Smoking low-cost cigarettes: disparities evident.

Diemert, Lori M. ; Cohen, Joanna E. ; Bondy, Susan J. 等

Dear Editor:

The availability of low-cost cigarettes undermines tobacco control's most effective measure to reduce smoking prevalence: keeping cigarette prices high by raising tobacco taxes. (1) The discount cigarette market share has grown considerably since 2003, (2) with discount cigarettes selling for $10-$15 less per carton than premium brands. Contraband cigarettes--cigarettes sold illegally--are even cheaper than discounts. (3) There is an urgent need to understand who is smoking these reduced-price cigarettes. We compiled baseline data from the Ontario Tobacco Survey, a population-based telephone survey of Ontario adults. (4)

Smokers' usual brand of cigarettes was categorized as premium, discount or contraband according to a list of discount cigarette brands (5) and known contraband cigarettes in Ontario. Differences in the characteristics of premium, discount and contraband cigarette smokers were examined using Chi-square tests and multinomial regression models. Analyses were adjusted for the complex survey design.

The proportions of users smoking premium, discount and contraband cigarettes were 60%, 30% and 10%, respectively. Discount cigarette smokers were more likely to be older, female, have made more lifetime quit attempts, and were more addicted to cigarettes compared to premium cigarette smokers (p<0.0001; Table 1); only perceived addiction was not significant in the adjusted model (Table 2).

Contraband cigarette smokers were more likely to reside in rural areas, be older, female, have less than high school education, have made more lifetime quit attempts, were more addicted to cigarettes, and had no intention to quit compared to premium smokers (Table 1). Age and perceived addiction were not significant in the adjusted model (Table 2). Compared to discount smokers, contraband cigarette smokers were more likely to reside in rural areas, be more addicted and less likely to intend to quit (Table 2).

In Ontario, 40% of smokers are smoking low-cost cigarettes, with 1 in 10 seeking illegal sources of cigarettes. This is significant and reduces the impact of tobacco control interventions in Ontario.

While young adults are more sensitive to cigarette price, they are also more susceptible to advertising and branding, (6) which may explain why they were less likely to smoke discount brands than older adults. Women were more likely to smoke both discount and contraband cigarettes, consistent with previous research indicating they are more price sensitive than men. (7) It was also expected that smokers with greater nicotine addiction smoked cheaper sources of cigarettes, consistent with findings of number of cigarettes smoked from previous studies. (7,8) While an earlier study reported that those purchasing low or untaxed sources had higher levels of education, (9) we found contraband brand use associated with lower levels of education.

There is substantial use of low-cost cigarettes, presenting a challenge for tobacco control in Ontario. Socio-economic disparities are evident among discount and contraband cigarette smokers. Minimum price laws and tax increases can counter the growing discount market; licensing, tax agreements with First Nations communities and enhanced enforcement are some evidence-based policies to manage contraband tobacco.10 To optimize the public health benefits of tobacco control initiatives and help reduce health disparities, these and other innovative solutions that address the issue of low-cost cigarettes are needed.

Acknowledgements: This research was conducted by the Ontario Tobacco Research Unit, which receives funding from the Ontario Ministry of Health Promotion and Sport. The authors acknowledge Dr. K. Stephen Brown, Dr. Paul McDonald, Mr. J. Charles Victor and the Survey Research Centre at the University of Waterloo for their contributions to the Ontario Tobacco Survey. The authors also thank Ms. Rita Luk for her significant contributions in coding cigarette brand data.

REFERENCES

(1.) Chaloupka FJ, Warner KE. The economics of smoking. In: Culyer AJ, New-house JP (Eds.), Handbook of Health Economics. New York, NY: Elsevier, 2000;1539-627.

(2.) Non-Smokers' Rights Association. Backgrounder on the Canadian Tobacco Industry and Its Market: 2009-10 Edition. March 2010. Available at: http://www.nsra-adnf.ca/cms/file/pdf/Backgrounder2009_10.pdf (Accessed April 27, 2010).

(3.) Royal Canadian Mounted Police. 2008 Contraband Tobacco Enforcement Strategy. 2008. Available at: http://pub.rcmp-grc.gc.ca/pubs/tobac-tabac/ tobacco-tabac-strat-2008-eng.htm (Accessed June 9, 2010).

(4.) Diemert L, Victor JC, Chaiton M, Bondy SJ. Ontario Tobacco Survey Technical Report 1: Baseline Data. Toronto, ON: Ontario Tobacco Research Unit, April 2010.

(5.) Non-Smokers' Rights Association. Backgrounder on the Canadian Tobacco Industry and Its Market: 2007-08 Edition. March 2008. Available at: http://www.nsra-adnf.ca/cms/file/pdf/Backgrounder2007_2008.pdf (Accessed April 27, 2010).

(6.) Biener L, Albers AB. Young adults: Vulnerable new targets of tobacco marketing. Am J Public Health 2004;94(2):326-30.

(7.) Leatherdale ST, Ahmed R, Barisic A, Murnaghan D, Manske S. Cigarette brand preference as a function of price among smoking youths in Canada: Are they smoking premium, discount or native brands? Tob Control 2009;18(6):466 73.

(8.) 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(2):86 92.

(9.) Hyland A, Laux FL, Higbee C, Hastings G, Ross H, Chaloupka FJ, et al. Cigarette purchase patterns in four countries and the relationship with cessation: Findings from the International Tobacco Control (ITC) Four Country Survey.

Tob Control 2006;15(Suppl 3):iii59-64.

(10.) Sweeting J, Johnson T, Schwartz R. Anti-contraband policy measures: Evidence for better practice. Ontario Tobacco Research Unit, Special Report Series, June 2009.

Lori M. Diemert, BSc *

Joanna E. Cohen, PhD *, ([dagger]), ([double dagger])

Susan J. Bondy, PhD *, ([dagger])

Russell C. Callaghan, PhD ([dagger]), ([double dagger])

Roberta Ferrence, PhD *, ([dagger]), ([double dagger])

John Garcia, PhD *, ([section])

Robert Schwartz, PhD *, ([dagger])

Peter Selby, MD *, ([double dagger])

* Ontario Tobacco Research Unit, Toronto, ON

([dagger]) Dalla Lana School of Public Health, University of Toronto, Toronto, ON

([double dagger]) Centre for Addiction and Mental Health, Toronto, ON

([section]) Department of Health Studies and Gerontology, University of Waterloo, Waterloo, ON

Correspondence: Dr. Joanna E. Cohen, Ontario Tobacco Research Unit, 33 Russell Street, Toronto, ON M5S 2S1, E-mail: joanna_cohen@camh.net

Table 1. Characteristics of Premium, Discount and Contraband
Cigarette Smokers *

Characteristic                          All Respondents    Premium

PREVALENCE

                                      n       % ([double      n
                                  ([dagger])   dagger])   ([dagger])

OTS Sample                             3696         100        2047
Age (years, grouped)
  18-29                                 773        27.4         504
  30-44                                1175        34.3         655
  45-59                                1233        27.2         630
  60+                                   496        11.1         247
Sex
  Women                                2047        47.1        1026
  Men                                  1649        52.9        1021
Education
  Less than high school                 637        15.2         316
  High school and some college         1603        43.5         924
  Completed college                    1450        41.3         804
Rurality
  Urban                                2684        82.6        1497
  Rural                                 936        17.4         505
Heaviness of Smoking Index (HSI)
  Low (0-2)                            1179        37.5         784
  Moderate (3-4)                       1395        36.1         725
  High (5-6)                           1076        26.4         508
Quit intention
  No, Don't know                       2176        60.2        1208
  Yes                                  1519        39.8         839
Lifetime number of quit attempts
  None                                  577        18.0         371
  One                                   839        23.5         491
  Two or more                          2274        58.5        1181
Perceived addiction
  Not at all addicted                   218         7.6         160
  Somewhat addicted                    1034        31.4         643
  Very addicted                        2429        61.1        1237

Characteristic                     Premium             Discount

PREVALENCE                             60.2                    30.1

                                  % ([double      n       % ([double
                                   dagger])   ([dagger])   dagger])

OTS Sample                              100        1183         100
Age (years, grouped)
  18-29                                32.1         191        20.1
  30-44                                34.1         379        35.0
  45-59                                24.2         432        31.7
  60+                                   9.6         175        13.2
Sex
  Women                                41.8         734        55.1
  Men                                  58.2         449        44.9
Education
  Less than high school                13.1         204        16.8
  High school and some college         43.8         501        44.2
  Completed college                    43.1         476        39.0
Rurality
  Urban                                84.2         873        83.6
  Rural                                15.8         285        16.4
Heaviness of Smoking Index (HSI)
  Low (0-2)                            44.8         334        30.4
  Moderate (3-4)                       33.1         496        41.2
  High (5-6)                           22.1         344        28.4
Quit intention
  No, Don't know                       59.6         638        57.3
  Yes                                  40.4         545        42.7
Lifetime number of quit attempts
  None                                 21.6         137        12.3
  One                                  24.2         241        21.8
  Two or more                          54.2         804        65.9
Perceived addiction
  Not at all addicted                   9.8          46         4.4
  Somewhat addicted                    35.1         303        27.8
  Very addicted                        55.2         828        67.8

                                                          Chi-square
                                                           Test for
                                                          Association,
Characteristic                             Contraband       p-value

PREVALENCE                                          9.7       <0.0001

                                      n       % ([double
                                  ([dagger])   dagger])

OTS Sample                              466         100
Age (years, grouped)
  18-29                                  78        21.1       <0.0001
  30-44                                 141        33.2
  45-59                                 171        31.7
  60+                                    74        14.0
Sex
  Women                                 287        55.4       <0.0001
  Men                                   179        44.6
Education
  Less than high school                 117        22.9        0.0016
  High school and some college          178        40.0
  Completed college                     170        37.1
Rurality
  Urban                                 314        70.2       <0.0001
  Rural                                 146        29.8
Heaviness of Smoking Index (HSI)
  Low (0-2)                              61        15.2       <0.0001
  Moderate (3-4)                        174        38.6
  High (5-6)                            224        46.2
Quit intention
  No, Don't know                        330        72.8        0.0002
  Yes                                   135        27.2
Lifetime number of quit attempts
  None                                   69        13.5       <0.0001
  One                                   107        24.5
  Two or more                           289        61.9
Perceived addiction
  Not at all addicted                    12         3.7       <0.0001
  Somewhat addicted                      88        19.9
  Very addicted                         364        76.5

* OTS Baseline data, Cohorts 1-6

([dagger]) Unweighted sample size. Numbers may not
sum to full sample due to missing values.

([double dagger]) Weighted estimates. Estimates may
not sum to 100% due to rounding.

Table 2. Factors Associated With Smoking Discount and Contraband
Cigarettes Among Ontario Adult Smokers: * Relative risks and
confidence intervals from simultaneously adjusted,
multinomial regression models

                                     Discount           Contraband
Characteristic                      vs. Premium         vs. Premium
                                    Cigarettes          Cigarettes
                                    RR (95% CI)         RR (95% CI)

Age (continuous, per year)       1.01 (1.01-1.02)    1.00 (0.99-1.01)
Sex
  Women                                 Reference           Reference
  Men                            0.60 (0.49-0.74)    0.53 (0.39-0.71)
Education
  Less than high school                 Reference           Reference
  High school and some college   0.89 (0.65-1.22)    0.69 (0.48-0.99)
  Completed college              0.81 (0.60-1.11)    0.77 (0.52-1.14)
Rurality
  Urban                                 Reference           Reference
  Rural                          0.85 (0.68-1.05)    1.75 (1.28-2.40)
Heaviness of Smoking
  Index (continuous)             1.13 (1.05-1.22)    1.47 (1.33-1.63)
Quit intention
  No, Don't know                        Reference           Reference
  Yes                            1.15 (0.93-1.42)    0.63 (0.45-0.86)
Lifetime number of
    quit attempts
  None                                  Reference           Reference
  One                            1.48 (1.05-2.10)    1.62 (1.02-2.60)
  Two or more                    1.87 (1.38-2.54)    1.78 (1.18-2.69)
Perceived addiction
  Not at all addicted                   Reference           Reference
  Somewhat addicted              1.40 (0.82-2.37)    0.97 (0.36-2.61)
  Very addicted                  1.48 (0.84-2.64)    0.98 (0.37-2.57)

Characteristic                   Contraband vs. Discount
                                       Cigarettes
                                       RR (95% CI)

Age (continuous, per year)             0.99 (0.98-1.00)
Sex
  Women                                       Reference
  Men                                  0.88 (0.64-1.19)
Education
  Less than high school                       Reference
  High school and some college         0.77 (0.52-1.14)
  Completed college                    0.95 (0.63-1.44)
Rurality
  Urban                                       Reference
  Rural                                2.07 (1.50-2.86)
Heaviness of Smoking
  Index (continuous)                   1.30 (1.17-1.46)
Quit intention
  No, Don't know                              Reference
  Yes                                  0.55 (0.39-0.76)
Lifetime number of
    quit attempts
  None                                        Reference
  One                                  1.10 (0.66-1.83)
  Two or more                          0.95 (0.61-1.49)
Perceived addiction
  Not at all addicted                         Reference
  Somewhat addicted                    0.69 (0.23-2.08)
  Very addicted                        0.66 (0.22-1.97)

* Weighted models adjusted for the complex sampling of the OTS
and year of data collection; bold text indicates significance