13.11 The impact of tobacco tax increases on socioeconomically disadvantaged populations

Despite robust evidence that tobacco tax increases are the single most effective, and cost-effective, policy to reduce tobacco use,^1,2 such increases are sometimes described as being ‘regressive’. That is, people from socioeconomically disadvantaged groups, vulnerable populations, and young people who smoke are likely to pay a greater percentage of their income on tobacco taxes (a greater tax burden) compared to less disadvantaged people who smoke. Consumption taxes, also known as ‘sin taxes’, are often viewed as regressive,³ especially those on products that young people and disadvantaged groups consume at higher rates such as tobacco and sugar-sweetened beverages.⁴ This view of regressivity based solely on the tax burden experienced by different populations—known as the accounting approach—is considered by many to be too narrow.⁵ Many researchers take a broader, welfare-based perspective that also considers how people behave in response to tax increases, and the impacts of tax increases on more than just disposable income.^3,5 Such researchers have examined how consumer factors such as price sensitivity, consumption rates can differ across population groups, and have studied how consumer behaviours may change over time.^6,7

Since the tobacco industry’s customers are disproportionately poorer and less educated, it could be argued that the tobacco market itself is regressive. Tobacco use also exacerbates inequalities, and the tobacco industry has a history of targeting disadvantaged people.⁸ Disadvantaged people also have the most to gain from reducing their tobacco use in terms of economic as well as health benefits, and precisely because of their greater price-sensitivity that disadvantaged groups will experience the most overall benefit.  

It is clear that increases in tobacco taxes have the largest impact among poorer population groups: that is what makes them an effective preventive tool.⁹ The key issues in determining whether tobacco taxes are regressive are: first, the extent to which people in various socioeconomic groups actually do quit in response to price increases; and second, what the consequences are for those low socioeconomic smokers who do not quit.³ This section will explore:

• why the tobacco market itself is regressive
• why tobacco tax increases are widely considered to be progressive
• evidence from major reviews that have examined the impact of tobacco taxes on disadvantaged groups
• the impacts of tobacco taxes on those with entrenched disadvantage, and
• implications for effective and equitable tobacco control policy.

13.11.1  Are tobacco taxes regressive?

There is an inverse relationship between socioeconomic status and tobacco consumption, and consequently also in inverse relationship between socioeconomic status and the level of harm experienced due to tobacco use.⁴ In Australia, like other countries, tobacco use is more prevalent¹⁰, quit rates are lower¹¹ and the duration of smoking is longer^12,13 among low compared with high socioeconomic groups¹⁴—see Chapter 9, Sections 9.1 and 9.2. There is no doubt that this creates a large financial burden in many low-income households^11,15,16 (see Chapter 2, Section 2.4 and Chapter 9, Section 9.5) and, in particular, in many Aboriginal communities.^17,18. Likewise, a disproportionate amount of ill-health and premature death due to smoking-caused illness is experienced by lower socio-economic groups (see Chapter 9, Section 9.3).

Because of the addictive nature of tobacco some may assume that tobacco consumption is price inelastic, that is, consumption does not fluctuate with price.¹⁹ As described in Sections 13.1 and 13.2, tobacco is in fact moderately price elastic, with greater rates of elasticity for disadvantaged and young populations. The tobacco industry targets these populations with efforts to make tobacco seem more affordable, recruiting new customers and discouraging people who smoke from quitting.^8,20 For these reasons, it is the tobacco market itself that is regressive.

13.11.2  Tax increases are progressive

Smoking, within the limits of addiction, is discretionary. Tobacco is not a staple item, and is used by a diminishing proportion of the population. Therefore, tobacco taxes can be avoided by remaining a non-smoker, giving up smoking, or reducing consumption to negate the impact of price increase. Those who quit smoking realise immediate and substantial cost savings.

Many analyses conclude that tobacco taxation is indeed regressive, where disadvantaged smokers experience a disproportionate effect of the tax burden,²¹ but that tax increases are not necessarily regressive and are, in fact, progressive in that disadvantaged groups experience more overall benefit.^2,4,5,19,22 Several factors contribute to this:

• Smoking rates are higher among disadvantaged populations.
• The health, economic, and social harms caused by smoking are disproportionately experienced by disadvantaged groups.
• Disadvantaged groups are more sensitive to increases in tobacco prices.
• When faced with a price increase, a greater proportion of people from low socioeconomic groups will quit or cut down than among less disadvantaged groups.
• Those who reduce their tobacco use will experience immediate and long-term economic benefits, such as increased disposable income, fewer medical expenses, and greater earning opportunities.
• Those who quit smoking will experience immediate and long-term health and social benefits.
• Because a greater proportion of disadvantaged people change their smoking behaviour in response to a price increase, there will be a greater overall population benefit in disadvantaged groups than less disadvantaged groups.

Evidence from low and middle-income countries shows that the progressive impacts of tobacco taxes create society-wide benefits and reduce poverty, reducing the ‘impoverishing effect’ of tobacco use.²⁰ As will be discussed in Section 13.11.5, the progressive impact of tax increases can be enhanced if the revenue raised is used to fund programs that assist disadvantaged populations.⁴

13.11.3  Evidence of the impact of tobacco tax increases on disadvantaged groups

Numerous major international studies and reviews have examined whether tax increases are effective (or more effective) in reducing smoking among disadvantaged groups. Together, they provide strong evidence that increased tobacco price via tax is the intervention with the greatest potential to reduce socioeconomic inequalities in smoking. Major syntheses of evidence about the impacts of tobacco tax increases on disadvantaged populations can be found in a review by the International Agency for Research on Cancer¹ (see also Section 13.0 for a summary of these findings), the World Health Organization’s 2015 Report on the global tobacco epidemic: Raising taxes on tobacco,², the US National Cancer Institute’s 2016²³ and 2017²⁴ monographs, and a 2019 policy briefing by the World Bank.¹⁹ Additional evidence of the impact of tobacco taxes on tobacco use among disadvantaged populations in Australia is summarised in Section 13.13.4. This section summarises several major studies over the past 20 years, demonstrating the growing strength of evidence and additional factors that bought into consideration over time.

In one of the first reviews of the effects of population interventions on social inequalities in smoking, Thomas and colleagues²⁵ investigated the strength of evidence for two opposing hypotheses: a negative gradient (greater effect on more disadvantaged populations) and the competing hypothesis of a positive gradient (greater effect on more advantaged populations). Twenty-eight studies concerning price increase were assessed on a harvest plot—see highlighted section of Figure 13.11.1 below. On the plot, studies with hard behavioural outcome measures are indicated with black bars, and studies with intermediate outcome measures with grey bars. The suitability of study design is indicated by the height of the bar, where the highest bars represent the most suitable study designs, and the lowest bars represent the least suitable. Each bar is annotated with the number of other methodological criteria (maximum six) met by that study. The authors concluded that price increases was the only one of the six population strategies examined for which there was strongest evidence of a negative gradient for income and occupation, meaning price had a greater impact on tobacco use in disadvantaged populations.

Figure 13.11.1 Harvest plot of studies examining relative effectiveness of cigarette price increases among disadvantaged groups

Extract from Thomas et al, highlighting outcomes relating to taxation

Source: Thomas DP, Ferguson M, Johnston V, and Brimblecombe J. Impact and Perceptions of Tobacco Tax Increase in Remote Australian Aboriginal Communities. Nicotine & Tobacco Research, 2012; 15(6):1099–106. Available from: https://doi.org/10.1093/ntr/nts232.

Several years after the publication of the Thomas review,²⁵ Canadian researchers Bader and colleagues²⁶ undertook a further synthesis of the results of studies that examined the effects of price increases among low-income or low-education populations. The majority of studies (rated strong or moderate) reported significant smoking participation and consumption effects. Twenty-four studies (22 published, two unpublished) met selection criteria. Nineteen published and two unpublished studies were rated as strong or moderate. Studies were conducted in Canada, the US, the UK, other European countries, New Zealand, China/Russia and Mexico. Twelve studies found that persons of low socio-economic status (SES) were more responsive to price than the general population. Five indicated that low SES groups had the same responsiveness to price as the general population, that is, increased price appears to benefit all socioeconomic groups equally in terms of reducing smoking participation and consumption.

Further building on the Thomas review, in 2014 an updated review and synthesis of the evidence on the equity impact of tobacco control interventions by socioeconomic status was published in Tobacco Control. Hill and colleagues²⁷ found, in line with the Thomas review, strong evidence that increases in tobacco price have a clear pro-equity effect on the socioeconomic gradient in smoking. While this strategy is supported by a robust body of research, there was scare or mixed evidence concerning the impact of other policies on disadvantaged populations, such as smoking bans, advertising bans, warning labels, cessation support, and media campaigns. Tax increases that raise the price of tobacco was found to be the only intervention to have a clear pro-equity effect.²⁷

The Global Tobacco Economics Consortium undertook a modelling study in 2018 to examine the impact of a 50% increase price on male smokers in 13 middle income countries.²⁸ The found substantial overall  health and economic benefits, with the greatest benefit among those in the lowest income group:

• 6.7 times more life years gained in the lowest income group compared to the highest income group
• 4.6 times more treatment costs averted in the lowest income group compared to the highest income group
• 8.8 million men, half of which were in the lowest income group, would avoid falling into extreme poverty
• The highest income group would pay twice as much in additional tax revenue as the lowest income group

“bottom income group would get 31% of the life years saved and 29% each of the averted disease costs and averted catastrophic health expenditures, while paying only 10% of the additional taxes.”²⁸ A 2024 study that examined the impact of increased tobacco taxation in 19 countries had similar findings.²⁹ A one-off 30% increase in price was found to reduce tobacco use most in the lowest income quintile in all but one country (Bhutan). This meant that while tobacco taxes increased by 30%, additional tobacco spending only increased by 12% in the lowest income quintile.

A modelling study in Aotearoa New Zealand by Blakely and colleagues³⁰ examined the impact of 10% annual excise increases over 20 years compared to a business-as-usual scenario of’ no excise increases on health outcomes, health inequalities, and health system costs among the Maori and non-Maori population. Due to greater price sensitivity and higher smoking rates among the Maori population, this population would be expected to experience 3.7 times greater gains in quality-adjusted life-years than non-Maori, and inequalities in mortality rates between Maori and non-Maori were expected decrease.

In addition to examining the differences in outcomes across different income groups, Verguet and colleagues⁶ also considered the differences in tobacco consumption and price sensitivity in their modelling of the impacts of tobacco tax increases. They varied these factors in a mathematical model, and found that the impact of tax increases on tax burdens are not inherently regressive (using the accounting definition of regressivity). In fact, tax increases were found to be progressive in many circumstances, including when there were large differences in elasticity (but not consumption) between income groups, or when substantial differences in smoking rates existed between income groups, regardless of differences in price elasticity.^5,6 Using this model, they quantified the relative values of these parameters for consumption, elasticity, and size of the tax increase that provided progressive population impacts.

13.11.4  Impacts of tax increases on entrenched disadvantaged groups and those who continue to smoke

Concern about the impact of tobacco tax increases on disadvantaged populations is a major impediment to the implementation of effective tax policy.^4,19 As discussed throughout this section, taxation is actually one of the few effective population-level mechanisms for addressing the disproportionately high smoking rates among disadvantaged populations. However, it is nevertheless important to consider the impacts of tax increases on vulnerable populations and disadvantaged people those who continue to smoke. People from vulnerable population groups who do not change their tobacco consumption—and people sharing their household budgets²¹—will be more adversely impacted than those not experiencing disadvantage,^3,9,21 including through increased financial stress and social stigma.³¹

Qualitative studies with highly disadvantaged smokers in Australia and New Zealand show that some smokers experienced greater financial stress and hardship such as paying bills late or forgoing other household purchases in order to continue to afford tobacco products, or they resorted to re-using cigarette butts. Many of these smokers also engaged in price minimising strategies in response to tax increases, including switching to cheaper brands or roll-your-own tobacco, and sharing tobacco with others.^32,33 However, many low-income smokers who do not quit after a tax increase do manage to cut down the number of cigarettes they smoke each day and each week, in some cases enough to offset the cost of the tax increase.⁶ Heavier smokers are particularly likely to cut consumption after tax increases.³⁴ While cutting down does not meaningfully reduce the health risks associated with smoking, it may increase the chances of the person eventually quitting altogether.^35,36

There is little research about the effects of tax increases among vulnerable population groups, such as those experiencing mental health disorders, drug addiction, or homelessness. A 2010 study³⁷ found that a 10% increase in cigarette prices was associated with 18.2% less smoking participation among individuals with alcohol, drug, or mental disorders, except those with alcohol dependence. The authors conclude that increasing cigarette taxes could be effective in reducing smoking among individuals with alcohol, drug, or mental disorders. Research on the effects of the 25% tobacco tax excise rise in 2010 on remote Indigenous communities in Australia found that there was strong overall support among Indigenous Australians for price increases as a means of reducing smoking. Participants also suggested that tax increases needed to be supported by other tobacco control activities and greater local cessation support. While findings regarding effects of the tax on consumption were inconclusive, participants did report adopting price minimising strategies, such as increased demand to share cigarettes.³⁸

Most critiques of tobacco taxes concerning regressivity do not recommend moving away from this policy. Rather, they call for additional steps to be taken to provide cessation support for vulnerable following a price increase, especially given the lower rates of quitting success among disadvantaged groups.³⁹ This may include directing more tobacco tax revenue to such programs, as well as efforts to minimise social stigma for vulnerable groups.^21,31 These are discussed further below.

13.11.5  Enhancing the progressive impact of tobacco tax increases

There are two, complementary, approaches that enhance the overall impact of tax increases, and improve their progressive impact. First, while taxation has been identified as the single most effective policy to reduce tobacco use, taxation should always be one component of a comprehensive tobacco control strategy.² The positive impacts of tobacco tax increases that reduce the affordability of tobacco products are enhanced by measures including mass media campaigns, smoking cessation support, and widespread smokefree policies.^2,40 Coinciding large tax increases with more radical measures such as reducing retailer density or increasing the legal age for sales has also been suggested to further accelerating declines in consumption and protecting financially vulnerable groups from the possibility of increased spending on tobacco products following tax increases.⁴¹ Similarly, using revenue from tax increases to directly provide assistance to disadvantaged further enhances their progressive impact.⁴

Second, efforts should be made to strengthen tobacco tax systems. The tobacco industry continuously devises strategies to undermine the impact of tobacco taxes, though manipulating tobacco pack and pouch sizes, volume discounts, the differential and delayed pass-through of tax increases, and price segmentation (among other strategies—see Section 13.4).^20,40 Strategies such as restricting product sizes, banning discounting, ensuring taxes on different types of tobacco are similar, and minimum pricing policies should be considered.

Improving the effectiveness of tax policy does not necessarily result in the price of any particular product increasing. Requiring companies to pass through tax increases on a specific date, for instance, or limiting price changes in retailers to two instances per year, would not make tobacco products cost more in the longer term, but would prevent under-shifting and cushioning of tax increases (incrementally passing on the tax increase), thereby making it very apparent to consumers when prices have increased. Efforts should also be made to identify new strategies that act to undermine tax policy.

Finally, authors such as Hirono^31,42 and Remler^3,21 stress the importance of acknowledging the impact of tobacco tax increases on disadvantaged and vulnerable people who continue to smoke, including:

• Understanding potential harms of tax increases and examine the impacts from an equity perspective or from the perspective of low-income smokers
• Allocating some of the revenue raised for measures supporting the most disadvantaged communities
• Working collaboratively with disadvantaged communities when it comes to tobacco taxes.³¹

Relevant news and research

For recent news items and research on this topic, click here  (Last updated June 2024)      

References

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