Cigarette Prices and Smoking Experimentation Among Zimbabwean Children: A Survival Analysis of the 2014 Global Youth Tobacco Survey.

INTRODUCTION: Zimbabwe has a smoking prevalence of 11.7% among the adult population (15 years and older). Thus, in the absence of effective tobacco control measures, the economic burden of tobacco use will be aggravated, especially considering the increasing tobacco industry activity in the country. Increasing cigarette prices is one possible strategy to reduce tobacco consumption. This study seeks to examine the relationship between cigarette prices and smoking experimentation among children in Zimbabwe, thereby expanding the evidence base for the likely impact of excise taxes on cigarette demand in low- and middle-income countries. AIMS AND METHODS: A survival analysis using the Zimbabwe 2014 Global Youth Tobacco Survey data. RESULTS: A 10% increase in the price of cigarettes reduces the probability of experimenting with smoking by 9%. Also, children are more likely to experiment with smoking if they have a smoking brother or father who smokes, or see teachers who smoke. The likelihood of experimenting with smoking is higher among boys than girls and is positively associated with age. CONCLUSIONS: There is strong evidence that increasing excise taxes can play an effective role in discouraging children from experimenting with cigarette smoking. Considering the relatively low excise tax burden in Zimbabwe, the government should consider substantially increasing the excise tax burden. IMPLICATIONS: With the number of smokers in low- and middle-income countries expected to increase as the industry intensively expands its market by targeting the youth, increasing excise taxes will play a significant role in preventing children from initiating smoking and help those who are already using tobacco to quit. An increase in the excise tax increases the retail price of tobacco products, making them less affordable, and reduces the demand for them.

Exposure to cigarette taxes as a teenager and the persistence of smoking into adulthood.

Are teenage and adult smoking causally related? Recent anti-tobacco policy is predicated on the assumption that preventing teenagers from smoking will ensure that fewer adults smoke, but direct evidence in support of this assumption is scant. Using data from three nationally representative sources and instrumenting for teenage smoking with cigarette taxes experienced at ages 14-17, we document a strong positive relationship between teenage and adult smoking: deterring 10 teenagers from smoking through raising cigarette taxes roughly translates into 5 fewer adult smokers. We conclude that efforts to reduce teenage smoking can have long-lasting consequences on smoking participation and, presumably, health.

Interpreting results, impacts and implications from WHO FCTC tobacco control investment cases in 21 low-income and middle-income countries.

BACKGROUND: Tobacco control investment cases analyse the health and socioeconomic costs of tobacco use and the benefits that can be achieved from implementing measures outlined in the WHO Framework Convention on Tobacco Control (WHO FCTC). They are intended to provide policy-makers and other stakeholders with country-level evidence that is relevant, useful and responsive to national priorities and policy context. METHODS: This paper synthesises findings from investment cases conducted in Armenia, Cabo Verde, Cambodia, Chad, Colombia, Costa Rica, El Salvador, Eswatini, Georgia, Ghana, Jordan, Laos, Madagascar, Myanmar, Nepal, Samoa, Sierra Leone, Sri Lanka, Suriname, Tunisia and Zambia. We examine annual socioeconomic costs associated with tobacco use, focusing on smoking-related healthcare expenditures, the value of lives lost due to tobacco-related mortality and workplace productivity losses due to smoking. We explore potential benefits associated with WHO FCTC tobacco demand-reduction measures. RESULTS: Tobacco use results in average annual socioeconomic losses of US$95 million, US$610 million and US$1.6 billion among the low-income (n=3), lower-middle-income (n=12) and upper-middle-income countries (n=6) included in this analysis, respectively. These losses are equal to 1.1%, 1.8% and 2.9% of average annual national gross domestic product, respectively. Implementation and enforcement of WHO FCTC tobacco demand-reduction measures would lead to reduced tobacco use, fewer tobacco-related deaths and reduced socioeconomic losses. CONCLUSIONS: WHO FCTC tobacco control measures would provide a positive return on investment in every country analysed.

Impact of cigarette price and tobacco control policies on youth smoking experimentation in Albania.

BACKGROUND: Albania has one of the highest smoking prevalence in Europe especially among the youth. There is a lack of evidence in Albania, as well as in most of Eastern Europe and middle-income countries, regarding the effect of price on smoking experimentation. OBJECTIVE: The study aims to assess the effect of price and tobacco control policies on youth smoking experimentation in Albania. METHODS: We used microdata from the Global Youth Tobacco Survey in Albania for 2004, 2009, 2015 and 2020. We constructed a pseudo-longitudinal dataset and estimated a split-population model to assess the hazard of smoking experimentation. RESULTS: Price is a significant predictor of smoking experimentation among teenagers in Albania for both males and females (p<0.001). Being male increases the odds for smoking experimentation by more than 50% as compared with females (p<0.001), whereas females appear to be more price sensitive. Peer and parent smoking are also important determinants for smoking experimentation. Introducing penalties for smokers and legal entities violating smoke-free policies implemented in 2014 is also associated with a lower hazard of smoking experimentation. CONCLUSION: Price is a significant predictor of smoking experimentation among teenagers in Albania for both males and females. A combination of increasing taxes and strengthening the rule of law to control tobacco use in public spaces, in addition to public awareness campaigns targeting both youth and smoking parents, could help to significantly reduce the probability of smoking experimentation.

Equity implications of tobacco taxation: results from WHO FCTC investment cases.

BACKGROUND: Across time, geographies and country income levels, smoking prevalence is highest among people with lower incomes. Smoking causes further impoverishment of those on the lower end of the income spectrum through expenditure on tobacco and greater risk of ill health. METHODS: This paper summarises the results of investment case equity analyses for 19 countries, presenting the effects of increased taxation on smoking prevalence, health and expenditures. We disaggregate the number of people who smoke, smoking-attributable mortality and cigarette expenditures using smoking prevalence data by income quintile. A uniform 30% increase in price was applied across countries. We estimated the effects of the price increase on smoking prevalence, mortality and cigarette expenditures. RESULTS: In all but one country (Bhutan), a one-time 30% increase in price would reduce smoking prevalence by the largest percent among the poorest 20% of the population. All income groups in all countries would spend more on cigarettes with a 30% increase in price. However, the poorest 20% would pay an average of 12% of the additional money spent. CONCLUSIONS: Our results confirm that health benefits from increases in price through taxation are pro-poor. Even in countries where smoking prevalence is higher among wealthier groups, increasing prices can still be pro-poor due to variable responsiveness to higher prices. The costs associated with higher smoking prevalence among the poor, together with often limited access to healthcare services and displaced spending on basic needs, result in health inequality and perpetuate the cycle of poverty.

Productivity costs of lifelong smoking-the Northern Finland Birth Cohort 1966 study.

BACKGROUND: Smoking is one of the leading causes of impaired health and mortality. Loss of paid and unpaid work and replacements due to morbidity and mortality result in productivity costs. Our aim was to investigate the productivity costs of lifelong smoking trajectories and cumulative exposure using advanced human capital method (HCM) and friction cost method (FCM). METHODS: Within the Northern Finland Birth Cohort 1966 (NFBC1966), 10 650 persons were followed from antenatal period to age 55 years. The life course of smoking behaviour was assessed with trajectory modelling and cumulative exposure with pack-years. Productivity costs were estimated with advanced HCM and FCM models by using detailed, national register-based data on care, disability, mortality, education, taxation, occupation and labour market. A two-part regression model was used to predict productivity costs associated with lifelong smoking and cumulative exposure. RESULTS: Of the six distinct smoking trajectories, lifetime smokers had the highest productivity costs followed by late starters, late adult quitters, young adult quitters and youth smokers. Never-smokers had the lowest productivity costs. The higher the number of pack-years, the higher the productivity costs. Uniform patterns were found in both men and women and when estimated with HCM and FCM. The findings were independent of other health behaviours. CONCLUSIONS: Cumulative exposure to smoking is more crucial to productivity costs than starting or ending age of smoking. This suggests that the harmful effects of smoking depend on dose and duration of smoking and are irrespective of age when smoking occurred.

Beer taxes associate with lower alcohol and cigarette use; cigarette taxes associate with lower cigarette but higher alcohol use.

Background: There is a yet unmet opportunity to utilize data on taxes and individual behaviors to yield insight for analyzing studies involving alcohol and cigarette use.Objectives: To inform the direction and strength of their mutual associations by leveraging the fact that taxation can affect individual consumption, but individual consumption cannot affect taxation.Methods: We linked state-level data on cigarette and beer taxes in 2009-2020 with individual-level data on self-reported current cigarette and alcohol use from the Behavioral Risk Factor Surveillance System, a telephone survey by the Centers for Disease Control and Prevention that is representative of the population of each state in the United States. We constructed linear and logistic models to examine associations between a $1 increase in cigarette taxes per pack and a $1 increase in beer taxes per gallon and self-reported cigarette use and alcohol consumption (assessed as any current intake, average drinks/day, heavy drinking, and binge drinking), adjusting for survey year and individual characteristics.Results: Among 2,968,839,352 respondents (49% male), a $1 increase in beer taxes was associated with .003 (95% confidence interval [CI] -.013, .008) fewer drinks/day and lower odds of any drinking (odds ratio [OR] = .81 95%CI .80, .83), heavy drinking (OR = .96 95%CI .93, .99), binge drinking (OR = .82 95%CI .80, .83), and smoking (OR = .98 95%CI .96, 1.00). In contrast, a $1 increase in cigarette taxes was associated with lower odds of smoking (OR = .94 95%CI .94, .95) but .007 (95%CI .005, .010) more drinks/day, and higher odds of any drinking (OR = 1.10 95%CI 1.10, 1.11), heavy drinking (OR = 1.02 95%CI 1.01, 1.02), and binge drinking (OR = .82 95%CI .80, .83).Conclusion: Higher beer taxes were associated with lower odds of drinking and smoking, but higher cigarette taxes were associated with lower odds of smoking and higher alcohol consumption. These results suggest that alcohol intake may be a determinant of cigarette use rather than cigarette use as a determinant of alcohol intake.

The impact of cigarette cost on pack sales per capita consumption in the United States.

OBJECTIVES: Evidence suggests that cigarette costs significantly impact tobacco use, yet the effect of state-level cost variations on cigarette sales per capita in the US remains uncertain. This study investigates how state-level cigarette costs affect pack sales per capita consumption. STUDY DESIGN: This was an observational study of cigarette-pack sales per capita consumption in the United States. METHODS: We used the tobacco tax burden data (1989-2019) and a two-way fixed-effects model to analyse how cigarette costs affect consumption. Our predictor variables were average cost per pack, state tax per pack, and combined federal and state tax as a percentage of the retail price. Additionally, we compared the percentage change in state cigarette taxes per pack for each state in five-year intervals, adjusting for inflation. RESULTS: Regression analysis revealed that a 10% increase in the average cost per pack was related to a 9.59% decrease in per capita cigarette consumption (ß_average cost = -0.959, P < 0.001). Similarly, a rise in state tax per pack and a higher tax as a proportion of the retail price per pack were related to a decline in consumption (ß_ state tax = -0.176, P < 0.001), (ß_retail price = -0.323, P < 0.001). States that raised cigarette taxes beyond the rate of inflation had a higher reduction in cigarette per capita sales than those maintaining stable tax rates. CONCLUSIONS: Some states have not raised their cigarette taxes sufficiently to account for inflation. It appears that cigarette costs have significantly reduced cigarette consumption in the US.

[Application of the cigarette purchase tasks in achieving China' s tobacco control goals].

OBJECTIVE: To assess cigarette demand among Chinese smokers through a cigarette purchase task (CPT) and to evaluate cigarette prices under different hypothetical scenarios in order to meet the goals of smoking prevalence reduction in China. METHODS: In the study, 447 participants completed a hypothetical CPT at baseline assessments of a trial, thus, cigarette demand curves were individually fitted for each participant using an exponentiated version of the exponential demand model. Typically, five demand indices were derived, intensity (consumption when free), breakpoint (first price at which consumption is suppressed to 0), maximum output (Omax), maximum price (Pmax, price at which Omax occurred), and elasticity (the ratio of the change in quantity demanded to the change in price). A one-way analysis of variance was used to explore the correlations between the cigarette purchase task indices and socio-demographic and smoking characteristics. The one-way decay model was employed to simulate the smoking cessation rates and determine optimal cigarette prices in a series of scenarios for achieving 20% smoking prevalence. RESULTS: The price elasticity drawn from CPT was 0.54, indicating that a 10% price increase could reduce smoking by 5.4% in the participated smokers. Smokers with higher income were less sensitive to cigarette prices (elasticity=-2.31, P=0.028). Cigarette purchase task indices varied significantly among the smokers with different prices of commonly used cigarettes, tobacco dependence, and smoking volume. The smokers who consumed cigarettes of higher prices reported higher breakpoint, Omax and Pmax, but lower intensity (P=0.001). The smokers who were moderately or highly nicotine dependent reported higher intensity, breakpoint, Omax and Pmax, and they had lower intensity (P=0.001). The smokers who had a higher volume of cigarettes reported higher intensity and Omax, and lower intensity (P < 0.001). To achieve the goal of reducing smoking prevalence to 20% in mainland China, we estimated the desired increase on smoking cessation rate and prices accordingly in a series of scenarios, considering the gender variance and reduced smoking initiation. In scenario (a), to achieve a smoking prevalence goal of 20%, it would be necessary for 24.81% of the current smokers to quit smoking when there were no new smokers. Our fitting model yielded a corresponding value of 59.64 yuan (95%CI 53.13-67.24). Given the assumption in scenario (b) that only males quitted smoking, the desired cessation rates would be 25.82%, with a higher corresponding price of 62.15 yuan (95%CI 55.40-70.06) to induce desired cessation rates. In the proposed scenario (c) where 40 percent of the reduction in smoking prevalence came from reduced smoking initiation, and females and males equally quitted smoking due to increased cigarette prices, the price of a pack of cigarettes would be at least 37.36 yuan (95%CI 32.32-42.69) (equals to $ 5.20) per pack to achieve the cessation rate of 14.89 percent. In scenario (d) where only males quitted smoking due to increased cigarette prices considering the reduced smoking initiation, the respective smoking cessation rates should be 15.49% with the desired prices of 38.60 yuan (95%CI 33.53-44.02). After adjusting for education levels and income levels in scenario (c), the price of cigarettes would be at least 37.37 yuan/pack (equals to $ 5.20) (95%CI 30.73-44.94) and 37.84 yuan/pack (equals to $ 5.26) (95%CI 31.94-44.53), respectively. CONCLUSION: Cigarette purchase task indices are significantly associated with income levels and prices of commonly used cigarettes, levels of tobacco dependence, and smoking volume, which is inspiring in studying price factors that influence smoking behavior. It is suggested that higher cigarette prices, surpassing the current actual market level, is imperative in mainland China. Stronger policy stra-tegies should be taken to increase tobacco taxes and retail cigarette prices to achieve the Healthy China 2030 goal of reducing smoking prevalence to 20%.

Cigarette Prices and Smoking Among Youth in 16 African Countries: Evidence From the Global Youth Tobacco Survey.

INTRODUCTION: African countries have among the lowest excise taxes in the world. This paper provides new evidence on the association between cigarette prices and youth smoking in 16 African countries. AIMS AND METHODS: We use Global Youth Tobacco Survey (GYTS) cross-country data from approximately 67 500 participants. The relationship between prices and youth smoking in Africa is estimated using probit models for smoking participation and generalized linear models for conditional cigarette demand. Each model is estimated using local-brand and foreign-brand cigarette prices. RESULTS: Higher prices are associated with lower demand across African countries, for both smoking prevalence and the intensity of cigarette consumption by smokers. The estimated price elasticity of participation is -0.70 [95% CI: -1.28 to -0.12] for local-brand cigarettes and -0.71 [95% CI: -0.98 to -0.44] for foreign-brand cigarettes. The price elasticity of conditional cigarette demand is -0.44 [95% CI: -0.76 to -0.12] for local brands and -0.75 [95% CI: -0.96 to -0.53] for foreign brands. The total price elasticity of demand for youth in our sample is -1.14 for local brands and -1.46 for foreign brands. CONCLUSIONS: Higher cigarette prices significantly decrease the likelihood of smoking and decrease the intensity of cigarette consumption among African youths. Increases in the excise tax that increase the retail price of cigarettes will play an important role in reducing youth tobacco use on the continent. Governments are encouraged to increase excise taxes in order to improve public health. IMPLICATIONS: Evidence on the association between cigarette prices and youth smoking in African countries is limited. The Global Youth Tobacco Survey (GYTS) was first introduced in 1999. In 2012, the Centers for Disease Control and Prevention revised the GYTS questionnaire, which removed some questions and introduced new questions into the survey. To the best of our knowledge, there are no published estimates of the relationship between cigarette prices and demand that have used this more recent individual-level GYTS data for African countries. In conducting this analysis, we add to the limited literature on the association between cigarette prices and youth smoking in Africa.

A Pragmatic Trial of E-Cigarettes, Incentives, and Drugs for Smoking Cessation.

BACKGROUND: Whether financial incentives, pharmacologic therapies, and electronic cigarettes (e-cigarettes) promote smoking cessation among unselected smokers is unknown. METHODS: We randomly assigned smokers employed by 54 companies to one of four smoking-cessation interventions or to usual care. Usual care consisted of access to information regarding the benefits of smoking cessation and to a motivational text-messaging service. The four interventions consisted of usual care plus one of the following: free cessation aids (nicotine-replacement therapy or pharmacotherapy, with e-cigarettes if standard therapies failed); free e-cigarettes, without a requirement that standard therapies had been tried; free cessation aids plus $600 in rewards for sustained abstinence; or free cessation aids plus $600 in redeemable funds, deposited in a separate account for each participant, with money removed from the account if cessation milestones were not met. The primary outcome was sustained smoking abstinence for 6 months after the target quit date. RESULTS: Among 6131 smokers who were invited to enroll, 125 opted out and 6006 underwent randomization. Sustained abstinence rates through 6 months were 0.1% in the usual-care group, 0.5% in the free cessation aids group, 1.0% in the free e-cigarettes group, 2.0% in the rewards group, and 2.9% in the redeemable deposit group. With respect to sustained abstinence rates, redeemable deposits and rewards were superior to free cessation aids (P<0.001 and P=0.006, respectively, with significance levels adjusted for multiple comparisons). Redeemable deposits were superior to free e-cigarettes (P=0.008). Free e-cigarettes were not superior to usual care (P=0.20) or to free cessation aids (P=0.43). Among the 1191 employees (19.8%) who actively participated in the trial (the "engaged" cohort), sustained abstinence rates were four to six times as high as those among participants who did not actively engage in the trial, with similar relative effectiveness. CONCLUSIONS: In this pragmatic trial of smoking cessation, financial incentives added to free cessation aids resulted in a higher rate of sustained smoking abstinence than free cessation aids alone. Among smokers who received usual care (information and motivational text messages), the addition of free cessation aids or e-cigarettes did not provide a benefit. (Funded by the Vitality Institute; ClinicalTrials.gov number, NCT02328794 .).

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

OBJECTIVE: Active smoking among patients undergoing interventions for intermittent claudication (IC) is associated with poor outcomes. Notwithstanding, current levels of active smoking in these patients are high. State-level tobacco control policies have been shown to reduce smoking in the general US population. We evaluated whether state cigarette taxes and 100% smoke-free workplace legislation are associated with active smoking among patients undergoing interventions for IC. METHODS: We queried the Vascular Quality Initiative database for peripheral endovascular interventions, infrainguinal bypasses, and suprainguinal bypasses for IC. Active smoking at the time of intervention was defined as smoking within one month of intervention. We implemented difference-in-differences analysis to isolate changes in active smoking owing to cigarette taxes (adjusted for inflation) and implementation of smoke-free workplace legislation. The difference-in-differences models estimated the causal effects of tobacco policies by adjusting for concurrent temporal trends in active smoking unrelated to cigarette taxes or smoke-free workplace legislation. The models controlled for age, sex, race/ethnicity, insurance type, diabetes, chronic obstructive pulmonary disease, state, and year. We tested interactions of taxes with age and insurance. RESULTS: Data were available for 59,847 patients undergoing interventions for IC in 25 states from 2011 to 2019. Across the study period, active smoking at the time of intervention decreased from 48% to 40%. Every $1.00 cigarette tax increase was associated with a 6-percentage point decrease in active smoking (95% confidence interval, -10 to -1 percentage points; P = .02), representing an 11% decrease relative to the baseline proportion of patients actively smoking. The effect of cigarettes taxes was greater in older patients and those on Medicare. Among patients aged 60 to 69 and 70 to 79 years, every $1.00 tax increase resulted in 14% and 21% reductions in active smoking relative to baseline subgroup prevalences of 53% and 29%, respectively (P < .05 for both); however, younger age groups were not affected by tax increases. Among insurance groups, only patients on Medicare exhibited a significant change in active smoking with every $1.00 tax increase (an 18% decrease relative to a 33% baseline prevalence; P = .01). The number of states implementing smoke-free workplace legislation increased from 9 to 14 by 2019; however, this policy was not significantly associated with active smoking prevalence. At follow-up (median, 12.9 months), $1.00 tax increases were still associated with decreased smoking prevalence (a 25% decrease relative to a 33% baseline prevalence; P < .001). CONCLUSIONS: Cigarette tax increases seem to be an effective strategy to decrease active smoking among patients undergoing interventions for IC. Older patients and Medicare recipients are the most responsive to tax increases.

Cost-Effectiveness Analysis of Smoking Cessation Interventions in the United Kingdom Accounting for Major Neuropsychiatric Adverse Events.

OBJECTIVES: Smoking is a leading cause of death worldwide. Cessation aids include varenicline, bupropion, nicotine replacement therapy (NRT), and e-cigarettes at various doses (low, standard and high) and used alone or in combination with each other. Previous cost-effectiveness analyses have not fully accounted for adverse effects nor compared all cessation aids. The objective was to determine the relative cost-effectiveness of cessation aids in the United Kingdom. METHODS: An established Markov cohort model was adapted to incorporate health outcomes and costs due to depression and self-harm associated with cessation aids, alongside other health events. Relative efficacy in terms of abstinence and major adverse neuropsychiatric events was informed by a systematic review and network meta-analysis. Base case results are reported for UK-licensed interventions only. Two sensitivity analyses are reported, one including unlicensed interventions and another comparing all cessation aids but removing the impact of depression and self-harm. The sensitivity of conclusions to model inputs was assessed by calculating the expected value of partial perfect information. RESULTS: When limited to UK-licensed interventions, varenicline standard-dose and NRT standard-dose were most cost-effective. Including unlicensed interventions, e-cigarette low-dose appeared most cost-effective followed by varenicline standard-dose + bupropion standard-dose combined. When the impact of depression and self-harm was excluded, varenicline standard-dose + NRT standard-dose was most cost-effective, followed by varenicline low-dose + NRT standard-dose. CONCLUSION: Although found to be most cost-effective, combined therapy is currently unlicensed in the United Kingdom and the safety of e-cigarettes remains uncertain. The value-of-information analysis suggested researchers should continue to investigate the long-term effectiveness and safety outcomes of e-cigarettes in studies with active comparators.

Independent Associations Between Different Measures of Socioeconomic Position and Smoking Status: A Cross-Sectional Study of Adults in England.

INTRODUCTION: To gain a better understanding of the complex and independent associations between different measures of socioeconomic position (SEP) and smoking in England. AIMS AND METHODS: Between March 2013 and January 2019 data were collected from 120 496 adults aged 16+ in England taking part in the Smoking Toolkit Study. Of these, 18.04% (n = 21 720) were current smokers. Six indicators of SEP were measured: social grade, employment status, educational qualifications, home and car ownership and income. Models were constructed using ridge regression to assess the contribution of each measure of SEP, taking account of high collinearity. RESULTS: The strongest predictor of smoking status was housing tenure. Those who did not own their own home had twice the odds of smoking compared with homeowners (odds ratio [OR] = 2.01). Social grade, educational qualification, and income were also good predictors. Those in social grades C1 (OR = 1.04), C2 (OR = 1.29), D (OR = 1.39), and E (OR = 1.78) had higher odds of smoking than those in social grade AB. Similarly, those with A-level/equivalent (OR = 1.15), GCSE/vocational (OR = 1.48), other/still studying (OR = 1.12), and no post-16 qualifications (OR = 1.48) had higher odds of smoking than those with university qualifications, as did those who earned in the lowest (OR = 1.23), third (OR = 1.18), and second quartiles (OR = 1.06) compared with those earning in the highest. Associations between smoking and employment (OR = 1.03) and car ownership (OR = 1.05) were much smaller. CONCLUSIONS: Of a variety of socioeconomic measures, housing tenure appears to be the strongest independent predictor of smoking in England, followed by social grade, educational qualifications, and income. Employment status and car ownership have the lowest predictive power. IMPLICATIONS: This study used ridge regression, a technique which takes into account high collinearity between variables, to gain a better understanding of the independent associations between different measures of SEP and smoking in England. The findings provide guidance as to which SEP measures one could use when trying to identifying individuals most at risk from smoking, with housing tenure identified as the strongest independent predictor.

The Economic Cost of Smoking in South Africa, 2016.

INTRODUCTION: Chronic, noncommunicable diseases are on the rise globally, with tobacco consumption being an important contributing risk factor. These increases result in significant economic costs due to increased healthcare costs, productive lives lost, and productive days lost due to illness. Estimates of these economic costs are scarce in low- and middle-income countries. METHODS: Drawing on a diverse range of data sources, direct healthcare costs, and productivity losses due to illness and premature deaths were estimated using the cost-of-illness approach. The present value of lifetime earnings was used to estimate productivity losses from premature deaths. RESULTS: We estimate that 25 708 deaths among persons aged 35-74 in 2016 are smoking-attributable. The economic cost of smoking was R42 billion (US$2.88 billion), of which R14.48 billion was for healthcare costs (hospitalization and outpatient department visits). The economic cost of smoking amounted to 0.97% of the South African GDP in 2016, while the healthcare cost of smoking-related diseases was 4.1% of total South African health expenditure. The costs are lower for women because of their lower smoking prevalence. CONCLUSION: The economic burden of smoking calls for a further scaling-up of tobacco-control interventions in South Africa. IMPLICATIONS: This article addresses the paucity of research on the detailed economic costs of smoking in low-and middle-income countries, including South Africa. Our calculations, based on an extensive range of recent data, provide the most detailed estimate to date and include quantification of the direct and indirect costs of smoking in South Africa. We found that the magnitude of the costs related to smoking in South Africa is larger than in the previous estimates and that for every Rand received in the form of cigarette tax, society loses 3.43 Rands. This article provides an economic case for evidence-based tobacco control in South Africa.

Economic Costs of Diseases and Deaths Attributable to Tobacco Use in India, 2017-2018.

INTRODUCTION: About 28.6% of Indian adults use tobacco. This study estimates the economic burden of deaths and diseases attributable to smoking and smokeless tobacco (SLT) use for persons aged ≥35 years. METHODS: The National Sample Survey data on healthcare expenditures, the Global Adult Tobacco Survey data on tobacco use prevalence, and relative risks of all-cause mortality from tobacco use were used to estimate the economic burden of diseases and deaths attributable to tobacco use in India, using a prevalence-based attributable-risk approach. Costs are estimated under the following heads: (1) direct medical and nonmedical expenditures; (2) indirect morbidity costs; and (3) indirect mortality costs of premature deaths. RESULTS: Total economic costs attributable to tobacco use from all diseases and deaths in India in the year 2017-2018 for persons 35 years or older amount to INR 1773.4 billion (US $27.5 billion), of which 22% is direct and 78% is indirect cost. Men bear 91% of the total costs. Smoking contributed 74% and SLT use contributed 26% of the costs. CONCLUSIONS: The economic costs of tobacco use amount to approximately 1.04% of India's gross domestic product (GDP), while the excise tax revenue from tobacco in the previous year was only 12.2% of its economic costs. The direct medical costs alone amount to 5.3% of total health expenditure. The enormous costs imposed on the nation's health care system due to tobacco use could potentially stress the public health care system and strain the economy and it warrants massive scaling up of tobacco control efforts in India. IMPLICATIONS: The study finds that the economic burden from tobacco constitutes more than 1% of India's GDP, and the direct health expenditures on treating tobacco-related diseases alone accounts for 5.3% of the total private and public health expenditures in India in a year. It shows that, for every INR 100 that is received as excise taxes from tobacco products, INR 816 of costs is imposed on society through its consumption. It establishes that tobacco consumption is a major resource drain on the national exchequer, and its effective regulation through comprehensive fiscal and non-fiscal policies is highly warranted.

One-Year Efficacy and Incremental Cost-effectiveness of Contingency Management for Cigarette Smokers With Depression.

INTRODUCTION: Contingency management (CM) is efficacious for smoking cessation. To date, the number of cost-effectiveness evaluations of behavioral and pharmacological smoking cessation treatments far outnumbers the ones on CM. This study estimated 1-year efficacy and incremental cost-effectiveness of adding CM in relation to abstinence outcomes for a cognitive-behavioral therapy (CBT)+behavioral activation (BA) treatment. METHODS: The study sample comprised 120 smokers with depression (% females: 70.8%; mean age: 51.67 [SD = 9.59]) enrolled in an 8-week randomized controlled clinical trial. Clinical effectiveness variables were point-prevalence abstinence, continuous abstinence, longest duration of abstinence (LDA), and Beck-Depression Inventory-II (BDI-II) scores at 1-year follow-up. Cost-effectiveness analyses were based on resource utilization, unit costs per patient, and incremental cost per additional LDA week at 1 year. RESULTS: There was a significant effect of time by treatment group interaction, which indicated superior effects of CBT+BA+CM across time. Point-prevalence abstinence (53.3% [32/60]) was superior in participants receiving CBT+BA+CM compared with those in CBT+BA (23.3% [14/60]), but both groups were equally likely to present sustained reductions in depression. The average cost per patient was €208.85 (US$236.57) for CBT+BA and €410.64 (US$465.14) for CBT+BA+CM, p < .001. The incremental cost of using CM to enhance 1-year abstinence by one extra LDA week was €18 (US$20.39) (95% confidence interval: 17.75-18.25). CONCLUSIONS: Behavioral treatments addressing both smoking and depression are efficacious for sustaining high quit rates at 1 year. Adding CM to CBT+BA for smoking cessation is highly cost-effective, with an estimated net benefit of €4704 (US$5344.80). IMPLICATIONS: Informing on the cost-effectiveness of CM might expedite the translation of research findings into clinical practice. Findings suggested that CM is feasible and highly cost-effective, confirming that its implementation is worthwhile. At a CM cost per patient of €410.64 (US$465.14), the net benefit equals €4704 (US$5344.80), although even starting from a minimum investment of €20 (US$22.72) was cost-effective. CLINICALTRIALS-GOV IDENTIFIER: NCT03163056.

Comparative Safety of Smoking Cessation Pharmacotherapies During a Government-Sponsored Reimbursement Program.

INTRODUCTION: The British Columbia Ministry of Health launched a Smoking Cessation Program on September 30, 2011, providing financial coverage for smoking cessation pharmacotherapies. Although pharmacotherapies have been shown to have a moderate short-term benefit as a quitting aid, substantial cardiovascular and neuropsychiatric safety concerns have been identified in adverse-reporting databases, leading to prescription label warnings by Health Canada and the U.S. Food and Drug Administration. However, recent studies indicate these warnings may be without merit. This study examined the comparative safety of medications commonly used to aid smoking cessation. AIMS AND METHODS: Population-based retrospective cohort study using B.C. administrative data to assess the relative safety between varenicline, bupropion, and nicotine replacement therapies (NRTs). The primary outcome was a composite of cardiovascular hospitalizations. Secondary outcomes included mortality, a composite of neuropsychiatric hospitalizations, and individual components of the primary outcome. Statistical analysis used propensity score-adjusted log-binomial regression models. A sensitivity analysis excluded patients with a history of cardiovascular disease. RESULTS: The study included 116 442 participants. Compared with NRT, varenicline was associated with a 10% 1-year relative risk decrease of cardiovascular hospitalization (adjusted risk ratio [RR] = 0.90, 95% confidence interval (CI): 0.82 to 1.00), a 20% 1-year relative risk decrease of neuropsychiatric hospitalization (RR: 0.80, CI: 0.7 to 0.89), and a 19% 1-year relative risk decrease of mortality (RR: 0.81, CI: 0.71 to 0.93). We found no significant association between NRT and bupropion for cardiovascular hospitalizations, neuropsychiatric hospitalizations, or mortality. CONCLUSIONS: Compared with NRT, varenicline is associated with fewer serious adverse events and bupropion the same number of serious adverse events. IMPLICATIONS: This study addresses the need for comparative safety evidence in a real-world setting of varenicline and bupropion against an active comparator. Compared with NRT, varenicline was associated with a decreased risk of mortality, serious cardiovascular events, and neuropsychiatric events during the treatment, or shortly after the treatment, in the general population of adults seeking pharmacotherapy to aid smoking cessation. These results provide support for the removal of the varenicline boxed warning for neuropsychiatric events and add substantively to the cardiovascular safety findings of previous observational studies and randomized clinical trials.

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

INTRODUCTION: Assessing long-term smoking cessation after tobacco price increases is more valuable than short-term cessation as smokers often relapse after temporary cessation. We investigated whether tobacco price increases were associated with long-term smoking cessation and whether the association differed according to demographic, socioeconomic, and behavioral factors, using a national longitudinal survey of middle-aged individual-level data from 10 waves, every November from 2005 to 2014. METHODS: Temporary and long-term at least 1 year (1y+) or 2 years (2y+) quitters were defined by smoking in any one wave and quitting in the subsequent two or three waves in a discrete-time design. November 2006 (after July 11% increase) and November 2010 (after October 37% increase) were used as proxy variables for price increases. Generalized estimating equation models adjusted for demographic, socioeconomic, and behavioral covariates, and analyses stratified by these covariates were performed to estimate the association between price increases and smoking cessation. RESULTS: Of 43 630 smokers aged 50-65, 7.7%, 5.6%, and 5.2% of smokers quit temporarily, for at least 1 year and at least 2 years, respectively. 2y+ quitters significantly increased in November 2005-November 2008 (adjusted odds ratio = 1.23, 95% confidence interval: 1.06-1.43) and November 2009-November 2012 (adjusted odds ratio = 1.85, 95% confidence interval = 1.57-2.16). In stratified analyses, higher prices were associated with 2y+ quitters in all subgroups with some exceptions, including participants who smoked 21-30 cigarettes per day and those aged 60-65. CONCLUSIONS: Increasing tobacco prices may be effective in promoting long-term smoking cessation in various subgroups among middle-aged Japanese adults. IMPLICATIONS: Few longitudinal studies have examined the effect of a tobacco price increase on long-term smoking cessation. In a national longitudinal survey of middle-aged Japanese from 10 waves, the 37% tobacco price increase was found to be a trigger for successful smoking cessation for two or more years. Price increases were significantly associated with 2y+ smoking cessation in most demographic, behavioral, and socioeconomic subgroups. Results indicate that higher tobacco prices may be effective for long-term smoking cessation in almost all subgroups. Raising tobacco taxes and prices may be one of the most effective strategies for promoting long-term smoking cessation.