Tobacco Use: Interventions to Increase the Unit Price for Tobacco Products

The CPSTF finding is based on evidence from 116 studies, including 103 studies identified in two systematic reviews (IARC 2011, search period: 1982-February 2010; Wilson et al. 2012, search period: 1998-January 2012) combined with more recent evidence (13 studies, search period: 2009-July 2012). The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice and policy related to tobacco use and secondhand smoke exposure. The finding updates and replaces two previous CPSTF findings on increasing the unit price of tobacco to increase cessation [PDF – 242 kB] and reduce initiation.

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement

Fifty-four of the included studies provided 90 measurements in the form of price elasticity. Effectiveness of the tobacco price interventions are captured by price elasticity estimates, which measure the change in quantity demanded corresponding to a 1% increase in price. For example, a price elasticity of demand of -0.25 means that a 20% increase in tobacco unit price would be expected to reduce tobacco demand by 5.0%.

Total demand estimates capture overall changes in both the use of tobacco products and the amount consumed.

Young people in this review refers to people under 30 years of age (youth: 13-18; young adults: 19-29), although individual studies used different age criteria.

• Total Demand (changes in use and consumption of tobacco products)
  • A 20% increase in tobacco unit price would be associated with:
    • 7.4% median reduction in demand among adults (16 studies, median price elasticity estimate: -0.37; Interquartile Interval [IQI]: -0.47 to 0.29)
    • 14.8% median reduction in demand among young people (13 studies, median elasticity of -0.74; IQI: -1.13 to -0.57)
• Prevalence of Tobacco Use
  • A 20% increase in tobacco unit price would be associated with:
    • 3.6% median reduction in the proportion of adults who use tobacco (26 studies, median elasticity of -0.18; IQI:-0.31 to -0.11)
    • 7.2% median reduction in the proportion of young adults who use tobacco (22 studies, median elasticity of -0.36; IQI: -0.73 to -0.24)
• Cessation of Tobacco Use
  • A 20% increase in tobacco unit price would be associated with:
    • 6.5% increase in cessation among adults (1 study, elasticity=0.375)
    • 18.6% median increase in cessation among young people (5 studies, median elasticity of 0.93; IQI: 0.37 to 1.00)
• Initiation of Tobacco Use
  • A 20% increase in tobacco unit price would be associated with:
    • 8.6% median reduction in initiation among young people (7 studies, median elasticity of -0.43; IQI: -0.90 to -0.00)

Sixty-two of the included studies provided other measurements of change regarding tobacco use and health outcomes.

• Thirty-nine studies found generally favorable effects of a change in unit price:
  • Reduced total demand for tobacco products among adults and young people (6 of 7 studies)
  • Reduced smoking prevalence among adults and young people (8 of 11 studies)
  • Increased smoking cessation among adults and young people (10 of 11 studies)
  • Reduced smoking initiation among young people (6 of 10 studies)
• Reductions in mortality rates from respiratory cancer and cardiovascular disease were seen in three studies that evaluated the effect of the intervention by modeling relationships with population-based data.
• Thirteen studies generated elasticity estimates based on the excise tax, not the overall change in price.
  • Favorable effects were seen on total demand, prevalence, cessation, or initiation of tobacco use among adults and young people in nine studies; the remaining four studies showed mixed or no effects.
• The remaining seven studies evaluated interventions by income and race/ethnicity and are included in the results below.

Fifteen of the included studies examined intervention effects on tobacco use by income and race/ethnicity.

• Greater reductions in both total demand and prevalence of tobacco use were found among low-income tobacco users when compared with higher-income users (10 studies).
• Studies that controlled for income differences showed price elasticity estimates for total demand and prevalence were greatest for Hispanics, followed by African-Americans, and white tobacco users (5 studies).

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement

Eight studies were included in the review. Four studies were conducted within a U.S. context, three were set within a European environment, and one considered all high-income countries as a group. All studies used simulation to estimate changes in healthcare and productivity costs. Monetary values are reported in 2011 U.S. dollars.

Interventions that increase the unit price of tobacco products generate substantial healthcare cost savings and can also generate additional savings in the form of productivity losses averted.

• Estimated healthcare costs savings from a 20% price increase for tobacco products ranged from -$0.14 to $90.02 per person per year (7 studies).
  • Four studies conducted in the U.S. found mean annual per capita healthcare (or healthcare and productivity) savings of $73.00.
  • Some studies included additional healthcare costs incurred by living longer after quitting (or avoiding initiation of) tobacco use.
• Price increases were also associated with averted productivity losses (3 studies).

• Findings of the review should be broadly applicable to U.S. jurisdictions, populations, and intervention options.
• In general, study samples were population-based, representative, and balanced for age (young people and adults) and gender.
• A small number of studies targeted populations affected by health disparities which may be sensitive to changes in price, for example racial or ethnic minorities, or low income populations.

The CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

Many studies from the updated search period evaluated the impact of specific intervention characteristics, but several questions remain for future research.

Effectiveness:

• What are the effects of these interventions on other tobacco products besides cigarettes?
• What are the effects of differential price, tax, and fee environments currently in place on the use of different tobacco products?
• What are the effects of non-tax and non-fee price influencing interventions such as minimum price laws, coupon and voucher restrictions, and restrictions on price discount programs on tobacco use?
• What are the synergistic effects between tobacco price interventions and revenue dedicated to support comprehensive tobacco prevention and control programs?

Applicability:

• Are there additional data that evaluate the differences in price responsiveness by race and ethnicity?

Barriers:

• What are the characteristics of local policies that successfully establish tobacco excise taxes and/or fees?

Economic:

• What are the costs associated with different tobacco policy (price) interventions?
• What are the effects of tobacco product price increases on productivity?
• What are the (estimated) economic effects of tobacco product price increases once differences in socio-economic status are accounted for?

Of the 116 included studies, 80 were conducted in the United States, and the remaining 36 evaluated price responsiveness of populations in other high-income countries.

Effectiveness Review

Analytic Framework

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Economic Review

No content is available for this section.

Effectiveness Review

Summary Evidence Table – Effectiveness Review

Economic Review

Summary Evidence Table – Economic Review

The Community Preventive Services Task Force recommendation on interventions to increase the unit price for tobacco products is based on evidence from two systematic reviews combined with a Community Guide review with more recent evidence.

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Community Guide Updated Search (13 studies, search period 2009 July 2012)

Adams EK, Markowitz S, Kannan V, Dietz PM, Tong VT, Malarcher AM. Am J Prev Med 2012; 43(1):34-40.

Bush T, Zbikowski S, Mahoney L, Deprey M, Mowery PD, Magnusson B. The 2009 US federal cigarette tax increase and quitline utilization in 16 states. J Environ Public Health 2012; 2012(May 8):1-9.

Choi TC, Toomey TL, Chen V, Forster JL. Awareness and reported consequences of a cigarette tax increase among older adolescents and young adults. Am J Health Promot 2011; 25(6):379-86.

Dunlop SM, Cotter TF, Perez DA. Impact of the 2010 tobacco tax increase in Australia on short-term smoking cessation: a continuous tracking survey. Med J Aust 2011; 195(8):469-72.

Goel RK, Nelson MA. Cigarette demand and effectiveness of U.S. smoking control policies: state-level evidence for more than half a century. Empirical Economics 2012; 42(3):1079-93.

Hawkins SS, Chandra A, Berkman L. The impact of tobacco control policies on disparities in children’s secondhand smoke exposure: a comparison of methods. Matern Child Health J 2012; 16(Suppl 1):70-7.

Lee JM, Chen MG, Hwang TC, Yeh CY. Effect of cigarette taxes on the consumption of cigarettes, alcohol, tea and coffee in Taiwan. Public Health 2010; 124(8):429-36.

Liu E, Yu WC, Hsieh HL. Cigarette taxes and respiratory cancers: New evidence from panel co-Integration analysis. J Health Care Finance 2011; 37(3):62 71.

MacFarlane K, Paynter J, Arroll B, Youdan B. Tax as a motivating factor to make a quit attempt from smoking: A study before and after the April 2010 tax increase. J Prim Health Care 2011; 3(4):283-8.

McLellan DL, Hodgkin D, Fagan P, Reif S, Horgan CM. Unintended consequences of cigarette price changes for alcohol drinking behaviors across age groups: evidence from pooled cross sections. Subst Abuse Treat Prev Policy 2012; 7(28):1-10.

Ong MK, Zhou Q, Sung HY. Sensitivity to cigarette prices among individuals with alcohol, drug, or mental disorders. Am J Public Health 2010; 100(7):1243-5.

Peretti-Watel P, L’haridon O, Seror V. Responses to increasing cigarette prices in France: how did persistent smokers react? Health Policy 2012; 106(2):169-76.

Sen A, Entezarkheir M, Wilson A. Obesity, smoking, and cigarette taxes: Evidence from the Canadian Community Health Surveys. Health Policy 2010; 97(2-3):180-6.

IARC Systematic Review (90 studies, search period 1982 February 2010)

Aristei D, Pieroni L. Addiction, social interactions and gender difference in cigarette consumption. Empirica 2009; 36(3):245-72.

Auld MC. Causal effect of early initiation on adolescent smoking patterns. Can J Econ 2005; 38(3):709-34.

Cameron L, Williams J. Cannabis, alcohol and cigarettes: substitutes or complements. Econ Rec 2001; 77(236):19-34

Carpenter C, Cook PJ. Cigarette taxes and youth smoking: new evidence from national, state, and local Youth Risk Behavior Surveys. J Health Econ 2008; 27(2):287-99.

Cawley J, Markowitz S, Tauras J. Lighting up and slimming down: the effects of body weight and cigarette prices on adolescent smoking initiation. J Health Econ 2004; 23(2):293-311.

Cawley J, Markowitz S, Tauras J. Obesity, cigarette prices, youth access laws and adolescent smoking intiation. East Econ J 2006; 32(1):149-70.

Centers for Disease Control and Prevention (CDC) (Farrelly M, Bray J). Responses to increases in cigarette prices by race/ethnicity, income, and age groups – United States, 1976-1993. MMWR 1998; 47(29):605-9.

Chaloupka FJ. Men, women, and addiction: the case of cigarette smoking. NBER Working Paper #3267. National Bureau of Economic Research, Cambridge (MA); 1990.

Chaloupka FJ. Rational Addictive Behavior and Cigarette Smoking. J Polit Econ 1991; 99(4):722-42.

Chaloupka FJ. Clean indoor air laws, addiction and cigarette smoking. Appl Econ 1992; 24(2):193-205.

Chaloupka FJ, Grossman M. Price tobacco control policies and youth smoking. NBER Working Paper Series. Working Paper #5740. National Bureau of Economic Research, Cambridge (MA); 1996.

Chaloupka FJ, Wechsler H. Price, tobacco control policies and smoking among young adults. J Health Econ 1997; 16(3):359-73.

Chaloupka FJ, Pacula RL. Sex and race differences in young people’s responsiveness to price and tobacco control policies. Tob Control 1999; 8(4):373-7.

Chung W, Lim S, Lee S et al. The effect of cigarette price on smoking behavior in Korea. J Prev Med Public Health 2007; 40(5):371-80.

Colman G, Remler DK. Vertical equity consequences of very high cigarette tax increases: if the poor are the ones smoking, how could cigarette tax increases be progressive? J Policy Anal Manage 2008; 27(2):376-400.

DeCicca P, Kenkel D, Mathios A. Racial difference in the determinants of smoking onset. J Risk Uncertain 2000; 21(2-3):311 40.

DeCicca P, Kenkel D, Mathios A. Putting out the fires: will higher taxes reduce the onset of youth smoking? J Polit Econ 2002; 110(1):144-69.

DeCicca P, Kenkel D, Mathios A. The fires are not out yet: higher taxes and young adult smoking. Adv Health Econ Health Serv Res 2005; 16:293-312.

DeCicca P, Kenkel D, Mathios A. Cigarette taxes and the transition from youth to adult smoking: smoking initiation, cessation, and participation. J Health Econ 2008; 27(4):904 17.

DeCicca P, McLeod L. Cigarette taxes and older adult smoking: evidence from recent large tax increases. J Health Econ 2008; 27(4):918-29.

Decicca P, Kenkel D, Mathios A et al. Youth smoking, cigarette prices, and anti-smoking sentiment. Health Econ 2008; 17(6):733 49.

Dee TS. The complementarity of teen smoking and drinking. J Health Econ 1999; 18(6):769-93.

Dinno A, Glantz S. Tobacco control policies are egalitarian: a vulnerabilities perspective on clean indoor air laws, cigarette prices, and tobacco use disparities. Soc Sci Med 2009; 68(8):1439-47.

Douglas S, Hariharan G. The hazard of starting smoking: estimates from a split population duration model. J Health Econ 1994; 13(2):213-30.

Douglas S. The duration of smoking habit. Econ Inq 1998; 36(1):49-64.

Dupont SD, Ward AJ. The economic impacts of cigarette tax reductions on youth smoking in Canada. Brock University; 2002.

Emery S, White MM, Pierce JP. Does cigarette price influence adolescent experimentation? J Health Econ 2001; 20(2):261-70.

Evans WN , Farrelly MC. The compensating behavior of smokers: taxes, tar and nicotine. Rand J Econ 1998, 29(3): 578-95.

Evans WN, Ringel JS, Stech D. Tobacco taxes and public policy to discourage smoking. Tax Policy and the Economy 1999; 13:1-56.

Farrelly MC, Bray JW, Pechacek T, Woollery T. Response by adults to increases in cigarette prices by sociodemographic characteristics. South Econ J 2001; 68(1):156 65.

Farrelly MC, Nimsch CT, A. Hyland A, Cummings M. The effects of higher cigarette prices on tar and nicotine consumption in a cohort of adult smokers. Health Econ 2004; 13(1):49-58.

Farrelly MC, Engelen M. Cigarette prices, smoking, and the poor, revisited. Am J Public Health 2008; 98(4):582-3.

Fletcher JM, Deb PS et al. Tobacco use, taxation and self-control in adolescence. NBER Working Paper Series #15130. National Bureau of Economic Research, Cambridge (MA); 2009.

Forster M, Jones AM. The role of tobacco taxes in starting and quitting smoking: duration analysis of British data. J R Stat Soc Ser A Stat Soc 2001; 164(3):517-47.

Franks P, Jerant AF, Leigh JP et al. Cigarette prices, smoking, and the poor: implications of recent trends. Am J Public Health 2007; 97(10):1873-7.

Franz GA. Price effects on the smoking behaviour of adult age groups. Public Health 2008; 122(12):1343-8.

Garc a J, Labeaga J. Alternative approaches to modelling zero expenditure: an application to Spanish demand for tobacco. Oxf Bull Econ Stat 1986; 58(3):489-506.

Glied S. Youth tobacco control: reconciling theory and empirical evidence. J Health Econ 2002; 21(1):117-35.

Gospodinov N, Irvine I. Tobacco taxes and regressivity. J Health Econ 2009; 28(2):375-84.

Gruber J, Zinman J. Youth smoking in the United States: evidence and implications. In: Gruber J. editor. Risky behaviour among youths: an economic analysis. Chicago: University of Chicago Press, 2001, pp. 69 120.

Gruber J, Sen A, Stabile M. Estimating price elasticities when there is smuggling: the sensitivity of smoking to price in Canada. J Health Econ 2003; 22(5):821-42.

Gruber J, Koszegi B. Tax incidence when individuals are time inconsistent: the case of cigarette excise taxes. J Public Econ 2004; 88(9-10):1959-87.

Hamilton VH, Levinton C, St- Pierre Y, Grimardm F. The effect of tobacco tax cuts on cigarette smoking in Canada. CMAJ 1997; 156(2):187-91.

Hanewinkel R, Isensee B. Opinion on tobacco tax increase: factors associated with individuals’ support in Germany. Health Policy 2008, 86(2-3):234 8

Harris JE, Chan SW. The continuum of-addiction: cigarette smoking in relation to price among Americans aged 15 29. Health Econ 1999; 8(1):81-6

Harris MN, Zaho X. A zero-inflated ordered probit model, with an application to modelling tobacco consumption. J Econom 2007; 141(2):1073-99.

Harris JE, Gonz lez L pez- Valc rcel B. Asymmetric peer effects in the analysis of cigarette smoking among young people in the United States, 1992 1999. J Health Econ 2008; 27(2):249-64.

Hersch J. Gender, income levels, and the demand for cigarettes. J Risk Uncertain 2000; 21(2-3):263-82.

Hu TW, Ren QF, Keeler TE, Bartlett J. The demand for cigarettes in California and behavioural risk factors. Health Econ 1995; 4(1):7-14.

Jim nez- Mart n S, Labeaga JM, L pez A. Participation, heterogeneity and dynamics in tobacco consumption: evidence from cohort data. Health Econ 1998; 7(5):401-14.

Jones A. The UK demand for cigarettes 1954 1986, a double hurdle approach. J Health Econ 1989; 8(1):133-41.

Kidd MP, Hopkins S. The hazards of starting and quitting smoking: some Australian evidence. Econ Rec 2004; 80(249):177-92.

Katzman B, Markowitz S, McGeary KA. An empirical investigation of the social market for cigarettes. Health Econ 2007; 16(10):1025-39.

Labeaga JM. A double-hurdle rational addiction model with heterogeneity: estimating the demand for tobacco. J Econom 1999; 93(1):49-72.

Lewit EM, Coate D, Grossman M. The effects of government regulation on teenage smoking. J Law Econ 1981; 24(3):545-69.

Lewitt EM, Coate D. The potential for using excise taxes to reduce smoking. J Health Econ 1982; 1(2):121-45.

Lewit EM, Hyland A, Kerrebrock N, Cummings KM. Price, public policy, and smoking in young people. Tob Control 1997; 6(Suppl 2):17-24.

Liang L, Chaloupka FJ. Differential effects of cigarette price on youth smoking intensity. Nicotine Tob Res 2002; 4(1):109 14.

L pez Nicol s A. How important are tobacco prices in the propensity to start and quit smoking? An analysis of smoking histories from the Spanish National Health Survey. Health Econ 2002; 11(6):521-35.

Moore MJ. Death and tobacco taxes. Rand J Econ 1996, 27(2):415 28.

Mullahy J. Cigarette smoking: habits, health concerns, and heterogeneous unobservables in a micro-econometric analysis of consumer demand. Ph.D. dissertation, University of Virginia; 1985.

Ohsfeldt RL, Boyle RG. Tobacco excise taxes and rates of smokeless tobacco use in the US: an exploratory ecological analysis. Tob Control 1994; 3(4):316-23.

Ohsfeldt, RL, Boyle RG, Capilouto E. Effects of tobacco excise taxes on the use of smokeless tobacco products in the United States. Health Econ 1997; 6(5):525-31.

Ohsfeldt RL, Boyle RG, Capiluouto E. Tobacco Taxes, Smoking Restrictions, and Tobacco Use. In Chaloupka FJ, Grossman M, Bickel WK, et al., eds.,The Economic Analysis of Substance Use and Abuse: An Integration of Econometrics and Behavioral Economic Research. Chicago: The University of Chicago Press, 1999, pp. 15-29.

Peretti- Watel P. Pricing policy and some other predictors of smoking behaviours: an analysis of French retrospective data. Int J Drug Policy 2005; 16(1):19-26.

Powell LM, Chaloupka FJ. Parents, public policy, and youth smoking. J Policy Anal Manage 2005; 24(1):93-112.

Ranson MK, Jha P, Chaloupka FJ, Nguyen SN. Global and regional estimates of the effectiveness and cost-effectiveness of price increases and other tobacco control policies. Nicotine & Tobacco Research 2002; 4(3):311-9.

Ringel JS, Evans WN. Cigarette taxes and smoking during pregnancy. Am J Public Health 2001; 91(11):1851-6.

Ross H, Chaloupka FJ. The effect of cigarette prices on youth smoking. Health Econ 2003; 12(3):217-23.

Ross H, Chaloupka FJ. The effect of public policies and prices on youth smoking. South Econ J 2004; 70(4):796-815.

Ross H, Prezwozniak K. Poland 1999 Global Youth Tobacco Survey: Economic Aspects. HNP Discussion Paper Series, Economics of Tobacco Control Paper No. 22. Washington (DC), The World Bank; 2004.

Ross H, Chaloupka FJ, Wakefield M. Youth smoking uptake progress: price and public policy effects. East Econ J 2006; 32(2):355-67.

Ross H, Blecher E, Yan L, Hyland A. Do cigarette prices motivate smokers to quit? New evidence from the ITC survey. Addiction 2011, 106(3):609-19.

Sen A, Wirjanto T. Estimating the impacts of cigarette taxes on youth smoking participation, initiation, and persistence: empirical evidence from Canada. Health Econ 2010, 19(11):1264 80.

Sheu ML, Hu TW, Keeler TE et al. The effect of a major cigarette price change on smoking behavior in california: a zero- inflated negative binomial model. Health Econ 2004, 13(8):781-91.

Slater SJ, Chaloupka FJ, Wakefield M et al. The impact of retail cigarette marketing practices on youth smoking uptake. Arch Pediatr Adolesc Med 2007, 161(5):440 5.

Sloan FA, Trogdon JG. The impact of the Master Settlement Agreement on cigarette consumption. J Pol Anal Manag 2004; 23(4):843-55.

Siahpush M, Wakefield MA, Spittal MJ et al. Taxation reduces social disparities in adult smoking prevalence. Am J Prev Med 2009; 36(4):285-91.

Stehr M. The effect of cigarette taxes on smoking among men and women. Health Econ 2007; 16(12):1333-43.

Stephens T, Pederson LL, Koval JJ, Kim C. The relationship of cigarette prices and no-smoking by laws to the prevalence of smoking in Canada. Am J Public Health 1997, 87(9):1519-21.

Tauras JA, Chaloupka FJ. Price, clean indoor air laws and cigarette smoking: evidence from longitudinal data for young adults. NBER Working Paper Series. Working Paper #6937. National Bureau of Economic Research, Cambridge (MA); 1999.

Tauras JA, Chaloupka FJ. Determinants of smoking cessation: an analysis of young adult men and women. In: Grossman M, Hsieh CR, editors. Economics of substance abuse: the experience of developed countries and lessons for developing countries. Cheltenham, United Kingdom: Edward Elgar Publishing Limited, 2001, p. 35.

Tauras JA. Public policy and some-day smoking among adults. J Appl Econ 2004; 7(5):137-62.

Tauras JA. Public policy and smoking cessation among young adults in the United States. Health Policy 2004; 68(3):321 32.

Tauras JA. Can public policy deter smoking escalation among young adults? J Policy Anal Manage 2005; 24(4):771-84.

Tauras JA. Smoke-free air laws, cigarette prices, and adult cigarette demand. Econ Inq 2006; 44(2):333-42.

Townsend J, Roderick P, Cooper J. Cigarette smoking by socioeconomic group, sex, and age: effects of price, income, and health publicity. BMJ 1994; 309(6959):923-7.

Tworek C, Yamaguchi R, Kloska DD et al. State-level tobacco control policies and youth smoking cessation measures. Health Policy 2010; 97(2-3):136 44.

Wasserman J, Manning WG, Newhouse JP, Winkler JD. The effects of excise taxes and regulations on cigarette smoking. J Health Econ 1991; 10(1):43 64.

Zhang B, Cohen J, Ferrence R, Rehm J. The impact of tobacco tax cuts on smoking initiation among Canadian young adults. Am J Prev Med 2006; 30(6):474-9.

Wilson Systematic Review (13 studies, search period 1998 January 2012)

Azagba S, Sharaf M. Cigarette taxes and smoking participation: evidence from recent tax increases in Canada. Int J Environ Res Public Health 2011; 8(5): 1583-600.

Bogdanovica I, Murray R, McNeill A, Britton J. Cigarette price, affordability and smoking prevalence in the European Union. Addiction 2012; 107(1):188-96.

Ding A. Youth are more sensitive to price changes in cigarettes than adults. Yale J Biol Med 2003; 76(3): 115-24.

Gallus S, Fernandez E, Townsend J, Schiaffino A, La Vecchia C .Price and consumption of tobacco in Italy over the last three decades. Eur J Cancer Prev 2003; 12(4):333-7.

Grossman M. Individual behaviours and substance use: the role of price. Advances in Health Economics and Health Services Research 2005; 16:15-39.

Gruber J. Youth smoking in the US: prices and policies. NBER Working Paper #7506, National Bureau of Economic Research, Cambridge (MA); 2000.

Hanewinkel R, Isensee B. Five in a row Reactions of smokers to tobacco tax increases: population-based cross-sectional studies in Germany 2001-2006. Tob Control 2007; 16(1):34-7.

Nonnemaker JM, Farrelly MC. Smoking initiation among youth: the role of cigarette excise taxes and prices by race/ethnicity and gender. J Health Econ 2011; 30(3):560-7.

Reed MB, Anderson CM, Vaughn JW, Burns DM. The effect of cigarette price increases on smoking cessation in California. Prev Sci 2008; 9(1):47-54.

Scollo M, Younie S, Wakefield M, Freeman J, Icasiano F. Impact of tobacco tax reforms on tobacco prices and tobacco use in Australia. Tob Control 2003; 12(S2):59-66.

Wakefield MA, Durkin S, Spittal MJ et al. Impact of tobacco control policies and mass media campaigns on monthly adult smoking prevalence. Am J Public Health 2008; 98(8):1443-50.

Waller BJ, Cohen JE, Ferrence R, Bull S, Adlaf EM. The early 1990s cigarette price decrease and trends in youth smoking in Ontario. Can J Public Health 2003; 94(1):31-5.

White VM, Warne CD, Spittal MJ, Durkin S, Purcell K, Wakefield MA. What impact have tobacco control policies, cigarette price and tobacco control programme funding had on Australian adolescents’ smoking? Findings over a 15-year period. Addiction 2011; 106(8):1493-502.

Economic Review

Ahmad S. Increasing excise taxes on cigarettes in California: a dynamic simulation of health and economic impacts. Preventive Medicine 2005;41(1):276-83.

Ahmad S, Franz G. Raising taxes to reduce smoking prevalence in the US: a simulation of the anticipated health and economic impacts. Public Health 2008;122(1):3-10.

Congressional Budget Office (CBO). Raising the excise tax on cigarettes: effects on health and the federal budget. June 2012. Available at URL: http://www.cbo.gov/sites/default/files/cbofiles/attachments/06-13-Smoking_Reduction.pdf [PDF – 981 kB] .

MacKillop J, Few LR, Murphy JG, Wier LM, Acker J, Murphy C, et al. High-resolution behavioral economic analysis of cigarette demand to inform tax policy. Addiction 2012;107(12):2191-200.

Ranson MK, Jha P, Chaloupka FJ, Nguyen SN. Global and regional estimates of the effectiveness and cost-effectiveness of price increases and other tobacco control policies. Nicotine & Tobacco Research 2002;4(3):311-9.

Reed H. The effects of increasing tobacco taxation: a cost benefit and public finances analysis. ASH (Action on Smoking and Health), London (UK); 2010. Available at URL: http://www.ash.org.uk/tax/analysis .

van Baal PH, Brouwer WB, Hoogenveen RT, Feenstra TL. Increasing tobacco taxes: a cheap tool to increase public health. Health Policy 2007;82(2):142-52.

van Genugten ML, Hoogenveen RT, Mulder I, Smit HA, Jansen J, de Hollander AE. Future burden and costs of smoking-related disease in the Netherlands: a dynamic modeling approach. Value in Health 2003;6(4):494-9.

Implementation Resource

Rural Health Information Hub, Tobacco Control and Prevention Toolkit
This toolkit compiles information, resources, and best practices to support development and implementation of tobacco control and prevention programs in rural communities. Modules include program models, implementation and evaluation resources, and funding and dissemination strategies.

• Interventions to Increase the Unit Price for Tobacco Products

The Task Force finding is based on evidence from three sources. These sources include two systematic reviews (International Agency for Research on Cancer, 2011; Wilson et al., 2012) combined with a Community Guide review with more recent evidence.

Effectiveness Review

IARC Search Strategy

This systematic review included studies specific to the effects of tobacco price on tobacco use that were performed between 1982-February 2010. See the IARC review for details regarding search terms and databases used.

Wilson et al. Search Strategy

This systematic review included studies specific to the effects of tobacco price on smoking initiation, cessation, or prevalence that were performed between 1998-January 2012. See the Wilson et al. review for details regarding search terms and databases used.

Community Guide Search Strategy

A broad search was conducted to identify intervention studies related to tobacco use (search period January 2000-July 2012). Studies specific to tobacco unit price were then assessed and assigned to this review. The following eight bibliographic databases were searched.

• Cochrane library
• EMBASE (OVID)
• Medline (OVID)
• OSH (CDC’s Office on Smoking & Health Database)
• PsycINFO (OVID)
• PubMed (NLM)
• Sociological Abstracts (ProQuest)
• Web of Science (Thomson)

The search included all years of publications available in each database. The databases searched covered publications in medical and social sciences, behavioral sciences, business and management, legal, legislative, and grey literature. The types of documents retrieved by the search included journal articles, books, book chapters, reports, handbooks, economics evaluations, dissertations, theses, technical reports, government reports, and conference papers.

Subsequently, English-language papers that evaluated tobacco control interventions were screened twice to identify papers specific to tobacco unit price interventions. For the effectiveness review, only studies from the 2009- July 2012 search period were included to update the IARC and Wilson et al. systematic reviews.

The following are search strategies specific to PubMed. These strategies were adapted to other databases, based on controlled and uncontrolled vocabularies and search software.

PubMed Overarching Search Strategy

((Tobacco[mesh] or “tobacco smoking”[mesh] or smoking[mesh] or ” tobacco use disorder”[mesh] or “tobacco use cessation”[mesh] or “tobacco industry”[mesh]

OR

tobacco[title] or smoking[title] or cigar*[title])

AND

( taxes[mesh] or “product labeling”[mesh] or “product packaging”{mesh:noexp] or “communications media”[mesh] or “social control, formal”[mesh] or “legislation as topic”[mesh:noexp]

OR

“price increase”[title/abstract] or tax[title/abstract] or taxed[title/abstract] or taxes[title/abstract] or “increasing the price”[title/abstract] or “increased price”[title/abstract] or “increasing price”[title/abstract] or “mass media”[title/abstract] or legislation[title/abstract] or jurisprudence[title/abstract] or “clean indoor air”[title/abstract] or law[title/abstract] or laws[title/abstract] or restrict*[title/abstract] or advertising or advertisement* or marketing or market* or label or labels or labeled or labeling or package* or packaging or consumption[title]))

OR

“tobacco smoke pollution/legislation and jurisprudence”[mesh] or “smoke-free”[title]

PubMed Search Strategy for Tobacco Cessation

#1 (“quit”[title] or “quitting”[title] or “quit line”[title] or “quit lines”[title] or “quitline”[title] or “quitlines”[title] or “abstinence”[title] or “abstinent”[title] or “stop” [title] or “stopped”[title] or “stopping”[title] or “cessation”[title] or “telephone”[title] or “hotline”[title] or “hotlines”[title] or “telephone”[MeSH] or “hotlines”[MeSH])

#2 “Smoking”[MeSH] or “tobacco”[MeSH] or “tobacco, smokeless”[MeSH] or “tobacco use disorder”[MeSH] or cigar*[title] or tobacco*[title] or hookah*[title] or “hubble-bubble”[title] or “narghile”[title] or “shisha”[title] or “smokeless”[title] or “snuff”[title] or “snuffs”[title]

#3 (“waterpipe” or “waterpipes” or “water pipe” or “water pipes”) and (tobacco or smoking or smoke)

#4 (“pipe” or “pipes”) and (smoke or smoking or tobacco))

#5 “Tobacco use cessation”[MeSH] or “smoking cessation” or “tobacco cessation”

#6 #1 AND (#2 OR #3 OR #4)

#7 #6 OR #5

#8 #7 Filters: Publication date from 2011/01/01 to 2012/12/31; English

Economic Review

The following economics databases were also searched using the corresponding search strategies below:

Database: Centre for Reviews and Dissemination at the University of York (tobacco or smoking or cigarette or cigarettes) AND (cost or costs or model* or benefit or utility or qaly or efficiency or dollar* or model* or reimburse* or price or pricing or priced or prices or economic* or tax or taxes or taxed) RESTRICT YR 2000-2012

Database: Web of Science Social Science Citation Index Title=(tobacco or smoking or cigarette*) AND Title=(economic* or model* or taxes or tax or taxed or price* or pricing or cost or costs or utility or qaly or dollar* or efficiency or reimburse*) AND Language=(English) Timespan 2000-2012

Database: EconLit (Tobacco or cigarette* or smoking)

AND

(economics or cost or costs or benefit or benefits or utility or qaly or “quality-adjusted life year” or efficiency or dollar or dollars or “dynamic modeling” or “dynamic modelling” or reimbursement* or “simulation model*” or “price elasticity” or “economic impact” or media or television or broadcast* or radio or tv or “motion picture*” or films or movies or magazine* or newspaper* or “multimedia” or “multi media” or “mass communications*” or audiovisual or telecommunications or televised or campaign* or marketing or advertis* or label or labels or labeling or labeled or labeled or labeling or communit* or policy or policies or telephone or twitter or facebook or “social media” or access* or increase* or increasing or price* or prohibit* or assist* or restaurant or pub or pubs or disco or discos or bars or nightclub* or clubs or “public places” or “quality adjusted” or youth or child* or school* or student* or adolescent* or teen* or juvenile* or girls or boys or kids or minors or prevention or intervention* or program* or promotion or promoting or cessation or quitline* or helpline* or “quit line*” or workplace * or occupation* or psychology or reduc* or stop or stopping or quit or quitting or contest* or uptake or onset or start* or occupational or smokeless or “smoke-free” or smokefree or law or laws or ordinance* or regulat* or tax or taxed or taxes or taxing or fee or fees or jurisprudence or control* or legislat* or free or legal or model* or politic* or war or kick or habit* or coalition* or initiat*) Limit to English, 2000-2012

Database: JSTOR (tobacco or smoking or cigarette or cigarettes) AND (cost or costs or model* or benefit or utility or qaly or efficiency or dollar* or model* or reimburse* or price or pricing or priced or prices or economic* or tax or taxes or taxed) RESTRICT YR 2000-2012

References

International Agency for Research on Cancer (IARC). IARC Handbooks of Cancer Prevention: Tobacco Control Volume 14. Effectiveness of price and tax policies for control of tobacco. Lyon, France: International Agency for Research on Cancer 2011;14:1-374.

Wilson LM, Avila Tang E, Chander G, et al. Impact of tobacco control interventions on smoking initiation, cessation, and prevalence: a systematic review. Journal of Environmental and Public Health 2012;2012:1-36.

International Agency for Research on Cancer. IARC Handbooks of Cancer Prevention: Tobacco Control Volume 14. Effectiveness of price and tax policies for control of tobacco. Lyon, France: International Agency for Research on Cancer; 2011.

Wilson LM, Avila Tang E, Chander G, et al. Impact of tobacco control interventions on smoking initiation, cessation, and prevalence: a systematic review. Journal of Environmental and Public Health 2012;2012:1-36.

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

• Successful legislative efforts have typically required coalitions organized around both public health and revenue objectives.
• Enforcement may be required in certain jurisdictions to address tax evasion activities such as smuggling and illicit distribution and sale of untaxed tobacco products.
• Political deliberations on price interventions typically result in media coverage, giving public health organizations and healthcare providers a chance to convey basic health information about tobacco use and the benefits of quitting.
• Policy adoption should be followed by expansion and promotion of cessation services to help tobacco users interested in quitting.
• Revenue-sharing agreements with tribes to include state or local excise taxes and fees on tobacco products sold in tribal outlets can protect the public health benefits of state and local price policies.
• Policies that treat tobacco products differently may increase substitution of tobacco products (for example tobacco users switching from cigarettes to lower-priced cigars or roll-your-own tobacco).
• A number of barriers to implementation were identified in the review.
  • City and local policies may be blocked by state preemption legislation.
  • Although it should be expected that some will oppose excise tax or fee increases, surveys typically show widespread public support for excise taxes.
  • Policies that propose to dedicate part of the revenue to tobacco prevention and control, especially services and support for tobacco users interested in quitting, may address concerns about revenue and be more acceptable.
• Policies may be implemented at national, state, or local levels.
  • National legislation would reduce cross-border issues and, depending on the stipulations, tobacco product substitution.
  • Most policy activity in the U.S. has occurred at the state level.
  • Local policies such as regulatory, health-impact, and abatement fees allow communities to use existing government mechanisms to address local concerns (such as the clean-up costs of tobacco product litter).

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Increase the national average tax on cigarettes — TU‑21