Romblon State University
College of Business and Accountancy
Graduate Education and Professional Studies
Position Paper on Seminar on Current Economic Problems
Tobacco taxation is an essential component of a comprehensive tobacco control
strategy. However, to fully realize the benefits it is vital to understand the impact of
increased taxes among high-risk subpopulations. Are they influenced to the same
extent as the general population? Do they need additional measures to influence
smoking behavior? The objectives of this study were to synthesize the evidence
regarding differential effects of taxation and price on smoking in: youth, young adults,
persons of low socio-economic status, with dual diagnoses, heavy/long-term smokers,
and Aboriginal people. Using a better practices approach, a knowledge synthesis was
conducted using a systematic review of the literature and an expert advisory panel.
Experts were involved in developing the study plan, discussing findings, developing
policy recommendations, and identifying priorities for future research. Most studies
found that raising cigarette prices through increased taxes is a highly effective measure
for reducing smoking among youth, young adults, and persons of low socioeconomic
status. However, there is a striking lack of evidence about the impact of increasing
cigarette prices on smoking behavior in heavy/long-term smokers, persons with a dual
diagnosis and Aboriginals. Given their high prevalence of smoking, urgent attention is
needed to develop effective policies for the six subpopulations reviewed. These findings
will be of value to policy-makers and researchers in their efforts to improve the
effectiveness of tobacco control measures, especially with subpopulations at most risk.
Although specific studies are needed, tobacco taxation is a key policy measure for
driving success.
INTRODUCTION
Significant gains have been made in reducing the prevalence of smoking for the general
population in North America and other high-income countries. However, smoking rates
remain high for some subpopulations. Responses to tobacco control interventions and
pathways to change in smoking behavior can vary substantially among subgroups of
smokers. Even for those who benefit from these measures, they do not gain equally and
major disparities exist.
Tobacco taxation, passed on to consumers in the form of higher cigarette prices, has
been recognized as one of the most effective population-based strategies for
decreasing smoking and its adverse health consequences [1–4]. On average, a price
increase of 10% on a pack of cigarettes would reduce demand for cigarettes by about
4% for the general adult population in high income countries [4]. Tobacco taxes can
benefit smokers who quit, reduce the overall consumption of tobacco, and put smoking
cessation on the radar of those who continue to smoke. Increased taxes also have a
positive impact on non-smokers by reducing their exposure to second-hand smoke.
However, much less is known about the impact of taxation on specific subgroups. Are
they influenced to the same extent as the general population? Do they need additional
measures and initiatives to reduce smoking?
Using a better practices approach to knowledge synthesis, this study illustrates the
value of using two complementary approaches (systematic review of literature and
expert opinion) in an area of high importance but with varying degrees of empirical
studies across subpopulations. The Better Practices Model, developed by the Canadian
Tobacco Control Research Initiative [5], provides a structure for integrating variable, but
complementary, sources of information which can lead to enhanced understanding of
chronic diseases. Integral to this approach is the belief that “good solutions to complex
problems draw upon both science and experience.” Broad sources of information (e.g.,
peer-reviewed studies, grey literature, expert opinion) are synthesized to increase
knowledge of a particular topic.
We systematically reviewed and synthesized evidence regarding the effects of tobacco
taxation and pricing (tobacco taxation and pricing hereafter referred to as “price”) on
smoking behavior in six high-risk subpopulations. They were selected based on
continued high rates of smoking (Table 1) and greater risk for the health consequences
of smoking (note: these are not always distinct categories and there may be
considerable overlap with some of these subpopulations. For example, heavy and long-
term smoking is characteristic of smokers with dual diagnoses; low socioeconomic
status is more common among Aboriginals, dual diagnosis individuals, and heavy
smokers).
Smoking
% of Total population prevalence (%)
Subpopulation
Canada US Canada US
General Population 33,212,696 (total 303,824,640 (total 19 20.8
population) population)
Youth 6.8 7.2 15 22
Young Adults 9.2 9.9 25 26
Low SES 11.4 17 ** **
Income *
Education
Dual Diagnosis 5–10 5–10 38–57 41–62
Smoking
% of Total population prevalence (%)
Subpopulation
Canada US Canada US
Heavy and/or Long- ** ** ** **
term Smokers
Aboriginals 3.8 1.5 60 32
1.1. Youth (<19 years)
Youth (<19 years) are a critical focus for tobacco control policy. Because most adult
smokers report smoking onset before the age of 20 years [6–8], if one can reach
adulthood without smoking, then the probability of smoking onset is greatly reduced.
Although youth continue to smoke, O’Loughlin and colleagues [9] found that 70% of
teens express a desire to quit. However, only 19% making a quit attempt remained
smoke-free for 12 months or more by the end of the five-year study. Because cessation
strategies have not been very effective for youth populations, the research suggests
that more needs to be done in terms of legislation, programming and taxation [10].
1.2. Young Adults (18–24 years)
Young Adults (18–24 years) continue to smoke at high rates, despite strong public
awareness of the health hazards [11]. This developmental period is a time of risk for
both initiation of smoking and progression to higher levels [12]. Moreover, smoking
among young adults is predictive of smoking in later adulthood. While smoking rates
have decreased over the past twenty years for both adults and teens, rates for young
adults aged 18 to 24 years have not substantially changed in most high-income
countries.
1.3. Low Socio-Economic Status (SES)
Smoking is strongly linked to social and economic status and is a significant contributor
to inequalities in health. Smoking rates in high income countries are highest among
those who have had the least education and are in the lowest socioeconomic groups
[13,14].
1.4. Dual Diagnosis
Smokers who are diagnosed with mental health and/or non-nicotine substance abuse
disorders are disproportionately affected by tobacco dependence. In North America, five
to 10 percent of the population has a diagnosable mental illness [15]. Yet, they carry
almost half the burden of Canadian and US tobacco consumption, smoking
approximately 40% of all cigarettes consumed [15–18].
1.5. Heavy and/or Long-Term Smokers
Heavy and/or Long-term smokers are at greater risk for the health consequences of
smoking. Both intensity and duration of smoking from onset to cessation have a strong
positive association with morbidity and mortality [19]. There is not a consistent definition
of either “heavy smokers” or “long-term smokers” in the literature. Generally, studies
describe heavy smokers as those who smoke more than 15 cigarettes per day [20],
although some define “heavy” by 25 cigarettes per day [21,22]. A measure of “long-
term” smokers was not found in the literature we reviewed.
1.6. Aboriginal People
Aboriginal people in North America have substantially higher rates of smoking than the
general population (Table 1). These rates have changed very little in the past 25 years.
Availability of inexpensive cigarettes (in North America, access to inexpensive
cigarettes is due to tax-exemption) has been cited as a major contributing factor,
exacerbated by relative poor socioeconomic status, lack of access to quality health
care, poor physical infrastructure and environmental factors [23–26].
The aim of this study was to determine the differential effects of tobacco taxation and
price on six subpopulations compared to the general population, primarily in high
income countries.
Main Effects: Do subpopulations respond differently than the general population to
changes in tobacco taxation and pricing?
Synergistic Effects: What are the interactive effects between taxation and other tobacco
control policies among the subpopulations under review?
Inadvertent Effects: Do subpopulations adopt price minimization strategies (e.g.,
switching to discount brands, smoking more of a cigarette, contraband) in response to
increased cigarette prices?
This article focuses primarily on high-income countries. We present an overview of the
main findings and key recommendations. A detailed description of the methods and
results is presented in the background report [27].
RECOMMENDATION
Subpopulation recommendations.
Subpopulation Recommendations
1. Conduct further studies on the impact of cigarette price on
Youth
smoking initiation
Young Adults
2. Evaluate the distinctions and differential impacts of higher
cigarette prices on subsets of youth—e.g., by gender,
income, school status, age (younger vs. older)
3. Conduct research on the importance of other determinants
of youth and young adult smoking behavior in addition to
cigarette price (e.g., peer and parental influence)
Low SES
1. Combine price increases with a comprehensive tobacco
prevention and control program for maximum effectiveness.
2. Accompany increased prices with other tobacco control
measures, specific to low SES populations, e.g.,
expanding/improving smoking cessation resources and
providing ways to mitigate hardships due to higher taxes,
such as free nicotine replacement therapies.
Dual Diagnosis
1. Determine the effectiveness of increasing the price of
Heavy and/or
cigarettes as a policy tool for reducing smoking among
Long-Term
these subpopulations.
Smokers
Aboriginal
1. Examine the effectiveness of increasing the price of
People
cigarettes as a policy tool for reducing smoking among
Aboriginal people.
Subpopulation Recommendations
2. Conduct research on the following topics: impediments to
using taxation as a tobacco control policy; effective
processes for implementing taxes on tobacco products;
impact of taxation and price of cigarettes on smoking
behavior of those living on-reserve and off-reserve, and in
reducing contraband sales.
