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

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

The Price Elasticity of Cigarettes: New Evidence From Spanish Regions, 2002-2016.

INTRODUCTION: There is an agreement in the literature that tobacco price elasticity is around -0.4 for given location. Furthermore, works only focus separately, on the temporal dimension or the spatial dimension, however, there are studies that show the existence of spillovers between different geographical areas due to the spatial dependence in tobacco consumption. The novelty of this study is the measurement of the effect that neighboring regions have on the price elasticity of cigarettes. AIMS AND METHODS: This study simultaneously analyzed, first, a dynamic spatial model used to measure the price elasticity of cigarettes in the short term and long term of the 47 provinces that make up the Spanish territory, detailing the influence of neighbors. Second, given the spatial arrangement of the elasticities observed in the provinces, we can detect behaviors typical of large-scale illicit trade and cross-border purchasing since geographical location can be an important factor in smuggling, and politicians should take this into account when making price policies. RESULTS: Results reveal that the consumption of the regions is influenced by the consumption of the neighboring regions in the same period. The price elasticity of cigarettes in the long term exceeds in many cases, in absolute value, unity. This result is novel because tobacco has historically been treated as an inelastic demand good. Finally, we found that the regions that are most sensitive to price are those bordering France and Gibraltar or tourist regions, demonstrating the effect that smuggling has on the behavior of the regions. CONCLUSIONS: These results are important because the price in Spain is set by the central government and fiscal policies regarding the price of tobacco can have different effects in different regions. This study has shown that the consumption of cigarettes is influenced by the neighboring regions and also measured different sensitivities for each region. Regional cooperation in tobacco control policies may have better effects than the elaborated policies based on historical information. IMPLICATIONS: Policy makers should consider that tobacco could be an elastic good in the long term and that cooperation between countries in terms of price differential should be taken to avoid tobacco smuggling. The allocation of resources to control smoking should consider the special dependence shown in this report. Also, academics should account for spatial dependence to measure tobacco consumption instead of temporal analysis.

Impact of the announcement and implementation of the UK Soft Drinks Industry Levy on sugar content, price, product size and number of available soft drinks in the UK, 2015-19: A controlled interrupted time series analysis.

BACKGROUND: Dietary sugar, especially in liquid form, increases risk of dental caries, adiposity, and type 2 diabetes. The United Kingdom Soft Drinks Industry Levy (SDIL) was announced in March 2016 and implemented in April 2018 and charges manufacturers and importers at £0.24 per litre for drinks with over 8 g sugar per 100 mL (high levy category), £0.18 per litre for drinks with 5 to 8 g sugar per 100 mL (low levy category), and no charge for drinks with less than 5 g sugar per 100 mL (no levy category). Fruit juices and milk-based drinks are exempt. We measured the impact of the SDIL on price, product size, number of soft drinks on the marketplace, and the proportion of drinks over the lower levy threshold of 5 g sugar per 100 mL. METHODS AND FINDINGS: We analysed data on a total of 209,637 observations of soft drinks over 85 time points between September 2015 and February 2019, collected from the websites of the leading supermarkets in the UK. The data set was structured as a repeat cross-sectional study. We used controlled interrupted time series to assess the impact of the SDIL on changes in level and slope for the 4 outcome variables. Equivalent models were run for potentially levy-eligible drink categories ('intervention' drinks) and levy-exempt fruit juices and milk-based drinks ('control' drinks). Observed results were compared with counterfactual scenarios based on extrapolation of pre-SDIL trends. We found that in February 2019, the proportion of intervention drinks over the lower levy sugar threshold had fallen by 33.8 percentage points (95% CI: 33.3-34.4, p < 0.001). The price of intervention drinks in the high levy category had risen by £0.075 (£0.037-0.115, p < 0.001) per litre-a 31% pass through rate-whilst prices of intervention drinks in the low levy category and no levy category had fallen and risen by smaller amounts, respectively. Whilst the product size of branded high levy and low levy drinks barely changed after implementation of the SDIL (-7 mL [-23 to 11 mL] and 16 mL [6-27ml], respectively), there were large changes to product size of own-brand drinks with an increase of 172 mL (133-214 mL) for high levy drinks and a decrease of 141 mL (111-170 mL) for low levy drinks. The number of available drinks that were in the high levy category when the SDIL was announced was reduced by 3 (-6 to 12) by the implementation of the SDIL. Equivalent models for control drinks provided little evidence of impact of the SDIL. These results are not sales weighted, so do not give an account of how sugar consumption from drinks may have changed over the time period. CONCLUSIONS: The results suggest that the SDIL incentivised many manufacturers to reduce sugar in soft drinks. Some of the cost of the levy to manufacturers and importers was passed on to consumers as higher prices but not always on targeted drinks. These changes could reduce population exposure to liquid sugars and associated health risks.

An evaluation of Chile's Law of Food Labeling and Advertising on sugar-sweetened beverage purchases from 2015 to 2017: A before-and-after study.

BACKGROUND: Chile's Law of Food Labeling and Advertising, implemented in 2016, was the first national regulation to jointly mandate front-of-package warning labels, restrict child-directed marketing, and ban sales in schools of all foods and beverages containing added sugars, sodium, or saturated fats that exceed set nutrient or calorie thresholds. The objective of this study is to evaluate the impact of this package of policies on household beverage purchases. METHOD AND FINDINGS: In this observational study, monthly longitudinal data on packaged beverage purchases were collected from urban-dwelling households (n = 2,383) participating in the Kantar WordPanel Chile Survey from January 1, 2015, to December 31, 2017. Beverage purchases were linked to nutritional information at the product level, reviewed by a team of nutritionists, and categorized as "high-in" or "not high-in" according to whether they contained high levels of nutrients of concern (i.e., sugars, sodium, saturated fat, or energy) according to Chilean nutrient thresholds and were thus subject to the law's warning label, marketing restriction, and school sales ban policies. The majority of high-in beverages were categorized as such because of high sugar content. We used fixed-effects models to compare the observed volume as well as calorie and sugar content of postregulation beverage purchases to a counterfactual based on preregulation trends, overall and by household-head educational attainment. Of households included in the study, 37% of household heads had low education (less than high school), 40% had medium education (graduated high school), and 23% had high education (graduated college), with the sample becoming more educated over the study period. Compared to the counterfactual, the volume of high-in beverage purchases decreased 22.8 mL/capita/day, postregulation (95% confidence interval [CI] -22.9 to -22.7; p < 0.001), or 23.7% (95% CI -23.8% to -23.7%). High-educated and low-educated households showed similar absolute reductions in high-in beverage purchases (approximately 27 mL/capita/day; p < 0.001), but for high-educated households this amounted to a larger relative decline (-28.7%, 95% CI -28.8% to -28.6%) compared to low-educated households (-21.5%, 95% CI -21.6% to -21.4%), likely because of the high-educated households' lower level of high-in beverage purchases in the preregulation period. Calories from high-in beverage purchases decreased 11.9 kcal/capita/day (95% CI -12.0 to -11.9; p < 0.001) or 27.5% (95% CI -27.6% to -27.5%). Calories purchased from beverages classified as "not high-in" increased 5.7 kcal/capita/day (95% CI 5.7-5.7; p < 0.001), or 10.8% (10.8%-10.8%). Calories from total beverage purchases decreased 7.4 kcal/capita/day (95% CI -7.4 to -7.3; p < 0.001), or 7.5% (95% CI -7.6% to -7.5%). A key limitation of this study is the inability to assess causality because of its observational nature. We also cannot determine whether observed changes in purchases are due to reformulation or consumer behavioral change, nor can we parse out the effects of the labeling, marketing, and school sales ban policies. CONCLUSIONS: Purchases of high-in beverages significantly declined following implementation of Chile's Law of Food Labeling and Advertising; these reductions were larger than those observed from single, standalone policies, including sugar-sweetened-beverage taxes previously implemented in Latin America. Future research should evaluate the effects of Chile's policies on purchases of high-in foods, dietary intake, and long-term purchasing changes.

The Sweetened Beverage Tax in Cook County, Illinois: Lessons From a Failed Effort.

Objectives. To describe the public health and policy lessons learned from the failure of the Cook County, Illinois, Sweetened Beverage Tax (SBT).Methods. This retrospective, mixed-methods, qualitative study involved key informant (KI) and discussion group interviews and document analysis including news media, court documents, testimony, letters, and press releases. Two coders used Atlas.ti v.8A to analyze 321 documents (from September 2016 through December 2017) and 6 KI and discussion group transcripts (from December 2017 through August 2018).Results. Key lessons were (1) the SBT process needed to be treated as a political campaign, (2) there was inconsistent messaging regarding the tax purpose (i.e., revenue vs public health), (3) it was important to understand the local context and constraints, (4) there was implementation confusion, and (5) the media influenced an antitax backlash.Conclusions. The experience with the implementation and repeal of the Cook County SBT provides important lessons for future beverage tax efforts.Public Health Implications. Beverage taxation efforts need to be treated as political campaigns requiring strong coalitions, clear messaging, substantial resources, and work within the local context.

Implementation of the First US Sugar-Sweetened Beverage Tax in Berkeley, CA, 2015-2019.

Objectives. To identify lessons learned from implementation of the nation's first sugar-sweetened beverage (SSB) excise tax in 2015 in Berkeley, California.Methods. We interviewed city stakeholders and SSB distributors and retailers (n = 48) from June 2015 to April 2017 and analyzed records through January 2019.Results. Lessons included the importance of thorough and timely communications with distributors and retailers, adequate lead time for implementation, advisory commissions for revenue allocations, and funding of staff, communications, and evaluation before tax collection begins. Early and robust outreach about the tax and programs funded can promote and sustain public support, reduce friction, and facilitate beverage price increases on SSBs only. No retailer reported raising food prices, indicating that Berkeley's SSB tax did not function as a "grocery tax," as industry claimed. Revenue allocations totaled more than $9 million for public health, nutrition, and health equity through 2021.Conclusions. The policy package, context, and implementation process facilitated translating policy into public health outcomes. Further research is needed to understand long-term facilitators and barriers to sustaining public health benefits of Berkeley's tax and how those differ from facilitators and barriers in jurisdictions facing significant industry-funded repeal efforts.

Smoking Behavior in Low- and High-Income Adults Immediately Following California Proposition 56 Tobacco Tax Increase.

Objectives. To compare the association of California Proposition 56 (Prop 56), which increased the cigarette tax by $2 per pack beginning on April 1, 2017, with smoking behavior among low- and high-income adults.Methods. Drawing on a sample of 17 206 low-income and 21 324 high-income adults aged 21 years or older from the 2012 to 2018 California Behavioral Risk Factor Surveillance System data, we explored 2 outcomes: current smoking prevalence and smoking intensity (average number of cigarettes per day among current smokers). For each income group, we estimated a multivariable logistic regression to analyze the association of Prop 56 with smoking prevalence and a multivariable linear regression to analyze the association of Prop 56 with smoking intensity.Results. Although we observed no association between smoking intensity and Prop 56, we found a statistically significant decline in smoking prevalence among low-income adults following Prop 56. No such association was found among the high-income group.Conclusions. Given that low-income Californians smoke cigarettes at greater rates than those with higher incomes, our results provide evidence that Prop 56 is likely to reduce income disparities in cigarette smoking in California.

Tobacco Industry Promotions and Pricing After Tax Increases: An Analysis of Internal Industry Documents.

BACKGROUND: Increasing tobacco taxes, and through them, prices, is an effective public health strategy to decrease tobacco use. The tobacco industry has developed multiple promotional strategies to undercut these effects; this study assessed promotions directed to wholesalers and retailers and manufacturer price changes that blunt the effects of tax and price increases. METHODS: We reviewed tobacco industry documents and contemporaneous research literature dated 1987 to 2016 to identify the nature, extent, and effectiveness of tobacco industry promotions and price changes used after state-level tobacco tax increases. RESULTS: Tobacco companies have created promotions to reduce the effectiveness of tobacco tax increases by encouraging established users to purchase tobacco in lower-tax jurisdictions and sometimes lowering manufacturer pricing to "undershift" smaller tax increases, so that tobacco prices increased by less than the amount of the tax. CONCLUSIONS: Policymakers should address industry efforts to undercut an effective public health intervention through regulating minimum prices, limiting tobacco industry promotions, and by enacting tax increases that are large, immediate, and result in price increases. IMPLICATIONS: Tobacco companies view excise tax increases on tobacco products as a critical business threat. To keep users from quitting or reducing tobacco use in response to tax increases, they have shifted manufacturer pricing and developed specific promotions that encourage customers to shop for lower-taxed products. Health authorities should address tobacco industry efforts to undercut the effects of taxes by regulating prices and promotions and passing large and immediate tax increases.

Identification of Policy Priorities to Address the Burden of Smokeless Tobacco in Pakistan: A Multimethod Analysis.

INTRODUCTION: We assessed the magnitude of smokeless tobacco (ST) use in Pakistan and identified policy gaps to help ascertain short-, medium-, and long-term priorities. We then elicited stakeholders' views as to which of these identified priorities are most important. METHODS: In a multimethod study, we: analyzed Global Tobacco Surveillance System data sets to estimate ST consumption and disease burden; conducted a documentary review to identify gaps in policies to control ST in comparison with smoking; elicited stakeholders' views in an interactive workshop to identify a set of policy options available to address ST burden in Pakistan; and ranked policy priorities using a postevent survey. RESULTS: Among all tobacco users in Pakistan (n = 24 million), one-third of men and two-thirds of women consume ST. In 2017, its use led to an estimated 18 711 deaths due to cancer and ischemic heart disease. Compared to smoking, policies to control ST lag behind significantly. Priority areas for ST policies included: banning ST sale to and by minors, advocacy campaigns, introduction of licensing, levying taxes on ST, and standardizing ST packaging. A clear commitment to close cooperation between state actors and stakeholder groups is needed to create a climate of support and information for effective policy making. CONCLUSIONS: Smokeless tobacco control in Pakistan should focus on four key policy instruments: legislation, education, fiscal policies, and quit support. More research into the effectiveness of such policies is also needed. IMPLICATIONS: A number of opportunities to improve ST regulation in Pakistan were identified. Among these, immediate priorities include banning ST sale to and by minors, mobilizing advocacy campaign, introduction of licensing through the 1958 Tobacco Vendors Act, levying taxes on ST, and standardizing ST packaging.

Tobacco control in Nepal during a time of government turmoil (1960-2006).

BACKGROUND: Nepal was a monarchy, then a dictatorship, then a democracy. This paper reviews how tobacco control progressed in Nepal in the context of these changes in government from 1950 through 2006. METHODS: We triangulated tobacco industry documents, newspaper articles and key informant interviews. RESULTS: Until 1983, the tobacco industry was mostly state owned. Transnational tobacco companies entered the Nepalese market through ventures with Surya Tobacco Company Private Limited (with Imperial Tobacco Company and British American Tobacco) in 1983 and Seti Cigarette Factory Limited (with Philip Morris International [PMI]) in 1985. Seminars and conferences on tobacco, celebrations of World No Tobacco Day (WNTD) and efforts by WHO helped promote tobacco control in Nepal beginning in the 1970s. Tobacco advocates in Nepal pushed the government to issue executive orders banning smoking in public places in 1992 and tobacco advertising in electronic media in 1998, and to introduce a tobacco health tax in 1993. The tobacco industry lobbied against these measures and succeeded in keeping the tobacco tax low by challenging it in court. Tobacco advocates sued the government in 2003 and 2005, resulting in a June 2006 Supreme Court decision upholding the smoking and advertising bans and requiring the government to enact a comprehensive tobacco control law. CONCLUSIONS: Political instability, conflict, weak governance and the dictatorship significantly affect tobacco control activities in low-income and middle-income countries. Nepal shows that tobacco control advocates can take advantage of global events, such as WNTD, and use domestic litigation to maintain support from civil societies and to advocate for stronger tobacco control policies.

Changes to the littered cigarette pack environment in New York City between 2011 and 2015.

INTRODUCTION: Imposing policies that increase tobacco prices is a key strategy for reducing smoking prevalence, although it may result in more cigarette trafficking. In 2013, New York City (NYC) passed the Sensible Tobacco Enforcement (STE) law requiring cigarettes be sold for a minimum price of $10.50 per pack. To evaluate whether cigarette price increases changed patterns of behaviour related to cigarette tax evasion, we examined littered pack study data from 2011 and 2015. METHODS: Littered cigarette packs were collected from a random sample of NYC census tracts in 2011 and 2015. The proportions of cigarette packs with proper local, known non-local, foreign or unknown, and no tax stamp were calculated. Changes in volume, source and consumption of domestically trafficked cigarettes over time were estimated. RESULTS: In 2011, 255 packs with cellophane were collected; in 2015, 226 packs with cellophane were collected. Packs without proper local stamp increased from 60.7% in 2011 to 76.3% in 2015 (p<0.05) and those with foreign or unknown stamp increased from 11.6% in 2011 to 31.4% in 2015 (p<0.05). The percentage of domestically sourced packs attributed to domestic trafficking increased significantly from a range of 47.9% to 52.8% in 2011 to a range of 59.4% to 63.2% in 2015. CONCLUSION: While the trafficking rate among domestically sourced cigarettes increased between 2011 and 2015 (before and after the STE minimum price floor on cigarette packs was in place), there was a decline in total consumption of domestically trafficked cigarettes due to a significant increase in consumption of foreign-sourced cigarettes. Jurisdictions considering price measures should bolster monitoring and enforcement efforts to maximise public health impact. Given the interstate nature of cigarette trafficking in the USA, Federal intervention would be optimal.

Hospital Taxes, Medicaid Supplemental Payments, and State Budgets.

The federal Medicaid statute provides states an incentive to tax hospitals (even otherwise tax-exempt ones) as a means of raising revenue and then leverage federal matching funds by returning at least some of the tax back to the hospitals in the form of Medicaid supplemental payments. The potential for supplemental payments is attractive to hospitals, especially those struggling to recoup the costs of treating Medicaid and uninsured patients, and has resulted in political support from hospitals for states to create hospital "taxes" in name only-hospitals and states both end up with more money than they did when they started because of the federal match. When state officials begin to perceive, however, that nonprofit hospitals may be serving private rather than public interests, they are able to use these hospital taxes as a way to incrementally chip away at the historic governmental support provided through tax exemption by redirecting the revenue raised from the hospital tax to general fund purposes rather than Medicaid supplemental payments. This article looks at how states have been using hospital taxes and supplemental payments to balance state budgets and whether this practice is consistent with the Medicaid program objectives that make the taxes politically feasible.

The Use of Excise Taxes to Reduce Tobacco, Alcohol, and Sugary Beverage Consumption.

In countries around the world, tobacco use, excessive alcohol consumption, and consumption of sugar-sweetened beverages (SSBs) are significant contributors to the global epidemic of noncommunicable diseases. As a consequence, they contribute, as well, to excess health care costs and productivity losses. A large and growing body of research documents that taxes specific to such products, known as excise taxes, reduce consumption of these products and thereby diminish their adverse health consequences. Although such taxation has historically been motivated primarily by revenue generation, governments are increasingly using these taxes to discourage unhealthy consumption. We review the global evidence on the impact of taxes and prices on the consumption of these products and the health and social consequences. We then evaluate arguments commonly raised against these taxes, identify best practices in excise tax policy, and conclude with a summary of the current status of tobacco, alcohol, and SSB excise taxes globally.

Modelling the impact of a tax on sweetened beverages in the Philippines: an extended cost-effectiveness analysis.

OBJECTIVE: To assess the potential impact of a new tax on sweetened beverages on premature deaths associated with noncommunicable diseases in the Philippines. METHODS: In January 2018, the Philippines began imposing a tax of 6 Philippine pesos per litre (around 13%) on sweetened beverages to curb the obesity burden. Using national data sources, we conducted an extended cost-effectiveness analysis to estimate the effect of the tax on the numbers of premature deaths averted attributed to type 2 diabetes mellitus, ischaemic heart disease and stroke, across income quintiles over the period 2018-2037. We also estimated the financial benefits of the tax from reductions in out-of-pocket payments, direct medical costs averted and government health-care cost savings. FINDINGS: The tax could avert an estimated 5913 deaths related to diabetes, 10 339 deaths from ischaemic heart disease and 7950 deaths from stroke over 20 years. The largest number of deaths averted could be among the fourth and fifth (highest) income quintiles. The tax could generate total health-care savings of 31.6 billion Philippine pesos (627 million United States dollars, US$) over 20 years, and raise 41.0 billion Philippine pesos (US$ 813 million) in revenue per annum. The poorest quintile could bear the smallest tax burden increase (14% of the additional tax; 5.6 billion Philippine pesos) and have the lowest savings in out-of-pocket payments due to relatively large health-care subsidies. Finally, we estimated that 13 890 cases of catastrophic expenditure could be averted. CONCLUSION: The new sweetened beverage tax may help to reduce obesity-related premature deaths and improve financial well-being in the Philippines.

Development of a sweetened beverage tax, Philippines.

PROBLEM: Both sugar-sweetened beverage consumption and the incidence of obesity have increased in the Philippines in recent years. APPROACH: A proposal to tax sugar-sweetened beverages was introduced in the House of Representatives and merged into a proposed comprehensive Tax Reform for Acceleration and Inclusion (TRAIN) Bill to increase the likelihood of acceptance. The health department and finance department recommended a policy that would maximize benefits to both public health and government revenue. To advance discussions, the health department expanded the health argument to include the country's poor performance in oral health. The approved TRAIN Law adopted the term sweetened beverage to emphasize that the tax covers both sugar and non-sugar sweetened beverages. The tax rate was set to 6.00 Philippine pesos (0.111 United States dollars) per litre of sweetened beverages. The sugar industry successfully lobbied for higher tax rates on beverages containing high-fructose corn syrup, resulting in a differential rate of 12.00 Philippine pesos per litre. LOCAL SETTING: Despite a 12% value-added tax on sugar-sweetened beverages, sales had been sustained by enhanced marketing and product variants being offered in small portions. RELEVANT CHANGES: One month after implementation of the tax in 1 January 2018, prices of taxable sweetened beverages had increased by 16.6 to 20.6% and sales in sari-sari (convenience) stores had declined 8.7%. LESSONS LEARNT: The tax benefited from high-level government commitment and support, keeping policy simple reduced opportunities for tax avoidance and evasion, and taking both health and non-health considerations into account were helpful in arguing for the tax.

Examining quit attempts and successful quitting after recent cigarette tax increases.

As cigarette smoking rates decline, an important policy question is whether increasing cigarette taxes will continue to encourage smoking cessation. We tested this question following recent tobacco tax increases. Data were from the Minnesota Adult Tobacco Survey, a serial cross-sectional telephone survey conducted statewide, and was limited to past-year cigarette smokers in 2010 (n = 1029) and 2014 (n = 1382). Weighted estimates were calculated of the prevalence of past year smokers, smokers who attempted to quit smoking, and those who successfully quit by demographics, tobacco use, use of evidence-based cessation assistance to quit, and smoker perceptions of the tax increases. Among past year smokers, almost 60% reported a quit attempt in both years, 12.8% successfully quit in 2010 and 15.6% in 2014. Although older age, daily smoking, mean cigarettes per day, and more days of e-cigarette use, were associated with quit attempts in unadjusted models, only the perceived tax increase effect (AOR = 8.9; 95% CI 6.3-12.5) and low nicotine dependence (AOR = 1.9, 95% CI 1.3-2.7) were associated with making a quit attempt in adjusted models. Successful 12-month quits were predicted by college education (AOR = 3.2, 95% CI 1.3-7.8), the use of cessation support (AOR = 2.1, 95% CI 1.3-3.6), and reporting the tax increase helped maintain a quit (AOR = 12.3, 95% CI 7.5-20.1). These findings suggest that a large tax increase is effective in promoting quitting even in the presence of strong tobacco control measures such as indoor smoking bans and other smoking restrictions, mass media campaigns, and universal access to cessation support.