摘要：Objective. We examined the relationship between smoking participation and cigarette pack price by income group and time period to determine role of cigarette prices in income-related disparities in smoking in the United States. Methods. We used data from the 1984–2004 Behavioral Risk Factor Surveillance System surveys linked to information on cigarette prices to examine the adjusted prevalence of smoking participation and smoking participation–cigarette pack price elasticity (change in percentage of persons smoking relative to a 1% change in cigarette price) by income group (lowest income quartile [lower] vs all other quartiles [higher]) and time period (before vs after the Master Settlement Agreement [MSA]). Results. Increased real cigarette-pack price over time was associated with a marked decline in smoking among higher-income but not among lower-income persons. Although the pre–MSA association between cigarette pack price and smoking revealed a larger elasticity in the lower- versus higher-income persons (−0.45 vs −0.22), the post–MSA association was not statistically significant ( P >.2) for either income group. Conclusions. Despite cigarette price increases after the MSA, income-related smoking disparities have increased. Increasing cigarette prices may no longer be an effective policy tool and may impose a disproportionate burden on poor smokers. The remarkable decline in cigarette smoking over the past 40 years has been more marked in higher- than in lower-income persons, creating a sizeable income-based disparity. 1 Contributors to the overall decline include increasing public awareness of the dangers of smoking, 2 changing societal views about smoking, 3 public health tobacco-control programs, 4 and rising excise taxes on tobacco. 5 The role of cigarette excise taxes, “passed through” to consumers as higher cigarette prices, 6 remains both controversial and salient to income-based disparities in smoking participation. Earlier studies from the United States 5 , 7 – 14 and United Kingdom 15 suggest that lower-income individuals are more sensitive than are higher-income individuals to cigarette pack prices, implying that, for a given increase in cigarette price, more lower- than higher-income individuals would stop smoking cigarettes. If this were so, then the substantial increases in cigarette pack prices of recent years 6 should have helped narrow the disparity in smoking participation between lower- and higher-income groups. Thus, even though cigarette taxes are regressive (because all smokers pay the same tax, the money spent on cigarettes represents a greater proportion of the income of lower- than of higher-income persons), lower-income individuals may benefit more through higher quit rates in response to rising cigarette taxes than higher-income individuals. Yet observational studies from the United States, 1 , 16 United Kingdom, 17 – 19 and other developed countries 20 – 24 suggest that the gap in smoking participation between lower- and higher-income groups has not lessened and may be widening. Furthermore, a second grouping of econometric studies from the United States, 25 , 26 United Kingdom, 27 and elsewhere 28 have found that smokers in general and low-income smokers in particular may be relatively insensitive to cigarette pack prices. Thus, rising cigarette taxes may represent a particular burden for low-income persons who continue to smoke. 29 The contradictory nature of these 2 groupings of studies is striking and not satisfactorily explained. We therefore sought to examine the relationship between cigarette pack price and smoking participation to inform future tobacco-control policy aimed at lessening income-based disparities in smoking. We analyzed data from 1984 to 2004 drawn from the Behavioral Risk Factor Surveillance System (BRFSS), a large, nationally representative telephone survey that includes data on smoking participation among adults, and The Tax Burden on Tobacco , 30 an annual compendium that includes cigarette tax and price data. In our analyses, we included data collected for 14 years before and 6 years after the tobacco Master Settlement Agreement (MSA) of 1998. 31 Data from the period after the MSA has been limited in prior studies, yet this data may be helpful in reconciling the studies’ disparate findings—the dramatic rise in cigarette pack prices around the time of the MSA represents a natural experiment in the possible effects of price on smoking. 32 Thus, we examined the adjusted relationship between price and smoking participation by income group (<25th percentile vs ≥ 25th percentile) and by time period (before vs after the MSA).
