Association Between Cigarette Price and Infant Mortality

In an effort to reduce smoking rates governments often increase the taxation levied on cigarettes. Previous research has shown that this is an effective strategy, including improvements in child health outcomes. However, tobacco companies often use differential pricing strategies to move the increased taxation on to their premium cigarettes. This lessens the effectiveness of increased taxes as it allows people to switch to the cheaper cigarettes instead. Researchers from Imperial College London set out to assess any associations between price rises, differential pricing (using data on the minimum and median cigarette prices) and infant mortality across 23 European countries.[1] This longitudinal study looked at more than 53.7m live births over a period of ten years. During this time the authors found that a median increase of €1 per pack of cigarettes was associated with 0.23 fewer deaths per 1000 live births in the year of the price hike (95% CI, -0.37 to -0.09), and a decline of 0.16 deaths per 1000 live births in the subsequent year (95% CI, -0.30 to -0.03). Using a counterfactual scenario, the authors estimated that, overall, cigarette price increases were associated with 9,208 fewer infant deaths (i.e. if cigarette prices had remained unchanged then there would have been 9,208 more deaths). Analysis of the price differentials showed that a 10% increase in the differential between the minimum and median priced cigarettes was associated with 0.07 more deaths per 1,000 live births the following year. Further, had there been no cost differential, they estimated that 3,195 infant deaths could have been avoided.

So, while increasing cigarette taxation can have a positive effect, there needs to be more of an effort to try to eliminate budget cigarettes. This is especially true in low-income countries where price differentials tend to be significantly higher than in high-income countries.

— Peter Chilton, Research Fellow

Reference:

1. Filippidis FT, Laverty AA, Hone T, Been JV, Millett C. Association of Cigarette Price Differentials With Infant Mortality in 23 European Union Countries. JAMA Pediatr. 2017.

Politics of Evidence or Evidence of Politics?

Tobacco control policy was the topic of John Britton’s Cochrane lecture at the Annual Scientific Meeting of the Society for Social Medicine this year. The lecture noted that the UK is the highest ranked European country in terms of its policies, yet failed to achieve the low smoking rates of Sweden, which is only ranked mid table for policy.[1] This is likely due to a large number of smokers in Sweden switching to using snus, an oral tobacco product. Snus, which is banned in the UK, has a much lower risk of causing severe tobacco related disease than smoking. Thus, while the numbers of nicotine users in Sweden is not remarkably low, the harm caused by such use is. A similar debate now focuses on e-cigarettes.

I was reminded by this lecture of David Nutt’s discussion of the purposes of drug control policy.[2] Nutt, the former head of the Advisory Council for the Misuse of Drugs, argues that policy makers focus on reducing the prevalence of drug use but that they ought to be focused on harm reduction instead. For example, causing the price of a drug or alcohol to rise, through prohibition or taxes, may reduce use among recreational low risk users but may have little effect on those with problematic use or lead them to switch to potentially more harmful drugs or products with lower prices (e.g. [3]).

E-cigarettes have become embroiled in a heated debate. The scientific discussion has intertwined with the political one. Some evidence suggests that it is less harmful than smoking and may reduce smoking prevalence and therefore harm from nicotine use. Nevertheless, the validity of this evidence, and the conflicts of interests involved – much of the research has been funded by both anti-tobacco groups and e-cigarette manufacturers – have been brought into question.[4] For example, a  row emerged recently after a paper in the NEJM showed that e-cigarettes can produce dangerously high levels of formaldehyde,[5] yet this is only at temperatures not typically produced through normal e-cigarette use. A number of critics argued that the paper “was so misleading it should be retracted.”[6] However, there has been suggestions of potential conflicts of interest of both authors and critics.[7] Nevertheless, while this paper is of potential scientific interest, it may not be of much use in formulating e-cigarette policy.

The e-cigarette debate shows no sign of abating soon. We agree with McKee and Capewell who say, ““directors of public health and the wider community desperately need advice on EC [electronic cigarettes] that is evidence-based and free from any suspicion of influence by vested interests”.[4] Indeed, no public health decision should turn on the basis of intuition alone.

 — Sam Watson, CLAHRC Research Fellow

References:

1. Joossens L & Raw M. The Tobacco Control Scale 2013 in Europe. Sixth European Conference on Tobacco or Health. Istanbul, Turkey, 26-29 March 2014.
2. Nutt D. Drugs: Without the Hot Air. 1st Edition. Cambridge: UIT Cambridge Ltd. 2012.
3. King L. Evidence based policy? Why banning mephedrone may not have reduced harms to users. 19 September 2011.
4. McKee M & Capewell S. Evidence about electronic cigarettes: a foundation built on rock or sand? BMJ. 2015;351:h4863.
5. Jensen RP, Luo W, Pankow JF, et al. Hidden Formaldehyde in E-Cigarette Aerosols. N Engl J Med. 2015;372:392–4.
6. Bates CD & Farsalinos KE. Research letter on e-cigarette cancer risk was so misleading it should be retracted. Addiction. 2015;110:1686–7.
7. Willingham E. Researchers call for retraction of NEJM paper showing dangers of e-cigarettes. 11 September 2015.