The Challenges of Tobacco Fiscal Policy Implementation in Mexico From the Perspective of Key Actors.

INTRODUCTION: Raising tobacco taxes is considered the most effective strategy to avoid smoking initiation and discourage its use, especially among vulnerable groups. However, few low- and middle-income countries have adopted high tobacco taxes. Raising taxes is, therefore, an opportunity to strengthen and accelerate tobacco control. The objective of this study is to analyze the barriers and facilitators to the tobacco tax increase in Mexico. AIMS AND METHODS: Based on the Governance Analytical Framework, data were generated through 17 in-depth interviews with key intersectoral actors for fiscal policy. The interviews were transcribed and coded according to Hufty's theory of governance. RESULTS: Robust scientific evidence, intersectoral coordination, and the presence of "champions" boosted progress in tobacco control (facilitators). The main barriers were the incomplete implementation of the World Health Organization-Framework Convention on Tobacco Control (WHO-FCTC) and MPOWER package and lack of commitment ("political will") by government decision makers and legislators, misinformation about the effects of tobacco taxes, and strong tobacco industry interference. CONCLUSIONS: Robust evidence is necessary but not sufficient to advance the implementation of the MPOWER (WHO-FCTC) actions. To achieve tobacco tax increases and public policies that protect people from unhealthy products in general, the implementation of policies or legal frameworks against industry interference in the development of public policies is imperative. IMPLICATIONS: By analyzing the barriers and facilitators to increasing the tobacco tax in Mexico, this study identifies two key messages: (1) The need to sensitize legislators and the general population to the problem of smoking not only through epidemiological data but also through testimonies that highlight the life experiences and adversities faced by people who smoke. (2) The need for a regulatory framework to prevent industry interference in public affairs and conflicts of interest. The same framework could be very useful for public health policies to control the consumption of ultra-processed food products or alcohol.

How Do Adolescent Smoking Prevention Interventions Work in Different Contextual Settings? A Qualitative Comparative Study Between the UK and Colombia.

BACKGROUND: Adolescent smoking is associated with significant health and social risks. Previous research has demonstrated the effectiveness of interventions based on behavior change theories in preventing adolescent smoking uptake. However, evidence from the theory-based perspective of evaluation is limited, especially for how such complex interventions work, and how they work when implemented in different contextual settings. METHOD: A comparative qualitative analysis was conducted to explore various influences on behavior change among participants taking part in two smoking prevention interventions in Northern Ireland and Bogotá. Twenty-seven focus groups were conducted in 12 schools (6 in Northern Ireland and 6 in Bogota, n = 195 pupils participated; aged 11-15 years). The Theoretical Domains Framework guided a content analysis of the data. RESULTS: We found similarities across settings in terms of knowledge, skills, and beliefs related to smoking or vaping behavior change, as well as differences in contextual resources and social influence. Different environmental resources included availability to purchase tobacco products in the neighborhoods and previous information about tobacco risk. Participants in both interventions perceived behavioral change outcomes related to personal skills and intention to not smoke or vape. CONCLUSION: These findings have highlighted how both individual factors and contextual resources influence behavior change for smoking prevention in practice. Local contextual factors and social influences affecting pupils should be taken into account in the implementation and evaluation of health behavior change interventions. In particular, this study supports using social and contextual influence strategies in interventions to reduce the onset of adolescent smoking and vaping.

Health, economic and social burden of tobacco in Latin America and the expected gains of fully implementing taxes, plain packaging, advertising bans and smoke-free environments control measures: a modelling study.

OBJECTIVE: To investigate the tobacco-attributable burden on disease, medical costs, productivity losses and informal caregiving; and to estimate the health and economic gains that can be achieved if the main tobacco control measures (raising taxes on tobacco, plain packaging, advertising bans and smoke-free environments) are fully implemented in eight countries that encompass 80% of the Latin American population. DESIGN: Markov probabilistic microsimulation economic model of the natural history, costs and quality of life associated with the main tobacco-related diseases. Model inputs and data on labour productivity, informal caregivers' burden and interventions' effectiveness were obtained through literature review, surveys, civil registrations, vital statistics and hospital databases. Epidemiological and economic data from January to October 2020 were used to populate the model. FINDINGS: In these eight countries, smoking is responsible each year for 351 000 deaths, 2.25 million disease events, 12.2 million healthy years of life lost, US$22.8 billion in direct medical costs, US$16.2 billion in lost productivity and US$10.8 billion in caregiver costs. These economic losses represent 1.4% of countries' aggregated gross domestic products. The full implementation and enforcement of the four strategies: taxes, plain packaging, advertising bans and smoke-free environments would avert 271 000, 78 000, 71 000 and 39 000 deaths, respectively, in the next 10 years, and result in US$63.8, US$12.3, US$11.4 and US$5.7 billions in economic gains, respectively, on top of the benefits being achieved today by the current level of implementation of these measures. CONCLUSIONS: Smoking represents a substantial burden in Latin America. The full implementation of tobacco control measures could successfully avert deaths and disability, reduce healthcare spending and caregiver and productivity losses, likely resulting in large net economic benefits.

[Benefits of the cigarette tax in Mexico, by sex and income quintileBenefícios do imposto sobre cigarros no México: análise por sexo e quintil de renda]. / Beneficios del impuesto a los cigarros en México: análisis por sexo y quintil de ingreso.

Objective: Estimate economic and health benefits, by sex and income quintile, of tax-based cigarette price increases in Mexico. Methods: An extended cost-effectiveness analysis (ECEA) model was used to estimate distributional benefits for women and men in the scenario of a 44% increase in the price of cigarettes (from 56.4 Mexican pesos [MX$] to MX$81.2 per pack), as a result of tripling the current specific excise tax (from MX$0.49/cigarette to MX$1.49/cigarette). The model was calibrated with official national information sources. Results: With a tax increase of one peso per cigarette, about 1.5 million smokers would quit (351 300 women and 1.1 million men). This would prevent approximately 630 000 smoking-attributable premature deaths. Reducing the burden of disease would save the health sector close to MX$42.8 billion and prevent more than 250 000 people (including 50 200 women smokers) from falling into poverty. It would also result in an additional MX$16.2 billion in revenue per year, of which the lowest income quintile would contribute less than 3% (1% for low-income women). Conclusions: The tobacco epidemic has clearly differentiated patterns between women and men, reflecting a gender component. While the tobacco tax in Mexico would have great benefits with respect to the current state of the epidemic, this could also contribute to the broader goal of social justice by reducing gender inequities.

Objetivo: Estimar os benefícios econômicos e de saúde, por sexo e quintil de renda, do aumento dos preços dos cigarros por meio de impostos no México. Métodos: Com um modelo de análise ampliada de custo-efetividade (ECEA, na sigla em inglês), foram estimados os benefícios distributivos em mulheres e homens com um cenário de aumento de 44% no preço dos cigarros (de 56,4 pesos mexicanos [MX$] para MX$ 81,2 por maço), como resultado da triplicação do imposto específico atual (de MX$ 0,49/cigarro para MX$ 1,49/cigarro). O modelo foi calibrado com fontes oficiais de informação nacional. Resultados: Com o aumento do imposto de um MX$ por cigarro, cerca de 1,5 milhão de fumantes abandonariam o consumo (351.300 mulheres e 1,1 milhão de homens). Assim, seriam evitadas aproximadamente 630.000 mortes prematuras atribuíveis ao tabaco. A redução da carga de doenças permitiria uma economia para o setor da saúde de cerca de MX$ 42,8 bilhões e evitaria que mais de 250.000 pessoas (incluindo 50.200 mulheres fumantes) caíssem na pobreza. Além disso, seriam arrecadados MX$ 16,2 bilhões adicionais por ano, dos quais o quintil mais baixo contribuiria com menos de 3% (1% no caso de mulheres de baixa renda). Conclusões: A epidemia de tabagismo tem padrões claramente diferenciados entre mulheres e homens e reflete um componente de gênero. Embora os benefícios do imposto sobre o tabaco no México tenham importância relativa no atual estado da epidemia em cada caso, poderiam contribuir para um objetivo mais amplo de justiça social ao reduzir as desigualdades de gênero.

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.

Tobacco Taxes as the Unsung Hero: Impact of a Tax Increase on Advancing Sustainable Development in Colombia.

Objective: Tobacco taxes are a well-established cost-effective policy to prevent Noncommunicable Diseases. This paper evaluates the expected effects of a tobacco tax increase on the Sustainable Development Goals in Colombia. Methods: We use microsimulation to build an artificial society that mimics the observed characteristics of Colombia's population, and from there we simulate the behavioral response to a tax increase of COP$4,750 (an increase that has been discussed by policy makers and legislators) and the subsequent effects in all SDGs. Results: The tobacco tax hike reduces the number of smokers (from 4.51 to 3.45 MM smokers) and smoking intensity, resulting in a drop in the number of cigarettes smoked in Colombia (from 332.3 to 215.5 MM of 20-stick packs). Such reduction is expected to decrease premature mortality, healthcare costs, poverty and people facing catastrophic expenditure on healthcare, to increase health, income and gender equity, and to strengthen domestic resource mobilization even in the presence of illicit cigarettes. Conclusion: Tobacco taxes are an effective intervention for public health and a powerful instrument to advance on the 2030 Sustainable Development Agenda. Relevance: A comprehensive analysis of the impact of tobacco taxes on all areas of Sustainable Development is missing in the empirical literature. Such perspective is needed to break the barriers for further tobacco tax increases by gathering wider societal support, especially from stakeholders and key decision makers from development areas other than health. SDG Nr: SDG3 (health), SDG 1 (no poverty), SDG 4 (education), SDG 5 (gender equality), SDG6 (water), SDG10 (inequality), SDG12 (responsible production and consumption), SDG17 (partnerships).

Evaluation of the implementation of the Framework Convention on Tobacco Control (FCTC) in Colombia.

Evidence-based interventions recommended in the Framework Convention on Tobacco Control of the World Health Organization (WHO FCTC) are subject to implementation factors that might affect their actual effectiveness. The Colombian law enacting key commitments from WHO's FCTC was signed in 2009. This study aims at evaluating the potential impact of the enactment and implementation of these WHO FCTC on four outcomes for tobacco consumption (last-year cigarette smoking prevalence, prevalence of heavy smokers, prevalence of lower-intensity smokers and monthly smoking incidence). We used data from the National Psychoactive Substances Consumption Survey (NPSCS) in 2008 (n = 29 164) and 2013 (n = 32 605), and assessed changes in these four outcomes WHO FCTC using propensity score matching (PSM). Propensity scores were obtained using key socio-demographic variables and by matching through a 'Kernel' estimation. Matching quality tests were performed. The common support for both survey samples was 60 793. Sub-analyses were conducted using a governance index to assess the effect of heterogeneous governance levels, proxying implementation, over the country. We found that cigarette year-prevalence and cigarette month-incidence decreased after matching around 8 and 1.2 percentage points between 2008 and 2013, respectively. Consumption might have shifted, at least partially, from heavy smoking towards lower-intensity smoking. Departments with a higher governance index showed larger reductions of tobacco use, possibly associated to a stronger WHO FCTC implementation. This study highlights the impact that the WHO FCTC had on tobacco consumption in a middle-income country and shows the importance of governance strength as a mediating mechanism for WHO FCTC impact. These results advance current knowledge on the effectiveness of WHO FCTC and shed light on the relevance of governance as a key factor in the WHO FCTC implementation.

Beneficios del impuesto a los cigarros en México: análisis por sexo y quintil de ingreso / Benefits of the cigarette tax in Mexico, by sex and income quintile / Benefícios do imposto sobre cigarros no México: análise por sexo e quintil de renda

RESUMEN Objetivo. Estimar los beneficios económicos y en salud, por sexo y por quintil de ingreso, del incremento de los precios de los cigarros mediante impuestos en México. Métodos. Con un modelo de costo-efectividad extendido (ECEA, por su sigla en inglés) se estimaron los beneficios distributivos en mujeres y hombres con un escenario de incremento del precio de los cigarros de 44% (de 56,4 pesos mexicanos [MX$] a MX$81,2 por cajetilla), como resultado de triplicar el impuesto específico actual (de MX$0,49/cigarro a MX$1,49/cigarro). El modelo se calibró con fuentes oficiales de información nacional Resultados. Con el incremento del impuesto de un peso por cigarro, cerca de 1,5 millones de fumadores abandonarían el consumo (351 300 mujeres y 1,1 millón de hombres). Así, se evitarían aproximadamente 630 000 muertes prematuras atribuibles al tabaco. La reducción de la carga de enfermedad permitiría ahorros para el sector salud cercanos a MX$42 800 millones y evitaría que más de 250 000 personas (entre ellas, 50 200 mujeres fumadoras) cayeran en situación de pobreza. Además, se recaudarían MX$16 200 millones adicionales por año, de los cuales el quintil más bajo aportaría menos de 3% (1% en el caso de las mujeres de menores ingresos). Conclusiones. La epidemia de tabaquismo tiene patrones claramente diferenciados entre mujeres y hombres y reflejan un componente de género. Si bien los beneficios del impuesto al tabaco en México tendrían magnitudes relativas al estado actual de la epidemia en cada caso, estos podrían contribuir a un objetivo más amplio de justicia social mediante la reducción de las inequidades de género.

ABSTRACT Objective. Estimate economic and health benefits, by sex and income quintile, of tax-based cigarette price increases in Mexico. Methods. An extended cost-effectiveness analysis (ECEA) model was used to estimate distributional benefits for women and men in the scenario of a 44% increase in the price of cigarettes (from 56.4 Mexican pesos [MX$] to MX$81.2 per pack), as a result of tripling the current specific excise tax (from MX$0.49/cigarette to MX$1.49/cigarette). The model was calibrated with official national information sources. Results. With a tax increase of one peso per cigarette, about 1.5 million smokers would quit (351 300 women and 1.1 million men). This would prevent approximately 630 000 smoking-attributable premature deaths. Reducing the burden of disease would save the health sector close to MX$42.8 billion and prevent more than 250 000 people (including 50 200 women smokers) from falling into poverty. It would also result in an additional MX$16.2 billion in revenue per year, of which the lowest income quintile would contribute less than 3% (1% for low-income women). Conclusions. The tobacco epidemic has clearly differentiated patterns between women and men, reflecting a gender component. While the tobacco tax in Mexico would have great benefits with respect to the current state of the epidemic, this could also contribute to the broader goal of social justice by reducing gender inequities.

RESUMO Objetivo. Estimar os benefícios econômicos e de saúde, por sexo e quintil de renda, do aumento dos preços dos cigarros por meio de impostos no México. Métodos. Com um modelo de análise ampliada de custo-efetividade (ECEA, na sigla em inglês), foram estimados os benefícios distributivos em mulheres e homens com um cenário de aumento de 44% no preço dos cigarros (de 56,4 pesos mexicanos [MX$] para MX$ 81,2 por maço), como resultado da triplicação do imposto específico atual (de MX$ 0,49/cigarro para MX$ 1,49/cigarro). O modelo foi calibrado com fontes oficiais de informação nacional. Resultados. Com o aumento do imposto de um MX$ por cigarro, cerca de 1,5 milhão de fumantes abandonariam o consumo (351.300 mulheres e 1,1 milhão de homens). Assim, seriam evitadas aproximadamente 630.000 mortes prematuras atribuíveis ao tabaco. A redução da carga de doenças permitiria uma economia para o setor da saúde de cerca de MX$ 42,8 bilhões e evitaria que mais de 250.000 pessoas (incluindo 50.200 mulheres fumantes) caíssem na pobreza. Além disso, seriam arrecadados MX$ 16,2 bilhões adicionais por ano, dos quais o quintil mais baixo contribuiria com menos de 3% (1% no caso de mulheres de baixa renda). Conclusões. A epidemia de tabagismo tem padrões claramente diferenciados entre mulheres e homens e reflete um componente de gênero. Embora os benefícios do imposto sobre o tabaco no México tenham importância relativa no atual estado da epidemia em cada caso, poderiam contribuir para um objetivo mais amplo de justiça social ao reduzir as desigualdades de gênero.

Outcomes and Risk Factors of Septic Shock in Patients With Infective Endocarditis: A Prospective Cohort Study.

BACKGROUND: Little is known about the characteristics and impact of septic shock (SS) on the outcomes of infective endocarditis (IE). We aimed to investigate the characteristics and outcomes of patients with IE presenting with SS and to compare them to those of IE patients with sepsis (Se) and those with neither Se nor SS (no-Se-SS). METHODS: This is a prospective cohort study of 4864 IE patients from 35 Spanish centers (2008 to 2018). Logistic regression analyses were performed to identify risk factors for SS and mortality. RESULTS: Septic shock and Se presented in 597 (12.3%) and 559 (11.5%) patients, respectively. Patients with SS were younger and presented significantly higher rates of diabetes, chronic renal and liver disease, transplantation, nosocomial acquisition, Staphylococcus aureus, IE complications, and in-hospital mortality (62.5%, 37.7% for Se and 18.2% for no-Se-SS, P < .001). Staphylococcus aureus (odds ratio [OR], 1.94; 95% confidence interval [CI], 1.34-2.81; P < .001), Gram negative (OR, 2.21; 95% CI, 1.25-3.91; P = .006), nosocomial acquisition (OR, 1.44; 95% CI, 1.07-1.94; P = .015), persistent bacteremia (OR, 1.82; 95% CI, 1.24-2.68; P = .002), acute renal failure (OR, 3.02; 95% CI, 2.28-4.01; P < .001), central nervous system emboli (OR, 1.48; 95% CI, 1.08-2.01; P = .013), and larger vegetation size (OR, 1.01; 95% CI, 1.00-1.02; P. = 020) were associated with a higher risk of developing SS. Charlson score, heart failure, persistent bacteremia, acute renal failure, mechanical ventilation, worsening of liver disease, S aureus, and receiving aminoglycosides within the first 24 hours were associated with higher in-hospital mortality, whereas male sex, native valve IE, and cardiac surgery were associated with lower mortality. CONCLUSIONS: Septic shock is frequent and entails dismal prognosis. Early identification of patients at risk of developing SS and early assessment for cardiac surgery appear as key factors to improve outcomes.

Implications of household tobacco and alcohol use on child health and women's welfare in six low and middle-income countries: An analysis from a gender perspective.

OBJECTIVE: To study the implications of household tobacco and alcohol use on child health and women's welfare using a gender lens in Ethiopia, India, Indonesia, Jordan, Kenya, and Nigeria with varied geographical and cultural characteristics in the pattern of tobacco and alcohol use. METHODS: We identified child health and women's welfare outcomes that may be impacted by tobacco and alcohol use, with a focus on the crowding-out effects on household resource allocation. For child health indicators, we focussed on engagement in preventative care, nutrition, and responses to acute illness. For women, we focused on access to resources for health-seeking and intimate partner violence (IPV). We used logistic regression to determine the association between household gender tobacco and/or alcohol use on child health and women's welfare, using data from six nationally-representative Demographic and Health Surveys, with each having a sample size of 5000-30,000 households and conducted after 2010. RESULTS: Children in households where men and women use tobacco are significantly less likely to receive the full schedule of Diphtheria-Pertussis-Tetanus (DPT) vaccine in India, Indonesia, and Jordan (Odds ratio or OR; ORIndia = 0.67, p < 0.001; ORIndonesia = 0.55, p = 0.028; ORJordan = 0.45, p = 0.048), and all basic vaccinations as well as receive appropriate treatment for fever/diarrhoea in India and Indonesia (all basic vaccinations: ORIndia = 0.78, p < 0.001, ORIndonesia = 0.43, p = 0.009; treatment for fever/diarrhoea: ORIndia = 0.65, p < 0.001; ORIndonesia = 0.50, p = 0.038). In most countries, women are significantly more likely to experience IPV when their husband/partner uses tobacco and/or alcohol. CONCLUSIONS: Across a diverse set of countries with varied cultural characteristics which affect the uptake and use of tobacco and alcohol, tobacco and alcohol use are associated with crowding-out of acute and preventative health-related behaviours and crowding-in of harmful behaviours. This has significant implications for tobacco and alcohol control programmes, and positions tobacco and alcohol control as central to human capital initiatives and in achieving health for all.

Cultural adaptation of two school-based smoking prevention programs in Bogotá, Colombia.

Smoking prevention among adolescents is a public health challenge that is even more significant in low- and middle-income countries where local evidence is limited and smoking rates remain high. Evidence-based interventions could be transferred to low- and middle-income country settings but only after appropriate cultural adaptation. This paper aims to describe the process of the cultural adaptation of two school-based smoking prevention interventions, A Stop Smoking in Schools Trial and Dead Cool, to be implemented in Bogotá, Colombia. A recognized heuristic framework guided the cultural adaptation through five stages. We conducted a concurrent nested mixed-methods study consisting of a qualitative descriptive case study and a quantitative pre- and post quasi-experiment without a control. Contextual, content, training, and implementation modifications were made to the programs to address cultural factors, to maintain the fidelity of implementation, and to increase the pupils' engagement with the programs. Modifications incorporated the suggestions of stakeholders, the original developers, and local community members, whilst considering the feasibility of delivering the programs. Involving stakeholders, original program developers, and community members in the cultural adaptation of evidence-based interventions is essential to properly adapt them to the local context, and to maintain the fidelity of program implementation.

MECHANISMS Study: Using Game Theory to Assess the Effects of Social Norms and Social Networks on Adolescent Smoking in Schools-Study Protocol.

This proof of concept study harnesses novel transdisciplinary insights to contrast two school-based smoking prevention interventions among adolescents in the UK and Colombia. We compare schools in these locations because smoking rates and norms are different, in order to better understand social norms based mechanisms of action related to smoking. We aim to: (1) improve the measurement of social norms for smoking behaviors in adolescents and reveal how they spread in schools; (2) to better characterize the mechanisms of action of smoking prevention interventions in schools, learning lessons for future intervention research. The A Stop Smoking in Schools Trial (ASSIST) intervention harnesses peer influence, while the Dead Cool intervention uses classroom pedagogy. Both interventions were originally developed in the UK but culturally adapted for a Colombian setting. In a before and after design, we will obtain psychosocial, friendship, and behavioral data (e.g., attitudes and intentions toward smoking and vaping) from ~300 students in three schools for each intervention in the UK and the same number in Colombia (i.e., ~1,200 participants in total). Pre-intervention, participants take part in a Rule Following task, and in Coordination Games that allow us to assess their judgments about the social appropriateness of a range of smoking-related and unrelated behaviors, and elicit individual sensitivity to social norms. After the interventions, these behavioral economic experiments are repeated, so we can assess how social norms related to smoking have changed, how sensitivity to classroom and school year group norms have changed and how individual changes are related to changes among friends. This Game Theoretic approach allows us to estimate proxies for norms and norm sensitivity parameters and to test for the influence of individual student attributes and their social networks within a Markov Chain Monte Carlo modeling framework. We identify hypothesized mechanisms by triangulating results with qualitative data from participants. The MECHANISMS study is innovative in the interplay of Game Theory and longitudinal social network analytical approaches, and in its transdisciplinary research approach. This study will help us to better understand the mechanisms of smoking prevention interventions in high and middle income settings.

Tobacco taxes and illicit cigarette trade in Colombia.

This paper estimates the short-term impact of a twofold increase of the tobacco excise tax on consumption of illicit cigarette trade in Colombia. Using data collected before and after the tax increase from a novel smoker survey (DEICS-Col), the impact is estimated as the change in the probability that a smoker has illicit cigarettes. The methodology follows a difference-in-differences strategy, measuring the year-to-year variation of the proportion of illicit cigarettes between smokers who report buying low-priced cigarettes (the highest treatment intensity) and those who bought high-priced cigarettes (lowest treatment intensity). Estimations of the impact show an average increase of 4-5 percentage points on the proportion of illicit cigarettes relative to an initial penetration of low-priced illicit cigarettes of nearly 5.1 %.

Smoke signals: monitoring illicit cigarettes and smoking behaviour in Colombia to support tobacco taxes.

BACKGROUND: A street cross-sectional survey in 2016 with a representative sample of 1697 smokers in five Colombian cities was used to estimate the penetration of illicit cigarettes (PIC). The first wave was collected 3 months before a 100% increase in tobacco excise tax, and a second wave collected data 9 months after tax reform was effective. OBJECTIVE : Analyse changes after a cigarette tax increase in PIC, prices and smoking behaviour patterns for five Colombian cities (63% of the market). Smoking behaviour includes consumption intensity, presentation (stick/pack) and place of purchase. METHODS : Repeated street cross-sectional survey with smokers' self-report on smoking behaviour, last purchase information and direct observation of smokers' packs. Sampling frame: smokers, men and women, aged 12 years or older, all income levels, resident in the five cities with the highest number of smokers representing 63% of cigarette market share (Bogotá, Medellín, Cali, Cartagena and Cúcuta) with 1 733 316 smokers in 2013. Sample size was 1697 per wave, with confidence level 95%, margin of error 3.5% for Bogotá and Medellín and 5% for the other three cities. Smokers in second wave match first wave's location, sex and age group. Illicit cigarettes were identified based on brand, health warnings and price. RESULTS : After the tax hike, the average real price of a 20-stick pack increased by 28.2% and by 23.1% for loose cigarettes. Illicit cigarettes represented 3.4% of total cigarette consumption in 2016 and increased to 6.4% in 2017, lower than the current industry estimate of 18%. Consumption intensity decreased: the proportion of heavy smokers (more than 10 cigarettes per day) wentdown from 37% in 2016 to 26% in 2017. CONCLUSION: After the tax increase, Colombia's PIC remained at low levels, and there is enough space for new tobacco tax hikes.

Distributional health and financial benefits of increased tobacco taxes in Colombia: results from a modelling study.

BACKGROUND: In Colombia, smoking is the second leading modifiable risk factor for premature mortality. In December 2016, Colombia passed a major tax increase on tobacco products in an effort to decrease smoking and improve population health. While tobacco taxes are known to be highly effective in reducing the prevalence of smoking, they are often criticised as being regressive in consumption. This analysis attempts to assess the distributional impact (across socioeconomic groups) of the new tax on selected health and financial outcomes. METHODS: This study builds on extended cost-effectiveness analysis methods to study the new tobacco tax in Colombia, and estimates, over a time period of 20 years and across income quintiles of the current urban population (80% of the country population), the years of life gained with smoking cessation and the increased tax revenues, all associated with a 70% relative price increase of the pack of cigarettes. Where possible, we use parameters that vary by income quintile, including price elasticity of demand for cigarettes (average of -0.44 estimated from household survey data). FINDINGS: Over 20 years, the tax increase would lead to an estimated 191 000 years of life gained among Colombia's current urban population, with the largest gains among the bottom two income quintiles. The additional annual tax revenues raised would amount to about 2%-4% of Colombia's annual government health expenditure, with the poorest quintiles bearing the smallest tax burden increase. CONCLUSIONS: The tobacco tax increase passed by Colombia has substantial implications for the country's population health and financial well-being, with large benefits likely to accrue to the two poorest quintiles of the population.

Measuring illicit cigarette trade in Colombia.

BACKGROUND: By 2016, tobacco industry provided the only illicit trade estimates in Colombia and used these to discourage tax increases since the 1990s. To establish the viability of a threefold hike in the excise tax, policy makers needed unbiased estimates of the illicit cigarette. OBJECTIVE: To estimate the size of illicit cigarette trade in five Colombian cities (63% of the market), analyse characteristics of smokers of illicit cigarettes and compare market share results with one industry-funded survey. METHODS: Street cross-sectional survey with smokers' self-report on consumption pattern, last purchase information and direct observation of smoker's packs. Sampling frame: smokers, men and women, 12 years old or older, all income levels, resident in five Colombian cities (Bogotá, Medellín, Cali, Cartagena and Cúcuta) with 1 733 316 smokers in 2013. Sample size 1697, simple random sample by city, sampling weights based on age groups and cities. Confidence level 95%, margin of error 3.5% for Bogotá and Medellín and 5% for the other three cities. Data collection period: 24 August-14 September 2016. RESULTS: Illicit cigarettes represent 3.5% of consumption in the five cities, a much lower estimate than the industry data. There are significant differences across cities, with Bogotá at the bottom (1.5%) and Cúcuta at the top (22.8%). CONCLUSION: The low overall penetration of illicit cigarettes in Colombia indicates that the industry's warnings against tax increases are not justified. The limited importance of tax levels as determinant of consumption of illicit cigarettes is also suggested by the differences across cities, all of them with the same tax regime.

[Cigarette taxes and demand in Colombia]. / Impuestos y demanda de cigarrillos en Colombia.

OBJECTIVE: Estimate price and income elasticities of aggregate demand for cigarettes in Colombia, by controlling for structural market changes since the late 1990s, to identify policy opportunities for taxes that could improve public health and increase tax revenues. METHODS: Measurement of aggregate demand for cigarettes using gross income reported on value-added tax returns submitted to Colombia's National Tax and Customs Office (DIAN is the acronym in Spanish) by the tobacco product manufacturing industry, subtracting exports. A quarterly time series was obtained for the period 1994-2014. The econometric estimation using two-stage least squares controls for price endogeneity and uses a set of dummy variables to control for structural changes in the market and in its regulation. RESULTS: Demand is, from a statistical standpoint, sensitive to price and to income. Price elasticity of demand is -0.78 and income elasticity is 0.61. CONCLUSIONS: Inelastic demand implies that it is possible, through cigarette excise taxes, to meet public health targets and increase revenues simultaneously. The results also suggest that the considerable increase in household income in Colombia in the first decade of the 21st century increased purchasing power, which, lacking an accompanying tax increase, promoted cigarette consumption, with negative effects on public health, and wasted an opportunity to increase tax revenues.

Impuestos y demanda de cigarrillos en Colombia / Cigarette taxes and demand in Colombia

RESUMEN Objetivo Estimar elasticidades precio e ingreso de la demanda agregada de cigarrillos para Colombia mediante el control de cambios estructurales en el mercado desde finales de los años 90, para identificar espacios de política de impuestos que mejoren la salud pública y aumenten los recaudos fiscales. Métodos La medición de la demanda agregada de cigarrillos utiliza los ingresos brutos reportados en la declaración del impuesto al valor agregado (IVA) a la Dirección de Impuestos y Aduanas Nacionales de Colombia (DIAN) por la industria de fabricación de productos de tabaco, con descuento de las exportaciones. Se obtuvo una serie de tiempo trimestral para el período 1994–2014. La estimación econométrica por mínimos cuadrados en dos etapas (2SLS) controla por la endogeneidad del precio y utiliza un conjunto de variables dummy para controlar por cambios estructurales en el mercado y en su regulación. Resultados La demanda es, desde el punto de vista estadístico, sensible al precio y al ingreso. La elasticidad precio de la demanda es -0,78 y la elasticidad ingreso es 0,61. Conclusiones La demanda inelástica implica que es posible, a través de impuestos al consumo de cigarrillo, alcanzar metas de salud pública y aumentar el recaudo de manera simultánea. Los resultados también sugieren que el aumento considerable del ingreso de los hogares de Colombia en la primera década del siglo xxi generó aumento del poder de compra. Este, al no ir acompañado de un aumento en el impuesto, impulsó el consumo de cigarrillo, con efectos negativos en salud pública, y se desperdició una oportunidad para aumentar el recaudo fiscal.

ABSTRACT Objective Estimate price and income elasticities of aggregate demand for cigarettes in Colombia, by controlling for structural market changes since the late 1990s, to identify policy opportunities for taxes that could improve public health and increase tax revenues. Methods Measurement of aggregate demand for cigarettes using gross income reported on value-added tax returns submitted to Colombia’s National Tax and Customs Office (DIAN is the acronym in Spanish) by the tobacco product manufacturing industry, subtracting exports. A quarterly time series was obtained for the period 1994-2014. The econometric estimation using two-stage least squares controls for price endogeneity and uses a set of dummy variables to control for structural changes in the market and in its regulation. Results Demand is, from a statistical standpoint, sensitive to price and to income. Price elasticity of demand is –0.78 and income elasticity is 0.61. Conclusions Inelastic demand implies that it is possible, through cigarette excise taxes, to meet public health targets and increase revenues simultaneously. The results also suggest that the considerable increase in household income in Colombia in the first decade of the 21st century increased purchasing power, which, lacking an accompanying tax increase, promoted cigarette consumption, with negative effects on public health, and wasted an opportunity to increase tax revenues.

Successful Treatment With Bosentan for Digital Ulcers Related to Mixed Cryoglobulinemia: A Case Report.

A 49-year-old man diagnosed with genotype 1 hepatitis C, CD5-positive marginal zone lymphoma, and mixed cryoglobulinemia type II developed skin ulcers and necrosis in his right foot. He was treated with amlodipine, corticosteroids, plasmapheresis, alprostadil, rituximab, and cyclophosphamide without a satisfactory response. For this reason, he required a partial amputation of the second, third, and fifth fingers of the right foot. To prevent ulcer deterioration of the first finger, bosentan was initiated. After 10 months of treatment, the ulcer completely healed and no adverse effects were experienced by the patient.