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

Summary of CPSTF Finding

The Community Preventive Services Task Force (CPSTF) recommends interventions that increase the unit price of tobacco products based on strong evidence of effectiveness in reducing tobacco use. Evidence is considered strong based on findings from studies demonstrating that increasing the price of tobacco products:

  • Reduces the total amount of tobacco consumed
  • Reduces the prevalence of tobacco use
  • Increases the number of tobacco users who quit
  • Reduces initiation of tobacco use among young people
  • Reduces tobacco-related morbidity and mortality

Public health effects are proportional to the size of the price increase and the scale of implementation. Based on results of the review on which this recommendation is based, an intervention that increases the unit price for tobacco products by 20% would reduce overall consumption of tobacco products by 10.4%, prevalence of adult tobacco use by 3.6%, and initiation of tobacco use by young people by 8.6%. Evidence also indicates these interventions are effective in reducing tobacco-related disparities among income groups and may reduce disparities by race and ethnicity. Economic evidence shows that raising the unit price of tobacco products substantially reduces healthcare costs and in addition can reduce productivity losses.

Intervention

Interventions to increase the unit price for tobacco products include public policies at the federal, state, or local level that increase the purchase price per unit of sale. The most common policy approach is legislation to increase the excise tax on tobacco products, though legislative actions and regulatory decisions may also be used to levy fees on tobacco products at the point of sale. Other policies that might influence tobacco product prices were not considered in this review.

CPSTF Finding and Rationale Statement

Read the full CPSTF Finding and Rationale Statement for details including implementation issues, possible added benefits, potential harms, and evidence gaps.

Promotional Materials

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About The Systematic Review

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.

Summary of Results

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).

Summary of Economic Evidence

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).

Applicability

  • 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.

Evidence Gaps

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?

Study Characteristics

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.

Analytic Framework

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.

Summary Evidence Table

Included Studies

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)

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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.

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

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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.

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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] .

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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.

Search Strategies

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.

Review References

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.

Considerations for Implementation

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).

Crosswalks

Healthy People 2030

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