers. As all cask wine purchases were under $1.30, a minimum unit price may largely affect cask wine purchases, applying to a far smaller proportion of bottled wine.

Promoting convergence and closing gaps using affordability-based minimum taxes: an illustration using the European Union Tobacco Tax Directive

BACKGROUND

The rules governing tobacco taxation in the European Union (EU) are currently under revision. Earlier research has proposed reforms aimed at stimulating price convergence across countries by linking national minimum taxes to a measure of average prices across the EU. This paper proposes that revised tax rules include an affordability criterion whereby minimum taxes are required to be no less than a common prespecified fraction of domestic average disposable income.

METHODS

Longitudinal data on prices and taxes on factory-made cigarettes and roll-your-own tobacco in 24 EU member states and the UK between 2011 and 2019 are used to estimate econometric models for their weighted average prices as a function of taxes. Two scenarios are simulated with the models' estimates: a baseline scenario for the actual tax stance pertaining to 2020 and a reform scenario implementing an additional affordability criterion.

RESULTS

The affordability criterion would significantly increase the price of both tobacco products, particularly in richer countries with relatively low tobacco prices that are often not affected by the increases in nominal minima mandated by the EU rules. There would also be some price convergence between the two tobacco products, both on average and in the majority of countries.

CONCLUSIONS

Such results show an affordability criterion could be a potentially fruitful complement to the tax reforms proposed in earlier research.

Follow the money: a closer look at US tobacco industry marketing expenditures

INTRODUCTION

While much of the concern with tobacco industry marketing has focused on direct media advertising, a less explored form of marketing strategy is to discount prices. Price discounting is important because it keeps the purchase price low and can undermine the impact of tax increases.

METHODS

We examine annual US marketing expenditures from 1975 to 2019 by the largest cigarette and smokeless tobacco companies as reported to the Federal Trade Commission. We consider three categories: direct advertising, promotional allowances and price discounting. In addition to considering trends in these expenditures, we examine how price discounting expenditures relate to changes in product prices and excise taxes.

RESULTS

US direct advertising expenditures for cigarettes fell from 80% of total industry marketing expenditures in 1975 to less than 3% in 2019, while falling from 39% in 1985 to 6% in 2019 for smokeless tobacco. Price discounting expenditures for cigarettes became prominent after the Master Settlement Agreement and related tax increases in 2002. By 2019, 87% of cigarette marketing expenditures were for price discounts and 7% for promotional allowances. Smokeless marketing expenditures were similar: 72% for price promotions and 13% for promotional allowances. Price discounting increased with prices and taxes until reaching their currently high levels.

CONCLUSIONS

Between 1975 and 2019, direct advertising dramatically fell while price discounting and promotional expenditures increased. Local, state and federal policies are needed that apply non-tax mechanisms to increase tobacco prices and restrict industry contracts to offset industry marketing strategies. Further study is needed to better understand industry decisions about marketing expenditures.

How cigarette excise tax pass-through to prices responds to the uptake and evolution of e-cigarettes (ECs)

BACKGROUND

How excise taxes are passed through to prices determines whether tax policies will be effective in changing smoking behaviours. Though previous literature has documented that cigarette taxes are overly shifted to prices, there is limited evidence on how cigarette tax pass-through to prices is affected by the uptake and evolution of e-cigarettes (ECs) in the US market.

OBJECTIVE

This study investigates how cigarette excise tax pass-through rate varied by price levels (the 25th, 50th, and 75th percentile prices) and the uptake and evolution of ECs.

METHODS

Tax pass-through rates were assessed using ordinary least squares regressions while controlling for state, year and month fixed effects. Different trends were then tested for the pre-EC uptake era (2006-2011), EC uptake era (2012-2016) and the evolution of nicotine salt-based ECs era (2017 and later).

FINDINGS

Cigarette excise taxes were fully shifted to the 25th and 50th percentile prices and overly shifted to the 75th percentile prices at a 1:1.1 rate. While cigarette excise taxes had a continuous impact on raising prices, the tax pass-through rates were lower for lower priced cigarettes, and states imposed lower taxes.

CONCLUSIONS

Continuing to raise cigarette taxes may be needed to create financial incentives to encourage people who smoke to switch to ECs. In addition, continuing to raise cigarette taxes and additional pricing policies such as price promotion restrictions are needed to increase retail prices and reduce price minimisation opportunities.

A Wealth Distribution Agent Model Based on a Few Universal Assumptions

We propose a new agent-based model for studying wealth distribution. We show that a model that links wealth to information (interaction and trade among agents) and to trade advantage is able to qualitatively reproduce real wealth distributions, as well as their evolution over time and equilibrium distributions. These distributions are shown in four scenarios, with two different taxation schemes where, in each scenario, only one of the taxation schemes is applied. In general, the evolving end state is one of extreme wealth concentration, which can be counteracted with an appropriate wealth-based tax. Taxation on annual income alone cannot prevent the evolution towards extreme wealth concentration.

Tax incidence of electronic nicotine delivery systems (ENDS) in the USA

BACKGROUND

A growing number of states or jurisdictions in the USA have imposed excise taxes on electronic nicotine delivery systems (ENDS). However, there is no consensus on how best to tax ENDS.

OBJECTIVES

We specifically compare the tax incidence or burden for ENDS and cigarettes and analyse how ENDS tax incidence is associated with the choices of tax bases and rates.

METHODS

We calculate ENDS excise tax incidence as the percentage of retail prices for each state or jurisdiction. Next, we use ordinary least squares to evaluate how tax incidence is associated with the choices of tax bases (eg, a specific tax base vs a value or ad valorem tax base) and rates and how these associations are moderated by product types.

RESULTS

ENDS and cigarette tax incidence is similar at the state level. Nonetheless, when federal cigarette taxes are considered, the cigarette tax incidence is higher than the tax incidence on closed-system ENDS. The proportion of states that impose value taxes is higher for open systems (65.4%) than for closed systems (46.2%). A value tax base is associated with a 7 percentage point lower tax incidence compared with a specific tax base. Product type further moderates the association between tax base and incidence.

CONCLUSION

Tax incidence can be used to measure the strength of ENDS tax policies and how they are compared with cigarette taxes. Policymakers who aim to prevent youth from using ENDS may consider a value tax base to raise the tax incidence of closed systems-the product type preferred by young people.

Skin Cancer Prevention across the G7, Australia and New Zealand: A Review of Legislation and Guidelines

Incidence rates of melanoma and keratinocyte skin cancers have been on the rise globally in recent decades. While there has been a select focus on personal sun protection awareness, to our knowledge, there is a paucity of legislation in place to help support citizens' efforts to protect themselves from the harmful effects of ultraviolet radiation (UVR). Given this, we conducted a comprehensive review of legislation and guidelines pertaining to a variety of sun protection-related topics in countries of the Group of Seven (G7), Australia and New Zealand. Australia was the only country to have banned tanning beds for individuals of all ages, while other select countries have instituted bans for minors. In workplace policy, there is very little recognition of the danger of occupational UVR exposure in outdoor workers, and thus very few protective measures are in place. With regard to sports and recreation, certain dermatological/professional associations have put forward recommendations, but no legislation was brought forward by government bodies outside of Australia and New Zealand. With regard to youth, while there are various guidelines and frameworks in place across several countries, adherence remains difficult in the absence of concrete legislation and standardization of procedures. Finally, only Australia and a few select jurisdictions in the United States have implemented sales tax exemptions for sunscreen products. In light of our findings, we have made several recommendations, which we anticipate will help reduce the rates of melanoma and keratinocyte cancers in years to come. However, minimizing UVR exposure is not without risk, and we, therefore, suggest the promotion of vitamin D supplementation in conjunction with sun protective practices to limit potential harm.

The cigarette market in Brazil: new evidence on illicit practices from the 2019 National Health Survey

OBJECTIVE

To explore new evidence on illicit practices, such as selling legal brands below the minimum legal price (MLP), and smugglers selling illicit brands at or above the MLP.

METHODS

For the first time in Brazil, self-reported information on cigarette brand name and price paid per pack in smokers' last purchase from a nationally representative survey conducted in 2019 was used to distinguish the illicit and the legal markets. We estimated the proportion of illicit cigarette consumption, using the combination of brand and price.

RESULTS

The proportion of smuggled illicit cigarette consumption based on brands not approved on the Brazilian market was estimated at 38.6% (95% CI: 35.8% to 41.5%). When we added legal brands not paying taxes, it increased to 47.1% (95% CI: 44.2% to 49.9%). Around 25% of illicit brand cigarettes were sold at or above MLP.

CONCLUSIONS

In Brazil, since 2017 there is a lack of adjustment in tobacco taxes and the MLP for inflation and income growth. The increase in cigarette affordability and the presence on the market of a segment of 'higher-priced' illicit brands suggest patterns of illicit brand loyalty and/or perceived 'brand quality' among smokers of illicit cigarettes. The evidence also shows that a sizeable proportion of legal brand cigarettes were sold below the MLP. This study offers insight into what happened in circumstances in which a government failed to keep current with tax policies and the monitoring of domestic manufacturing. Brazil has been a world leader in the monitoring of the tobacco epidemic, and this study also offers an innovative use of data that an increasing number of countries are collecting.

Health policy under the microscope: a micro policy design perspective

The comparative study of health policy has focused mainly on the macro-structural dimensions of health systems and reforms that have sought to change these organizational arrangements. Thus, a great deal of attention has been paid to the multiple models of insurance against sickness risks and various modes of organizing and financing healthcare providers. However, little attention has been paid to policy tools and policy design in the health policy domain. This research gap largely impedes a focus on the micro (granular) dimension of health policy, although this is the level at which health policies impact reality and thus deliver progress toward the expected goals. Such a focus on the micro dimension could not only allow a finer-grained comparison of how health systems work but also shed light on how capable health policies are of achieving the expected outcomes. This paper fills this gap by presenting an analytical framework capable of illuminating the granular dimension of policy design (the instrumental delivery package) and shows the analytical relevance of the framework by applying it to the designs of maximum waiting time guarantee and vaccination mandate policies.

Earmarked Taxes for Mental Health Services in the United States: A Local and State Legal Mapping Study

Policy Points Local governments are increasingly adopting policies that earmark taxes for mental health services, and approximately 30% of the US population lives in a jurisdiction with such a policy. Policies earmarking taxes for mental health services are heterogenous in their design, spending requirements, and oversight. In many jurisdictions, the annual per capita revenue generated by these taxes exceeds that of some major federal funding sources for mental health.

CONTEXT

State and local governments have been adopting taxes that earmark (i.e., dedicate) revenue for mental health. However, this emergent financing model has not been systematically assessed. We sought to identify all jurisdictions in the United States with policies earmarking taxes for mental health services and characterize attributes of these taxes.

METHODS

A legal mapping study was conducted. Literature reviews and 11 key informant interviews informed search strings. We then searched legal databases (HeinOnline, Cheetah tax repository) and municipal data sources. We collected information on the year the tax went into effect, passage by ballot initiative (yes/no), tax base, tax rate, and revenue generated annually (gross and per capita).

FINDINGS

We identified 207 policies earmarking taxes for mental health services (95.7% local, 4.3% state, 95.7% passed via ballot initiative). Property taxes (73.9%) and sales taxes/fees (25.1%) were most common. There was substantial heterogeneity in tax design, spending requirements, and oversight. Approximately 30% of the US population lives in a jurisdiction with a tax earmarked for mental health, and these taxes generate over $3.57 billion annually. The median per capita annual revenue generated by these taxes was $18.59 (range = $0.04-$197.09). Per capita annual revenue exceeded $25.00 in 63 jurisdictions (about five times annual per capita spending for mental health provided by the US Substance Abuse and Mental Health Services Administration).

CONCLUSIONS

Policies earmarking taxes for mental health services are diverse in design and are an increasingly common local financing strategy. The revenue generated by these taxes is substantial in many jurisdictions.

A narrative review of alcohol control policies in Latvia between 1990 and 2020

ISSUES

Latvia has one of the highest alcohol per capita consumption in Europe. This study provides a narrative review of all evidence-based population-level alcohol control policies implemented in Latvia during the past 30 years.

APPROACH

A review of country-level alcohol control policies implemented in Latvia between 1990 and 2020 was conducted. The World Health Organization's "best buys" and other recommended interventions for alcohol control were used to guide the search.

KEY FINDINGS

Alcohol control policies in Latvia have evolved significantly over the last three decades. The most changes to alcohol control policy occurred in the transitional period between regaining independence in 1991 and joining the European Union in 2004. A number of significant alcohol control policies have been implemented to reduce alcohol availability and affordability, to restrict alcohol marketing and to counter drunk-driving. However, since 2010, when an increasing trend of alcohol consumption was observed, there has been a reluctance to pursue national public health policy actions to reduce alcohol consumption, and few adjustments to legislation to increase alcohol control have been made.

IMPLICATIONS

Despite the progress in alcohol control, Latvia still has considerable potential for strengthening alcohol control to reduce the high levels of alcohol consumption.

CONCLUSION

Although several alcohol control policies have been established in Latvia, many of the planned activities to limit alcohol intake and related harm have not been executed. Public health goals rather than political and economic incentives should be prioritised to reduce high levels of alcohol consumption in Latvia.

Healthy People Countdown 2030: reaching 5% cigarette smoking prevalence among US adults through state cigarette excise tax increases

OBJECTIVE

The Healthy People 2030 goal is to reduce US current adult cigarette smoking prevalence to 5% by 2030. The objective of this report is to investigate if this goal is achievable using state cigarette excise tax increases.

METHODS

State-specific linear trends in smoking prevalence over 2011-2019 were determined using fractional logit regression and compared with the desired linear trends for achieving 5% smoking prevalence by 2030 in individual states and the District of Columbia (DC). The gaps between price-adjusted and desired trends were used in a simulation model for identifying state-specific systematic annual increases in state cigarette excise tax rates based on state-specific price elasticity of smoking prevalence, maintaining the status quo in other non-tax tobacco control measures.

RESULTS

The price-adjusted trends in smoking prevalence observed over 2011-2019 exceed the desired trends for achieving 5% smoking prevalence target by 2030 in only five states (eg, Washington, Utah, Rhode Island, Massachusetts and Maryland) and the DC. It suggests that majority of states and USA overall will miss the target smoking prevalence at the current rate of reduction in smoking. 45 states would need systematic annual increases in cigarette excise tax rate in a range of $0.02-$1.37 per pack over 2022-2030 to meet the target.

CONCLUSIONS

The feasibility of reaching the Healthy People 2030 goal would critically depend on the acceleration of progress in tobacco control. Tax increases tailored to the needs of individual states combined with scaled-up non-tax tobacco control policy interventions can help achieve the desired progress.

US Policies That Define Foods for Junk Food Taxes, 1991-2021

Policy Points Suboptimal diet is a leading cause of mortality and morbidity in the United States. Excise taxes on junk food are not widely utilized in the United States. The development of a workable definition of the food to be taxed is a substantial barrier to implementation. Three decades of legislative and regulatory definitions of food for taxes and related purposes provide insight into methods to characterize food to advance new policies. Defining policies through Product Categories combined with Nutrients or Processing may be a method to identify foods for health-related goals.

CONTEXT

Suboptimal diet is a substantial contributor to weight gain, cardiometabolic diseases, and certain cancers. Junk food taxes can raise the price of the taxed product to reduce consumption and the revenue can be used to invest in low-resource communities. Taxes on junk food are administratively and legally feasible but no definition of "junk food" has been established.

METHODS

To identify legislative and regulatory definitions characterizing food for tax and other related purposes, this research used Lexis+ and the NOURISHING policy database to identify federal, state, territorial, and Washington DC statutes, regulations, and bills (collectively denoted as "policies") defining and characterizing food for tax and related policies, 1991-2021.

FINDINGS

This research identified and evaluated 47 unique laws and bills that defined food through one or more of the following criteria: Product Category (20 definitions), Processing (4 definitions), Product intertwined with Processing (19 definitions), Place (12 definitions), Nutrients (9 definitions), and Serving Size (7 definitions). Of the 47 policies, 26 used more than one criterion to define food categories, especially those with nutrition-related goals. Policy goals included taxing foods (snack, healthy, unhealthy, or processed foods), exempting foods from taxation (snack, healthy, unhealthy, or unprocessed foods), exempting homemade or farm-made foods from state and local retail regulations, and supporting federal nutrition assistance objectives. Policies based on Product Categories alone differentiated between necessity/staple foods on the one hand and nonnecessity/nonstaple foods on the other.

CONCLUSIONS

In order to specifically identify unhealthy food, policies commonly included a combination of Product Category, Processing, and/or Nutrient criteria. Explanations for repealed state sales tax laws on snack foods identified retailers' difficulty pinpointing which specific foods were subject to the tax as a barrier to implementation. An excise tax assessed on manufacturers or distributors of junk food is a method to overcome this barrier and may be warranted.

Affordability of cigarettes in ten Southeastern European countries between 2008 and 2019

BACKGROUND

The empirical evidence shows that tobacco consumption is strongly associated with its affordability. The nominal growth in tobacco prices imposed by taxation should exceed or at least keep pace with nominal income growth, ensuring that tobacco products become less affordable over time. No analysis covering affordability issues in the Southeastern European (SEE) region has been conducted prior to this research.

OBJECTIVES

The study aims to examine trends in cigarette affordability in ten selected SEE countries over the period 2008-2019 and the impact of affordability on the consumption of cigarettes. On the policy side, it aims to support conducting of more effective evidence-based policy of tobacco taxation.

METHODS

The relative income price of cigarettes and the tobacco affordability index are used as affordability measures. The panel regression was run to estimate the impact of affordability measures and other covariates on cigarette consumption.

RESULTS

The affordability of cigarettes in the selected SEE countries has decreased on average but showed different patterns over the observed period. A decline in affordability has been more dynamic in Western Balkan (non-EU members) countries and low-and-middle-income countries within the SEE region. Econometric estimation confirms affordability as the main determinant of tobacco consumption, indicating that a decline in affordability considerably reduces tobacco consumption.

CONCLUSIONS

Despite the evidence, affordability is still widely ignored by SEE policymakers when designing national tobacco taxation policies. Policymakers should be aware of the risk that future increases in cigarette prices could lag behind real income growth, making tax policy less effective at reducing consumption. Reducing affordability should be the paramount consideration in designing effective tobacco taxation policies.

Extent of illicit cigarette sales in Nepal: findings from a retail survey

INTRODUCTION

Increasing the tax on cigarettes is widely considered the most effective method to reduce its consumption. However, Nepal has a low cigarette tax as policymakers in Nepal are concerned about illicit trade of cigarettes if taxes are increased.

METHODS

The study employed a retail survey approach used in India suitable for countries with prevalent loose cigarette sales, with improved methodology. In 2021, empty cigarette packs generated in a day's loose cigarette sales were collected directly from cigarette retailers from 23 primary sampling units covering rural/urban, geographic divisions, border/non-border to India and tobacco factory locations. The central points of each primary sampling unit were identified, and retailers were selected for the survey. A cigarette pack was classified as illicit if it had at least one of the following attributes: (a) no authentic excise duty sticker, (b) no graphic health warning, (c) no mention of 'maximum retail price/MRP' and (d) no production date, name, address and trademark.

FINDINGS

We collected 4307 empty cigarette packs from 1204 retailers and 0.33% of them were classified as illicit. The estimates varied across location with the highest prevalence of illicit packs in Kathmandu (1.25%). All the illicit cigarettes were imported and were high-priced brands (>90%), mostly found in urban areas and not bordering India.

CONCLUSION

Our estimate of the illicit cigarette market share of 0.33% suggests that the industry's statement of 25% is grossly overstated.

Evaluating the Impact of Alcohol Policy on Suicide Mortality: A Sex-Specific Time-Series Analysis for Lithuania

OBJECTIVE

It is reasonable to believe that the alcohol policy environment can impact the suicide mortality rates in a given country, considering the well-known link between alcohol use and death by suicide. The current literature, albeit limited, suggests that an increase in alcohol taxation may result in a decrease in deaths by suicide and that the effect is sex-specific. Therefore, the objective of the current study was to test the impact of three alcohol control policy enactments (in 2008, 2017 and 2018) on suicide mortality among adults 25-74 years of age in Lithuania, by sex.

METHODS

To estimate the unique impact of three alcohol control policies, we conducted interrupted time-series analyses by employing a generalized additive mixed model on monthly sex-specific age-standardized suicide mortality rates from January 2001 to December 2018.

RESULTS

Analyses showed a significant impact of the 2017 (p = 0.016) alcohol control policy on suicide mortality for men only. Specifically, we estimated that in the year following the 2017 policy enactment, approximately 57 (95% CI: 9-107) deaths by suicide were prevented among men, 25-74 years of age. The three policy enactments tested were not found to significantly impact the suicide mortality rate among women.

CONCLUSION

Alcohol control policies involving pricing, which result in a notable decrease in alcohol affordability, could be a cost-effective indirect suicide prevention mechanism in not only countries of the former Soviet Union, but in other high-income countries with a comparable health care system to that in Lithuania. HIGHLIGHTSIncreasing excise tax on alcohol was found to have a sex-specific impact on suicide mortalityThe 2017 alcohol policy prevented 57 deaths by suicide among men, 25-74 years of age, in the following yearAlcohol pricing policies may be a cost-effective indirect suicide prevention mechanism.

Crowding-out effect of tobacco consumption in Serbia

BACKGROUND

Although smoking prevalence and intensity in Serbia have decreased in recent years, expenditures on tobacco products still represent a significant portion of household budgets. As households have limited resources at their disposal, consuming tobacco means that they spend less on other items such as food, clothing, education and healthcare. This is particularly true for low-income households, for whom the pressure on the household budget is even higher.

OBJECTIVES

In this research we estimate the effect of tobacco consumption on other consumption items in Serbia, which is the first estimation of this type for the countries in Eastern Europe.

METHODS

We use microdata from the Household Budget Survey and estimation approach that includes the combination of seemingly unrelated regression and instrumental variables. Besides estimating the overall effect we analyse the differences in effects between low-income, medium-income and high-income households.

RESULTS

Expenditures on tobacco reduce consumption on food, clothing and education and increase the budget shares spent on complementary consumption items such as alcohol, hotels, bars and restaurants. In most cases, the effects are more pronounced for low-income households than for other groups. These results suggest that aside from the negative effects of tobacco consumption on health, it also distorts household consumption structure, while affecting intrahousehold allocation and future health and development of other household members.

CONCLUSIONS

The results from this research underline the negative effect that tobacco expenditures have on consumption of other products. The only way for households to decrease expenditures on tobacco is to stop smoking, as the consumption of those who continue smoking changes less than cigarettes prices. To ensure that households stop smoking and instead direct their expenditures towards more productive purposes, the Serbian government should adopt new policies and strengthen enforcement of existing tobacco control measures.

Monitoring and Combating Waterpipe Tobacco Smoking Through Surveillance and Taxation

Waterpipe tobacco smoking (WTS) is a traditional tobacco use method that originated in the Eastern Mediterranean Region (EMR) and has resurged in recent decades. WTS rates in the EMR are the highest worldwide, especially among youth, exceeding cigarette-smoking rates in select jurisdictions. Despite its documented harm, the growing prevalence of WTS has been met with a poor regulatory response globally. At the epicenter of the WTS epidemic, countries in the EMR are in urgent need of effective tobacco control strategies that consider the particularities of WTS. A roundtable session, titled "Monitoring and Combating WTS Through Taxation and the Global Tobacco Surveillance System (GTSS)," was held as part of the 7th Eastern Mediterranean Public Health Network's regional conference. The session provided an overview of evidence to date about WTS policy control, the taxation of WTS, volumetric choice experiments for tobacco control research, and monitoring WTS patterns and control policies among adults and youth through the GTSS. The session highlighted the need to update the regulation of WTS in the current global tobacco control policy frameworks and the need for developing tailored, evidence-based, and WTS-specific regulations to complement current tobacco control policy frameworks. Raising taxes to increase the price of tobacco products is the single most effective tobacco control measure, and these taxes can fund expanded government health programs. The effectiveness of taxation can be measured via volumetric choice experiments, which allow for the estimation of a complete set of own-price and cross-price elasticities that are instrumental for fiscal policy simulations. Finally, the surveillance of WTS (for example, through the GTSS) is critical to informing policy and decision makers. The Global Youth Tobacco Survey (GYTS) and Global Adult Tobacco Survey (GATS) are 2 GTSS products that provide nationally representative data among students aged 13-15 years and persons ≥15 years, respectively.

Which alcohol products might be affected by the introduction of a minimum unit price in Western Australia? Findings from a survey of alcohol retail prices

INTRODUCTION

Minimum unit price (MUP) policies establish a retail floor price below which alcohol may not be sold, and have been shown to reduce harmful alcohol use. We aimed to collect retail price data to estimate the proportion of alcohol products that would potentially be impacted by a MUP policy in Western Australia.

METHODS

We purposively sampled the four largest off-premises alcohol retail chains, a further random sample of other off-premise alcohol outlets (n = 16) and on-premise inner-city outlets (n = 11). Using website data from May to June 2021, we estimated the proportion of products across four beverage categories priced ≤A$1.30, ≤A$1.50 and ≤A$1.75 per standard drink (10 g alcohol).

RESULTS

Of 27,797 off-premise products identified, 5.7% were available at ≤$1.30 per standard drink, 7.6% at ≤$1.50 and 10.4% at ≤$1.75. The proportion of products available at ≤$1.30 per standard drink varied by beverage category: 7.8% wine, 2.9% beer and cider, <0.1% spirits, 0.0% ready-to-drink spirits. Cask-packaged wines represented only 1.9% of off-premise wine products and 98.9% of this cask wine was priced ≤$1.30 per standard drink. No on-premise products were priced ≤$1.75 per standard drink.

DISCUSSION AND CONCLUSIONS

A comprehensive survey of alcohol prices in Western Australia found only a small proportion of products would potentially be affected by a MUP of $1.30 to $1.75 per standard drink. A MUP policy has potential to target the small proportion of alcohol products available at very low prices (i.e., off-premise cask wine), with negligible impact on other off-premise beverage categories, and no impact on on-premises products.

Assessing the impact of Hungary's public health product tax: an interrupted time series analysis

OBJECTIVES

Imposing taxes on unhealthy goods can generate income, raise people's health awareness, and eventually decrease the prevalence of chronic diseases. Our aim was to assess the impact of Hungary's public health product tax (PHPT) since its implementation in September 2011. Differences in purchasing habits between households with different income statuses were also compared.

METHODS

A retrospective, descriptive analysis of tax bases and income was carried out, and an interrupted time series analysis using the generalised least squares method was performed to examine the changes in trends regarding the purchase of taxable products before and after the implementation of the tax. The amount of tax base (in kilograms or litres), income (in HUF and EUR), and annual purchased quantity of food and beverage groups per household were assessed. Data were derived from the National Tax and Customs Administration of Hungary and the Hungarian Household Budget and Living Conditions Surveys. The study sample was composed of households who participated in the surveys (mean = 8,359, SD = 1,146) between 2006 and 2018.

RESULTS

The households' tax bases and incomes increased constantly (with a few exceptions). The total revenue was 19.49 billion HUF (67.37 million EUR) in 2012 and 59.19 billion HUF (168.55 million EUR) in 2020. However, the households' purchasing habits did not change as expected. A significant short-term decrease (between 2012 and 2013) in purchasing unhealthy goods was observed for three groups: soft drinks (p = 0.009), jams (p = 0.047), and fruit juices (p = 0.038). Only soft drinks showed a significant decreasing trend in the post-intervention period between 2012 and 2018 (p < 0.001).

CONCLUSIONS

We concluded that the PHPT did not decrease households' unhealthy food purchasing trend, although it has a positive effect as it can create revenue for health care and health-promoting programmes.

Classifying alcohol control policies enacted between 2000 and 2020 in Poland and the Baltic countries to model potential impact

AIMS

The study's aim is to identify and classify the most important alcohol control policies in the Baltic countries (Estonia, Latvia and Lithuania) and Poland between 2000 and 2020.

METHODS

Policy analysis of Baltic countries and Poland, predicting potential policy impact on alcohol consumption, all-cause mortality and alcohol-attributable hospitalizations was discussed.

RESULTS

All Baltic countries implemented stringent availability restrictions on off-premises trading hours and different degrees of taxation increases to reduce the affordability of alcoholic beverages, as well as various degrees of bans on alcohol marketing. In contrast, Poland implemented few excise taxation increases or availability restrictions and, in fact, reduced stipulations on prior marketing bans.

CONCLUSIONS

This classification of alcohol control policies in the Baltic countries and Poland provides a basis for future modeling of the impact of implementing effective alcohol control policies (Baltic countries), as well as the effects of loosening such policies (Poland).

Tobacco industry pricing strategies in response to excise tax policies: a systematic review

OBJECTIVE

To explore what is known about the tobacco industry's (TI) price-based responses to tobacco excise tax policies and whether these vary by country income group using a systematic review.

DATA SOURCES

Studies assessing TI pricing tactics were identified via searches of five online databases using a combination of search keywords.

STUDY SELECTION

Inclusion criteria were applied by two reviewers independently who screened all search results (titles and abstracts) for possible inclusion. They identified 37 publications that reported TI pricing tactics.

DATA EXTRACTION

Study details were tabulated, and information was extracted on the country income group, population characteristics, excise tax structure, and pricing strategies.

DATA SYNTHESIS

Of the 37 publications identified, 22 were conducted in high-income countries, while 15 covered low-income and middle-income countries (LMICs). Major pricing strategies employed were: differentially shifting taxes between products (35 studies); launching new brands/products as pathways for downtrading (six studies), product promotions and different prices for the same products for different customers (six studies); price smoothing (two studies); and changing product attributes such as length/size of cigarettes or production processes (three studies).

CONCLUSIONS

While there is limited evidence to fully ascertain industry responses to tax increases, this review suggests that the TI widely uses a multitude of sophisticated pricing strategies across different settings around the world with the intention of undermining tax policies, thereby increasing tobacco consumption and maximising their profits. There is a need for further research in this area especially in LMICs so that effective policy responses can be developed.

Reduction of Alcoholic Strength: Does It Matter for Public Health?

In this work, reduction of alcoholic strength was discussed as a means to reduce consumption and alcohol-attributable harm. Statistical modelling was conducted to (1) estimate its potential for the largest six Western and Central European countries (France, Germany, Italy, Poland, Spain, UK); (2) calculate the increase in taxation necessary to reach this potential, and (3) estimate the mortality gains achieved with the introduction of no- or low-alcohol beverages in the UK and Spain. The high public health potential of reducing alcoholic strength was demonstrated via modelling a scenario in which the strength of all beverages was reduced by 10%, which would avert thousands of deaths in these six European countries per year. However, methods by which to achieve these gains were not clear, as the alcohol industry has shown no inclination toward reductions in the alcoholic strength of beer, wine, or spirits via a reformulation on a large scale. The increase of excise taxation to achieve the public health gains of such a reduction would result in markedly increasing prices-a situation unlikely to be implemented in Europe. Finally, the introduction of beer and wine with an alcoholic strength below 0.5% led to some substitutions of higher-strength beverages, but did not show a marked public health impact. New taxation initiatives to achieve the potential of a reduction of alcoholic strength will need to be implemented.

Making smoking history: temporal changes in support for a future smoking ban and increasing taxes in the general population of Denmark

BACKGROUND

An end date for smoking has been adopted in several countries and is now being discussed by governments all over the world. However, little is known about temporal changes in citizens' support for a future smoking ban.

AIM

To examine temporal changes in support for a future smoking ban and for increasing taxes on tobacco in Denmark, and to explore whether these changes differ across sex, age, educational attainment, smoking status and between smokers with/without intention to quit.

METHOD

The study was based on two waves of 'The Danish Capital Region Health Survey' conducted in 2013 and 2017. The pooled study sample included 96 521 citizens aged ≥16 years old.

RESULTS

Public support for a future smoking ban increased from 30.6% in 2013 to 50.3% in 2017, whereas support for increasing tobacco taxes remained unchanged at 59%. Support for a future smoking ban increased significantly in almost all subgroups from 2013 to 2017: Support among daily smokers increased by 27% between 2013 and 2017. Support among never smokers was almost 2.63 times higher than among smokers in 2013 and increased further in 2017 (OR: 2013=2.63; 2017=5.13).

CONCLUSION

This study indicates a readiness to support a future smoking ban and increasing tobacco taxes. Support for a future smoking ban has increased from 2013 to 2017 among both young people and adults. By 2017, about half of the population supported a future smoking ban and increasing tobacco taxes. Findings may help inform policy-making related to endgame strategies.

Promoting convergence and closing gaps: a blueprint for the revision of the European Union Tobacco Tax Directive

BACKGROUND AND AIMS

Despite the European Union (EU) Tobacco Tax Directive (TTD), a lack of convergence in EU tobacco prices promotes high levels of cross-border shopping and down-trading from factory-made (FM) to roll-your-own tobacco (RYO) cigarettes. This study presents a blueprint for reform, whereby minimum taxes are related to the overall price level in the EU and where taxation of RYO is related to that of FM.

METHODS

Longitudinal data on prices and taxes on FM and RYO in 25 member states over 2011-2019 are used to estimate econometric models for their weighted average prices as a function of taxes. Two scenarios are simulated with the models' estimates: a baseline scenario for the actual tax stance pertaining to 2020 and a reform scenario implementing the blueprint.

RESULTS

The baseline results show that, while the prices of both products have experienced a slight increase since 2016 in real terms, the dispersion in the prices of FM across countries has increased and the difference in the prices of RYO within countries has widened. The results for the reform scenario show dispersion would diminish both EU-wide and in hotspots for cross-border sales of FM. The reform would also lead to a substantial reduction in the price gap between FM and RYO.

CONCLUSION

To promote price convergence and close the price gap between FM and RYO, the revised TTD should ensure minimum FM taxes track a measure of their average EU price, and RYO taxes are related to FM taxes.

Analysis of the illicit tobacco market in Georgia in response to fiscal and non-fiscal tobacco control measures

BACKGROUND

Georgian illicit cigarette consumption was 1.5% in 2017. In 2018, a new tobacco control law took effect followed by a substantial cigarette excise tax increase in 2019. Research shows these policies reduce tobacco consumption, but the tobacco industry argues they increase illicit trade. There is limited evidence on this, particularly from developing countries.

METHODS

A panel household survey in Georgia obtained data over three waves: 2017 baseline, 2018 after the tobacco control law took effect and 2019 after taxes increased. A sample of 1578 smokers (and quitters in later waves) from five regions reported their tobacco use and were asked to present a cigarette pack in their possession. These were examined for tax stamps and health warnings to establish legality.

FINDINGS

There was no evidence of an increase in illicit cigarette consumption in Tbilisi, Kutaisi, Akhaltsikhe or Gori in any wave. In Zugdidi, near the Russian-occupied Abkhazia, illicit cigarette consumption was increasing even prior to the tax increase, reaching 30.9% by wave 3. A country-wide shift occurred from manufactured cigarettes to roll-your-own tobacco (whose tax remained unchanged) between waves 2 and 3.

CONCLUSION

No evidence of a country-wide increase in illicit cigarette trade was found after non-fiscal tobacco measures took effect and cigarette taxes increased. Relatively high illicit cigarette consumption in Zugdidi highlights the role of disputed territories and border administration in illicit cigarette supply. Substitution towards roll-your-own tobacco after manufactured cigarette taxes increased demonstrates the importance of equalising taxes on tobacco products to maximise public health benefits.

Do sugar-sweetened beverage taxes improve public health for high school aged adolescents?

Sugar-sweetened beverage taxes have become an increasingly popular policy to combat the worldwide obesity epidemic, but relatively little is known about their impact on health outcomes, particularly among high school aged students. In this paper, I use public-use data from the Youth Risk Behavioral Surveillance System to determine whether high school students living in three of the American cities which have implemented Sugar-sweetened beverage taxes have experienced public health improvements. Using an event-study design that compares outcomes in treated districts to a group of similar control districts, I find reductions in soda consumption in Philadelphia and average body mass index in Philadelphia, San Francisco and Oakland, with suggestive evidence that the improvements are concentrated among female and non-white respondents in both cases.

Own-price and cross-price elasticities of demand for cigarettes and waterpipe tobacco in three Eastern Mediterranean countries: a volumetric choice experiment

BACKGROUND

Waterpipe tobacco smoking rates in the Eastern Mediterranean region are among the highest worldwide, yet little evidence exists on its economics. Estimates of demand elasticities for tobacco products are largely limited to cigarettes. This study aimed to estimate own-price and cross-price elasticities of demand for cigarettes and waterpipe tobacco products in Lebanon, Jordan and Palestine.

METHODS

A volumetric choice experiment was conducted using nationally representative household surveys. The choice experiment elicited respondents' stated purchases of eight cigarette and waterpipe tobacco product varieties by hypothetically varying prices. Data were analysed using zero-inflated Poisson models that yielded demand elasticity estimates of cigarette and waterpipe tobacco consumption.

RESULTS

The study included 1680 participants in Lebanon (50% female), 1925 in Jordan (44.6% female) and 1679 in Palestine (50% female). We found the demand for premium cigarettes to be price elastic (range, -1.0 to -1.2) across all three countries, whereas the demand for discount cigarettes was less elastic than premium cigarettes in Lebanon (-0.6) and Jordan (-0.7) and more elastic in Palestine (-1.2). The demand for premium waterpipe tobacco was highly elastic in Lebanon (-1.9), moderately elastic in Jordan (-0.6) and inelastic in Palestine (0.2). The cross-price elasticity between cigarettes and waterpipe tobacco was near zero, suggesting that the two products are not considered to be close substitutes by consumers.

CONCLUSIONS

These results serve as a strong evidence base for developing and implementing fiscal policies for tobacco control in the Eastern Mediterranean region that address cigarettes and waterpipe tobacco products.

Awareness, perceptions of and compliance with tobacco control policies among naswar vendors in Khyber Pakhtunkhwa Pakistan

INTRODUCTION

Regulatory compliance in the retail environment is integral to the success of tobacco control. We assessed compliance among naswar (smokeless tobacco product widely used in South Asia) vendors with tobacco control laws. We also assessed their awareness of tobacco-related harms and policies and perceived effect of policies on their sales.

METHODS

We surveyed 286 naswar vendors in three districts of the Khyber Pakhtunkhwa province of Pakistan. We recruited general and specialty vendors from urban and rural areas through multistage cluster sampling. Compliance was measured for promotion, sale to/by minors and tax paid on naswar. We used logistic regression analyses for assessing the association between the outcome variables (awareness of tobacco harms and laws, perceptions about the effect of policies on business and compliance with laws) and their predictors.

RESULTS

Most vendors (70%) were aware of tobacco-related harms of naswar. Although educated vendors were more aware of tobacco control policies, the greatest awareness was for a ban on sales to/by minors (21% overall). The majority of vendors (76%) violated this policy (measured by self-report), and violations were more common among rural than urban vendors (OR 2.27, 95% CI 1.05 to 4.96). Most vendors (71%) violated a ban on promotion of naswar. Vendors perceived tax increases and sales ban to/by minors as most detrimental for business.

CONCLUSIONS

There was poor awareness and compliance among naswar vendors in Pakistan with tobacco control laws. This study finds potential areas for policy interventions that can reduce urban/rural disparities in implementation of and compliance with tobacco control laws.

Analysing the trend of illicit tobacco in the Philippines from 1998 to 2018

Tobacco taxation is the most effective measure to reduce cigarette consumption and consequently improve public health outcomes. It is also an important source of government revenue. The presence of an illicit tobacco market diminishes the public health and fiscal gains of cigarette levies by making cheaper non-taxed cigarettes available. To date, the research on the extent of illicit tobacco trade in the Philippines, despite its potential to inform policies for controlling the supply of illicit cigarettes, has been limited. This study provides an estimate of the size of the illicit tobacco market in the Philippines from 1998 to 2018. It employs gap analysis comparing an estimate of the survey-based adult cigarette consumption with legally sold cigarettes in the Philippines. The illicit trade estimates are contrasted with the evolution of tax changes. The results show that the illicit cigarette market share dropped by 42% from 2003 to 2008 and by an additional 79% from 2008 to 2013. In spite of the large tax increases by the Philippine government through the Sin Tax Law starting from 2013 until 2018, the illicit share in 2018 remains similar to its 1998 level of 16% of the total market. Hence, our study finds no evidence of a positive relationship between tobacco taxes and size of illicit cigarette market in the Philippines.

Demand for tobacco products in Bangladesh

BACKGROUND

Tobacco tax increase is considered as one of the most effective means to reduce tobacco consumption and its consequences. An increase in taxes, which results in an increase in the price of tobacco products, reduces consumption. Historically, a number of studies estimated the responsiveness of quantity demanded to a change in price-the price elasticity of demand-of tobacco products in Bangladesh. However, the government's stronger commitment to reducing tobacco use, rising standard of living, rapidly changing cultural norms due to globalisation, and the substantial fall in tobacco use seen in GATS 2017 necessitate an updated measure of price elasticity of tobacco use, which will allow for more accurate answers to questions of tobacco tax policy in the country. This study endeavours to fill this gap in the literature on demand for tobacco products in Bangladesh.

OBJECTIVE

To estimate the price elasticity of demand for tobacco products, namely cigarettes, biris and smokeless tobacco (SLT) products with the 2016 household income and expenditure survey data in Bangladesh.

METHODS

We used the Deaton model (1997) to estimate the price elasticities of demand for tobacco products using the Household Income and Expenditure Survey (HIES) 2016 dataset of the Bangladesh Bureau of Statistics. The HIES 2016 surveyed 46 076 households spread over 2304 primary sampling units across the country. We have calculated own price elasticities of demand for tobacco products by expenditure groups and by regions (rural and urban).

RESULTS

The estimates of own-price elasticity of demand for cigarette, biri and SLT products are -1.03, -1.34 and -0.30, respectively. The results show that rural households are more responsive to changes in the prices of cigarettes than urban households. Households with low expenditure are found to be more responsive to changes in the price of cigarettes than the households with high expenditure. This suggests that increases in cigarette prices at the lower end would effectively reduce cigarette consumption among the people having low expenditure and improve health equity.

CONCLUSIONS

Our results suggest that the demand for smoking tobacco products is responsive to price changes. Therefore, substantial increase in the prices of tobacco products through taxation will result in significant reduction in tobacco use, particularly among the low expenditure households, while increasing government revenue.

E-cigarette-inclusive smoke-free policies, excise taxes, tobacco 21 and changes in youth e-cigarette use: 2017-2019

BACKGROUND

We examined whether the implementation of electronic cigarette (e-cigarette) policies at the state level (e-cigarette-inclusive smoke-free (ESF) policies, excise taxes on e-cigarettes and raising tobacco legal purchasing age to 21 years (T21)) affected recent upward trends in youth e-cigarette use.

METHODS

Data were from participants from 34 US states who completed the Youth Risk Behavior Survey (YRBS) state surveys in 2017 and 2019 (n=278 271). States were classified as having or not having ESF policies, any e-cigarette excise tax and T21 policies by 1 January 2019. Participants reported ever, past 30-day and frequent (≥20 days) e-cigarette use; past 30-day combustible cigarette smoking; and age, sex and race/ethnicity. Weighted multivariable logistic regression models assessed whether changes in e-cigarette use over time differed by policy status, adjusting for participants' demographics and combustible cigarette smoking.

RESULTS

Prevalence of ever and past 30-day youth e-cigarette use in states with ESF policies decreased during 2017-2019, while the prevalence of these measures in states without ESF policies increased. States with T21 policies showed non-significant changes in prevalence of ever and past 30-day youth e-cigarette use, whereas states without T21 policies showed significant increases in ever and past 30-day youth e-cigarette use. States with ESF and T21 policies showed slower increases in youth frequent e-cigarette use. E-cigarette excise taxes were not associated with decreasing prevalence of youth e-cigarette use.

CONCLUSIONS

State-level ESF and T21 policies could be effective for limiting growth of youth e-cigarette use despite an overall national increase. Higher e-cigarette excise tax rates may be needed to effectively reduce youth e-cigarette use.

Effects of the Brazilian tax reform plans on the tobacco market

BACKGROUND

There has been an intense debate in the Brazilian National Congress on how to reform the country's tax system on consumption. This paper investigates the effects of the tax reform under the Constitutional Amendment Bill 45/2019 on cigarette prices, consumption and tax collection. The reform will introduce a new goods and services tax (GST) and tobacco excise tax (TET).

METHODS

The micro data from the National Household Sample Survey (PNAD) of 2008 and the National Health Survey (PNS) of 2013 are inputs in the simulation in order to determine the smoking behaviour and consumer responses to price changes as accurately as possible across the different Brazilian states. We developed three scenarios for the tobacco tax reform and their effects on cigarette prices, smoking behaviour and tax collection. We also estimate the size of the illicit cigarette market by Brazilian state and simulate the impacts of a 10% reduction in its market share.

FINDINGS

Overall, we found that a GST of 27% and a TET of either 51%, 56% or specific 3.89 BRL per pack would lead to considerably higher cigarette prices, lower cigarette consumption and, above all, an increase of cigarette tax collection between 8% and 27% depending on the state. A discretionary 10% reduction in the illicit market would add about 8.5% of extra tax collection per year to the country.

CONCLUSIONS

The simulated scenarios demonstrated that, to keep the cigarette prices at least at the same level as those in the current tax scheme, TET should be no less than 77.85% of the retail price. This means that any politically feasible tax reform should result in higher cigarette prices and a reduction in cigarette consumption. Considering the nationwide effect, in all scenarios, the total increase in tobacco tax revenue is around 8.5% or 1.5 billion BRL per year. This extra revenue is highly desirable in an environment of chronic fiscal imbalance and the COVID-19 pandemic crisis.

Evidence of cushioning of tobacco tax increases in large retailers in Australia

BACKGROUND

Tobacco companies may attempt to minimise the impact of tobacco tax increases on consumers by gradually passing on the price rise over several months. This study examined whether there was evidence of large Australian tobacco retailers engaging in this practice (known as cushioning) over a period including both routine indexation and large annual tobacco excise increases.

METHODS

Advertised prices of nine factory-made cigarette (FMC) and nine roll-your-own tobacco (RYO) products were recorded from two stores monthly from December 2016 to December 2019. Per cent change in price from the previous month was analysed for FMC and RYO products, controlling for year, month, tobacco company and supermarket chain.

RESULTS

Significant main effects of month were observed for FMC and RYO products (both p<0.001). Large, significant average increases in per cent change in price were observed in September for FMC (6.51%) and RYO (11.45%) products, the month of the annual excise increase and prices also significantly increased in October (FMC: 3.01%; RYO: 1.91%). Significant increases were also observed in the months after the March annual routine indexation: by 1.10% in May for FMC products and by 1.09% in April for RYO products.

CONCLUSION

This study has demonstrated evidence of cushioning of tax increases of FMC and RYO products in large Australian supermarkets. The monthly per cent change in price significantly increased several months after routine excise indexation and in the 2 months following a large annual excise increase. Further research with a larger sample of products and stores is needed to confirm these findings.

Illicit cigarette trade in the cities of Pakistan: comparing findings between the consumer and waste recycle store surveys

BACKGROUND

Concerns about the magnitude of illicit cigarette trade have prevented the Government of Pakistan from increasing tobacco taxes. We estimated the proportion of illicit cigarettes sold in Pakistani cities. Moreover, we compared two methods for collecting cigarette packs and investigated if the illicit cigarette trade equates to tax evasion.

METHOD

We analysed cigarette packs collected from 10 cities of Pakistan using two methods: consumer survey based on a two-stage random sampling strategy to recruit adult smokers and photograph their cigarette packs and waste recycle store survey to purchase used cigarette packs. Cigarettes were considered illicit if any one of the following was absent from their packs: text and pictorial health warning, underage sale prohibition warning, retail price and manufacturer's name. From the consumer survey, we also estimated the proportion of smokers who purchased loose cigarettes (illegal) and packs below the minimum retail price. Taxation officers (n=4) were consulted to assess their level of confidence in judging tax evasion using the above criteria.

RESULTS

Out of 2416 cigarette packs in the consumer survey, 454 (17.8%; 95% CI 15.4% to 20.2%) were illicit. Similarly, out of 6213 packs from waste recycle shops, 1046 (16.8%; 95% CI 15.9% to 17.7%) were illicit; the difference was not statistically significant (p=0.473). Among consumers, 29.5% bought loose cigarettes and 13.8% paid less than the minimum retail price. The taxation officers considered the manufacturer's name and retail price on cigarette packs as the most relevant criteria to detect tax evasion.

CONCLUSIONS

One in six cigarette packs consumed in Pakistan could be illicit. These figures are far less than those propagated by the tobacco industry. Collecting packs from waste recycle stores is an efficient and valid method to estimate illicit cigarette trade.