|Year : 2021 | Volume
| Issue : 1 | Page : 28-33
Perceived effect of increased pricing on smoked tobacco products quit rates: A cross-sectional study in a block of Haryana
Kirtan Rana1, Sonu Goel2, Shankar Prinja3
1 Senior Resident, Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Professor, Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
3 Additional Professor, Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||01-Apr-2020|
|Date of Decision||24-May-2020|
|Date of Acceptance||01-Nov-2020|
|Date of Web Publication||20-Mar-2021|
Room No. 130, First Floor, RN Dogra Block, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: The price of cigarettes and bidis is known to be related to the cessation of these products. Objective: To assess the perception of smokers about their quitting behavior on price increase in smoke tobacco product. Methods: A population-based cross-sectional study among people who were 18 years of age and above was conducted in 2017 among 277 participants in Haryana. Global adult tobacco survey 2009 questionnaire with objective oriented modification was used to examine the willingness to pay (WLP) for a smoked tobacco product, maximum price for quitting smoking, reinitiating smoking, and the knowledge about harmful effects of using tobacco products. Descriptive statistics and odds ratio (OR) with 95% confidence interval (CI) were used to find the relationship among various demographic characteristics and price of quitting smoking. Results: Among the participants, 65 (23.4%) were found to be current smoker and of them 48 (74%) smokers responded to quit smoking on increasing the price of smoked tobacco products. Average daily price paid by the smokers was Rs. 23 and Rs. 8 for cigarettes and bidis, respectively. The odds of quitting smoking among cigarette smokers were higher than those of among bidi smokers (OR = 5.2, 95% CI 2.877–10.04). The odds of quitting smoking among those spending more than Rs. 10/day were lower than those spending <Rs. 10 on these products (OR = 4.8, 95% CI 1.1–22.3). 72.9% of the smokers declared >100% increase in current price for quitting smoking. Conclusion: An increased magnitude of price increase on smoke tobacco products is invariably an effective method of decreasing smoking prevalence.
Keywords: Cessation policies, higher price, quit smoking, smoking
|How to cite this article:|
Rana K, Goel S, Prinja S. Perceived effect of increased pricing on smoked tobacco products quit rates: A cross-sectional study in a block of Haryana. Indian J Public Health 2021;65:28-33
|How to cite this URL:|
Rana K, Goel S, Prinja S. Perceived effect of increased pricing on smoked tobacco products quit rates: A cross-sectional study in a block of Haryana. Indian J Public Health [serial online] 2021 [cited 2021 Apr 13];65:28-33. Available from: https://www.ijph.in/text.asp?2021/65/1/28/311519
| Introduction|| |
Tobacco taxation has proven to be the most effective strategy out of the six strategies in MPOWER for reducing tobacco consumption across the globe. The framework convention on Tobacco Control-World Health Organization (WHO-FCTC) in its article 6 has stated price and tax measure to control the demand of tobacco. Many studies have unequivocally proven that an increased price of tobacco to be the single most important strategy to decrease its prevalence.,,,,,, Tobacco taxation in India is very complex even after recent introduction of Goods and Service Tax (GST) on July 2017, under which tobacco products fall under 28% slab of GST to which National Calamity contingent duty, Cess specific and Cess Ad valorem which is levied differently on different lengths of cigarette and type of tobacco products (cigarette and bidi). As per the WHO report on tobacco taxation in 2017, the taxation rate on cigarette and bidi was 43% and 19%, respectively, of the retail price, which is much below the proposed taxation rate of 75% by the WHO FCTC. Many countries such as Bulgaria (83.2%), Finland (84.9%), France (80.3%), Greece (80.6%), and United Kingdom (80.5%) have raised their taxes on tobacco products well above that recommended by WHO FCTC.
In order to prevent morbidity and mortality due to tobacco use thoughtful increase in taxation need to be done to reach the goal of relative reduction of smoking by 30% by 2025. It is commonly found that smokers respond to increase in cigarette price by quit smoking, switching to cheaper brands or products or by making no change and continue to purchase and use tobacco products as before the price increase. A multicentric study conducted by the international tobacco control four-country survey found that the smokers living in areas where the cigarette price is higher and taxes are significantly more tend to have more quitting rates. Another study found that similar kind of smokers tend to report higher quit rates even on a hypothetical increase in the price of tobacco products.
The present study assessed the smoker's perception on quitting smoked tobacco products based on “willingness to pay (WLP)” concept, with self-expressed prices for quitting currently used smoked tobacco products.
| Materials and Methods|| |
Study design, area and duration
A cross-sectional study was done in Shahzadpur block of district Ambala, in the state of Haryana, India. The data were collected from June to September 2017. Ambala district is one of the 22 districts of Haryana state that has a population of around 1.1 million spread across 1574 sq. km. and has a population density of 720/sq. km. Shahzadpur block has a population of around 0.2 million and has 31 subcenters, each catering to population of around 5000.
The population of Shahzadpur block was taken as study population. People who were 18 years of age and above were included in the study. The people who were mentally unable to understand the questionnaire were excluded from the study.
Sample size and sampling
The sample size was calculated using the prevalence of smoking (19.6%) among adults of Haryana with absolute precision of 6%, design effect of 1.5, and a nonresponse rate of 10% giving us the total sample size of 277. Post hoc calculations demonstrated that a sample of 48 would allow estimation of tobacco use behavior with 95% confidence interval (CI) of ∝ = 0.5% for binary variables, with 84.5% power and ∝ = 0.05.
The sample was divided proportionally into rural (70%, n = 194) and urban (30%, n = 83) area based on probability proportional to size method. The ratio of male to female was taken at 50:50. Out of 31 subcenters in Shahzadpur block, six subcenters were randomly chosen using lottery method. The village in which the subcenter was located was selected for collecting the required information. From each village, 32 respondents were selected by systematic random sampling in which every twentieth household was sampled based on the population of the village. For the urban area, the respondents were enrolled from Shahzadpur town using a similar methodology as adopted for the rural population. The survey at each jurisdiction (village/town) started from the center point (old tree, hand pump, school). A random direction from the center was selected by spinning the bottle. Then, the first house that came in the direction of a bottle with the respondent was enrolled. The first person to who the primary investigator met was asked about the family members and one respondent was selected out of all the family members falling into inclusion criteria using the Kish method. The subsequent houses were selected using systematic random sampling until the desired sample size is reached from the village. The flowchart showing the scheme of selecting required sample size is shown in [Figure 1].
|Figure 1: Flow chart showing the scheme of selecting the desired sample size n = 277.|
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Tools and technique: Data collection
The data were collected after taking written consent from the participant, and face to face interview method was chosen for data collection using a predesigned schedule. All the data were collected by the primary investigator to avoid any bias in data collection.
A subset of 40 questions from the GATS questionnaire 2010 was used in the schedule of data collection to achieve the objectives of the study. The schedule included background characteristics and specified variables. The dependent variable was the intention to quit smoking on self-reported price increase, while the independent variables were sociodemographic (age, gender, education, occupation, residence, and monthly income) and smoking (smoking product, quit attempts, and daily tobacco expenditure).
The following were the operational definitions used in the study.
- Current tobacco smokers: Person who currently smokes at least one tobacco product every day for 1 month or more
- Bidi: It is made by rolling a dried rectangular piece of temburni leaf (Diospyros melanoxylon) with 0.15–0.25 g of sun-dried flaked tobacco into a conical shape and securing the roll with a thread
- Interest in quitting smoking: Current tobacco smoker who is planning or thinking about quitting smoking within the next month, 12 months or someday
- WLP: Contingent valuation (CV) methods were used to obtain the smoker's WLP for smoked tobacco products. CV methods are used to assess the willingness for cessation treatment and to assess the WLP for the smoked tobacco products. The participants were asked about smoking habits and other relevant information. The participants who were current smokers were then asked about the maximum price that they can pay for the smoked tobacco product that they were currently using. The “WLP” concept was used in a way to find out the maximum price beyond which the user loses his/her capacity to pay for the product which was used as “price to quit.” Further the average price for quitting smoking will be calculated to suggest an increase in current prices for smoked tobacco products.
The ethical clearance was given by the Institutional Ethical Committee with reference number NK/3479/MD on May 15, 2017, and the permission was also soughed from the Director General Health Service office Haryana under number CFMSN 12518.
Statistical Package for the Social Sciences version 16.0 (manufactured by the SPSS Inc., 233 South Wacker Drive, 11th floor, Chicago, IL 60606-6412, US). The descriptive statistics were calculated in numbers and percentages. The Chi-square analysis was done to establish the relationship between the various underlying characteristics of the smokers and increase in price of smoked tobacco products for quitting smoking. Odds ratio (OR), 95% CI and P value was calculated to establish the statistical significance between the independent and dependent factors.
| Results|| |
[Table 1] shows the sociodemographic characteristics of the study participants, out of a total of 277 participants, 198 were over 30 years of age (68.6%); 194 belonged to rural area (70%); 209 (75.5%) were literate and had monthly income more than Rs. 10,000 (57.8%). Around one quarter (23.5%, 65/277) of the study participants were smokers. Majority (92%) of tobacco smokers were bidi smokers. The average number of cigarettes and bidis consumed was 5.4 and 14 per capita per day for which the average price paid by the smokers was Rs. 23 and Rs. 8, respectively. Around 69.2% of the smokers had made quit attempts due to one or the other reasons in the past. Majority (78%) of all participants and 71% of the smokers had knowledge related to the harmful effects of smoking among those who use smoked tobacco products [Table 2].
|Table 1: Socio - demographic characteristics of the study participants (n=277)|
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|Table 2: Characteristics regarding smoking behavior of smokers among the study participants (n=65)|
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The odds of quitting smoking among cigarette smokers at a price increase of <100% were higher than those of quitting among bidi smokers at the same increase in price (OR = 5.2, 95% CI 2.877–10.04, P = 0.001). The odds of quitting smoking on price increase of >100% on current price of smoked tobacco products was more among those spending more than Rs. 10/day on smoked tobacco products than those spending more than Rs. 10 on these products (OR = 4.8, 95% CI 1.1–22.3, P = 0.048), as shown in [Table 3].
|Table 3: Factors associated with quitting smoking on a self-reported increase in the current price of smoked tobacco products using the willingness to pay method (n=48)|
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About 72.9% of the current smokers agreed to quit smoking on self-declared increasing price of current smoked tobacco product >100%. Further, a step ahead the study computed that a self-reported average increase of 600% (six times) on current price of smoked tobacco products would make current smokers to quit smoking. Around 13.5% of the current smokers who responded to quit smoking on increasing the price of the smoked tobacco products had shown their interest in reinitiating smoking if the price of these products will decrease in the future.
| Discussion|| |
The present study analyzed the price to quit smoking among current smokers from the smoker's perspective. The study observed that the current smokers were willing to quit smoking if the price of the smoked tobacco product increases by more than 100% of the current price depicting probability to quit with higher price increase. The findings are in concordance with the study by Guillaumier et al. which found that more smokers endorsed to quit smoking in the scenario where there was a larger increase in price (at-least 20% increase in current price) while other responses (switching brands, purchasing small quantity, using loose tobacco) were at a lower increase in price. The present study found that odds of quitting smoking on price increase of >100% on current price of smoked tobacco products was more among those spending more than Rs. 10/day on smoked tobacco products than those spending more than Rs. 10 on these products. A multicentric study by Pawar et al. found that lower increase in price (two times) of bidis has least impact on bidi smokers especially those who smoke <10 bidi daily which indirectly corresponds that they have to spend less money to continue smoking. Since most of the smokers in our study were bidi smokers, there was less spending on tobacco products in our study (around Rs. 8/day) which is due to its easy affordability of bidi and cheaper source of smoked tobacco products as compared to cigarettes.
The present study observed higher odds (OR = 5.3) of quitting cigarettes at lower increase (<100%) in current price as compared to bidis. The reasons were the higher prices being already paid by the cigarette smokers and inability to afford further higher prices for their smoke as around one-fourth of the smokers has monthly income of <Rs. 10,000. A study by Hyland et al. found that 59% of the smokers reported quit smoking at a higher increase in the price of tobacco products. Another reason for quitting cigarettes at lower increases in price apart from affordability is their price elasticity for demand which is very low as compared to bidis. A study by Selvaraj et al. calculated price elasticity for cigarettes is low in both rural and urban parts of the country when compared to bidis based on consumer behavior with a two stage two equation system. Similarly, low price elasticity of demand for cigarette consumption as compared to bidi consumption was also given by John in 2008. In contrast to the current study, a study by Sharbaugh et al. found that increase in cigarette taxes had least impact on smoking prevalence in low-income countries and interventions other than excise tax can help in decreasing the prevalence of cigarette. Similarly, the smokers who were resistant to quit smoking on increasing the price of smoked tobacco products can be dealt with nonprice strategies as mentioned under WHO MPOWER strategy.
The higher increase in quitting price (approximately six times the current price) for smoked tobacco products (of which the bidi smoking shares a major proportion) can be well supplemented by the findings of John's study in which he found the tax on bidis need to be increased to Rs. 100 instead of current Rs. 14/1000 sticks to decrease the smoking prevalence. Higher prices influence the demand of tobacco products by discouraging the initiation of smoking, encouraging quitting by current tobacco users, helping former users to stay quit, and preventing the occasional users becoming regular users.
Smokers in our study population considered smoking as a part of their culture and a mean of socialization which seems to be not statistically influenced by the education, occupation, gender and region, and monthly income, though the prevalence is seen more among elders, males, living in rural areas, literate, and employed people. Various other studies have found a positive association between tobacco use and education and occupational status of the participants.,, Similar to the findings, another study by Peretti-Watel and Constance 2009 found that poor smokers are poor quitters as most of the them smoke tobacco to reduce negative feelings and to cope up with loneliness and work-stress.
The study is first of its kind in Indian settings to use the “WLPpay” method to elicit the perceived price at which smokers quit smoking. However, the WLP method can have a bias in the form of a lower or higher ceiling in deciding the quit price. The use of a cross-sectional design with a sample drawn from a single site also limits the generalizability of the study. Further the absence of design effect while calculating the sample size can be a source of bias while generalizing the results. Further, using hypothetical scenarios for predicting behavior may not truly reflect actual behavior of respondents. There is also a possibility of social desirability bias while responding to quitting smoking, thus underestimating the actual behavior. The results could not adjust the effect of confounders in quitting smoking as regression could not be applied for getting adjusted OR.
| Conclusion|| |
The present study concludes that a large increase in the price of smoked tobacco products is desired for quitting smoking and in-turn reduce the prevalence of smoking. Being the strongest measure of WHO-MPOWER policy, governments should consider raising® taxes on smoked tobacco products, so that the price of products can be significantly increased. The larger studies based upon the current WLP approach should be planned to generate stronger evidence for increase in taxation rates in the country.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. A Policy Package to Reverse the Tobacco Epidemic. World Health Organization; 2008.
World Health Organization. WHO Framework Convention on Tobacco Control. World Health Organization; 2005.
John RM. Price elasticity estimates for tobacco products in India. Health Policy Plan 2008;23:200-9.
Selvaraj S, Srivastava S, Karan A. Price elasticity of tobacco products among economic classes in India, 2011-2012. BMJ Open 2015;5:e008180.
Levy DT, Wen CP, Chen TY. Increasing taxes to reduce smoking prevalence and smoking attributable mortality in Taiwan: Results from a tobacco policy simulation model. Tob Control 2005;14:45-50.
Ross H, Kostova D, Stoklosa M, Leon M. The impact of cigarette excise taxes on smoking cessation rates from 1994 to 2010 in Poland, Russia, and Ukraine. Nicotine Tob Res 2014;16 Suppl 1:S37-43.
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 Tob Res 2002;4:311-9.
Ross H, Blecher E, Yan L, Cummings KM. Predictors of what smokers say they will do in response to future price increases. Findings from the International Tobacco Control (ITC) Four Country Survey. Nicotine Tob Res 2011;13:419-25.
Tabuchi T, Fujiwara T, Shinozaki T. Tobacco price increase and smoking behaviour changes in various subgroups: A nationwide longitudinal 7-year follow-up study among a middle-aged Japanese population. Tob Control 2017;26:69-77.
GST Council Government of India. Rate of GST on Goods. GST Council Government of India; 2017.
World Health Organization. WHO Report on the Global Tobacco Epidemic, 2017: Monitoring Tobacco use and Preventive Policies. World Health Organization; 2017.
World Health Organization. Global Action Plan for the Prevention and Control of Non Communicable Disease 2013-2020. World Health Organization; 2013. p. 55.
Guillaumier A, Bonevski B, Paul C, D'Este C, Doran C, Siahpush M. Paying the price: A cross-sectional survey of Australian socioeconomically disadvantaged smokers' responses to hypothetical cigarette price rises. Drug Alcohol Rev 2014;33:177-85.
Nagarajan P, Tripathy JP, Goel S. Is mother and child tracking system (MCTS) on the right track? An experience from a northern state of India. Indian J Public Health 2016;60:34-9.
] [Full text]
Tripathy JP, Goel S, Kumar AM. Measuring and understanding motivation among community health workers in rural health facilities in India-a mixed method study. BMC Health Serv Res 2016;16:366.
Global Tobacco Survillance System: Ministry of Health and Family welfare Government of India. Global Adult Tobacco Survey (GATS), Fact Sheet, Haryana, India: Global Tobacco Survillance System 2009-2010; 2010.
Kish L. A procedure for objective respondent selection within the Household. J Am Stat Assoc 1949;44:380-7.
Tata Institute of Social Science Mumbai and Ministry of Health and Family Welfare G of I. Global Adult Tobacco Survey GATS 2 India 2016-17; 2017.
Varian HR. MIcroeconomic Analysis. 3rd
ed. New York: W.W. Norton & Company Ltd.; 1992.
Pawar PS, Pednekar MS, Gupta PC, Shang C, Quah AC, Fong GT. The relation between price and daily consumption of cigarettes and bidis: Findings from the tobacco control policy evaluation wave 1 survey. Indian J Cancer 2014;51 Suppl 1:S83-7.
Hyland A, Bauer JE, Li Q, Abrams SM, Higbee C, Peppone L, et al
. Higher cigarette prices influence cigarette purchase patterns. Tob Control 2005;14:86-92.
Sharbaugh MS, Althouse AD, Thoma FW, Lee JS, Figueredo VM, Mulukutla SR. Impact of cigarette taxes on smoking prevalence from 2001-2015: A report using the Behavioral and Risk Factor Surveillance Survey (BRFSS). Akinyemiju TF, editor. PLoS One 2018;13:e0204416.
Prabhakar B, Narake SS, Pednekar MS. Social disparities in tobacco use in India: The roles of occupation, education and gender. Indian J Cancer 2012;49:401-9.
] [Full text]
Sharma D, Goel S, Lal P. Education differential in relation to tobacco use and its predictors across different regions of India. Indian J Cancer 2017;54:584-8.
] [Full text]
Wang Q, Shen JJ, Sotero M, Li CA, Hou Z. Income, occupation and education: Are they related to smoking behaviors in China? PLoS One 2018;13:e0192571.
Peretti-Watel P, Constance J. “It's all we got left”. Why poor smokers are less sensitive to cigarette price increases. Int J Environ Res Public Health 2009;6:608-21.
[Table 1], [Table 2], [Table 3]