Smoking behaviour and health care costs coverage: a European cross-country comparison.

The empirical evidence about the effect of smoking on health care cost coverage is not consistent with the expectations based on the notion of adverse selection. This evidence is mostly based on correlational studies which cannot isolate the adverse selection effect from the moral hazard effect. Exploiting data from the Survey of Health, Aging, and Retirement in Europe, this study uses an instrumental variable strategy to identify the causal effect of daily smoking on perceived health care cost coverage of those at age 50 or above in 12 European countries. Daily smoking is instrumented by a variable indicating whether or not there is any other daily smoker in the household. A self-assessment of health care cost coverage is used as the outcome measure. Among those who live with a partner (72% of the sample), the result is not statistically significant which means we find no effect of smoking on perceived health care cost coverage. However, among those who live without a partner, the results show that daily smokers have lower self-assessed perceived health care cost coverage. This finding replicates the same counter-intuitive relationship between smoking and health insurance presented in previous studies, but in a language of causality. In addition to this, we contribute to previous studies by a cross-country comparison which brings in different institutional arrangements, and by using the self-assessed perceived health care cost coverage which is broader than health insurance coverage.

An organisational change intervention for increasing the delivery of smoking cessation support in addiction treatment centres: study protocol for a randomized controlled trial.

BACKGROUND: The provision of smoking cessation support in Australian drug and alcohol treatment services is sub-optimal. This study examines the cost-effectiveness of an organisational change intervention to reduce smoking amongst clients attending drug and alcohol treatment services. METHODS/DESIGN: A cluster-randomised controlled trial will be conducted with drug and alcohol treatment centres as the unit of randomisation. Biochemically verified (carbon monoxide by breath analysis) client 7-day-point prevalence of smoking cessation at 6 weeks will be the primary outcome measure. The study will be conducted in 33 drug and alcohol treatment services in four mainland states and territories of Australia: New South Wales, Australian Capital Territory, Queensland, and South Australia. Eligible services are those with ongoing client contact and that include pharmacotherapy services, withdrawal management services, residential rehabilitation, counselling services, and case management services. Eligible clients are those aged over 16 years who are attending their first of a number of expected visits, are self-reported current smokers, proficient in the English language, and do not have severe untreated mental illness as identified by the service staff. Control services will continue to provide usual care to the clients. Intervention group services will receive an organisational change intervention, including assistance in developing smoke-free policies, nomination of champions, staff training and educational client and service resources, and free nicotine replacement therapy in order to integrate smoking cessation support as part of usual client care. DISCUSSION: If effective, the organisational change intervention has clear potential for implementation as part of the standard care in drug and alcohol treatment centres. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry, ACTRN12615000204549 . Registered on 3 March 2015.

La financiación del tratamiento del tabaquismo en los fumadores con EPOC / Financing of smoking cessation treatment in smokers with COPD

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Analysis of hospital cost outcome of DHA-rich fish-oil supplementation in pregnancy: Evidence from a randomized controlled trial.

OBJECTIVE: Recent research emphasized the nutritional benefits of omega-3 long chain polyunsaturated fatty acids (LCPUFAs) during pregnancy. Based on a double-blind randomised controlled trial named "DHA to Optimize Mother and Infant Outcome" (DOMInO), we examined how omega 3 DHA supplementation during pregnancy may affect pregnancy related in-patient hospital costs. METHOD: We conducted an econometric analysis based on ordinary least square and quantile regressions with bootstrapped standard errors. Using these approaches, we also examined whether smoking, drinking, maternal age and BMI could influence the effect of DHA supplementation during pregnancy on hospital costs. RESULTS: Our regressions showed that in-patient hospital costs could decrease by AUD92 (P<0.05) on average per singleton pregnancy when DHA supplements were consumed during pregnancy. Our regression results also showed that the cost savings to the Australian public hospital system could be between AUD15 - AUD51 million / year. CONCLUSION: Given that a simple intervention like DHA-rich fish-oil supplementation could generate savings to the public, it may be worthwhile from a policy perspective to encourage DHA supplementation among pregnant women.

Factors involved in the collaboration between the national comprehensive cancer control programs and tobacco control programs: a qualitative study of 6 States, United States, 2012.

INTRODUCTION: Historically, federal funding streams to address cancer and tobacco use have been provided separately to state health departments. This study aims to document the impact of a recent focus on coordinating chronic disease efforts through collaboration between the 2 programs. METHODS: Through a case-study approach using semistructured interviews, we collected information on the organizational context, infrastructure, and interaction between cancer and tobacco control programs in 6 states from March through July 2012. Data were analyzed with NVivo software, using a grounded-theory approach. RESULTS: We found between-program activities in the state health department and coordinated implementation of interventions in the community. Factors identified as facilitating integrated interventions in the community included collaboration between programs in the strategic planning process, incorporation of one another's priorities into state strategic plans, co-location, and leadership support for collaboration. Coalitions were used to deliver integrated interventions to the community. Five states perceived high staff turnover as a barrier to collaboration, and all 5 states felt that federal funding requirements were a barrier. CONCLUSIONS: Cancer and tobacco programs are beginning to implement integrated interventions to address chronic disease. Findings can inform the development of future efforts to integrate program activities across chronic disease prevention efforts.

The effect of quitting smoking on costs and healthcare utilization in patients with chronic obstructive pulmonary disease: a comparison of current smokers versus ex-smokers in routine clinical practice.

PURPOSE: Chronic obstructive pulmonary disease (COPD) is a prevalent condition mainly related to smoking, which is associated with a substantial economic burden. The purpose was to compare healthcare resource utilization and costs according to smoking status in patients with COPD in routine clinical practice. METHODS: A retrospective cohort nested case-control study was designed. The cohort was composed of male and female COPD outpatients, 40 years or older, covered by the Badalona Serveis Assistencials (a health provider) health plan. Cases were current smokers with COPD and controls (two per case) were former smokers with COPD (at least 12 months without smoking), matched for age, sex, duration of COPD, and burden of comorbidity. The index date was the last visit recorded in the database, and the analysis was performed retrospectively on healthcare resource utilization data for the 12 months before the index date. RESULTS: A total of 930 COPD records were analyzed: 310 current and 620 former smokers [mean age 69.4 years (84.6 % male)]. Cases had more exacerbations, physician visits of any type, and drug therapies related to COPD were more common. As a consequence, current smokers had higher average annual healthcare costs: €3,784 (1,888) versus €2,302 (2,451), p < 0.001. This difference persisted after adjusting for severity of COPD. CONCLUSIONS: Current smokers with COPD had significantly higher use of healthcare resources, mainly COPD drugs and physician visits, compared with former smokers who had abstained for at least 12 months. As a consequence, current smokers had higher healthcare costs to the National Health System in Spain than ex-smokers.

Cost effectiveness of full coverage of the medical management of smoking cessation in France.

OBJECTIVE: To estimate the incremental cost effectiveness of full coverage of the medical management of smoking cessation from the perspective of statutory health insurance (SHI) in France. DESIGN AND POPULATION: Cost-effectiveness analysis based on a Markov state-transition decision analytic model was used to compare full SHI coverage of smoking cessation and actual coverage based on an annual €50 lump sum per insured person among current French smokers aged 15-75 years. We used a scenario approach to take into account the many different behaviours of smokers and the likely variability of SHI policy choices in terms of participation rate and number and frequency of attempts covered. INTERVENTIONS: Drug treatments for smoking cessation combined with six medical consultations including individual counselling. MAIN OUTCOMES MEASURES: The cost effectiveness of full coverage was expressed by the incremental cost-effectiveness ratio (ICER) in 2009 euros per life-year gained (LYG) at the lifetime horizon. RESULTS: The cost effectiveness per LYG for smokers ranged from €1786 to €2012, with an average value of €1911. The minimum value was very close to the maximum value with a difference of only €226. The cost-effectiveness ratio was only minimally sensitive to the participation rate, the number of attempts covered and the cessation rate. CONCLUSIONS: Compared to other health measures in primary and secondary prevention of cardiovascular disease already covered by SHI, full coverage of smoking cessation is the most cost-effective approach.

Global alliance against chronic respiratory diseases in Italy (GARD-Italy): strategy and activities.

The steady increase in incidence of chronic respiratory disease (CRD) now constitutes a serious public health problem. CRDs are often underdiagnosed and many patients are not diagnosed until the CRD is too severe to prevent normal daily activities. The prevention of CRDs and reducing their social and individual impacts means modifying environmental and social factors and improving diagnosis and treatment. Prevention of risk factors (tobacco smoke, allergens, occupational agents, indoor/outdoor air pollution) will significantly impact on morbidity and mortality. The Italian Ministry of Health (MoH) has made respiratory disease prevention a top priority and is implementing a comprehensive strategy with policies against tobacco smoking, indoor/outdoor pollution, obesity, and communicable diseases. Presently these actions are not well coordinated. The Global Alliance against Chronic Respiratory Diseases (GARD), set up by the World Health Organization, envisages national bodies; the GARD initiative in Italy, launched 11/6/2009, represents a great opportunity for the MoH. Its main objective is to promote the development of a coordinated CRD program in Italy. Effective prevention implies setting up a health policy with the support of healthcare professionals and citizen associations at national, regional, and district levels. What is required is a true inter-institutional synergy: respiratory diseases prevention cannot and should not be the responsibility of doctors alone, but must involve politicians/policymakers, as well as the media, local institutions, and schools, etc. GARD could be a significant experience and a great opportunity for Italy to share the GARD vision of a world where all people can breathe freely.

Social, economic and legal dimensions of tobacco and its control in South-East Asia region.

This paper examines the social, cultural, economic and legal dimensions of tobacco control in the South-East Asia Region in a holistic view through the review of findings from various studies on prevalence, tobacco economics, poverty alleviation, women and tobacco and tobacco control laws and regulations. Methods were Literature review of peer reviewed publications, country reports, WHO publications, and reports of national and international meetings on tobacco and findings from national level surveys and studies. Tobacco use has been a social and cultural part of the people of South-East Asia Region. Survey findings show that 30% to 60% of men and 1.8% to 15.6% of women in the Region use one or the other forms of tobacco products. The complex nature of tobacco use with both smoking and smokeless forms is a major challenge for implementing tobacco control measures. Prevalence of tobacco use is high among the poor and the illiterate. It is higher among males than females but studies show a rising trend among girls and women due to intensive marketing of tobacco products by the tobacco industry. Tobacco users spend a huge percent of their income on tobacco which deprives them and their families of proper nutrition, good education and health care. Some studies of the Region show that cost of treatment of diseases attributable to tobacco use was more than double the revenue that governments received from tobacco taxation. Another challenge the Region faces is the application of uniform tax to all forms of tobacco, which will reduce not only the availability of tobacco products in the market but also control people switching over to cheaper tobacco products. Ten out of eleven countries are Parties to the WHO Framework Convention on Tobacco Control and nine countries have tobacco control legislation. Enforcement of control measures is weak, particularly in areas such as smoke-free environments, advertisement at the point of sale and sale of tobacco to minors. Socio-cultural acceptance of tobacco use is still a major challenge in tobacco control efforts for the governments and stakeholders in the South-East Asia Region. The myth that chewing tobacco is less harmful than smoking tobacco needs to be addressed with public awareness campaigns. Advocacy on the integration of tobacco control with poverty alleviation campaigns and development programs is urgently required. Law enforcement is a critical area to be strengthened and supported by WHO and the civil society organizations working in the area of tobacco control.

Development and validation of a microsimulation economic model to evaluate the disease burden associated with smoking and the cost-effectiveness of tobacco control interventions in Latin America.

OBJECTIVE: To describe the development and validation of a health economic model (HEM) to address the tobacco disease burden and the cost-effectiveness of smoking cessation interventions (SCI) in seven Latin American countries. METHODS: The preparatory stage included the organization of the research network, analysis of availability of epidemiologic data, and a survey to health decision makers to explore country-specific information needs. The development stage involved the harmonization of a methodology to retrieve local relevant parameters and develop the model structure. Calibration and validation was performed using a selected country dataset (Argentina 2005). Predicted event rates were compared to the published rates used as model inputs. External validation was undertaken against epidemiologic studies that were not used to provide input data. RESULTS: Sixty-eight decision makers were surveyed. A microsimulation HEM was built considering the availability and quality of epidemiologic data and relevant outcomes conceived to suit the identified information needs of decision makers. It considers all tobacco-related diseases (i.e., heart, cerebrovascular and chronic obstructive pulmonary disease, pneumonia/influenza, lung cancer, and nine other neoplasms) and can incorporate individual- and population-level interventions. The calibrated model showed all simulated event rates falling within ± 10% of the sources (-9%-+5%). External validation showed a high correlation between published data and model results. CONCLUSIONS: This evidence-based, internally and externally valid HEM for the assessment of the effects of smoking and SCIs incorporates a broad spectrum of tobacco related diseases, SCI, and benefit measures. It could be a useful policy-making tool to estimate tobacco burden and cost-effectiveness of SCI.

The economic burden of ill health due to diet, physical inactivity, smoking, alcohol and obesity in the UK: an update to 2006-07 NHS costs.

BACKGROUND: Estimates of the economic cost of risk factors for chronic disease to the NHS provide evidence for prioritization of resources for prevention and public health. Previous comparable estimates of the economic costs of poor diet, physical inactivity, smoking, alcohol and overweight/obesity were based on economic data from 1992-93. METHODS: Diseases associated with poor diet, physical inactivity, smoking, alcohol and overweight/obesity were identified. Risk factor-specific population attributable fractions for these diseases were applied to disease-specific estimates of the economic cost to the NHS in the UK in 2006-07. RESULTS: In 2006-07, poor diet-related ill health cost the NHS in the UK £5.8 billion. The cost of physical inactivity was £0.9 billion. Smoking cost was £3.3 billion, alcohol cost £3.3 billion, overweight and obesity cost £5.1 billion. CONCLUSION: The estimates of the economic cost of risk factors for chronic disease presented here are based on recent financial data and are directly comparable. They suggest that poor diet is a behavioural risk factor that has the highest impact on the budget of the NHS, followed by alcohol consumption, smoking and physical inactivity.

Predictors of what smokers say they will do in response to future price increases. Findings from the International Tobacco Control (ITC) Four Country Survey.

INTRODUCTION: Given the impact of higher tobacco prices on smoking cessation, we studied the role of future cigarette prices on forming expectation about smoking behavior. METHODS: Using a random sample of 9,058 adult cigarette smokers from the United States, Canada, Australia, and the United Kingdom collected in 2002, we examined predictors of what smokers say they will do in response to a hypothetical 50% increase in the price they paid for their last cigarette purchase. A series of regression analyses examined factors associated with intentions that have a positive impact on health, that is, intentions to quit and/or to consume fewer cigarettes. RESULTS: The quit and/or smoke less intentions were more pronounced among those who lived in areas with higher average cigarette prices and who paid higher prices for their brand of choice during the last purchase. The magnitude of the price increase is a more important predictor of an intention to quit/smoke less compared with the average cigarette price. CONCLUSIONS: The availability of alternative (cheaper) cigarette sources may reduce but would not eliminate the impact of higher prices/taxes on smokers' expected behavior that has been linked to actual quit intentions and quitting in follow-up surveys.

Effect of cigarette taxes on the consumption of cigarettes, alcohol, tea and coffee in Taiwan.

OBJECTIVES: To analyse whether a health tax of 10 New Taiwan Dollars (NT$) (US$0.3) imposed on cigarettes in 2009 will help to reduce cigarette consumption, and whether or not the cigarette tax will affect consumption of alcohol, coffee and tea. STUDY DESIGN: Time series data for consumption and retail prices of tobacco, alcohol, tea and coffee were collected and analysed for the period 1973-2007. METHODS: To establish the Central Bureau of Statistics demand function to estimate the overall demand price elasticities of cigarettes, alcohol, tea and coffee, a seemingly unrelated regression analysis was used. The independent variables were annual consumption of cigarettes, alcohol, tea and coffee. The dependent variables were prices of and expenditures on cigarettes, alcohol, tea and coffee. RESULTS: The estimated own-price elasticities for cigarettes and alcohol are close to -0.726. The own-price elasticities for tea and coffee are less than those for cigarettes and alcohol. Hence, it is predicted that the NT$10 health tax on cigarettes will reduce cigarette consumption by a significant 13.19%. Analysis of cross-price elasticity reveals that alcohol is complementary to cigarettes. CONCLUSIONS: Taxation is an effective smoking control policy tool that not only helps to reduce consumption of cigarettes, but also reduces consumption of alcoholic beverages.

Medical expenditures of men with hypertension and/or a smoking habit: a 10-year follow-up study of National Health Insurance in Shiga, Japan.

Hypertension and smoking are major causes of disability and death, especially in the Asia-Pacific region, where there is a high prevalence of a combination of these two risk factors. We attempted to measure the medical expenditures of a Japanese male population with hypertension and/or a smoking habit over a 10-year period of follow-up. A cohort study was conducted that investigated the medical expenditures due to a smoking habit and/or hypertension during the decade of the 1990s using existing data on physical status and medical expenditures. The participants included 1708 community-dwelling Japanese men, aged 40-69 years, who were classified into the following four categories: 'neither smoking habit nor hypertension', 'smoking habit alone', 'hypertension alone' or 'both smoking habit and hypertension.' Hypertension was defined as a systolic blood pressure of > or =140 mm Hg, a diastolic blood pressure of > or =90 mm Hg or taking antihypertensive medications. In the study cohort, 24.9% had both a smoking habit and hypertension. During the 10-year follow-up period, participants with a smoking habit alone (18,444 Japanese yen per month), those with hypertension alone (21,252 yen per month) and those with both a smoking habit and hypertension (31,037 yen per month) had increased personal medical expenditures compared with those without a smoking habit and hypertension (17,418 yen per month). Similar differences were observed even after adjustment for other confounding factors (P<0.01). Japanese men with both a smoking habit and hypertension incurred higher medical expenditures compared with those without a smoking habit, hypertension or their combination.

[Smoking among students at the School of Health and Social Development and the Health Service Institute in Senegal]. / Le tabagisme chez les élèves de l'Ecole de Développement Sanitaire et Social et de l'Institut Santé Service.

We have undertaken a transverse study of smoking among students at the National School of Health and Social Development (ENDSS) and the Health Service Institute (ISS) in Senegal. 683 out of 1142 students were questioned. 609 (89%) replied, of whom 313 (52%) were at the ENDSS and 293 (48%) at the ISS. Senior technical students were most strongly represented at 37.8%, followed by student nurses (27.4%) and midwifery students (23.3%). There were more women (n=378) than men with a sex ratio of 0.61. The average age of the population was 27.5 +/- 6.8 years (range 15 to 58). The average age was 26.2 +/- 5.6 years in the women and 29.6 +/- 8 in the men. The group aged 25-34 was significantly the most affected in both men and women (p=0.0000). The population comprised 502 non-smokers (82.4%), 62 ex-smokers (10.2%) and 45 smokers (7.4%).We found variable alcohol consumption in 119 subjects (19.2%) and 5 students admitted using cannabis. The 62 ex-smokers made up 10.2% of the population. The average age was 31.4 years. 25 ex-smokers (40.3%) drank alcohol, with a sex ratio of 1.95. The reasons for stopping smoking were illness and guilt in 27.4% of cases respectively, economic in 24.2%, medical statements on the effects of smoking on health in 17.7% and personal wishes in only 11.3%. The smokers, numbering 45 (7.4%), had an average age of 27.6 +/- 6.6 years with a sex ratio of 2 (p=0.00000). The age of starting smoking was 20.7 +/- 4.2 years for the women and 19.9 +/- 2.9 years for the men. The latter had smoked for an average of 9.2 years. Cigarettes were used by the great majority of smokers. It was associated with alcohol consumption in 35.6% and cannabis in 11.1% of cases. In the men the motives for starting smoking were stress (60%), pleasure (55.2%) and social influence (53.3%). By contrast, among the women, the two main reasons were stress and fashion in 60% (p=0.04). Our students smoked mostly in public places and in their homes. 34 smokers (75.6%) wished to stop (p=0.02) but only 27 of them expressed the need for medical or psychological support to do this. Dependence, quantified by the Fagerström Score, was medium (score 5-6) in 60% (n=27) and strong (score 7-10) in 31.1% (n=14).The estimated monthly cost of smoking increased with the degree of dependence. It was, on average, 12,143 F CFA (18.5euro) in cases of high dependence, representing 37% of the minimum wage in Senegal which is 33000F CFA (50euro). The students understood well the diseases caused by smoking (whether they were smokers, ex-smokers or non-smokers). These comprise mainly pulmonary diseases (96.2%) and cardio-vascular diseases (78.3%) All the recommended methods of the fight against smoking presented in the media, the publicity, national anti-smoking campaigns, personal contact and consultation, received more than 60% of favourable opinions among the total population studied.

Acute responses to nicotine and smoking: implications for prevention and treatment of smoking in lower SES women.

Compared with men, smoking reward and reinforcement in women tend to be less sensitive to nicotine but more sensitive to the nonpharmacological aspects of cigarette smoking (e.g. cues). Drawing mostly on findings from our laboratory, including new analyses of existing data, we explored whether characteristics possibly related to socioeconomic status (SES) may moderate acute responses to nicotine or smoking in women. Effects of nicotine in nonsmokers and in smokers were thought to identify factors that may be involved in the onset of nicotine dependence and in persistence of dependence, respectively. In nonsmokers, impulsive personality, prior marijuana use, and DRD2 and DRD4 genotypes may moderate nicotine responses in men but apparently not in women. However, the DRD4 gene may alter smoking reinforcement in response to negative mood in women but not men, a finding that could help explain smoking persistence in low SES women. Increasing women smoker's quit motivation via monetary reinforcement for abstinence may enhance the efficacy of nicotine patch during a quit attempt, at least in the short run. These findings clearly are tentative and require replication and extension in larger samples. A potentially more promising area of research concerns the recent finding from animal research that nicotine may enhance the reinforcing value of other reinforcers unrelated to smoking. Such an effect could increase our understanding of why quitting smoking is so difficult, why lapses after a quit attempt strongly predict failure of that attempt, and why nicotine replacement therapy aids cessation. Although speculative, low SES smokers may find smoking particularly hard to give up if doing so results in an overall decline in reinforcement, but they may gain more relative benefit from nicotine replacement therapy during quit attempts.

Estimating the impact of different cigarette package warning label policies: the auction method.

The study estimated the reduction in demand associated with implementing cigarette package warning labels that contain imagery illustrating the consequences of smoking. The experimental auction method was used, wherein adult smokers in Mexico (n=89) placed separate bids on two packs of cigarettes: one with a text-only warning label and the other with a warning label that included text and a graphic image. Differences in the values attributed to each pack were assessed using t-tests and multivariate regression. The pack with the graphic image had a mean attributed value which was 17% lower ($3.21 pesos) than the pack with the text-only warning, and this difference remained statistically significant within subgroups defined by sociodemographics, amount of smoking, number of quit attempts, and levels of perceived smoking risks. In the multivariate model, the difference in attributed values was greater among females than males, but no such differences were found for other sociodemographic or smoking-related variables. The consistently lower value that smokers attributed to cigarette packages with the graphic warning label indicates that these labels are likely to reduce cigarette demand.

Changes in health care costs before and after smoking cessation.

Previous research on health care costs among former smokers suggests that quitters incur greater health care costs for up to 4 years after cessation compared with continuing smokers. However, little is known about the relationship between health care costs and utilization in the periods before as well as after cessation. The present study used a retrospective cohort design with automated health plan and primary data to examine the health care costs and clinical experiences before and after smoking cessation among former smokers compared with a sample of continuing smokers. Subjects were a random sample of adults (aged 25 and older) whose smoking status was identified by a physician during a primary care visit to the Group Health Cooperative (GHC), a nonprofit, integrated health care delivery system in western Washington state. Total direct health care costs among former smokers began to rise in the quarter prior to cessation and were significantly greater (p < .001) than those of continuing smokers in the quarter immediately following cessation. This difference dissipated within one quarter following cessation. We replicated the postquit cost spike among former smokers found by other research and showed that this spike dissipated within the first year postquit. Smoking cessation did not result in sustained cost increases among former smokers.

Fighting a tobacco-tax rollback: a political analysis of the 1994 cigarette contraband crisis in Canada.

We identify factors that led a regional government (Quebec, Canada) to opt for a reduction of its tobacco tax to combat tobacco smuggling. Then we explore the fallout of Quebec's tobacco-tax rollback on its tobacco control policy. We conducted qualitative research using a case-study design and multiple sources of data. We applied the Advocacy Coalition Framework in respect of data collection and analysis. Advocates of the tobacco-tax rollback framed the contraband problem in a way that won the support of an array of actors. However, anti-tobacco activists succeeded in convincing the government to invest more in tobacco control. The new resources were instrumental in enhancing the activists' ability to promote legislative measures. Our approach sheds light on the tobacco industry's strategy to have governments reducing their tobacco tax. Quebec offers an example of how tobacco control activists can transform defeat into the cornerstone of a comprehensive tobacco control policy.