Cigarette packaging, warnings, prices, and contraband: A discrete choice experiment among smokers in Ontario, Canada.

In Canada, despite substantial decline, tobacco use remains the leading risk factor responsible for mortality and morbidity. There is overwhelming evidence that higher tobacco taxes reduce tobacco use, even if high taxes create an incentive to avoid or evade tobacco taxes. Recently, in addition to taxes, plain and standardized packaging and printing a warning on each cigarette have been lauded to reduce tobacco use. In November 2019, Canada became the country with the most comprehensive cigarette packaging regulations; and in June 2022, Canada proposed to print health warnings on individual cigarettes, the first jurisdiction to ever do so. The regulations came into force on August 1, 2023, and are being implemented through a stepwise approach. Our objective was to examine the effects of plain and standardized packaging, warning on cigarettes, price, and the availability of illicit cigarettes on intention to purchase and risk perceptions. We conducted a discrete choice experiment, and examined heterogeneity in preferences using latent class models among smokers in Ontario, Canada. We found that using latent class analyses was essential in quantifying preferences for attributes of cigarettes and cigarette packs. First, nearly half of smokers stated a preference for cheaper illicit cigarettes in a branded pack without any health warnings, regardless of the licit cigarette alternatives. For about 20% of respondents, plain packaging and especially warning on cigarette sticks decreased the probability of stating a purchasing preference for these alternatives. Third, about a third of respondents chose competing alternatives with mostly one attribute in mind, price. Lastly, none of the products and attributes seem to have significantly influenced risk perception. Our findings attest to the importance of prices and taxes, to the potential of warnings on cigarette sticks to control tobacco use, and indicate that efforts to restrict the availability of illicit cigarettes may yield substantial benefits.

Socioeconomic differences in the impact of prices and taxes on tobacco use in low- and middle-income countries-A systematic review.

There is indisputable evidence that increases in taxes that raise tobacco prices reduce tobacco use. Consumption taxes on manufactured tobacco products, however, can be regressive in socioeconomic status (e.g., when the ratio of tax paid to income is lower for higher-income groups than for lower-income groups). Nevertheless, if the poor or less educated are more price responsive, a change in tobacco tax may be progressive in socioeconomic status. Existing reviews clearly indicate that populations with lower income or education are more responsive to tobacco tax and price changes than higher-income and more educated populations in high-income countries. Research pertaining to low- and middle-income countries was, however, limited and inconclusive. We conducted a review of quantitative studies that examined if socioeconomic status modified the association between prices and taxes and tobacco use in low- and middle-income countries. We searched two electronic databases, two search engines, and two working paper repositories. At least two reviewers independently screened articles for inclusion, extracted detailed characteristics, and assessed the risk of bias of each included study. Thirty-two studies met our inclusion criteria. Overall, we found that the evidence in low- and middle-income countries was too limited and methodologically weak to make any conclusive statements. Our review highlights a number of data and methodological limitations in existing studies. The most important limitation was the lack of formal assessment of socioeconomic differences in price responsiveness. Only seven of 32 studies assessed statistically whether own-price effects were modified by socioeconomic status. Many modelling studies have examined the distributional effect of a tax increase on tobacco use, while assuming a strong own-price elasticity gradient in income. The poor were generally assumed to be more responsive to price by a factor of two to five, relative to the wealthy. Although there are theoretical reasons to expect poorer individuals to be more responsive to monetary prices than wealthy ones in low- and middle-income countries, our review provides little empirical support.

Return on investment of Canadian tobacco control policies implemented between 2001 and 2016.

OBJECTIVES: To determine the return on investment (ROI) associated with tobacco control policies implemented between 2001 and 2016 in Canada. METHODS: Canadian expenditures on tobacco policies were collected from government sources. The economic benefits considered in our analyses (decrease in healthcare costs, productivity costs and monetised life years lost, as well as tax revenues) were based on the changes in smoking prevalence and attributable deaths derived from the SimSmoke simulation model for the period 2001-2016. The net economic benefit (monetised benefits minus expenditures) and ROI associated with these policies were determined from the government and societal perspectives. Sensitivity analyses were conducted to check the robustness of the result. Costs were expressed in 2019 Canadian dollars. RESULTS: The total of provincial and federal expenditures associated with the implementation of tobacco control policies in Canada from 2001 through 2016 was estimated at $2.4 billion. Total economic benefits from these policies during that time were calculated at $49.2 billion from the government perspective and at $54.2 billion from the societal perspective. The corresponding ROIs were $19.8 and $21.9 for every dollar invested. Sensitivity analyses yielded ROI values ranging from $16.3 to $28.3 for every dollar invested depending on the analyses and perspective. CONCLUSIONS: This analysis has found that the costs to implement the Canadian tobacco policies between 2001 and 2016 were far outweighed by the monetised value associated with the benefits of these policies, making a powerful case for the investment in tobacco control policies.

Do cigarette prices near secondary schools vary by area-level socioeconomic status? Findings from a field study in Ontario and Québec, Canada.

OBJECTIVES: To examine, in the context of youth smoking, whether cigarette prices near secondary schools varied by area-level socioeconomic status in Southwestern and Central Ontario, and the greater Montréal region. METHODS: We collected cigarette prices four times between 2016 and 2019 from stores near secondary schools and used mixed-effects and ordinary least squares regressions. RESULTS: We found consistent evidence that cigarette prices near secondary schools were lower in neighbourhoods with lower area-level household income, and that differences were large enough to be meaningful. In Ontario and Québec, our results indicate a Can$0.26 [0.04, 0.47] to Can$0.51 [0.33, 0.69] and Can$0.10 [-0.04, 0.24] to Can$0.37 [0.22, 0.52] difference in prices for a pack of 25 cigarettes between neighbourhoods with a median household income standard deviation below/above the provincial median, respectively. CONCLUSION: Policy changes that limit area-level cigarette price differences without lowering cigarette prices may reduce inequities in youth smoking.

Inequity in insurance coverage for prescription drugs in New Brunswick, Canada.

OBJECTIVES: To describe the extent to which New Brunswick residents reported having drug insurance coverage supplementary to Canadian Medicare; to examine associations between socioeconomic and demographic characteristics, health status, language identity, and having reported such coverage; and to document any changes in coverage associated with the introduction of the New Brunswick Drug Plan in 2014. METHODS: We used repeated cross-sectional data for New Brunswick from eight cycles of the Canadian Community Health Survey from 2007 to 2017 and undertook logistic regression analysis. RESULTS: We found statistically significant, substantial and policy-relevant socioeconomic differences in the reporting of prescription drug insurance coverage among those 25-64 years and those ≥ 65 years of age, and an increasing reliance on private drug insurance over time. We found that individuals in the second decile of household income were particularly vulnerable to reporting neither public nor private drug coverage. The introduction of the New Brunswick Drug Plan in 2014 does not appear to have led to increased public drug coverage; however, from 2014, the decreasing trend in public drug coverage appears to have ceased. Those who reported lower health status usually had lower odds of reporting private drug coverage but higher odds of reporting public drug coverage. Driven by differences in private coverage, we found that relative to anglophones, francophones were less likely to report any drug coverage. CONCLUSION: Our findings emphasize the shortcomings of drug insurance systems such as that introduced in New Brunswick and substantiate calls for a universal drug program. New Brunswick's increasing reliance on private drug insurance is of concern and warrants additional research.

RéSUMé: OBJECTIFS: Décrire la mesure dans laquelle les résidents du Nouveau-Brunswick ont déclaré avoir une couverture d'assurance médicaments supplémentaire au régime public d'assurance maladie canadien; examiner les associations entre les caractéristiques socioéconomiques et démographiques, l'état de santé, l'identité linguistique et avoir déclaré une telle couverture; et documenter tout changement de couverture associé à l'introduction du Régime médicaments du Nouveau-Brunswick en 2014. MéTHODES: Nous avons utilisé des données transversales répétées du Nouveau-Brunswick de huit cycles de l'Enquête sur la santé dans les collectivités canadiennes de 2007 à 2017 et avons entrepris une analyse de régression logistique. RéSULTATS: Nous avons constaté des différences socioéconomiques statistiquement significatives, substantielles et pertinentes en matière de politiques dans la déclaration de la couverture d'assurance médicaments chez les 25 à 64 ans et les 65 ans et plus, et une dépendance croissante à l'égard de l'assurance médicaments privée au fil du temps. Nous avons constaté que les personnes appartenant au deuxième décile du revenu du ménage étaient particulièrement vulnérables au fait de ne pas avoir déclaré d'assurance médicaments publique ou privée. La mise en place du Régime médicaments du Nouveau-Brunswick en 2014 ne semble pas avoir entraîné une augmentation de la couverture publique des médicaments; cependant, à partir de 2014, la tendance à la baisse de la couverture publique des médicaments semble avoir cessé. Ceux qui ont déclaré un état de santé inférieur avaient généralement une cote exprimant la probabilité plus faible de déclarer une assurance médicaments privée, mais plus élevée de déclarer une couverture publique des médicaments. En raison des différences de couverture privée, nous avons trouvé que, par rapport aux anglophones, les francophones étaient moins susceptibles de déclarer une couverture pour les médicaments. CONCLUSION: Nos résultats mettent en évidence les lacunes des systèmes d'assurance médicaments comme celui mis en place au Nouveau-Brunswick et justifient les appels en faveur d'un programme universel de médicaments. La dépendance croissante du Nouveau-Brunswick à l'égard de l'assurance médicaments privée est préoccupante et justifie des recherches supplémentaires.

Body mass index, waist circumference, waist-to-hip ratio, and body fat in relation to health care use in the Canadian Longitudinal Study on Aging.

BACKGROUND/OBJECTIVES: Obesity is associated with increased health care use (HCU), but it is unclear whether this is consistent across all measures of adiposity. The objectives were to compare obesity defined by body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), and percent body fat (%BF), and to estimate their associations with HCU. SUBJECTS/METHODS: Baseline data from 30,092 participants aged 45-85 years from the Canadian Longitudinal Study on Aging were included. Measures of adiposity were recorded by trained staff and obesity was defined as BMI ≥ 30.0 kg/m2 for all participants and WC ≥ 88 cm and ≥102 cm, WHR ≥ 0.85 and ≥0.90, and %BF > 35% and >25% (measured using dual energy x-ray absorptiometry) for females and males, respectively. Self-reported HCU in the past 12 months was collected for any contact with a general practitioner, specialist, emergency department, and hospitalization. Pearson correlation coefficients (r) compared each measure to %BF-defined obesity, the reference standard. Relative risks (RR) and risk differences (RD) adjusted for age, sex, education, income, urban/rural, marital status, smoking status, and alcohol use were calculated, and results were age- and sex-stratified. RESULTS: Obesity prevalence varied by measure: BMI (29%), WC (42%), WHR (62%), and %BF (73%). BMI and WC were highly correlated with %BF (r ≥ 0.70), while WHR demonstrated a weaker relationship with %BF, with differences by sex (r = 0.29 and r = 0.46 in females and males, respectively). There were significantly increased RR and RD for all measures and health care services, for example, WC-defined obesity was associated with an increased risk of hospitalization (RR: 1.40, 95% CI: 1.28-1.54 and RD per 100: 2.6, 95% CI:1.9-3.3). Age-stratified results revealed that older adult groups with obesity demonstrated weak or no associations with HCU. CONCLUSIONS: All measures of adiposity were positively associated with increased HCU although obesity may not be a strong predictor of HCU in older adults.

Area-level differences in the prices of tobacco and electronic nicotine delivery systems - A systematic review.

OBJECTIVE: To examine associations between area-level characteristics (socioeconomic status, racial or ethnic characteristics, age, and any other characteristics that may be associated with vulnerability) and the prices of tobacco products and electronic nicotine delivery systems (ENDS). DATA SOURCES: We searched MEDLINE, EconLit and Scopus, unpublished and grey literature, hand-searched four specialty journals, examined references of relevant studies, and contacted key informants. STUDY SELECTION: We considered all studies that quantitatively examined area-level variations in the prices of tobacco products and ENDS. We included all studies that examined any area-level measures regardless of the geographic location, language or time of publication. At least two reviewers independently screened the articles. We identified 20 studies. DATA EXTRACTION: At least two reviewers independently extracted the characteristics, methods, and main results and assessed the quality of each included study. DATA SYNTHESIS: Overall, cigarette prices were found to be lower in lower socioeconomic status neighbourhoods, and in neighbourhoods with a higher percentage of youth, and Blacks or African Americans. We identified too few studies that examined price differences for cigarillos, chewing tobacco, roll-your-own, and ENDS to reach any conclusions. CONCLUSIONS: Our findings are in keeping with tobacco industry documents that detailed how manufacturers used race, class, and geography to target vulnerable populations and suggest that regulations that can limit industry price manipulation such as minimum, maximum, and uniform prices, and high specific excise taxes should be considered. More frequent and systematic monitoring of tobacco prices and ENDS is warranted.

Contraband Cigarette Purchasing from First Nation reserves in Ontario and Quebec: Findings from the 2002-2014 ITC Canada Survey.

Backround: The availability of contraband cigarettes provides incentives for price-sensitive smokers to reduce their monetary costs of smoking. The objectives of this study were to examine whether Canadian smokers' geographic proximity to First Nations reserves and attempts to quit smoking influenced the likelihood of purchasing lower-cost cigarettes from reserves. METHODS: Data were from the International Tobacco Control (ITC) Canada Survey, a prospective survey of Canadian adult smokers conducted from 2002 to 2014 using telephone and online interviewing methods. Analysis was restricted to smokers from Ontario (n=2105) and Quebec (n=1427) participating in at least one survey wave. Smokers' postal codes were used to calculate distance to the nearest reserve. Weighted logistic generalised estimating equations (GEE) regression examined the linear relationship between distance and the log odds of last purchasing cigarettes on reserve in each province. GEE models also examined the relationship between past-year quit attempts and the log odds of on-reserve purchasing. RESULTS: Controlling for other factors, from 2002-2014, smokers from Ontario who lived 10 km closer to reserves than otherwise similar smokers had significantly higher odds of last purchasing on reserve (OR ranged from 1.16 to 1.65). Distance had little effect on smokers' purchasing behaviours in Quebec. Moreover, in Ontario, for every 10 km increase in distance, smokers who did not try to quit had significantly greater odds of purchasing from a reserve than smokers who tried to quit (p=0.002). CONCLUSION: In order for tobacco taxation policies to achieve their maximal benefit, governments must limit potential sources of lower-cost cigarettes. Collaborative governance arrangements can ensure tobacco products sold on reserve to non-Indigenous people are appropriately taxed while allowing First Nations communities to keep the revenue generated by such taxes.

Association of Tobacco Control Policies With Youth Smoking Onset in Chile.

IMPORTANCE: Tobacco smoking is still responsible for more than 6 million preventable deaths annually, most of which occur in low- and middle-income countries. South American countries, Chile in particular, endure some of the highest cigarette smoking prevalence rates globally. Despite the lack of any meaningful increases in cigarette taxes (the most effective tobacco control measure) between 1999 and 2014, cigarette prices in Chile increased sharply almost entirely driven by British American Tobacco (BAT). OBJECTIVE: To examine the associations between cigarette prices and nonprice tobacco control policies targeted at youth introduced in 2006 (Law 20105) and smoking onset among Chilean youths. DESIGN, SETTING, AND PARTICIPANTS: This study used data from 8 waves of a large national school survey of urban communities in Chile conducted between October and December in 2001, 2003, 2015, 2007, 2009, 2011, 2013, and 2015 and discrete-time hazard models. Data analysis was performed from May 2017 to January 2019. EXPOSURES: Prices, advertising, and retail restrictions. MAIN OUTCOMES AND MEASURES: Smoking onset (the transition between never smoking and smoking) in youth. RESULTS: In this study of 181 624 survey respondents in 8751 Chilean secondary schools, higher prices (own-price elasticity [percentage change in quantity demanded in response to a 1% change in price], -0.40; 95% CI, -0.45 to -0.36) and the tobacco control policies enacted in 2006 (hazard ratio, 0.83; 95% CI, 0.81-0.85) were associated with lower hazards of starting smoking. The study found that an increase in real prices of 58.6% and the introduction of Law 20105 were associated with similar lower hazards of starting smoking (hazard ratio, 0.83; 95% CI, 0.81-0.85); in comparison, between 1999 and 2017, inflation-adjusted cigarette prices increased by 206%. CONCLUSIONS AND RELEVANCE: The findings suggest that higher prices initiated by BAT and the tobacco control policies enacted by the Ministry of Health in 2006 were associated with lower hazards of starting smoking in Chilean youth. Large cigarette tax increases may be a strategy that can be used to help reduce smoking among youths in Chile.

Visualizing data: Trends in smoking tobacco prices and taxes in India.

Background : Tobacco smoking remains a leading risk factor for disease burden globally. In India alone, about 1 million deaths are caused annually by smoking. Although increasing tobacco prices has consistently been found to be the most effective intervention to reduce tobacco use, the documentation of prices and taxes across time and space has not been an essential component of tobacco control surveillance in most jurisdictions. This study aimed to examine, using graphical methods, trends in smoking tobacco taxes and prices in India at national and state-level. Methods : We used retail prices, price indices, and unit values (household expenditures on a commodity divided by the quantity purchased) collected and reported by government agencies. For bidis and cigarettes, we examined current and real (inflation-adjusted) prices, affordability (cost in terms of income), and key tax changes at both national and state-level. Results : We show that real prices of bidis and cigarettes were relatively flat (even decreasing in the case of bidis) between 2000 and 2007, and clearly increasing from 2010. When rising income is taken into account, however, both cigarettes and bidis have become more affordable since 2000. We found that some but not all tax changes were accompanied by price changes and in particular, that tax decreases did not result in price decreases. Conclusion : It is feasible to evaluate tax and price policies at national and regional level using routinely collected data.

[Tobacco advertisement exposure and tobacco consumption among youths in South America]. / Exposición a la publicidad de tabaco y consumo de tabaco en adolescentes en América del Sur.

OBJECTIVE:: To assesses the statistical association between exposure to tobacco marketing and tobacco consumption among adolescents in South America, by using data from the Global Youth Tobacco Survey. MATERIALS AND METHODS:: Using data from the Global Youth Tobacco Survey (GYTS), the exposure to tobacco marketing at the school level was studied from advertising in TV, radio, massive public events and street advertisement. Tobacco behaviour was considered. The total pooled sample used was 134 073 youths from Argentina, Bolivia, Chile, Peru, Brazil, Uruguay, Suriname, Colombia, Guyana, Ecuador, Paraguay and Venezuela. RESULTS:: The exposure to tobacco marketing is positively and significantly associated to the probability of youths experimenting with tobacco (at least once in their lifetime). For regular smokers, exposure to tobacco marketing is positively and significantly associated to smoking intensity. CONCLUSIONS:: These results call for the implementation of strong restrictions on tobacco advertisement of various types in South American countries.

Exposición a la publicidad de tabaco y consumo de tabaco en adolescentes en América del Sur / Tobacco advertisement exposure and tobacco consumption among youths in South America

Resumen: Objetivo: Este estudio evalúa la relación estadística entre la exposición a la publicidad de tabaco y el tabaquismo en los adolescentes de América del Sur. Material y métodos: Usando datos de la Encuesta Mundial de Tabaquismo en Jóvenes (GYTS) se estudiaron los niveles de exposición a nivel de escuela, ante distintos tipos de publicidad, además se evaluaron los comportamientos asociados al tabaquismo durante la experimentación y consumo. La muestra total fue de 134 073 jóvenes de Argentina, Bolivia, Chile, Perú, Brasil, Uruguay, Surinam, Colombia, Guyana, Ecuador, Paraguay y Venezuela que se combinaron en el análisis. Resultados: La exposición a la publicidad está positiva y significativamente asociada a un incremento en las probabilidades de que los jóvenes experimenten con el cigarrillo al menos una vez en sus vidas. Para los fumadores activos, la exposición a la publicidad está positiva y significativamente asociada con el número de cigarrillos fumados. Conclusiones: La publicidad de productos de tabaco debe ser controlada fuertemente o eliminada totalmente en varios países de Sudamérica.

Abstract: Objective: To assesses the statistical association between exposure to tobacco marketing and tobacco consumption among adolescents in South America, by using data from the Global Youth Tobacco Survey. Materials and methods: Using data from the Global Youth Tobacco Survey (GYTS), the exposure to tobacco marketing at the school level was studied from advertising in TV, radio, massive public events and street advertisement. Tobacco behaviour was considered. The total pooled sample used was 134 073 youths from Argentina, Bolivia, Chile, Peru, Brazil, Uruguay, Suriname, Colombia, Guyana, Ecuador, Paraguay and Venezuela. Results: The exposure to tobacco marketing is positively and significantly associated to the probability of youths experimenting with tobacco (at least once in their lifetime). For regular smokers, exposure to tobacco marketing is positively and significantly associated to smoking intensity. Conclusions: These results call for the implementation of strong restrictions on tobacco advertisement of various types in South American countries.

[The Impact of Prices and Taxes on the Use of Tobacco Products in Latin America and the Caribbean]. / El impacto de los precios e impuestos sobre el consumo de productos de tabaco en América Latina y el Caribe.

We examined the impact of tobacco prices or taxes on tobacco use in Latin America and Caribbean countries. We searched MEDLINE, EconLit, LILACS, unpublished literature, 6 specialty journals, and reviewed references. We calculated pooled price elasticities using random-effects models. The 32 studies we examined found that cigarette prices have a negative and statistically significant effect on cigarette consumption. A change in price is associated with a less than proportional change in the quantity of cigarettes demanded. In most Latin American countries, own-price elasticity for cigarettes is likely below -0.5 (pooled elasticities, shortrun: -0.31; 95% confidence interval = -0.39, -0.24; longrun: -0.43; 95% CI = -0.51, -0.35). Tax increases effectively reduce cigarette use. Lack of studies using household- or individual-level data limits research's policy relevance.

El impacto de los precios e impuestos sobre el consumo de productos de tabaco en América Latina y el Caribe / The Impact of Prices and Taxes on the Use of Tobacco Products in Latin America and the Caribbean

RESUMEN Examinamos la repercusión de los precios del tabaco o los impuestos sobre el consumo de tabaco en países de América Latina y el Caribe. Efectuamos búsquedas en MEDLINE, EconLit, LILACS, bibliografía inédita, seis revistas especializadas y referencias de revisiones. Calculamos las elasticidades combinadas de los precios usando modelos de efectos aleatorios. En los 32 estudios que examinamos se observó que los precios de los cigarrillos tienen un efecto negativo y estadísticamente significativo sobre el consumo. Un cambio en el precio está asociado con un cambio menos que proporcional en la magnitud de la cantidad demandada de cigarrillos. En la mayoría de los países latinoamericanos, la elasticidad-precio para los cigarrillos probablemente sea inferior a –0,5 (elasticidades combinadas, a corto plazo: –0,31; intervalo de confianza de 95% = –0,39 a –0,24; a largo plazo: –0,43; IC de 95% = –0,51 a –0,35). Los aumentos de impuestos reducen eficazmente el consumo de cigarrillos. La falta de estudios que usen datos de hogares o de individuos limita la pertinencia de las políticas de investigación.

ABSTRACT We examined the impact of tobacco prices or taxes on tobacco use in Latin America and Caribbean countries. We searched MEDLINE, EconLit, LILACS, unpublished literature, 6 specialty journals, and reviewed references. We calculated pooled price elasticities using random-effects models. The 32 studies we examined found that cigarette prices have a negative and statistically significant effect on cigarette consumption. A change in price is associated with a less than proportional change in the quantity of cigarettes demanded. In most Latin American countries, own-price elasticity for cigarettes is likely below –0.5 (pooled elasticities, shortrun: –0.31; 95% confidence interval = –0.39, –0.24; longrun: –0.43; 95% CI = –0.51, –0.35). Tax increases effectively reduce cigarette use. Lack of studies using household- or individual-level data limits research’s policy relevance.

Levels and trends in cigarette contraband in Canada.

BACKGROUND: There is overwhelming evidence that increases in tobacco taxes reduce tobacco use, save lives and increase government tax revenue. High taxes, however, create an incentive to devise ways to avoid or evade tobacco taxes through contraband tobacco. The associated consequences are significant and call for an accurate measurement of contraband's magnitude. However, its illegal nature makes the levels and trends in contraband intrinsically difficult to measure accurately. OBJECTIVE: To examine levels and trends in cigarette contraband in Canada. METHODS: We employed 2 approaches: first, we contrasted estimates of tax-paid cigarettes sales with consumption estimates based on survey data; second, we used data from several individual-level surveys that examined smokers' purchasing and use behaviours. We placed a particular emphasis on the provinces of Québec and Ontario because existing research suggests that cigarette contraband levels are far higher than in any other province. RESULTS: The estimates presented show a clear upward trend from the early 2000s in cigarette contraband in Québec and Ontario followed by, on the whole, a decreasing trend from about 2007 to 2009. None of the data presented provide support to the narrative that cigarette contraband has been increasing in recent years. Of note are Québec estimates which suggest relatively low levels of cigarette contraband since 2010, at levels no higher than in the early 2000s. CONCLUSIONS: The data presented suggest that policies to tackle cigarette contraband introduced from the mid-2000s to late 2000s, at both federal and provincial levels, may have dampened the demand for contraband cigarettes.

Effect of a mobile phone intervention on quitting smoking in a young adult population of smokers: randomized controlled trial study protocol.

BACKGROUND: Tobacco use remains the number one cause of preventable chronic disease and death in developed countries worldwide. In North America, smoking rates are highest among young adults. Despite that the majority of young adult smokers indicate wanting to quit, smoking rates among this age demographic have yet to decline. Helping young adults quit smoking continues to be a public health priority. Digital mobile technology presents a promising medium for reaching this population with smoking cessation interventions, especially because young adults are the heaviest users of this technology. OBJECTIVE: The primary aim of this trial is to determine the effectiveness of an evidence-informed mobile phone app for smoking cessation, Crush the Crave, on reducing smoking prevalence among young adult smokers. METHODS: A parallel randomized controlled trial (RCT) with two arms will be conducted in Canada to evaluate Crush the Crave. In total, 1354 young adult smokers (19 to 29 years old) will be randomized to receive the evidence-informed mobile phone app, Crush the Crave, or an evidence-based self-help guide known as "On the Road to Quitting" (control) for a period of 6 months. The primary outcome measure is a 30-day point prevalence of abstinence at the 6-month follow-up. Secondary outcomes include a 7-day point prevalence of abstinence, number of quit attempts, reduction in consumption of cigarettes, self-efficacy, satisfaction, app utilization metrics, and use of smoking cessation services. A cost-effectiveness analysis is included. RESULTS: This trial is currently open for recruitment. The anticipated completion date for the study is April 2016. CONCLUSIONS: This randomized controlled trial will provide the evidence to move forward on decision making regarding the inclusion of technology-based mobile phone interventions as part of existing smoking cessation efforts made by health care providers. Evidence from the trial will also inform the development of future apps, provide a deeper understanding of the factors that drive change in smoking behavior using an app, and improve the design of cessation apps. This trial is among the first to assess the effect of a comprehensive and evidence-informed mHealth smoking cessation app on a large sample of young adult smokers. Strengths of the trial include the high-quality research design and in-depth assessment of the implementation of the intervention. If effective, the trial has the potential to demonstrate that including mHealth technology as a population-based intervention strategy can cost-effectively reach a greater proportion of the population and help young adult smokers to quit. TRIAL REGISTRATION: ClinicalTrials.gov NCT01983150; http://clinicaltrials.gov/ct2/show/NCT01983150 (Archived by WebCite at http://www.webcitation.org/6VGyc0W0i).

The impact of prices and taxes on the use of tobacco products in Latin America and the Caribbean.

We examined the impact of tobacco prices or taxes on tobacco use in Latin America and Caribbean countries. We searched MEDLINE, EconLit, LILACS, unpublished literature, 6 specialty journals, and reviewed references. We calculated pooled price elasticities using random-effects models. The 32 studies we examined found that cigarette prices have a negative and statistically significant effect on cigarette consumption. A change in price is associated with a less than proportional change in the quantity of cigarettes demanded. In most Latin American countries, own-price elasticity for cigarettes is likely below -0.5 (pooled elasticities, short-run: -0.31; 95% confidence interval=-0.39, -0.24; long-run: -0.43; 95% CI=-0.51, -0.35). Tax increases effectively reduce cigarette use. Lack of studies using household- or individual-level data limits research's policy relevance.

Estimates of the economic contributions of the bidi manufacturing industry in India.

BACKGROUND: Bidis, the most common smoking tobacco product in India, remain largely untaxed and are subject to very few regulations to discourage their use. A major argument against tax increases is the large potential loss of economic activity and employment in the bidi industry from reduced consumption. METHODS: We used a nationally representative survey of unorganised bidi manufacturing firms (n=2841) in India to estimate the economic contribution of the industry. RESULTS: We find that of the 35 states and union territories of India, the bidi industry operated across 17 states, with over 95% of its production concentrated in 10 states. Bidi manufacturing firms contributed 0.50% of total sales and 0.6% of the gross value added by the manufacturing economy in 2005-2006. The industry employed approximately 3.4 million full-time workers, which comprise about 0.7% of employment in all sectors. A further 0.7 million were part-time workers. Bidi workers were also among the lowest paid employees in India. The industry offered only 0.09% of all compensation provided in the manufacturing sector (organised and unorganised). CONCLUSIONS: Considering the relatively small economic footprint of the bidi industry in India, higher excise taxes and regulations on bidis are unlikely to disrupt economic growth at an aggregate level, or lead to mass unemployment and economic hardship among small bidi workers. On average, the economic annual output per bidi worker is about US$143, which is an order of magnitude smaller than the large economic losses from the several hundred thousand deaths due to bidi smoking per year.

The impact of tobacco prices on smoking onset in Vietnam: duration analyses of retrospective data.

The benefits of preventing smoking onset are well known, and even just delaying smoking onset conveys benefits. Tobacco control policies are of critical importance to low-income countries with high smoking rates such as Vietnam where smoking prevalence is greater than 55 % in young men between the ages of 25 and 45. Using a survey of teens and young adults, I conducted duration analyses to explore the impact of tobacco price on smoking onset. The results suggest that tobacco prices in Vietnam have a statistically significant and fairly substantial effect on the onset of smoking. Increases in average tobacco prices, measured by an index of tobacco prices and by the prices of two popular brands, are found to delay smoking onset. Of particular interest is the finding that Vietnamese youth are more sensitive to changes in prices of a popular international brand that has had favourable tax treatment since the late 1990s.