Intended for healthcare professionals


Story on smoking and poor people is incomplete

BMJ 2001; 323 doi: (Published 03 November 2001) Cite this as: BMJ 2001;323:1070
  1. Prabhat Jha, senior scientist (jhap{at},
  2. Philip Musgrove, lead economist, World Bank (on assignment),
  3. Frank J Chaloupka, professor of economics,
  4. Derek Yach, executive director
  1. World Health Organization, CH-1211 Geneva, Switzerland
  2. University of Chicago, Chicago, IL 60607-7121, USA
  3. World Health Organization

    EDITOR—Wiltshire et al have added to the tobacco control debate by documenting that smokers in deprived areas perceive a lack of support for cessation.1 Their findings need to be interpreted in the totality of the evidence.

    Firstly, the study did not pose or answer the key question: “If the government were to subsidise nicotine replacement or other cessation programmes, would they take advantage of the subsidy and try to quit?” A “yes” answer would deserve respect and a public response, such as increased length of nicotine replacement under the NHS.

    Secondly, the study discussed perceived benefits but not perceived or actual risks. About half of long term smokers will be killed by their addiction, losing about 20-25 years of life.2 Smoking seems to account for much of the observed socioeconomic differences in adult male mortality.3

    Thirdly, as with any other consumer tax, increases in cigarette taxes are regressive among those who continue to consume (smoke). But people on lower incomes may well respond more to price changes than those on high incomes.4 Higher tobacco taxes would thus narrow differences in consumption between rich and poor. If more of the poor smokers quit, then the recent tobacco tax increases in the United Kingdom may well be progressive, even though overall tobacco tax itself is regressive.

    What matters in defining regressivity is the overall system of expenditure and taxation, not simply one tax. A priori, one would expect greater welfare losses among continuing poor smokers, as the study notes. Moreover, many welfare-enhancing health interventions, such as child immunisation or family planning, are often more costly to poor households. For example, poor families may have to spend more time in transport to attend clinics than rich families and may lose income in the process.

    Finally, the study implies that individual smuggling is the key source of contraband. In fact, the key source is large scale tobacco smuggling involving criminal organizations. The tobacco industry uses smuggled cigarettes to argue for lower taxes on cigarettes and gain market share for their brands. But even in the presence of smuggling, higher taxes reduce consumption. Lowering taxes is a poor way to reduce smuggling. Cheaper cigarettes are more likely to increase smoking among poor and young people. For example, when Canada lowered taxes in 1994 in response to organised smuggling, smoking among teenagers increased dramatically. A better solution is to crack down more aggressively on criminal suppliers.5


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