Who's still smoking? Disparities in adult cigarette smoking prevalence in the United States.

The continuing high prevalence of cigarette smoking among specific subpopulations, many of them vulnerable, is one of the most pressing challenges facing the tobacco control community. These populations include individuals in lower education and/or socioeconomic groups; from certain racial/ethnic groups; in the lesbian, gay, bisexual, and transgender community; with mental illness; and in the military, particularly among those in the lowest pay grades. Although traditional tobacco control measures are having positive health effects for most groups, the effects are not sufficient for others. More attention to and support for promising novel interventions, in addition to new attempts at reaching these populations through conventional interventions that have proven to be effective, are crucial going forward to find new ways to address these disparities. CA Cancer J Clin 2018;68:106-115. © 2018 American Cancer Society.

A blueprint for the primary prevention of cancer: Targeting established, modifiable risk factors.

In the United States, it is estimated that more than 1.7 million people will be diagnosed with cancer, and more than 600,000 will die of the disease in 2018. The financial costs associated with cancer risk factors and cancer care are enormous. To substantially reduce both the number of individuals diagnosed with and dying from cancer and the costs associated with cancer each year in the United States, government and industry and the public health, medical, and scientific communities must work together to develop, invest in, and implement comprehensive cancer control goals and strategies at the national level and expand ongoing initiatives at the state and local levels. This report is the second in a series of articles in this journal that, together, describe trends in cancer rates and the scientific evidence on cancer prevention, early detection, treatment, and survivorship to inform the identification of priorities for a comprehensive cancer control plan. Herein, we focus on existing evidence about established, modifiable risk factors for cancer, including prevalence estimates and the cancer burden due to each risk factor in the United States, and established primary prevention recommendations and interventions to reduce exposure to each risk factor.

Key issues surrounding the health impacts of electronic nicotine delivery systems (ENDS) and other sources of nicotine.

Answer questions and earn CME/CNE Over the last decade, the use of electronic nicotine delivery systems (ENDS), including the electronic cigarette or e-cigarette, has grown rapidly. More youth now use ENDS than any tobacco product. This extensive research review shows that there are scientifically sound, sometimes competing arguments about ENDS that are not immediately and/or completely resolvable. However, the preponderance of the scientific evidence to date suggests that current-generation ENDS products are demonstrably less harmful than combustible tobacco products such as conventional cigarettes in several key ways, including by generating far lower levels of carcinogens and other toxic compounds than combustible products or those that contain tobacco. To place ENDS in context, the authors begin by reviewing the trends in use of major nicotine-containing products. Because nicotine is the common core-and highly addictive-constituent across all tobacco products, its toxicology is examined. With its long history as the only nicotine product widely accepted as being relatively safe, nicotine-replacement therapy (NRT) is also examined. A section is also included that examines snus, the most debated potential harm-reduction product before ENDS. Between discussions of NRT and snus, ENDS are extensively examined: what they are, knowledge about their level of "harm," their relationship to smoking cessation, the so-called gateway effect, and dual use/poly-use. CA Cancer J Clin 2017;67:449-471. © 2017 American Cancer Society.

Physical activity counseling in primary care: Insights from public health and behavioral economics.

Physical inactivity has reached epidemic proportions in modern society. Abundant evidence points to a causal link between physical inactivity and increased risk for numerous noncommunicable diseases, such as some types of cancer and heart disease, as well as premature mortality. Yet, despite this overwhelming evidence, many individuals do not meet the recommended amount of physical activity required to achieve maximum health benefits. Because primary care physicians' advice is highly regarded, clinicians have the unique opportunity to play an important role in enabling patients to modify their behavior at the point of care with the goal of guiding patients to adopt and maintain an active lifestyle. In the current study, the authors evaluate pertinent literature from the fields of medicine/public health and economics/psychology to suggest a comprehensive approach to physical activity counseling at the primary care level. They first examine the public health approach to physical activity counseling, and then proceed to offer insights from behavioral economics, an emerging field that combines principles from psychology and economics. The application of key behavioral economics tools (eg, precommitment contracts, framing) to physical activity counseling in primary care is elaborated. CA Cancer J Clin 2017;67:233-244. © 2017 American Cancer Society.

Maternal smoking prevalence in Brazil in 2013 and 2019: not what we expected when they were expecting!

INTRODUCTION: Monitoring tobacco use during pregnancy is critical for achieving the United Nations Sustainable Development Goals. We examined changes between 2013 and 2019 in the relative differences in smoking prevalence rates between pregnant and non-pregnant women aged 18-49 years. METHODS: We used data from a nationally representative health survey conducted in Brazil in 2013 and 2019. A generalized linear model with binomial family and logarithmic link function was used to estimate, for each year of analysis, the crude and adjusted (by age-group, educational attainment, place of residence, and status of protection from passive smoking at home) relative differences. RESULTS: In 2013,the proportion point estimate of tobacco use among pregnant women was lower than that observed among non-pregnant women (4.7% vs. 9.6%). However, in 2019 proportion point estimates were virtually the same (8.5% vs. 8.4%). After adjustment for selected variables, in 2013, smoking prevalence among pregnant women was 42% (p-value≤0.05) lower than that observed among non-pregnant women. On the other hand, in 2019, maternal smoking prevalence was 13% (p-value>0.05) higher than that found among non-pregnant women. CONCLUSIONS: Ongoing tobacco industry interference and the marketing of tobacco products to vulnerable populations pose serious threats to public health and likely contributed to increasing maternal smoking prevalence. The fact that women smoke in such an important phase of their and their unborn children's lives reinforces the need to strengthen the implementation of concurrent tobacco control actions, including tobacco excise tax policy and pre-natal tobacco prevention and cessation interventions as part of health professionals' routine consultation. IMPLICATIONS: The decline in smoking prevalence among non-pregnant women between 2013 and 2019 was accompanied by an increase in maternal smoking prevalence. Monitoring tobacco use during pregnancy is critical for achieving the United Nations Sustainable Development Goals. Ongoing tobacco industry interference and the marketing of tobacco products to vulnerable populations in Brazil pose serious threats to public health. The fact that women smoke in such an important phase of their and their unborn children's lives reinforces the need to strengthen the implementation of concurrent tobacco control actions, including tobacco excise tax policy and primary healthcare professionals´ tobacco-related assistance during interaction with their patients.

Assessing the level of poverty and utilization of government social programs among tobacco farmers in Indonesia.

INTRODUCTION: Studies examining profit suggest that former tobacco farmers do as well or better than current tobacco farmers. Research has yet to examine the relationship among current and former tobacco farmers, poverty, and receipt of government social assistance. This type of research is critical to understanding the direct and indirect subsidization of tobacco growing. This study analyzed tobacco farmers' poverty levels and receipt of government social assistance programs. METHODS: We designed and conducted an original four-wave economic survey of current and former tobacco farming households in Indonesia between 2016 and 2022. We then used descriptive analysis and probit regression for panel data to estimate the relationship between tobacco farming and poverty status. RESULTS: Tobacco farmers' per capita income and poverty rates vary across years. The poverty rate was significantly higher in the year with a higher-than-normal rainfall as it negatively affected farming outcomes. During this year, the poverty rate among current tobacco farmers was also higher than that of former tobacco farmers. Regression estimates from the panel data confirm the association between tobacco farming and the likelihood of being poor. We also found a high share of current tobacco farmers who receive government social assistance programs, such as cash transfer programs and a universal healthcare program. CONCLUSIONS: Our findings show high poverty rates-particularly during bad farming years-and high rates of government social assistance among tobacco farmers. The high rates of government assistance among tobacco farmers living in poverty show that the government is indirectly subsidizing the tobacco industry.

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 cigarette market in Brazil: new evidence on illicit practices from the 2019 National Health Survey.

OBJECTIVE: To explore new evidence on illicit practices, such as selling legal brands below the minimum legal price (MLP), and smugglers selling illicit brands at or above the MLP. METHODS: For the first time in Brazil, self-reported information on cigarette brand name and price paid per pack in smokers' last purchase from a nationally representative survey conducted in 2019 was used to distinguish the illicit and the legal markets. We estimated the proportion of illicit cigarette consumption, using the combination of brand and price. RESULTS: The proportion of smuggled illicit cigarette consumption based on brands not approved on the Brazilian market was estimated at 38.6% (95% CI: 35.8% to 41.5%). When we added legal brands not paying taxes, it increased to 47.1% (95% CI: 44.2% to 49.9%). Around 25% of illicit brand cigarettes were sold at or above MLP. CONCLUSIONS: In Brazil, since 2017 there is a lack of adjustment in tobacco taxes and the MLP for inflation and income growth. The increase in cigarette affordability and the presence on the market of a segment of 'higher-priced' illicit brands suggest patterns of illicit brand loyalty and/or perceived 'brand quality' among smokers of illicit cigarettes. The evidence also shows that a sizeable proportion of legal brand cigarettes were sold below the MLP. This study offers insight into what happened in circumstances in which a government failed to keep current with tax policies and the monitoring of domestic manufacturing. Brazil has been a world leader in the monitoring of the tobacco epidemic, and this study also offers an innovative use of data that an increasing number of countries are collecting.

Foregrounding women and household dynamics to inform Article 17: a qualitative description analysis of tobacco farming households in Mozambique.

PURPOSE: This paper examines the intrahousehold dynamics between women and men present in tobacco farming households in Mozambique. Attention to the experiences and realities of the smallholder farmers is crucial for understanding approaches to alternative livelihoods. Intrahousehold dynamics can provide important insights into how these households and their members view tobacco production and engage with the political economy of tobacco farming, how they make decisions, and the rationale and values behind these decisions. METHODS: Data were collected through single-gender focus group discussions (n=8) with 108 participants (men=57, women=51). Analysis was informed by a qualitative description methodology. This research presents a gender-based analysis examining the perspectives, roles, decision-making processes and desires of female and male tobacco farmers in four key tobacco-growing districts in Mozambique. FINDINGS: Throughout this paper, women are found to hold leverage and influence in tobacco farming households, and this leverage is in part gained via the necessity of women's unpaid labour in achieving profitability in tobacco farming. Both women and men are also found to strongly desire and pursue the well-being of the household. CONCLUSION: Women hold agency within tobacco-growing households and participate in decision-making processes regarding tobacco agriculture. Women should be included in future tobacco control policies and programmes pertaining to Article 17.

Better cigarette tax policies and higher tobacco excise tax revenues.

BACKGROUND: In November 2021, the Tobacconomics team published the second edition of the Cigarette Tax Scorecard which evaluates cigarette taxation in each country based on four components-cigarette price, affordability change, tax share and tax structure. This study examines the relationship between the overall cigarette tax score and tobacco excise tax revenue between 2014 and 2018. METHODS: Using cigarette tax scores from the Tobacconomics Cigarette Tax Scorecard and tobacco excise tax revenue information from WHO, this analysis is based on ordinary least squares estimations to assess the association between the overall cigarette tax scores and tobacco excise tax revenues per capita controlling for countries' tobacco control environment, sociodemographic characteristics and country and year fixed effects. RESULTS: A 1-point higher overall cigarette tax score is associated with higher tobacco excise tax revenue per capita of $11.98 (in constant 2018 purchasing power parity international dollars). For low and middle-income countries and lower performing countries at baseline, a 1-point higher overall cigarette tax score is associated with higher tobacco excise tax revenue per capita of $11.32 and $6.92, respectively. If all countries had increased their scores to '5', the tobacco excise tax revenue per capita would have increased by 22.51%. CONCLUSIONS: Higher overall cigarette tax scores are associated with higher tobacco excise tax revenue per capita. Countries aiming to reach higher cigarette tax scores would be able to reduce tobacco use and increase their tobacco tax revenue, which can be allocated to development priorities.

Unemployment and cancer screening: Baseline estimates to inform health care delivery in the context of COVID-19 economic distress.

BACKGROUND: During the coronavirus disease 2019 pandemic, US unemployment rates rose to historic highs, and they remain nearly double those of prepandemic levels. Employers are the most common source of health insurance among nonelderly adults. Thus, job loss may lead to a loss of health insurance and reduce access to cancer screening. This study examined associations between unemployment, health insurance, and cancer screening to inform the pandemic's potential impacts on early cancer detection. METHODS: Up-to-date and past-year breast, cervical, colorectal, and prostate cancer screening prevalences were computed for nonelderly respondents (aged <65 years) with 2000-2018 National Health Interview Survey data. Multivariable logistic regression models with marginal probabilities were used to estimate unemployed-versus-employed unadjusted and adjusted prevalence ratios. RESULTS: Unemployed adults (2000-2018) were 4 times more likely to lack insurance than employed adults (41.4% vs 10.0%; P < .001). Unemployed adults had a significantly lower up-to-date prevalence of screening for cervical cancer (78.5% vs 86.2%; P < .001), breast cancer (67.8% vs 77.5%; P < .001), colorectal cancer (41.9 vs 48.5%; P < .001), and prostate cancer (25.4% vs 36.4%; P < .001). These differences were eliminated after accounting for health insurance coverage. CONCLUSIONS: Unemployment was adversely associated with up-to-date cancer screening, and this was fully explained by a lack of health insurance. Ensuring the continuation of health insurance coverage after job loss may mitigate the pandemic's economic distress and future economic downturns' impact on cancer screening.

Regional implications of the tobacco value chain in Paraguay.

BACKGROUND: Paraguay is a major supplier of illicit cigarettes for the Latin American region and beyond. In July 2022, Paraguay ratified the FCTC Protocol. This is an opportunity and a challenge for neighboring countries to implement coordinated actions. This is the first analysis of the foreign trade data for cigarettes and their inputs using Paraguayan data to contextualise the illicit trade problem in Latin America and globally. METHODS: Combining publicly available Paraguayan databases, this research constructs a database to analyse imported cigarette inputs, particularly by identifying the companies and their national origins. RESULTS: A complex multinational supply chain perpetuates a flow of inputs into Paraguay that contributes to the production and export of illicit tobacco products. Brazil is a relevant legal supplier of intermediate goods for the Paraguayan tobacco industry yet is not a significant destination of the legal exports of cigarettes produced in Paraguay. Yet, Paraguayan cigarettes are widely available in the Brazilian market, almost all of them illicit. Trade data also show the role of other countries in the region as major cigarette input exporters to Paraguay. Evidence also supports that high volumes of legal exports from Paraguay to third countries (including Bolivia, Suriname, Aruba and Curacao) may be fuelling illicit trade through triangulation to other countries. CONCLUSIONS: The oversupply-that is, more supply than necessary for domestic consumption and legal exports-of cigarette inputs likely divert illegally back to the countries exporting these inputs and others. Thus, the responsibility for illicit trade in cigarettes falls not only on Paraguayan companies but also on companies exporting inputs to Paraguay to producing these illicit goods. Furthermore, Paraguay is not only exporting illicitly directly to Brazil and Argentina, but also appears to oversupply other countries in South America and the Caribbean that cannot legally absorb this trade through domestic consumption and/or legal re-export.

Tobacco farming: overcoming an understated impediment to comprehensive tobacco control.

Tobacco farming has emerged as an important concern for tobacco control advocates. Tobacco-growing countries face unique and important challenges to comprehensive, intersectoral tobacco control. These challenges stem from narratives that position tobacco as an important driver of economic growth and development, perpetuated by tobacco interests with close ties to government decision-making. While the global tobacco control movement has enshrined a commitment to alternatives to tobacco growing, there remain numerous obstacles. Tobacco growing is often situated in contexts with limited markets for other agricultural products, limited knowledge and economic resources to pursue alternatives, and/or a structure that favours industry control over the supply chain, all constraining the decision space of farmers. An evidence-informed approach is necessary to address tobacco supply, including growing, processing, manufacturing and trade, in this complex context. This paper reviews the economic, environmental and policy context of tobacco growing with an emphasis on the past decade of empirical work on the political economy of tobacco supply and introduces strategies to pursue alternatives. This analysis debunks many of the arguments used to perpetuate the narrative of tobacco's prosperity and provides critical insights into the institutional constraints faced by government sectors in pursuing a policy of alternatives.

Tobacco 21 adoption decreased sales of cigarette brands purchased by young people: a translation of population health survey data to gain insight into market data for policy analysis.

INTRODUCTION: Policies raising the minimum age of sale of tobacco products to 21 (T21) proliferated at state and local levels across the USA before a federal policy was adopted. Evidence of the effectiveness of these policies is building and lags implementation. This study exploits demographic patterns of cigarette brand purchasing to evaluate the effectiveness of T21. METHODS: To capture the effect of T21 implementation on cigarette sales, we used universal product code-level data from Nielsen Scantrack data covering January 2015 to October 2019. We used the 2015 to 2018 National Survey on Drug Use and Health to identify cigarette brands where smokers under 21 comprised a disproportionately high (young) and low (old) share of consumption. We fit fixed-effects linear regressions in Nielsen designated market areas to test if sales of young or old cigarette brands were changed by T21. Unadjusted models controlled for time and T21 implementation date. Adjusted models controlled for price, seasonality and unemployment. A permutation test of 5000 randomised placebo T21 policies were fit to determine how well the true date of implementation fit sales data stratified by brand group. RESULTS: Sales of disproportionately young brands declined after T21 implementation. T21 policy implementation dates fit disproportionately young brand sales trends better than 99% of adjusted randomised placebo models. T21 implementation fit disproportionately old brand sales trends better than just 1% of adjusted randomised placebo models. CONCLUSION: This study adds compelling empirical evidence that T21 decreased purchases of the cigarette brands consumed disproportionately by young people, the policy's target demographic.

As countries improve their cigarette tax policy, cigarette consumption declines.

BACKGROUND: This study examines the association between the Tobacconomics cigarette tax scores and cigarette consumption in 97 countries during the period of 2014-2020. METHODS: Data on countries' retail cigarette sales and overall cigarette tax scores from 2014 to 2020 are drawn from the proprietary Euromonitor International database and the Tobacconomics Cigarette Tax Scorecard (second edition). Information on countries' tobacco control environments and demographic characteristics is from the relevant years' WHO Report on the Global Tobacco Epidemic, and the World Bank's World Development Indicators database. Ordinary least squares regressions are employed to examine the link between countries' overall cigarette tax scores and cigarette consumption. All regressions control for countries' tobacco control environments, countries' demographic characteristics, year indicators and country fixed effects. RESULTS: Each unit increase in the overall cigarette tax scores is significantly associated with a reduction of 9% in countries' per-capita cigarette consumption during 2014-2020. The reduction is more pronounced in low and middle-income countries (9%) than in high-income countries (6%). The modest improvement in scores from 2014 to 2020 is associated with a reduction of 3.27% in consumption, while consumption could have been reduced by 20.74% had countries implemented optimal tax policies that would earn the highest score of 5. CONCLUSIONS: Our results provide evidence on the association between higher cigarette tax scores and lower cigarette consumption. To reduce tobacco consumption, governments must strive to implement all four components in the Cigarette Tax Scorecard at the highest level.

A comprehensive economic assessment of the health effects of tobacco use and implications for tobacco control in Bangladesh.

BACKGROUND: Despite modest progress in reducing tobacco use, tobacco remains one of the major risk factors for non-communicable diseases in Bangladesh. METHODS: Using disease-specific, prevalence-based, cost-of-illness approach, this research estimated the economic costs of tobacco use and exposure to secondhand smoke based on data collected from a nationally representative survey of 10 119 households in 2018. RESULTS: The study estimated that 1.5 million adults were suffering from tobacco-attributable diseases and 61 000 children were suffering from diseases due to exposure to secondhand smoke in Bangladesh in 2018. Tobacco use caused 125 718 deaths in that year, accounting for 13.5% of all-cause deaths. The total economic cost was 305.6 billion Bangladeshi taka (BDT) (equivalent to 1.4% of gross domestic product or US$3.61 billion), including direct costs (private and public health expenditures) of BDT83.9 billion and indirect costs (productivity loss due to morbidity and premature mortality) of BDT221.7 billion. The total economic cost of tobacco more than doubled since 2004. CONCLUSION: Tobacco use imposes a significant and increasing disease and financial burden on society. The enormous tobacco-attributable healthcare costs and productivity loss underscore the need to strengthen the implementation of tobacco control policies to curb the epidemic.

Cross-validation of four different survey methods used to estimate illicit cigarette consumption in Brazil.

OBJECTIVE: To cross-validate estimates of the size of the illicit cigarette trade based on the results of four different survey methods. METHODS: In 2018/2019, four non-industry-funded, large-scale studies were conducted in selected Brazilian cities: packs discarded in household garbage/PDG (1 city), packs littered in the streets/PLS (5 cities), a phone survey of tobacco users' purchase behaviors/VIGITEL (5 cities), and a face-to-face household survey of tobacco users' purchase behaviors/FTF-household (2 cities). The proportions of illicit cigarettes consumed were based on the price paid by smokers in their last purchase (VIGITEL or FTF-household) and/or direct observation of brand names and health warnings (PDG, PLS or FTF-household). RESULTS: Based on PLS, the share of packs that avoided taxation ranged from 30.4% (95% CI 25.6% to 35.7%) in Rio de Janeiro to 70.1% (95% CI 64.6% to 75.0%) in Campo Grande; and PDG conducted in Rio de Janeiro found an even lower proportion point estimate of illicit cigarette use (26.8%, 95% CI 25.1% to 28.6%). In FTF-household, the share of illicit cigarette consumption based on the self-reported price ranged from 29.1% (95% CI 22.4% to 35.7%) in Rio de Janeiro to 37.5% (95% CI 31.2% to 43.7%) in São Paulo, while estimates based on pack observation ranged from 29.9% (95% CI 23.3% to 36.5%) in Rio de Janeiro to 40.7% (95% CI 34.3% to 47.0%) in São Paulo. For all cities, VIGITEL presented the lowest levels of illicit consumption, and most illicit brands were produced in Paraguay. CONCLUSIONS: Small differences in the estimated levels of illicit trade across methods were found, except for the phone survey. The cross-validation of estimates from independent studies is important to help effectively implement tobacco excise tax policy in Brazil and other low-income and middle-income countries.

Recent evidence on the illicit cigarette trade in Latin America.

The tobacco industry continues to present the illicit trade of tobacco products as a reason to slow, stop, or reverse tobacco control efforts in Latin America, including increasing tobacco excise taxes. In most cases, industry estimates of illicit trade, usually non-transparent and flawed, dwarf those of independent, rigorous research. Often, independent studies find that the levels of illicit trade are mostly non-consequential or easily manageable (<12%). Almost always, industry findings grossly overestimate the illicit market. Fortunately, a burgeoning empirical literature in the region-including Argentina, Brazil, Chile, Colombia, Mexico, and Uruguay-is illuminating the genuine levels and nature of this trade, typically employing gap analysis that compares tax-paid sales to consumption and/or pack inspection studies using packs shown by smokers in surveys or discarded in the streets or garbage. Additional research in countries including Brazil, Colombia, Ecuador, and Paraguay examines supply chains to help identify the illicit sources. This research is already helping governments to address any real problems with illicit trade and to reassure stakeholders that tobacco control efforts should be strengthened, not diminished.

La industria tabacalera sigue presentando el comercio ilícito de los productos derivados del tabaco como argumento para ralentizar, detener o revertir las actividades de control del tabaco en América Latina, como el aumento de los impuestos especiales al consumo de tabaco. En la mayoría de los casos, las estimaciones de la industria sobre el comercio ilícito, que generalmente tienen fallas y son poco transparentes, son pequeñas frente a las estimaciones hechas mediante investigaciones independientes y rigurosas. A menudo, los estudios independientes concluyen que los niveles de comercio ilícito son en su mayoría inconsecuentes o fácilmente manejables (< 12 %). Casi siempre, los resultados de la industria sobreestiman de manera considerable el mercado ilícito. Afortunadamente, una floreciente bibliografía empírica en la región, en países como Argentina, Brasil, Chile, Colombia, México y Uruguay, está arrojando luz sobre la verdadera naturaleza y los niveles reales de este comercio, generalmente empleando análisis de brechas que comparan las ventas que generan impuestos con el consumo, así como estudios de inspección de paquetes mostrados por fumadores encuestados o paquetes desechados en las calles o en la basura. En otras investigaciones en países como Brasil, Colombia, Ecuador y Paraguay se examinan las cadenas de suministro para ayudar a identificar las fuentes ilícitas. Esta investigación ya está ayudando a los gobiernos a abordar cualquier problema real con el comercio ilícito y reafirmar ante las partes interesadas que los esfuerzos de control del tabaco deben fortalecerse, no minimizarse.

A indústria do tabaco continua a apresentar o comércio ilícito de produtos derivados do tabaco como um motivo para retardar, interromper ou reverter os esforços para controlar o tabagismo na América Latina, incluindo o aumento dos impostos específicos sobre o consumo de tabaco. Na maioria dos casos, as estimativas do comércio ilícito feitas pela indústria, de modo geral falhas e pouco transparentes, fazem com que os resultados de pesquisas independentes e rigorosas pareçam menores. Não raro, estudos independentes constatam que os níveis do comércio ilícito são, na maioria dos casos, pouco significativos ou facilmente administráveis (<12%). Quase sempre, as constatações da indústria superestimam grosseiramente o mercado ilícito. Felizmente, uma bibliografia empírica crescente na região ­ abrangendo Argentina, Brasil, Chile, Colômbia, México e Uruguai ­ está lançando luz sobre os níveis efetivos e a natureza desse comércio, normalmente empregando uma análise de lacunas que compara as vendas tributadas com o consumo e/ou estudos baseados na inspeção das embalagens, usando embalagens mostradas por fumantes em levantamentos ou descartadas nas ruas ou no lixo. Outros estudos em países como Brasil, Colômbia, Equador e Paraguai examinam as cadeias de fornecimento para ajudar a identificar as fontes ilícitas. Este estudo já está ajudando os governos a abordar problemas reais com o comércio ilícito e a assegurar às partes interessadas que os esforços para controlar o tabagismo devem ser reforçados em vez de reduzidos.

Cancer deaths attributable to cigarette smoking in 152 U.S. metropolitan or micropolitan statistical areas, 2013-2017.

PURPOSE: There are limited data on the burden of cancer attributable to cigarette smoking by metropolitan areas to inform local tobacco control policies in the USA. We estimated the proportion of cancer deaths attributable to cigarette smoking (or population attributable fraction [PAF]) in 152 U.S. metropolitan or micropolitan statistical areas (MMSAs). METHODS: Smoking-related PAFs for cancer mortality in ages ≥ 30 years in 2013-2017 were estimated using cross-sectional age-, sex-, and MMSA-specific cigarette smoking prevalence and cancer mortality data obtained from the Behavioral Risk Factor Surveillance System and the U.S. Cancer Statistics Database, respectively. RESULTS: Overall smoking-related PAFs of cancer ranged from 8.8% (95% CI, 6.3-11.9%) to 35.7% (33.3-37.9%); MMSAs with the highest PAFs were in the South region and Appalachia. PAFs also substantially varied across MMSAs within regions or states. In the Northeast, for example, the PAF ranged from 24.2% (23.7-24.7%) to 33.7% (31.3-36.2%). CONCLUSION: The proportion of cancer deaths attributable to cigarette smoking is considerable in each MMSA, with as many as 4 in 10 cancer deaths attributable to smoking in the South region and Appalachia. Broad and equitable implementation and enforcement of proven tobacco control interventions at all government levels could avert many cancer deaths across the USA.

Price, Income, and Affordability as the Determinants of Tobacco Consumption: A Practitioner's Guide to Tobacco Taxation.

INTRODUCTION: Tobacco product prices and consumers' income are the two major economic determinants of tobacco demand. The affordability of tobacco products is dependent on the price of tobacco products relative to consumer income. Increase in tobacco tax is expected to lead to higher price, lower affordability, and reduced consumption. Price elasticity and affordability elasticity are used in analyzing the effect of tobacco tax increases on tobacco consumption and public health. The availability of both parameters raises the question of which one to apply in policy discussions. AIMS AND METHODS: Using global data on cigarette consumption, price, income, and tobacco control measures for 169 countries over 2007-2016, this study estimated the price elasticity and affordability elasticity of cigarette consumption by country income classification using country-specific fixed effects model for panel data. RESULTS: The estimates show that the restriction of equal strength of the effects of price and income changes on tobacco consumption maintained in affordability elasticity estimation is valid for low- and middle-income countries, while it is rejected for high-income countries. CONCLUSIONS: Affordability elasticity may prove to be a useful parameter to explain and predict the sensitivity of consumers to tobacco tax and price policy changes under conditions of robust economic growth, which are more likely to be observed in countries with initial low- or middle-income setting. It can provide a reasonable benchmark for tobacco tax and price increase necessary to effectively reduce affordability and consumption of tobacco, which can form a basis for building systematic tax and price increases into the tobacco tax policy mechanism. IMPLICATIONS: Price elasticity measures the sensitivity of consumers to changes in real prices, holding real income constant. Affordability elasticity measures the sensitivity of consumers to price changes adjusted for inflation and income changes. Existing scientific literature on tobacco demand abounds in both price and affordability elasticity estimates, without providing a clear explanation of the theoretical and policy implications of using one parameter over the other. By estimating and comparing price and affordability elasticities for high-income and low-and-middle-income countries separately, this article offers a guide to the practitioners in tobacco taxation for evaluating the effectiveness of tax-induced price increases on tobacco consumption.