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INTRODUCTION: Tobacco use has a disproportionate impact on lower socioeconomic groups in India. The study quantifies the number of people who would fall under the national poverty line if the direct spending on tobacco and healthcare expenditures attributable to tobacco use were subtracted from their monthly expenditures. It also aims to estimate the extent to which tobacco use increases the probability of poverty status in India. AIMS AND METHODS: We quantify the increase in poverty by multiplying the difference between headcount ratios with and without tobacco-related spending by population size. We use propensity score matching to estimate the extent to which tobacco use increases the probability of poverty. RESULTS: About 18.4 million (1.5% of all Indians) are pushed into poverty due to either direct tobacco-related expenditures or tobacco-related healthcare spending. Tobacco use increases households' likelihood of being poor by 3.4%-3.7%. CONCLUSIONS: With over 22% of the global poor, achieving poverty reduction goals is a significant challenge for India. We show that this challenge is accentuated by increased tobacco spending, which pushes millions of Indians into poverty. To address this, the Government of India must implement both fiscal and non-fiscal policies that regulate tobacco use and, in turn, contribute to poverty reduction in the country. IMPLICATIONS: Tobacco use has a disproportionate impact on lower socioeconomic groups in India, leading to increased and deeper poverty. This paper finds that, based on existing proven measures of poverty, tobacco use accounts for an additional 18.4 million poor individuals. It also shows that tobacco use increases the likelihood of a household being classified as poor by 3.4% to 3.7%. As India is home to a significant proportion of the global poor, addressing tobacco use becomes crucial for global and domestic poverty reduction goals. Fiscal and non-fiscal policies can be used to regulate tobacco and potentially reduce poverty levels in India.
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Lipid nanoparticles (LNPs) have gained prominence as primary carriers for delivering a diverse array of therapeutic agents. Biological products have achieved a solid presence in clinical settings, and the anticipation of creating novel variants is increasing. These products predominantly encompass therapeutic proteins, nucleic acids and messenger RNA. The advancement of efficient LNP-based delivery systems for biologics that can overcome their limitations remains a highly favorable formulation strategy. Moreover, given their small size, biocompatibility, and biodegradation, LNPs can proficiently transport therapeutic moiety into the cells without significant toxicity and adverse reactions. This is especially crucial for the existing and upcoming biopharmaceuticals since large molecules as a group present several challenges that can be overcome by LNPs. This review describes the LNP technology for the delivery of biologics and summarizes the developments in the chemistry, manufacturing, and characterization of lipids used in the development of LNPs for biologics. Finally, we present a perspective on the potential opportunities and the current challenges pertaining to LNP technology.
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There is indisputable evidence that increases in taxes that raise tobacco prices reduce tobacco use. Consumption taxes on manufactured tobacco products, however, can be regressive in socioeconomic status (e.g., when the ratio of tax paid to income is lower for higher-income groups than for lower-income groups). Nevertheless, if the poor or less educated are more price responsive, a change in tobacco tax may be progressive in socioeconomic status. Existing reviews clearly indicate that populations with lower income or education are more responsive to tobacco tax and price changes than higher-income and more educated populations in high-income countries. Research pertaining to low- and middle-income countries was, however, limited and inconclusive. We conducted a review of quantitative studies that examined if socioeconomic status modified the association between prices and taxes and tobacco use in low- and middle-income countries. We searched two electronic databases, two search engines, and two working paper repositories. At least two reviewers independently screened articles for inclusion, extracted detailed characteristics, and assessed the risk of bias of each included study. Thirty-two studies met our inclusion criteria. Overall, we found that the evidence in low- and middle-income countries was too limited and methodologically weak to make any conclusive statements. Our review highlights a number of data and methodological limitations in existing studies. The most important limitation was the lack of formal assessment of socioeconomic differences in price responsiveness. Only seven of 32 studies assessed statistically whether own-price effects were modified by socioeconomic status. Many modelling studies have examined the distributional effect of a tax increase on tobacco use, while assuming a strong own-price elasticity gradient in income. The poor were generally assumed to be more responsive to price by a factor of two to five, relative to the wealthy. Although there are theoretical reasons to expect poorer individuals to be more responsive to monetary prices than wealthy ones in low- and middle-income countries, our review provides little empirical support.
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INTRODUCTION: We studied the change in affordability of tobacco products, an important determinant of tobacco use, across the different socio-economic status (SES) in India. AIMS AND METHODS: We calculated affordability in the form of relative income price (RIP-cost of tobacco products relative to income) for the years 2011-2012 and 2018-2019 using three different denominators, that is per capita gross domestic product (GDP) and net state domestic product at national and state levels, respectively; monthly per capita consumer expenditure (MPCE); and individual wages. We investigated RIP for cigarettes, bidis, and smokeless tobacco (SLT) across different SES groups (caste groups, type of employment, and education). RESULTS: RIP increased marginally for cigarettes, bidis and remained almost constant for SLT across casual workers. However, when RIP was adjusted with SES variables, there was no significant change (p > .05) in the affordability of products for casual workers in the year 2018-2019 as compared to 2011-2012. For regular workers, cigarettes and bidis became marginally less affordable (ß < 1), whereas affordability remained constant for SLT. All products became more affordable for backward caste groups within regular workers. When RIP was calculated using MPCE all tobacco products became less affordable in the year 2018-2019. However, after adjusting for SES variables SLT reported no change in affordability. There was a marginal increase in affordability for all products when RIP was calculated with GDP. CONCLUSIONS: Although implementation of GST has increased the price of tobacco products, it is still not sufficient to reduce the affordability of tobacco products, particularly SLT and especially for the lower SES group. IMPLICATIONS: Tobacco use and economic disadvantage conditions of the population are intricately linked. Affordability of tobacco products is influenced by socio-economic indicators like age, sex, income, education, etc. The literature measuring the affordability of tobacco products across different SES groups is scant in India. Additionally, existing literature measures affordability of tobacco products based on per capita GDP as a proxy for income. This is the first study in Indian context to report the change in affordability of tobacco products across different SES groups after adjusting for SES indicators, using individual-level income data. We have calculated the change in affordability of tobacco products between the year 2011-2012 and 2018-2019 using GDP, household income, and individual wages as a proxy for income.
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Tobacco Products , Tobacco, Smokeless , Humans , Nicotiana , Economic Status , Social Class , Costs and Cost Analysis , India/epidemiologyABSTRACT
BACKGROUND: The sale of aerated or sugar-sweetened beverages (ASBs) has been consistently growing in India which has also experienced a major increase in non-communicable diseases. This study estimates the price elasticities of ASBs by different household-income groups in India and examine the trends in their affordability. METHODS: The price elasticity for ASBs were estimated using a nationally representative household sample survey on consumption of ASBs in India and with Deaton's method which is robust to self-reported household expenditure surveys. Trends in affordability of ASBs were estimated using relative income price (RIP) which measured the proportion of per capita gross domestic product (GDP) required to purchase 100 L of ASBs in a given year. The elasticity parameters were used to estimate the incremental tax needed for a 10% reduction in ASB consumption. RESULTS: The own-price elasticity of ASBs is - 0.94 in the overall sample and varied between - 1.04 to - 0.83 from low- to high-income households. There has been an annual average decline of about 6.8% in RIP of ASBs or an increase in their affordability over the last 13 years. Increasing the compensation cess on ASBs under the current Goods and Services Tax (GST) to 29%, will have the effect of decreasing ASB consumption by 10% and increasing the tax revenue by about 27%. CONCLUSION: The taxation policy on ASBs in India has largely been ineffective at increasing the real retail prices of ASBs as a result of which ASB consumption grew. ASBs should be classified along with other unhealthy products like tobacco and alcohol as demerit products for the purpose of taxation and their taxes should be regularly increased sufficiently enough to compensates for both general price inflation and income growth so as to decreases their affordability.
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Sugar-Sweetened Beverages , Beverages , Commerce , Costs and Cost Analysis , Elasticity , Humans , TaxesABSTRACT
Polyunsaturated fatty acids (PUFAs) are a class of fatty acids that are closely associated with the development and function of the brain. The most abundant PUFA is docosahexaenoic acid (DHA, 22:6 n-3). In humans, low plasmatic concentrations of DHA have been associated with impaired cognitive function, low hippocampal volumes, and increased amyloid deposition in the brain. Several studies have reported reduced brain DHA concentrations in Alzheimer's disease (AD) patients' brains. Although a number of epidemiological studies suggest that dietary DHA consumption may protect the elderly from developing cognitive impairment or dementia including AD, several review articles report an inconclusive association between omega-3 PUFAs intake and cognitive decline. The source of these inconsistencies might be because DHA is highly oxidizable and its accessibility to the brain is limited by the blood-brain barrier. Thus, there is a pressing need for new strategies to improve DHA brain supply. In the present study, we show for the first time that the intranasal administration of nanovectorized DHA reduces Tau phosphorylation and restores cognitive functions in two complementary murine models of AD. These results pave the way for the development of a new approach to target the brain with DHA for the prevention or treatment of this devastating disease.
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This paper investigates the impact of cigarette prices on adults' smoking and smokeless tobacco (SLT) use initiation and cessation decisions in India from 1980 to 2017. We use individual-level data from the 2017 Global Adult Tobacco Survey (GATS) to recreate the smoking history of current or past adult tobacco users using self-reported data on the years of tobacco use, initiation, and cessation merged with historical data on cigarettes, bidis, and SLT product prices. To estimate the effect of price changes on smoking and SLT use transitions, we use a pooled linear model and propensity score matching (PSM) to construct an artificial treatment group where weights capture the likelihood of being an ever-smoker. We find that price increases are a statistically significant deterrent to smoking initiation, with price elasticity of initiation being on average -0.0236 (CI: -0.024 -0.023) and -0.000428 (0.0 - 0.0) for smoking and SLT, respectively. This implies, for example, that a 10% increase in prices results in a 0.24% smaller smoking initiation and 0.004% smaller SLT use initiation. We find that prices can also encourage quitting, but the effects are not always significant, with elasticities of 0.0218 (CI: 0.017 0.026) and 0.0026 (CI: 0.001 0.004) for smoking and SLT, respectively. This implies that a 10% increase in prices will result in a 0.22% increase in the probability of quitting smoking and a 0.03% increase in the probability of quitting SLT use. The elasticity varied by income group, gender, and between young and all adults, with larger effects among lower-income adults and especially among young females. Higher cigarette prices that can be achieved by tobacco tax increases can significantly reduce initiation and encourage cessation, thus improving public health, especially among the most vulnerable population subgroups.
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Tobacco, Smokeless , Adult , Commerce , Female , Humans , Policy , Self Report , Smoking , Taxes , Tobacco Use/epidemiologyABSTRACT
INTRODUCTION: In India, 38.7% of adults are exposed to SHS at home and 30.2% at work. This paper estimates the direct economic costs of diseases attributable to secondhand smoking (SHS) in India for persons aged 15 years and above. AIMS AND METHODS: Nationally representative data on healthcare expenditures, healthcare utilization, and SHS prevalence were used to estimate economic costs attributable to SHS. A prevalence-based attributable risk approach was used for estimating the attributable direct costs. To estimate the SHS-attributable fraction, the excess utilization of healthcare among SHS exposed non-smokers compared to unexposed non-smokers was estimated using a method of propensity score matching (PSM). RESULTS: The annual direct economic costs attributable to SHS from all diseases in India in the year 2017 for persons aged more than 15 years amounted to INR 566.7 billion (USD 8.7 billion). This amounted to INR 705 per adult non-smoker. The SHS attributable costs were higher among the youngest age group 20 to 24, and women bear 71% of the direct medical costs attributable to SHS. CONCLUSIONS: The annual direct economic costs of SHS amount to approximately 0.33% of India's Gross Domestic Product (GDP), or 8.1% of total healthcare expenditures in India. It is also much larger than the total excise tax revenue from cigarettes and bidis. As bidi smoking is the most popular form of smoking in India and bidis are mostly consumed by the poor, a disproportionate burden of SHS is likely borne by poor households in India. IMPLICATIONS: In India, 38.7% of adults are exposed to SHS at home and 30.2% at work. However, there is no estimate of the economic burden of any kind from SHS exposure in India. This study used a prevalence-based attributable risk approach combined with a PSM technique to estimate excess healthcare utilization for SHS exposed non-smokers and the annual direct economic costs of SHS in India. Annual direct SHS-attributable costs in India is INR 566.7 billion (USD 8.7 billion) SHS costs constituted 0.33% of GDP and 8.1% of healthcare expenditures in India.
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Tobacco Smoke Pollution , Adult , Female , Health Care Costs , Health Expenditures , Humans , India/epidemiology , Patient Acceptance of Health Care , Tobacco Smoke Pollution/adverse effectsABSTRACT
We present a nanosuspension of betulin, a BCS class II anticancer drug, particularly effective against resistant breast cancer. As anticancer efficacy of betulin is hampered by poor aqueous solubility, a nanosuspension with surface area was considered to enhance efficacy. An innovative approach wherein the betulin nanosuspension is generated instantaneously in situ, by adding a betulin preconcentrate (BeTPC) comprising drug and excipients, to aqueous medium, is successfully demonstrated. The optimal BeTPC when added to isotonic dextrose solution instantaneously generated an in situ nanosuspension (BeTNS-15) with high precipitation efficiency (92.7 ± 1.21%), average particle size (383.74 ± 7.24 nm) and good stability as per ICH guidelines. TEM revealed elongated particles while DSC and XRD indicated partial amorphization. Significantly higher cytotoxicity of BeTNS-15 (IC50 38.44 µg/ml) compared to betulin (BetS) (IC50 69.54 µg/ml) in the resistant triple negative human breast cancer cell line MDA-MB-231, was attributed to high intracellular uptake confirmed by HPLC and Imaging Flow cytometry (IFC). IFC confirmed superior anti-cancer efficacy of BeTNS-15 mediated by mitochondrial membrane disruption and inhibition of the G0/G1 phase. BeTNS-15 also exhibited significantly greater anti-angiogenic efficacy (p < 0.05) in the zebrafish model confirming superior efficacy. Simplicity of the innovative in situ approach coupled with superior efficacy proposes BeTNS as an innovative and highly promising anticancer formulation.
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Nanoparticles , Triple Negative Breast Neoplasms , Triterpenes , Animals , Cell Line , Humans , Particle Size , Solubility , Suspensions , Triple Negative Breast Neoplasms/drug therapy , ZebrafishABSTRACT
INTRODUCTION: The objective of the review was to study the impact of tobacco taxes or prices on affordability and/or consumption of tobacco products in WHO South-East Asia Region (SEAR) countries, overall and by socioeconomic status; and change in consumption of one tobacco product for a given change in price/tax on another tobacco product. METHODS: The searches were made in five databases (Medline, Embase, Cinahl, EconLit, Tobacconomics) using keywords such as 'tobacco', 'tax', 'price', 'impact' with their synonyms. Additionally, the first 100 articles through google search and e-reports from targeted sources were also reviewed. Studies illustrating the impact of prices/taxes on consumption/affordability of tobacco products in SEAR, in English and with no limitation on year, were included in the review. After two steps of screening, data from 28 studies were extracted using a structured and pre-tested data extraction form. RESULTS: Of the 28 studies, 12 studies reported an inverse association between price and consumption/affordability, while 11 studies reported no or positive association between price and consumption/affordability of tobacco products. Five studies had unclear interpretations. The majority of studies estimated that the less affluent group were more price responsive compared to the more affluent group. Some studies indicated increased consumption of one product in response to price rise of another product, although, the findings were inconsistent. CONCLUSIONS: The findings of our review support the use of tobacco tax and price measures as effective tools to address the tobacco epidemic. Our findings, however, also emphasize the importance of increasing tobacco product taxes and prices sufficiently to outweigh the effects of income growth, in order for the measures to be effective in reducing the affordability and consumption of tobacco products.
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OBJECTIVE: To estimate the trends in affordability of bidis, cigarettes and smokeless tobacco (SLT) in India and examine the impact of transition from the earlier indirect taxation system to the new goods and services tax (GST) on the affordability. METHODS: Retail price data and per-capita gross domestic product data were used to examine the trends in affordability of cigarettes, bidis and SLT from 2007-2008 to 2018-2019. Relative income price defined as the share of real per-capita income required to purchase a given quantity of a product was used to measure affordability. Changes in affordability were decomposed to disaggregate the effects of real prices or income changes. FINDINGS: On average, cigarettes, bidis and SLT have become increasingly affordable over the past 10 years. Bidis were found to be nine times more affordable than cigarettes. The GST has accentuated the increase in the affordability of cigarettes and SLT, and did not significantly alter the high affordability of bidis. In general, states with high (low) value-added tax rates during the pre-GST period experienced increases (decreases) in tobacco products' affordability after GST. CONCLUSION: Bidis continue to be highly affordable while the affordability of cigarettes and SLT increased mainly due to lack of any tax changes after GST and the growth in per-capita income. To effectively reduce affordability, significant increase in either the excise taxes and/or the compensation cess-a temporary duty in addition to GST-is warranted. Compensation cess should also be applied on bidis to address the huge tobacco use problem in India.
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Commerce , Tobacco Products , Costs and Cost Analysis , Humans , India/epidemiology , TaxesABSTRACT
INTRODUCTION: About 28.6% of Indian adults use tobacco. This study estimates the economic burden of deaths and diseases attributable to smoking and smokeless tobacco (SLT) use for persons aged ≥35 years. METHODS: The National Sample Survey data on healthcare expenditures, the Global Adult Tobacco Survey data on tobacco use prevalence, and relative risks of all-cause mortality from tobacco use were used to estimate the economic burden of diseases and deaths attributable to tobacco use in India, using a prevalence-based attributable-risk approach. Costs are estimated under the following heads: (1) direct medical and nonmedical expenditures; (2) indirect morbidity costs; and (3) indirect mortality costs of premature deaths. RESULTS: Total economic costs attributable to tobacco use from all diseases and deaths in India in the year 2017-2018 for persons 35 years or older amount to INR 1773.4 billion (US $27.5 billion), of which 22% is direct and 78% is indirect cost. Men bear 91% of the total costs. Smoking contributed 74% and SLT use contributed 26% of the costs. CONCLUSIONS: The economic costs of tobacco use amount to approximately 1.04% of India's gross domestic product (GDP), while the excise tax revenue from tobacco in the previous year was only 12.2% of its economic costs. The direct medical costs alone amount to 5.3% of total health expenditure. The enormous costs imposed on the nation's health care system due to tobacco use could potentially stress the public health care system and strain the economy and it warrants massive scaling up of tobacco control efforts in India. IMPLICATIONS: The study finds that the economic burden from tobacco constitutes more than 1% of India's GDP, and the direct health expenditures on treating tobacco-related diseases alone accounts for 5.3% of the total private and public health expenditures in India in a year. It shows that, for every INR 100 that is received as excise taxes from tobacco products, INR 816 of costs is imposed on society through its consumption. It establishes that tobacco consumption is a major resource drain on the national exchequer, and its effective regulation through comprehensive fiscal and non-fiscal policies is highly warranted.
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Cost of Illness , Health Care Costs , Health Expenditures , Smoking/economics , Smoking/mortality , Tobacco Products/economics , Adult , Aged , Female , Humans , India/epidemiology , Male , Middle Aged , Prevalence , Smoking/epidemiology , South Africa/epidemiology , Surveys and Questionnaires , Survival Rate , Time FactorsABSTRACT
The illicit tobacco trade undermines the effectiveness of tobacco tax policies; increases the availability of cheap cigarettes, which, in turn, increases tobacco use and tobacco related deaths; and causes huge revenue losses to governments. There is limited evidence on the extent of illicit tobacco trade particularly cigarettes in Bangladesh. The paper presents the protocol for a mixed-methods study to estimate the extent of illicit cigarette trade in Bangladesh. The study will address three research questions: (a) What proportion of cigarettes sold as retail are illicit? (b) What are the common types of tax avoidance and tax evasion? (c) Can pack examination from the trash recycle market be considered as a new method to assess illicit trade in comparison to that from retailers and streets? Following an observational research method, data will be collected utilizing empty cigarette packs from three sources: (a) retailers; (b) streets; and (c) trash recycle market. In addition, a structured questionnaire will be used to collect information from retailers selling cigarettes. We will select post codes as Primary Sampling Unit (PSU) using a multi-stage random sampling technique. We will randomly select eight districts from eight divisions stratified by those with land border and non-land border; and within each district, we will randomly select ten postcodes, stratified by rural (five) and urban (five) PSU to ensure maximum geographical variation, leading to a total of eighty post codes from eight districts. The analysis will report the proportions of packs that do not comply with the study definition of illicit. Independent estimates of illicit tobacco are rare in low- and middle-income countries such as Bangladesh. Findings will inform efforts by revenue authorities and others to address the effects of illicit trade and counter tobacco industry claims.
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Commerce/legislation & jurisprudence , Tobacco Industry/legislation & jurisprudence , Tobacco Products , Bangladesh , TaxesABSTRACT
Smokeless tobacco is consumed by 356 million people globally and is a leading cause of head and neck cancers. However, global efforts to control smokeless tobacco use trail behind the progress made in curbing cigarette consumption. In this Policy Review, we describe the extent of the policy implementation gap in smokeless tobacco control, discuss key reasons on why it exists, and make recommendations on how to bridge this gap. Although 180 countries have agreed that the WHO Framework Convention on Tobacco Control is the best approach to control the demand and supply of smokeless tobacco, only 138 (77%) Parties define smokeless tobacco in their statutes. Only 34 (19%) Parties tax or report taxing smokeless tobacco products, six (3%) measure content and emissions of smokeless tobacco products, and 41 (23%) mandate pictorial health warnings on these products. Although awareness of the harms related to smokeless tobacco is growing in many parts of the world, few Parties collect or present data on smokeless tobacco use under global or national surveillance mechanisms (eg, Global Tobacco Surveillance System and WHO STEPwise). Only 16 (9%) Parties have implemented a comprehensive ban on smokeless tobacco advertisement, promotion, and sponsorships. Globally, a smaller proportion of smokeless tobacco users are advised to quit the use of smokeless tobacco products compared to tobacco users. Use of smokeless tobacco is becoming a global cause of concern, requiring a greater commitment on the full implementation of the WHO Framework Convention on Tobacco Control measures.
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Health Policy/legislation & jurisprudence , Smoking Prevention/legislation & jurisprudence , Tobacco, Smokeless/legislation & jurisprudence , Humans , International Cooperation , Smoking/adverse effects , Smoking/epidemiology , Smoking Prevention/standards , Smoking Prevention/statistics & numerical data , Social Control, Formal , Tobacco, Smokeless/adverse effects , World Health OrganizationABSTRACT
OBJECTIVE: To estimate the economic burden of diseases and deaths attributable to bidi smoking in India for persons aged 30-69 years. METHODS: The National Sample Survey data on healthcare expenditures, data on bidi smoking prevalence from the Global Adult Tobacco Survey and relative risks of all-cause mortality from bidi smoking are used to estimate the economic burden of diseases and deaths attributable to bidi smoking in India using a prevalence-based attributable-risk approach. Costs are estimated under the following heads: (1) direct medical expenditure of treating diseases; (2) indirect morbidity costs and (3) indirect mortality costs of premature deaths. FINDINGS: The total economic costs attributable to bidi smoking from all diseases and deaths in India in the year 2017 for persons aged 30-69 years amount to INR805.5 billion (US$12.4 billion), of which 20.9% is direct and 79.1% is indirect cost. Men bear 93.7% of the total costs. CONCLUSION: The total annual economic costs of bidi smoking amount to approximately 0.5% of India's gross domestic product, while the excise tax revenue from bidi is only half a per cent of its economic costs. The direct medical costs of bidi smoking amount to 2.24% of total health expenditure. Since the poor bear a disproportionately large share of the economic costs of bidi smoking, the unregulated use of bidi would potentially push more households in India, which incur heavy out-of-pocket expenditures on healthcare, into poverty.
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Cost of Illness , Health Care Costs/statistics & numerical data , Smoking/adverse effects , Tobacco Products/economics , Adult , Aged , Female , Health Expenditures/statistics & numerical data , Humans , India/epidemiology , Male , Middle Aged , Poverty , Prevalence , Sex Factors , Smoking/economics , Smoking/epidemiology , Surveys and Questionnaires , Tobacco Products/statistics & numerical dataABSTRACT
Background and Aim: There is a need to improve utilization of cessation assistance in low- and middle-income countries (LMICs), and tobacco cessation research has been identified as priority in LMICs. This study evaluates the relationship between health care provider intervention and cessation assistance utilization in LMICs. Methods: Data from 13 967 participants (aged ≥15 years, 90.3% males) of the Global Adults Tobacco Survey conducted in 12 LMICs (74.3%-97.3% response rates) were analyzed with utilization of counseling/cessation clinic, WHO-recommended medications, and quitline as outcome variables. Health care provider intervention ("no intervention," only "tobacco screening," "quit advice") was the exposure variable. Weighted multiple logistic regression models were used to examine the relationship between each outcome variable and the exposure variable, adjusting for other covariates. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) are reported. Results: Approximately 52%, 8%, and 40% of participants received no intervention, only tobacco screening, and advice to quit, respectively. Overall, 0.4%, 1.9%, 3.0%, and 4.5% used quitline, WHO-recommended medications, counseling/cessation clinic, and any cessation assistance, respectively. Compared with no intervention, quit advice was associated with increased utilization of quitline (OR = 2.24, 95% CI = 1.2 to 4.4), WHO-recommended medications (OR = 1.67, 95% CI = 1.2 to 2.3), counseling/cessation clinic (OR = 4.41, 95% CI = 3.2 to 6.1), and any assistance (any of the three types) (OR = 2.80, 95% CI = 2.2 to 3.6). Conclusion: The findings of this study suggest that the incorporation of quit advice by health care providers in tobacco control programs and health care systems in LMICs could potentially improve utilization of cessation assistance to improve smoking cessation in LMICs. Implications: This first study of association between health care provider intervention and the utilization of cessation assistance in LMICs reports that there was a missed opportunity to provide quit advice to about 60% of smokers who visited a health care provider in the past year. The odds of utilization of counseling/cessation clinic, WHO-recommended medications, and quitline were significantly increased in participants who were advised to quit smoking. The results suggest that effective integration and implementation of advice to quit in tobacco control programs and the national health care systems may increase the use of cessation assistance to quit smoking.
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Developing Countries , Health Personnel/psychology , Poverty/psychology , Smoking Cessation/methods , Smoking Cessation/psychology , Surveys and Questionnaires , Adolescent , Adult , Aged , Counseling/methods , Developing Countries/economics , Female , Health Personnel/economics , Humans , Male , Middle Aged , Poverty/economics , Smoking Cessation/economics , Tobacco Smoking/economics , Tobacco Smoking/psychology , Tobacco Smoking/therapy , Young AdultABSTRACT
OBJECTIVE: To examine the potential impact of the goods and services tax (GST) on price, consumption and tax revenue from tobacco products in India and across states. METHODS: Data on prices, tax rates and tax revenue are used to estimate a benchmark scenario prior to the GST implementation in 2017-2018. Using own-price elasticity of demand for tobacco products, we estimate the impact of GST at the state level and the aggregate state-wise impact to obtain the national level impact. FINDINGS: We predict that the statutory GST rate of 28% plus compensation cess will increase the price of cigarettes, bidi and smokeless tobacco by 0.18%, 8.8% and 6%, respectively, and, as a result, it will reduce the weighted average consumption by 0.3%, 10% and 6% and increase tax revenue by 0.17%, 35% and 4.7%, respectively. Most states will experience a fall in tax revenue from tobacco products by more than 50% compared with the value-added tax revenue they collected pre-GST. The GST compensation cess will have to be used to compensate states' revenue shortfalls. CONCLUSIONS: The GST has increased the complexity of the tax system for tobacco products. In particular, for cigarettes, the specific cess constitutes the majority of tax revenue, and therefore, it must be revised regularly to protect revenue and keep real prices from falling. In addition, India should reintroduce excise taxation on all tobacco products, at least in part, on top of the GST, to make them less affordable and to smooth the transition after the expiration of the compensation cess.
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Commerce/economics , Taxes/economics , Tobacco Products/economics , Humans , India , Tobacco, Smokeless/economicsABSTRACT
Southeast Asia accounts for nearly 86 per cent of the smokeless tobacco (SLT) consumers in the world. The heterogeneous nature of SLT is a major impediment to using taxation as a tool to regulate SLT. This study was aimed to review issues around fiscal policies on SLT with the objective of providing clarity on the use of taxation as an effective policy instrument to regulate SLT use. Descriptive statistics and graphical representations were used to analyze published data from different sources. An analysis of prices and tax between smoke and SLT products was done to understand the impact of tax policies on SLT consumption. India, Bangladesh and Myanmar together account for 71 per cent of the world SLT users. The retail prices (PPP$) and tax were lower for SLT in low- and lower-middle-income countries and higher in high-income countries, on an average, suggesting a direct relationship between the two. Evidence from India and Bangladesh suggested that taxation had significantly reduced SLT use among adults. The compounded levy scheme used in India to tax SLT was found effective after incorporating speed of packing machines into the assessment of deemed production and tax on SLT products. The current analysis shows that taxation can be an effective instrument to regulate SLT consumption if tax rates are harmonized across SLT products and in a manner not to encourage substitution with other tobacco products. It is also imperative to set a minimum floor price on all tobacco products including SLT.
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Taxes , Tobacco, Smokeless/economics , Adult , Asia, Southeastern , Bangladesh , Humans , India , SmokingABSTRACT
BACKGROUND: Non-communicable diseases (NCDs) account for over two-thirds of deaths worldwide, and global efforts to address NCDs have accelerated. Current prevention and control efforts rely primarily on individual behavior/lifestyle approaches that place the onus of responsibility for health on the individual. These approaches, however, have not stopped the increasing trend of NCDs worldwide. Thus, there is urgent need for exploring alternative approaches in order to attain the aim of reducing global premature NCDs mortality by 25% by 2025, and meeting the NCD reduction objective in the Sustainable Development Goals. DISCUSSION: We suggest the need for a structural approach to addressing the NCDs epidemic that integrates social science and public health theories. We evaluate two overarching principles (empowerment and human rights) and three social determinants of health (labor and employment, trade and industry, and macroeconomics) addressed in the 2013 Global Action Plan for the Prevention and Control of NCDs to demonstrate how a structural approach to NCDs can be incorporated into existing NCD interventions. For each area considered, theoretical considerations for structural thinking are provided and conclude with recommended actions. CONCLUSION: Achieving the global health agenda goals of reducing NCDs mortality will require a shift to a paradigm that embraces concerted efforts to address both behavioral/lifestyle factors and structural dimensions of NCDs.
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Global Health/statistics & numerical data , Health Policy , Noncommunicable Diseases/prevention & control , Goals , Humans , Mortality, Premature , Noncommunicable Diseases/mortality , Social Determinants of HealthABSTRACT
OBJECTIVE: To estimate illicit cigarette consumption in India using a modified and replicable method and compare it with estimates generated by the tobacco industry and by a commercial entity. METHODS: The study employed a modified approach to cigarette pack analysis suitable for countries with prevalent single-cigarette sales. Empty cigarette packs generated by 1 day's single-cigarette sales were collected directly from cigarette vendors in four large and four small cities covering the length and breadth of India. Ten areas were randomly selected in each city/town, and all shops selling cigarettes within 1 km of the central point were surveyed. A cigarette pack was classified as illicit if it had at least one of the following attributes: (a) a duty-free sign; (b) no graphic health warnings; (c) no textual health warnings; or (d) no mention of 'price inclusive of all taxes' or similar text. FINDINGS: We collected 11 063 empty cigarette packs from 1727 retailers, and 2.73% of them were classified as illicit. The estimates varied substantially across locations with the highest prevalence of illicit packs in the town of Aizawl near the Bangladesh and Myanmar border (35.87%). The share of illicit cigarettes was found to be much higher (13.77%) among the cheapest cigarette brands. Illicit cigarettes are primarily distributed via formal stores rather than informal tea/pan shops. CONCLUSION: Our estimate of the illicit cigarette market share of 2.73% casts serious doubt on the tobacco industry estimate of 20% and Euromonitor's estimate of 21.3%.