Health
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Tripling taxes on cigarettes around the world would reduce the number of smokers by one-third and prevent 200 million premature deaths from lung cancer and other diseases this century, according to a review published today in the New England Journal of Medicine.
Such a large tax increase would double the street price of cigarettes in some countries and narrow the price gap between the cheapest and most expensive cigarettes, which would encourage people to stop smoking rather than switch to a cheaper brand and help young people not to start.
This would be especially effective in low- and middle-income countries, where the cheapest cigarettes are relatively affordable and where smoking rates continue to rise, said Dr. Prabhat Jha, director of the Centre for Global Health Research of St. Michael's Hospital and a professor in the Dalla Lana School of Public Health at the University of Toronto.
But it would also be effective in rich countries, he said, noting that France halved cigarette consumption between 1990 and 2005 by raising taxes well above inflation.
"Death and taxes are inevitable, but they don't need to be in that order," Dr. Jha said. "A higher tax on tobacco is the single most effective intervention to lower smoking rates and to deter future smokers."
Countries around the world agreed at the United Nations General Assembly and the World Health Organization's 2013 Assembly to decrease the prevalence of smoking by about one-third by 2025 to reduce premature deaths from cancer and other chronic diseases by 25 per cent.
Tobacco causes about 200,000 deaths a year of people under 70 in Canada and the United States (120,000 men and 80,000 women).
Doubling cigarette prices would prevent about 70,000 of those deaths and provide new revenue that governments could spend on health care.
Dr. Jha said that even while higher tobacco taxes would reduce consumption, they would still generate an additional $100 billion U.S. a year for a total of $400 billion.
"Worldwide, around a half-billion children and adults under the age of 35 are already – or soon will be – smokers and on current patterns few will quit," said Professor Sir Richard Peto of the University of Oxford, the co-author.
"So there's an urgent need for governments to find ways to stop people starting and to help smokers give up. This study demonstrates that tobacco taxes are a hugely powerful lever and potentially a triple win – reducing the numbers of people who smoke and who die from their addiction, reducing premature deaths from smoking and yet, at the same time, increasing government income,” said Peto.
“All governments can take action by regularly raising tobacco taxes above inflation, and using occasional steep tax hikes starting with their next budget. Young adult smokers will lose about a decade of life if they continue to smoke – they've so much to gain by stopping,” Peto added.
Controlling tobacco marketing is also key to helping people quit smoking. An independent review in the United Kingdom concluded that plain packaging would reduce the appeal of cigarettes, a switch that is expected before the next election. Australia changed to plain packaging in 2011, a measure New Zealand plans to follow.
Dr. Jha and Sir Richard noted that the 21st-century hazards of smoking have been reliably documented only in the past year, when several researchers published papers showing that men and women who started smoking when they were young and continued throughout adulthood had two or three times the mortality rate of non-smokers. An average of 10 years of life is lost from smoking. Many of those killed are still in middle age, meaning on average they lose about 20 years of life expectancy.
Both Dr. Jha and Sir Richard published papers last year showing that people who quit smoking when they are young can regain almost all of the decade of life they might otherwise have lost.
Smoking around the world: Facts and figures
Worldwide, about 1.3 billion people smoke, mostly in low- and middle-income countries.
Two-thirds of all smokers live, in descending order, in China, India, the European Union, Indonesia, the United States, Russia, Japan, Brazil, Bangladesh and Pakistan.
China consumes more than 2 trillion cigarettes a year, out of a world total of about 6 trillion.
Smoking causes about 12-25 per cent of all deaths in middle-age men in China, India, Bangladesh and South Africa, and these proportions are set to rise as successive generations in which few people smoked are being replaced by generations in which many people have smoked throughout their adult lives.
Numerous studies find that a 50 per cent higher inflation-adjusted price for cigarettes reduces consumption by about 20 per cent with stronger effects in the young and in the poor.
In most high-income countries, about 50-60 per cent of the retail price of a pack of cigarettes is the excise tax (based on the quantity or weight of tobacco, and which is difficult for the tobacco industry to manipulate). By contrast, this proportion is only 35-40 per cent in most low- and middle-income countries.
About $300 billion dollars is raised from tobacco tax worldwide. Tripling the tax would double the price of a package of cigarettes and reduce consumption by one third, yet still yield another $100 billion US in revenue.
A low excise tax is the main reason cigarettes are cheaper in many low- and middle-income countries than in high-income countries.
The federal excise tax on a carton of cigarettes in Canada is $17. Federal and provincial sales taxes bring the total cost of carton from between $46 and $87.
About 10 per cent of all cigarettes manufactured worldwide are smuggled. Smart taxation strategies and efforts to clamp down on criminals who smuggle reduce smuggling. Even in the presence of smuggling, higher taxes reduce consumption and raise more revenue.
Non-price interventions such as complete bans on tobacco advertising and promotion, plain packaging (already used in Australia) or pictorial warning labels, smoke-free laws and support for cessation help reduce smoking, and raise support for higher taxes.
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People with severe mental illness such as schizophrenia or bipolar disorder have a higher risk for substance use, especially cigarette smoking, and protective factors usually associated with lower rates of substance use do not exist in severe mental illness, according to a new study funded by the National Institute on Drug Abuse (NIDA), part of the National Institutes of Health.
Estimates based on past studies suggest that people diagnosed with mood or anxiety disorders are about twice as likely as the general population to also suffer from a substance use disorder.
Statistics from the 2012 National Survey on Drug Use and Health indicate close to 8.4 million adults in the United States have both a mental and substance use disorder.
However, only 7.9 percent of people receive treatment for both conditions, and 53.7 percent receive no treatment at all, the statistics indicate.
Studies exploring the link between substance use disorders and other mental illnesses have typically not included people with severe psychotic illnesses.
“Drug use impacts many of the same brain circuits that are disrupted in severe mental disorders such as schizophrenia,” said NIDA Director Dr. Nora D. Volkow. “While we cannot always prove a connection or causality, we do know that certain mental disorders are risk factors for subsequent substance use disorders, and vice versa.”
In the current study, 9,142 people diagnosed with schizophrenia, schizoaffective disorder or bipolar disorder with psychotic features, and 10,195 controls matched to participants according to geographic region, were selected using the Genomic Psychiatry Cohort program.
Mental disorder diagnoses were confirmed using the Diagnostic Interview for Psychosis and Affective Disorder (DI-PAD), and controls were screened to verify the absence of schizophrenia or bipolar disorder in themselves or close family members. The DI-PAD was also used for all participants to determine substance use rates.
Compared to controls, people with severe mental illness were about four times more likely to be heavy alcohol users (four or more drinks per day); 3.5 times more likely to use marijuana regularly (21 times per year); and 4.6 times more likely to use other drugs at least 10 times in their lives.
The greatest increases were seen with tobacco, with patients with severe mental illness 5.1 times more likely to be daily smokers. This is of concern because smoking is the leading cause of preventable death in the United States.
In addition, certain protective factors often associated with belonging to certain racial or ethnic groups – or being female – did not exist in participants with severe mental illness.
“In the general population, women have lower substance use rates than men, and Asian-Americans have lower substance use rates than white Americans, but we do not see these differences among people with severe mental illness,” said Dr. Sarah Hartz, from the Washington University School of Medicine in St. Louis and first author on the study. “We also saw that among young people with severe mental illness, the smoking rates were as high as smoking rates in middle-aged adults, despite success in lowering smoking rates for young people in the general population.”
Previous research has shown that people with schizophrenia have a shorter life expectancy than the general population, and chronic cigarette smoking has been suggested as a major contributing factor to higher morbidity and mortality from malignancy as well as cardiovascular and respiratory diseases.
These new findings indicate that the rates of substance use in people with severe psychosis may be underestimated, highlighting the need to improve the understanding of the association between substance use and psychotic disorders so that both conditions can be treated effectively.
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The Surgeon General's report of 1964 which outlined, for the first time, the effects of smoking on health, along with the tobacco control efforts that followed, are responsible for adding nearly 20 years of life to eight million people, according to a study in the Jan. 8 issue of JAMA.
“The report and subsequent tobacco control efforts represent the most dramatic and successful public health campaign in modern history, in terms of benefit to the entire population,” said the study's senior author, David T. Levy, PhD, a population scientist at Georgetown Lombardi Comprehensive Cancer Center.
“In 1964, more than 40 percent Americans adults smoked, and now, 50 years later, less than 20 percent use cigarettes. Our research suggests that this dramatic reduction is due to the 1964 Surgeon General's report and the tobacco control activity that followed, “ he said. “While this is a significant public health achievement, we have much more to do – smoking continues to be the leading contributor to the nation's death toll.”
The researchers also estimated that, over the past 50 years, 17.6 million deaths in the United States were related to smoking.
Of these deaths, 6.6 million occurred in individuals below the age of 65, implying a large productivity loss due to illness and death during the working ages, Levy says.
The study was conducted by a group of researchers who are part of the Cancer Intervention and Surveillance Modeling Network or CISNET, funded by the National Cancer Institute. CISNET uses statistical modeling to improve understanding of cancer control interventions.
The lead investigator of the study is Theodore Holford, PhD, from Yale School of Public Health, and researchers from the University of Michigan and Fred Hutchinson Cancer Research Center also participated.
The research team examined smoking patterns up through 1964 and then modeled mortality rates based on what would likely have happened in the absence of tobacco control.
They then compared actual death rates. This resulted in an estimated 157 million years of life saved – 19.6 additional years for each smoker who quit.
Tobacco control policies had an impact on John Hilburn of San Antonio. He gave up his two pack-a-day 20-year habit 30 years ago due to two factors – the Surgeon General's warning on his cigarette pack and an increase in price for a pack of cigarettes.
“I thought smoking might be unhealthy, but when I read the warning, I knew it was. I just decided I didn't want to pay $1 a pack to ruin my health,” Hilburn said.
He threw his carton of cigarettes away, and hasn't smoked since.
“I'm 67 years old and I attribute the health I have to giving up cigarettes,” he said.
Levy's research mirrors Hilburn's experience. “Higher taxes on cigarettes have had the most impact on cessation, and smoke-free air laws – prohibiting smoking indoors – have also been very effective.”
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The United States' global share of biomedical research spending fell from 51 percent in 2007 to 45 percent in 2012, while Japan and China saw dramatic increases in research spending.
The research and development spending in the United States dropped from $131 billion to $119 billion, when adjusted for inflation, from 2007-2012, while Japan increased spending by $9 billion and China increased by $6.4 billion.
Overall, Asia's share of spending grew from 18 percent to 24 percent. Europe held steady at 29 percent.
Prior analyses have suggested the United States' share of global expenditures were once as high as 80 percent.
Results of this new analysis, conducted by researchers from industry and academia, including both medical researchers and economists, appear in the Jan. 2 New England Journal of Medicine.
“The United States has long been a world leader in driving research and development in the biomedical science. It's important to maintain that leadership role because biomedical research has a number of long term downstream economic benefits, especially around job creation,” said study author Reshma Jagsi, M.D., D.Phil., associate professor of radiation oncology at the University of Michigan Health System.
Despite reductions in funding from the National Institutes of Health, including a 20 percent drop in purchasing power since 2003, the researchers discovered that the United States' decline was driven almost entirely by reduced investment from industry, not the public sector. This includes support for clinical trials testing potential new therapies.
Jagsi suggests that this may boil down to fewer regulations and less expense to conduct research in Asia – labor costs less, government may be offering subsidies and the research infrastructure is not as bureaucratic as it is in the United States.
“We were surprised the impact of industry funding was that dramatic, but it's key to note that government funding is equally important to maintain or grow. Research funded through the National Institutes of Health helps scientists understand how diseases work – this will happen slower as NIH funding continues to be cut,” says study author Justin Chakma, a venture capital investor with Thomas, McNerney & Partners in La Jolla, Calif.
Historically, about half of drugs approved by the U.S. Food and Drug Administration had some federal government funding during the course of the research and development.
The authors note the critical need for increased NIH funding coupled with incentives to industry for investing in biomedical research and development here. They call the lack of a coordinated national biomedical R&D strategy “disappointing.”