American Cancer Society's report on the status of cancer disparities in the United States, 2021.

In this report, the authors provide comprehensive and up-to-date US data on disparities in cancer occurrence, major risk factors, and access to and utilization of preventive measures and screening by sociodemographic characteristics. They also review programs and resources that have reduced cancer disparities and provide policy recommendations to further mitigate these inequalities. The overall cancer death rate is 19% higher among Black males than among White males. Black females also have a 12% higher overall cancer death rate than their White counterparts despite having an 8% lower incidence rate. There are also substantial variations in death rates for specific cancer types and in stage at diagnosis, survival, exposure to risk factors, and receipt of preventive measures and screening by race/ethnicity, socioeconomic status, and geographic location. For example, kidney cancer death rates by sex among American Indian/Alaska Native people are ≥64% higher than the corresponding rates in each of the other racial/ethnic groups, and the 5-year relative survival for all cancers combined is 14% lower among residents of poorer counties than among residents of more affluent counties. Broad and equitable implementation of evidence-based interventions, such as increasing health insurance coverage through Medicaid expansion or other initiatives, could substantially reduce cancer disparities. However, progress will require not only equitable local, state, and federal policies but also broad interdisciplinary engagement to elevate and address fundamental social inequities and longstanding systemic racism.

Healthy People Countdown 2030: reaching 5% cigarette smoking prevalence among US adults through state cigarette excise tax increases.

OBJECTIVE: The Healthy People 2030 goal is to reduce US current adult cigarette smoking prevalence to 5% by 2030. The objective of this report is to investigate if this goal is achievable using state cigarette excise tax increases. METHODS: State-specific linear trends in smoking prevalence over 2011-2019 were determined using fractional logit regression and compared with the desired linear trends for achieving 5% smoking prevalence by 2030 in individual states and the District of Columbia (DC). The gaps between price-adjusted and desired trends were used in a simulation model for identifying state-specific systematic annual increases in state cigarette excise tax rates based on state-specific price elasticity of smoking prevalence, maintaining the status quo in other non-tax tobacco control measures. RESULTS: The price-adjusted trends in smoking prevalence observed over 2011-2019 exceed the desired trends for achieving 5% smoking prevalence target by 2030 in only five states (eg, Washington, Utah, Rhode Island, Massachusetts and Maryland) and the DC. It suggests that majority of states and USA overall will miss the target smoking prevalence at the current rate of reduction in smoking. 45 states would need systematic annual increases in cigarette excise tax rate in a range of $0.02-$1.37 per pack over 2022-2030 to meet the target. CONCLUSIONS: The feasibility of reaching the Healthy People 2030 goal would critically depend on the acceleration of progress in tobacco control. Tax increases tailored to the needs of individual states combined with scaled-up non-tax tobacco control policy interventions can help achieve the desired progress.

Trends in public interest in shopping and point-of-sales of JUUL and Puff Bar 2019-2021.

INTRODUCTION: We investigated public interest in shopping and point-of-sales (POS) of JUUL and Puff Bar products in the context of five regulatory, company sales policy and other events of interest that may have influenced the trajectory of these products during 2019-2021. METHODS: Outcome variables included relative search volume (RSV) from Google search queries indicative of shopping interest in and aggregate dollar sales from Nielsen POS for JUUL and Puff Bar in the USA from March 2019 to May 2021. Adjusted autoregressive integrated moving average assessed the observed and predicted trends and adjusted linear regression analysis measured the relative rate of change in the outcome variables for each time period of interest. RESULTS: After the Trump administration announced its plans to ban flavoured e-cigarettes and JUUL Labs, Inc.'s decided to suspend the sales of its sweet and fruity flavoured products, JUUL's shopping interest RSV and sales declined while Puff Bar's shopping interest RSV peaked, and its sales increased. From the period following FDA's announcement of its enforcement guidance policy on unauthorised flavoured cartridge-based e-cigarettes until May 2021, JUUL's shopping interest RSV and sales continued to decline. Puff Bar's shopping interest RSV increased, and its sales peaked until the House approved the flavoured e-cigarette ban bill. Puff Bar's sales steeply declined following suspension of its sales in February 2020. The decline, however, slowed after Puff Bar products were relaunched as 'synthetic nicotine' e-cigarettes. CONCLUSIONS: Puff Bar's unprecedented peak in the shopping interest and sales of Puff Bar warrants continued surveillance.

Association between cigarette sales in the USA and FDA's announcement of its intention to prohibit menthol as a characterising flavour in cigarettes.

INTRODUCTION: On 29 April 2021, the US Food and Drug Administration (FDA) announced its intention to prohibit menthol as a characterising flavour in cigarettes. METHODS: We assessed the changes in cigarette sales associated with the FDA's announcement using interrupted time series analysis based on monthly retail point-of-sale data on cigarettes from the NielsenIQ Local Trade Area (LTA) data from September 2019 to April 2022. Main outcome variables included LTA-level monthly menthol and non-menthol cigarette sales per 1000-persons. RESULTS: Monthly cigarette sales were declining before the FDA's announcement (menthol vs non-menthol: -1.68 (95% CI -1.92, -1.45) vs -3.14 (95% CI -3.33, -2.96) packs per 1000-persons). Monthly menthol cigarette sales increased immediately in May 2021 after the FDA's announcement by 6.44 packs per 1000-persons (95% CI 3.83, 9.05). Analysis stratified by LTA-level racial/ethnic compositions showed that LTAs with a relatively higher proportion of non-Hispanic Black population (>8.94%) experienced higher spike in menthol cigarette sales in May 2021 immediately after the announcement and higher post-announcement 12-month menthol cigarette sales than expected. CONCLUSIONS: Areas with a relatively higher proportion of non-Hispanic Black population are potentially at risk of experiencing increased burden of menthol cigarette consumption. Targeted community level cessation support in non-Hispanic Black majority areas may help mitigate the growing burden of menthol cigarette smoking and improve health equity. The findings of this study also suggest that FDA's prompt finalisation and enforcement of such ban may help avoid extending the increased burden of menthol cigarette consumptions in non-Hispanic Black majority areas.

Price elasticity of cigarette smoking in Bangladesh: evidence from the Global Adult Tobacco Surveys (GATS).

INTRODUCTION: The overall prevalence of cigarette smoking has not changed significantly for over a decade in Bangladesh. Raising the price of cigarettes through taxation is an important policy instrument for reducing consumption and achieving public health goals. The price elasticity of cigarette demand is an important parameter for evaluating the effectiveness of raising prices through tax increases in reducing cigarette consumption. The objective of the study was to estimate the price elasticity of cigarette demand in Bangladesh using Global Adult Tobacco Survey 2009 and 2017 data. METHODS: Smoking prevalence and smoking intensity were estimated using a two-part model. Endogeneity of prices was minimised using the average consumption-weighted cigarette price in a cluster, for both smokers and non-smokers residing in a specific cluster. RESULTS: Cigarette demand was found to be price inelastic and ranged between -0.51 and -0.73. It is also price inelastic across wealth groups and areas of residence in Bangladesh. Although the total price elasticity did not differ considerably between rural and urban locations, it is evident that individuals in the lower-wealth group are more than twice as responsive to price increases as their high-wealth counterparts. CONCLUSION: A significant increase in cigarette prices through a tax increase would decrease smoking prevalence and increase tax revenue in Bangladesh. The greater price sensitivity among smokers in lower-wealth groups indicates that a tax-induced cigarette price increase would provide more health benefits to them, thereby contributing to improved health equity.

Association of nicotine replacement therapy product sales with menthol cigarette sales restriction in Massachusetts.

BACKGROUND: Massachusetts was the first to implement a state-wide menthol cigarette sales restriction in the USA. Following its implementation in June 2020, evidence showed declines in cigarette sales in Massachusetts; however, changes in nicotine replacement therapy (NRT) product sales are unknown. METHODS: This cohort study analysed NRT products sold by US-based retailers available in 26 states from the Nielsen Retail Scanner Data. Outcomes were state-level 4-week aggregate sales of gum, lozenge and patch NRT products converted into pieces per 1000 adults (aged ≥18 years) who smoke cigarettes based on smoking rates from the Behavioral Risk Factor Surveillance System and corresponding population from the US Census Bureau. We used a difference-in-differences method to compare changes in NRT product sales in Massachusetts before (1 January 2017 to 13 June 2020) and after (14 June 2020 to 4 December 2021) the policy with sales in 25 states. RESULTS: The analysis included 1664 observations for each NRT product, with 1170 from before and 494 from after the policy change. The 4-week NRT product sales per 1000 adults who smoke cigarettes in Massachusetts compared with the comparison states increased for gums by 643.11 (95% CI 365.33 to 920.89; p<0.001) pieces or 12.9% and for lozenges by 436.97 (95% CI 292.88 to 581.06; p<0.001) pieces or 17.9% but no statistically significant change in patches after implementing the policy. CONCLUSION: The increases in sales of gum and lozenge NRT products in Massachusetts after implementing the policy suggest that a nationwide ban on menthol cigarettes can increase NRT product use; therefore, interventions are needed to strengthen cessation support for adults who smoke cigarettes but intend to quit.

Estimating own-price and cross-price elasticity of cigarette consumption by price tiers in Bangladesh.

OBJECTIVES: The overall price elasticity of cigarette consumption in Bangladesh has been studied extensively. The estimates of price elasticity by price tiers are not available in the existing literature. METHODS: Using cohort data of nearly 6000 individuals from the International Tobacco Control Bangladesh survey, this study estimated the own-price and cross-price elasticity and income elasticity of cigarette demand by price tiers in Bangladesh. The elasticity was estimated in three stages of consumer decisions: whether to smoke, which brand to smoke and finally, how many cigarettes to smoke per day. The decision to smoke cigarettes and the choice of cigarette brands were modelled using instrumental variable probability regression. The cigarette consumption per day was modelled using seemingly unrelated regression. RESULTS: The price elasticity of cigarette smoking prevalence with respect to the price of low-price cigarettes is -0.0487. The total elasticity for low-price cigarette consumption with respect to its own price is -0.1678. The own-price elasticity of smoking intensity of high-priced brands is -0.2512. The cross-price elasticity of low-price cigarette consumption with respect to high-price brand prices is 0.2643. The income elasticity of smoking prevalence overall is 0.0564. The income elasticity of daily consumption of low-price cigarettes is -0.1934 and for high-price cigarettes, it is 1.4044. The total income elasticity is 1.4608 for high-price cigarettes. CONCLUSION: A cigarette tax policy that raises the prices of both low-price and high-price brands-but increases prices in the low-price tier at a faster rate than in the high-price tier and increases prices of all brands at a pace faster than income growth-can effectively reduce cigarette consumption in Bangladesh. JEL CODES: H29, L66, I18.

Person-years of life lost and lost earnings from cigarette smoking-attributable cancer deaths, United States, 2019.

State-specific information on lost earnings due to smoking-attributable cancer deaths to inform and advocate for tobacco control policies is lacking. We estimated person-years of life lost (PYLL) and lost earnings due to cigarette smoking-attributable cancer deaths in the United States nationally and by state. Proportions and numbers of cigarette smoking-attributable cancer deaths and associated PYLL among individuals aged 25 to 79 years in 2019 were calculated and combined with annual median earnings to estimate lost earnings attributable to cigarette smoking. In 2019, estimated total PYLL and lost earnings associated with cigarette smoking-attributable cancer deaths in ages 25 to 79 years in the United States were 2 188 195 (95% CI, 2 148 707-2 231 538) PYLL and $20.9 billion ($20.0 billion-$21.7 billion), respectively. States with the highest overall age-standardized PYLL and lost earning rates generally were in the South and Midwest. The estimated rate per 100 000 population ranged from 352 (339-366) in Utah to 1337 (1310-1367) in West Virginia for PYLL and from $4.3 million ($3.5 million-$5.2 million) in Idaho to $14.8 million ($10.6 million-$20.7 million) in Missouri for lost earnings. If age-specific PYLL and lost earning rates in Utah had been achieved by all states, 58.2% (57.0%-59.5%) of the estimated total PYLL (1 274 178; 1 242 218-1 306 685 PYLL) and 50.5% (34.2%-62.4%) of lost earnings ($10.5 billion; $7.1 billion-$13.1 billion) in 2019 nationally would have been avoided. Lost earnings due to smoking-attributable cancer deaths are substantial in the United States and are highest in states with weaker tobacco control policies.

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.

Price and Income Elasticities of Cigarette Smoking Demand in Bangladesh: Evidence from Urban Adolescents and Young Adults.

INTRODUCTION: Understanding the elasticities of cigarette smoking demand among the youth could help improve the effectiveness of tobacco control interventions. The objective of this study is to measure the price and income elasticities of cigarette smoking demand among urban Bangladeshi male adolescents and young adults aged 10-24 years. METHOD: Using data from a cross-sectional survey conducted in seven urban districts of Bangladesh, we applied probit and ordinary least square (OLS) models to examine the effect of price and income on smoking participation (decision to smoke) and intensity (number of cigarettes smoked). RESULTS: Our results showed that price was not significantly associated with the decision to smoke, while income was a significant determinant of smoking participation. Both price and income determined the smoking intensity. The positive income elasticity (0.39) indicated that participants with greater access to money were more likely to participate in cigarette smoking and smoked more cigarettes. Negative price elasticity (-0.62) implied that increasing prices could lead to a reduction in smoking intensity among adolescents and young adults in urban Bangladesh. CONCLUSION: The inelastic price demand for cigarette smoking suggests that there is scope for increasing tax on cigarettes without compromising the tax revenue. IMPLICATIONS: This is the first study to investigate price and income elasticities among urban adolescents and young adults in Bangladesh. The study found no evidence that increasing the price of cigarettes discourages smoking participation but did show that increasing the price reduces the intensity of smoking among existing smokers. The results also suggest that economic measures such as taxation that increase the price of cigarettes could be a useful policy tool to limit smoking intensity without compromising government tax revenue.

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.

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.

Tobacco or not tobacco: predicting farming households' income in Indonesia.

BACKGROUND: Recent research in several countries has demonstrated that small-holder tobacco farming is typically not a profitable enterprise. Many farming households report losing money in this economic endeavour, even without incorporating the value of their household labour. Losses are typically considerably worse when household labour is considered. We take advantage of panel data that include information about both current and former tobacco farming households' characteristics and economic decisions to be the first to rigorously estimate the effects of both tobacco and non-tobacco farming on income. METHODS: We designed and implemented a two-wave economic survey of current and former tobacco farming households in Indonesia's two largest tobacco-growing regions. We use regression analysis to estimate the effects of tobacco farming on household income per farming area in both survey waves. RESULTS: We find that former tobacco farming households are typically generating profits from their non-tobacco farming, while current tobacco farming households experience greater variability, including experiencing economic losses. Former tobacco farming households' income were comparable to current tobacco farming households' even in the period in which tobacco leaf production and prices of tobacco leaf were relatively high. We find a negative and significant effect of tobacco farming on household income. CONCLUSIONS: One of the main arguments from those opposing tobacco control policies-especially increasing cigarette excise taxes-is their alleged effect on tobacco farming households' livelihoods through a lower demand for tobacco leaves. Our finding that there is a negative effect of tobacco farming on household income shows that the narrative is grossly inaccurate. Shifting to non-tobacco farming would allow farming households to reallocate their resources to other more lucrative economic opportunities.

Revisiting the association between worldwide implementation of the MPOWER package and smoking prevalence, 2008-2017.

BACKGROUND: We revisited the association between progress in MPOWER implementation from 2008 to 2016 and smoking prevalence from 2009 to 2017 and offered an in-depth understanding of differential outcomes for various country groups. METHODS: We used data from six rounds of the WHO Reports on the Global Tobacco Epidemic and calculated a composite MPOWER Score for each country in each period. We categorised the countries in four initial conditions based on their tobacco control preparedness measured by MPOWER score in 2008 and smoking burden measured by age-adjusted adult daily smoking prevalence in 2006: (1) High MPOWER - high prevalence (HM-HP). (2) High MPOWER - low prevalence (HM-LP). (3) Low MPOWER - high prevalence (LM-HP). (4) Low MPOWER - low prevalence (LM-LP). We estimated the association of age-adjusted adult daily smoking prevalence with MPOWER Score and cigarette tax rates using two-way fixed-effects panel regression models including both year and country fixed effects. RESULTS: A unit increase of the MPOWER Score was associated with 0.39 and 0.50 percentage points decrease in adult daily smoking prevalence for HM-HP and HM-LP countries, respectively. When tax rate was controlled for separately from MPOWE, an increase in tax rate showed a negative association with daily smoking prevalence for HM-HP and LM-LP countries, while the MPOWE Score showed a negative association for all initial condition country groups except for LM-LP countries. CONCLUSION: A decade after the introduction of the WHO MPOWER package, we observed that the countries with higher initial tobacco control preparedness and higher smoking burden were able to reduce the adult daily smoking prevalence significantly.

Tobacco industry pricing undermines tobacco tax policy: A tale from Bangladesh.

The effectiveness of tax increase in reducing tobacco use depends on the extent to which the industry passes on the tax to consumers. Evidence suggests that tobacco industry may absorb or raise the price more than the tax increase depending on the price segment of tobacco products. In this paper, we examined the industry's pricing strategy by price segment of the cigarette market in Bangladesh by observing the deviation between the market retail prices (MRP) of cigarettes faced by consumers and government recommended retail prices (RRP) used as tax base in a four-tiered ad valorem tax structure. The RRPs by brands were collected from government sources. The MRPs by brands were collected by the International Tobacco Control Bangladesh Wave 3 Survey 2011-12 and Wave 4 Survey 2014-15. Applying linear regression to the deviation of MRP from RRP by price tiers, we found MRPs were higher than RRPs for higher-price brands allowing extra profit margin from the high end while lowering the relative price of and expanding demand for cheaper brands. Bangladesh cigarette industry adopted a differential pricing strategy that undermined the intended effect of tax policy change in reducing cigarette consumption and improving public health. This pricing strategy was supported by the tiered excise tax structure which should be replaced with a uniform specific excise system. In the face of growing cigarette affordability, it is crucial that the specific tax be increased routinely by an amount that induces cigarette price increases large enough to make cigarettes less affordable over time.

Price and expenditure elasticity of cigarette demand in El Salvador: a household-level analysis and simulation of a tax increase.

BACKGROUND: In El Salvador, 8.8% of adults 15 years and older smoke cigarettes. Little is known about the sensitivity of cigarette consumption among the adults in El Salvador to tax and price increases and income growth. METHODS: Elasticities are estimated using Deaton's Almost Ideal Demand System model applied to data from the National Household Income and Expenditure Survey 2005/2006 for the total population and separately for income groups. The estimates are then used to simulate the effects of a proposed change in tobacco tax policy on cigarette consumption and tax revenue. FINDINGS: The estimated price elasticities (-0.77 for the total population) are within the range of price elasticity estimates available for low and middle-income countries. Given the estimated elasticities, a tobacco tax increase is expected to reduce the number of smokers (by almost 20%) and increase tobacco tax revenue (by more than 50%). CONCLUSIONS: Increasing tobacco taxes has the potential to decrease consumption in El Salvador and raise fiscal revenues. The tobacco tax burden in El Salvador is one of the lowest in Latin America and the social costs of tobacco consumption largely exceed the tobacco tax revenues. An increase in tobacco tax could significantly decrease the number of smokers and reduce the burden of tobacco-related diseases and deaths.

Effect of IQOS introduction on cigarette sales: evidence of decline and replacement.

BACKGROUND: Philip Morris International, one of the largest transnational cigarette manufacturers, has heavily invested in its new heated tobacco product, IQOS, marketing it aggressively as a less harmful alternative to cigarette smoking. The company's assertions that the product replaces cigarettes in a market have never been independently tested. The objective of this study is to determine whether introduction of IQOS affected cigarette sales in a large economy. DATA AND METHODS: Using 2014 to 2018 monthly retailer panel data from Japan, we analyse whether different dates of IQOS introduction across Japan's regions are reflected in the patterns of cigarette sales in those regions. A series of placebo models are estimated to test if events other than IQOS introduction could have better explained the observed trends in cigarette sales. RESULTS: Cigarette sales begin to substantially decline at the time of the introduction of IQOS in each of 11 Japanese regions (Chow tests p<0.001). IQOS introduction, which varied across regions, better predicted the timing of cigarette sales decline than any one time applied to all regions simultaneously (a national-level exogenous shock) and than nearly all possible rearrangements of the true IQOS introduction months among the regions (exact permutation test's p value from 0.02 to 0.13, depending on the study approach). CONCLUSIONS: The introduction of IQOS likely reduced cigarette sales in Japan. The net population health impact, however, cannot be assessed without resolving several key uncertainties related to the direct harms of IQOS and the precise patterns of both smoking and IQOS use.

Smokeless tobacco control in 180 countries across the globe: call to action for full implementation of WHO FCTC measures.

Smokeless tobacco is consumed by 356 million people globally and is a leading cause of head and neck cancers. However, global efforts to control smokeless tobacco use trail behind the progress made in curbing cigarette consumption. In this Policy Review, we describe the extent of the policy implementation gap in smokeless tobacco control, discuss key reasons on why it exists, and make recommendations on how to bridge this gap. Although 180 countries have agreed that the WHO Framework Convention on Tobacco Control is the best approach to control the demand and supply of smokeless tobacco, only 138 (77%) Parties define smokeless tobacco in their statutes. Only 34 (19%) Parties tax or report taxing smokeless tobacco products, six (3%) measure content and emissions of smokeless tobacco products, and 41 (23%) mandate pictorial health warnings on these products. Although awareness of the harms related to smokeless tobacco is growing in many parts of the world, few Parties collect or present data on smokeless tobacco use under global or national surveillance mechanisms (eg, Global Tobacco Surveillance System and WHO STEPwise). Only 16 (9%) Parties have implemented a comprehensive ban on smokeless tobacco advertisement, promotion, and sponsorships. Globally, a smaller proportion of smokeless tobacco users are advised to quit the use of smokeless tobacco products compared to tobacco users. Use of smokeless tobacco is becoming a global cause of concern, requiring a greater commitment on the full implementation of the WHO Framework Convention on Tobacco Control measures.

A decade of cigarette taxation in Bangladesh: lessons learnt for tobacco control.

Bangladesh has achieved a high share of tax in the price of cigarettes (greater than the 75% benchmark), but has not achieved the expected health benefits from reduction in cigarette consumption. In this paper we explore why cigarette taxation has not succeeded in reducing cigarette smoking in Bangladesh. Using government records over 2006-2017, we link trends in tax-paid cigarette sales to cigarette excise tax structure and changes in cigarette taxes and prices. We analysed data on smoking prevalence from Bangladesh Global Adult Tobacco Surveys to study consumption of different tobacco products in 2009 and 2017. Drawing on annual reports from tobacco manufacturers and other literature, we examine demand- and supply-side factors in the cigarette market. In addition to a growing affordability of cigarettes, three factors appear to have undermined the effectiveness of tax and price increases in reducing cigarette consumption in Bangladesh. First, the multitiered excise tax structure widened the price differential between brands and incentivized downward substitution by smokers from higher-price to lower-price cigarettes. Second, income growth and shifting preferences of smokers for better quality products encouraged upward substitution from hand-rolled local cigarettes (bidi) to machine-made low-price cigarettes. Third, the tobacco industry's market expansion and differential pricing strategy changed the relative price to keep low-price cigarettes inexpensive. A high tax share alone may prove inadequate as a barometer of effective tobacco taxation in lower-middle income countries, particularly where the tobacco tax structure is complex, tobacco products prices are relatively low, and the affordability of tobacco products is increasing.

Le Bangladesh applique un fort pourcentage de taxe sur les prix du tabac (au-delà du référent habituel de 75% du prix de détail) sans pour autant avoir atteint le bénéfice sanitaire attendu de réduction du tabagisme. Cet article se penche sur les raisons pour lesquelles la taxation du tabac n'est pas parvenue à réduire le tabagisme au Bangladesh. En utilisant les données gouvernementales couvrant la période comprise en 2006 et 2017, nous avons relié les tendances de vente des produits du tabac taxés avec la structure des droits d'accise sur le tabac et avec l'évolution des prix et des taxes sur le tabac. Nous avons analysé les données relatives à la prévalence du tabagisme à partir des enquêtes sur le tabagisme des adultes (GATS) réalisées en 2009 et 2017 au Bangladesh afin d'étudier la consommation des différents produits du tabac. À partir des rapports annuels des fabricants de tabac et d'autres ressources, nous avons examiné l'évolution du marché du tabac, côté demande et côté offre. Outre le fait que les cigarettes sont devenues plus abordables au fil du temps, trois facteurs semblent avoir sapé l'efficacité de l'augmentation des prix et des taxes dans l'objectif de réduction de la consommation de tabac au Bangladesh. Premièrement, la structure multi-niveau des droits d'accise sur le tabac a eu pour effet d'augmenter le différentiel de prix entre les marques, ce qui a poussé les consommateurs à opter pour des cigarettes moins chères. Deuxièmement, l'augmentation des revenus et le changement de préférence des consommateurs en faveur de produits de meilleure qualité ont fait que les consommateurs ont délaissé le tabac à rouler local (« bidi ¼) pour se tourner vers les cigarettes industrielles les moins chères. Troisièmement, du fait de l'expansion de ses marchés et de sa stratégie de différenciation des prix, l'industrie du tabac a fait évoluer les prix relatifs afin que les cigarettes les moins chères restent abordables. Un fort pourcentage de taxation peut s'avérer inapproprié, à lui seul, en tant que baromètre de l'efficacité des mesures de taxation du tabac dans les pays à revenu faible ou intermédiaire, notamment lorsque la structure de taxation du tabac est complexe, que les prix des produits du tabac sont relativement bas et qu'ils deviennent plus abordables au fil du temps.

Bangladesh ha alcanzado una elevada cuota de impuestos en el precio de los cigarrillos (superior al 75 % de referencia), pero no ha logrado los beneficios para la salud esperados de la reducción del consumo de cigarrillos. En este artículo exploramos por qué los impuestos sobre los cigarrillos no han logrado reducir el consumo de cigarrillos en Bangladesh. Utilizando los registros del gobierno entre 2006 y 2017, vinculamos las tendencias de las ventas de cigarrillos pagados con la estructura de los impuestos al consumo de cigarrillos y los cambios en los impuestos y precios de los cigarrillos. Se analizaron los datos sobre la prevalencia del tabaquismo de la Encuesta Mundial del Tabaco en Adultos de Bangladesh para estudiar el consumo de diferentes productos de tabaco en 2009 y 2017. Basándonos en los informes anuales de los fabricantes de tabaco y otras publicaciones, examinamos los factores de la demanda y la oferta en el mercado de cigarrillos. Además de la creciente asequibilidad de los cigarrillos, tres factores parecen haber socavado la eficacia de los aumentos de impuestos y precios en la reducción del consumo de cigarrillos en Bangladesh. En primer lugar, la estructura del impuesto especial de varios niveles amplió la diferencia de precios entre las marcas e incentivó la sustitución a la baja por parte de los fumadores, que pasaron de los cigarrillos de precio más alto a los de precio más bajo. En segundo lugar, el crecimiento de los ingresos y el cambio de las preferencias de los fumadores por productos de mejor calidad fomentaron la sustitución de los cigarrillos locales enrollados a mano (bidi) por cigarrillos de bajo precio hechos a máquina. Tercero, la expansión del mercado de la industria tabacalera y la estrategia de precios diferenciales cambiaron el precio relativo para mantener los cigarrillos de bajo precio baratos. Una elevada cuota de impuestos por sí sola puede resultar inadecuada como barómetro de los impuestos efectivos sobre el tabaco en los países de ingresos medios-bajos, en particular cuando la estructura de los impuestos sobre el tabaco es compleja, los precios de los productos del tabaco son relativamente bajos y la asequibilidad de los productos del tabaco está aumentando.

Are the Same Health Warnings Effective Across Different Countries? An Experimental Study in Seven Countries.

INTRODUCTION: More than 100 countries have implemented pictorial health warnings on cigarette packages. However, few studies have compared how consumers from different geographic and cultural contexts respond to health warning content. The current study compares perceptions of warnings among adult smokers and youth in seven countries, to examine the efficacy of different health warning themes and images. METHODS: Between 2010 and 2012, online and face-to-face surveys were conducted with ~500 adult smokers and ~500 youth (age 16-18) smokers and nonsmokers in each of Mexico, United States, China, Germany, India, Bangladesh, and Republic of Korea (total N = 8182). Respondents were randomized to view and rate sets of 5-7 health warnings (each set for a different health effect); each set included a text-only warning and various types (ie, themes) of pictorial warnings, including graphic health effects, "lived experience," symbolic images, and personal testimonials. Mixed-effects models were utilized to examine perceived effectiveness of warning themes, and between-country differences in responses. RESULTS: Overall, pictorial warnings were rated as more effective than text-only warnings (p < .001). Among pictorial themes, "graphic" health effects were rated as more effective than warnings depicting "lived experience" (p < .001) or "symbolic" images (p < .001). Pictorial warnings with personal testimonials were rated as more effective than the same images with didactic text (p < .001). While the magnitude of differences between warning themes varied across countries, the pattern of findings was generally consistent. CONCLUSIONS: The findings support the efficacy of graphic pictorial warnings across diverse geographic and cultural contexts, and support sharing health warning images across jurisdictions. IMPLICATIONS: Although over 100 countries have implemented pictorial health warnings on cigarette packages, there is little research on the most effective types of message content across geographic and cultural contexts. The current study examined perceived effectiveness of text and pictorial health warnings featuring different message content-graphic health effects, "lived experience," personal testimonials, and symbolic imagery-among more than 8000 adults and youth in Mexico, United States, China, Germany, India, Bangladesh, and Korea. Across countries, "graphic" pictorial messages were rated as most effective. Consistencies across countries in rating message content suggests there may be "globally effective" themes and styles for designing effective health warnings.