1. Death and Taxes: Global Effects of Smoking, of Quitting, and of Taxing Tobacco
World Bank Spring Meetings, April 18-19, 2017
Prabhat Jha
Thanks to Richard Peto, Patricio Marquez, Sheila Dutta

2. CONCLUSIONS Prolonged smokers lose a decade of life
Cessation by age 40 (and preferably earlier) avoids 90% of the excess risk of continued smoking
Tobacco is a big cause of poverty and tobacco control reduces poverty
A tripling of the excise tax on cigarettes worldwide would cut consumption by 1/3 and avoid ~200 M deaths
Source: Jha and Peto, NEJM 2014

3. World annual tobacco deaths Developed countries ~2M
China ~1M
India ~1M
World ~5-6M, rising
to 10M by mid-century
* Global sales ~6,000 B sticks (vs 5,000 B in 1990), with $10,000 profit per death
1 ton of tobacco=1 M sticks=1 death
Source: Peto and Lopez, 2001, Jha and Peto, 2014

4. Source: Lancet
27 June 2009

5. Russian 1990s male death rate ratios ~1 bottle of vodka/day vs <1 bottle/week x any medical cause 4 x road traffic accident 6 x any other accident 8 x suicide 10 x murder
Source: Lancet 27 June 2009

6. Life expectancy loss of 3 years with moderate obesity and 10 years with smoking
2 kg/m2 extra BMI (if overweight) or 10% smoking prevalence shortens life by ~1 yr
Male British Doctors’ Study
Prospective Studies Collaboration (males)
100
100
Moderate obesity 80 80
Severe obesity
Low-mortality BMI
Cigarette smokers
Never-
smokers 60 60
% survival from age 35
Yearly dots
Yearly dots 40 40 10
years
BMI, kg/m2 20 20
22½-25 (~24)
30-35 (~32)
40-50 (~43) 40 50 60 70 80 90
100 40 50 60 70 80 90
100
Age (years)
Source: Peto, Whitlock, Jha, NEJM 2010

7. UK Million Women Study: contrast between the relevance of happiness and of smoking to 10-year all-cause mortality among women who do not already have a chronic disease
MWS: Lancet : 27-8

8. 21st century hazards of cigarette smoking in 6 distinct populations
Jha and Peto, NEJM 2014

10. US Women, smoker: non-smoker lung cancer mortality risks over time
Source: Thun et al, NEJM 2013

11. FEMALES: Survival probabilities
between ages 25 and 80 years among current and
never-smokers in the US
HR adjusted for age, education, alcohol, adiposity (BMI), scaled to 2004 national rates, but comparable results if only actual cohort used
Source: Jha et al, NEJM 2013

12. Years gained by age of quitting smoking
Source: Jha et al, NEJM 2013

13. ONTARIO, CANADA and UNITED STATES: Risk of a 30-year-old man dying by age 69 from smoking (shaded) or from any cause (shaded+ white),
ONTARIO MEN
US WHITE MEN
-40% -26% % %
Irving, CGHR Unpublished

14. China: Proportion of deaths among middle-aged males from smoking 1990s
12%
2010
20%
(25% urban, 15% rural)
1998 Hong Kong +
33%
2030s China
+ Hong Kong male smokers started smoking seriously 20 years before
Source: Chen, Peto, Lancet, 2015, Li, Peto et al, 1998, Lam et al, 2001, Peto 2001

15. (note that currently, few females smoke cigarettes)
INDIA: Years of life lost among 30 year old smokers*
(MDS results)
Men who smoke bidis
6 years
Women who smoke bidis
8 years
Men who smoke cigarettes
10 years
* At current risks of death versus non-smokers, adjusted for age, alcohol use and education
(note that currently, few females smoke cigarettes)
Source: Jha et al, NEJM 2009

16. Evidence for tobacco control

17. Higher taxes help current smokers to quit
Higher cigarette/bidi taxes: 100% higher price means 20% of CURRENT SMOKERS WILL QUIT
Greater effects on the poor and in youth
A BIG single increase (e.g. 100%) has greater impact than yearly smaller increases (e.g. 10% per year for 10 years)
Price responsiveness does not fall even at higher prices
Reduces consumption widely; no such thing as “hard core addicted smoker”
Source: Curbing the Epidemic, Jha et al, 2015-DCP3; IARC 2011

18. Cigarette prices tripled, consumption halved, tax revenue doubled: FRANCE

19. Low specific excise taxes in LMICs
Tripling excise would:
1.Double street price 2. Raise $100 B more in revenue
Source: NEJM 2014, BMJ 2017

20. Objections to higher tobacco taxes
Job losses: In most economies, no net impact (money not spent on tobacco is spent on other goods and services)
Revenue loss: “Laffer curve”- revenue declines not seen in practice nearly anywhere
Hurts the poor: poor more price responsive, and gain more of the health benefits than the rich
Smuggling: legitimate concern but consumption falls, revenue increases even with smuggling, and can counter with labels with tax stamp, smart labels, and coordination
There’s no reason people in developing countries should be left behind when it comes to health. 57

21. Social inequalities in male mortality in 1996 from smoking (shaded) and any cause
Education level
Source: Jha et al, Lancet, July 2006

22. People’s Republic of China Distribution of marginal taxes and health benefits by SES group
Low SES group:
Pays 6.4% of increased taxes but receives 32.1% of health benefits: hence, health/tax ratio: 5.02
% of income: Net gain for lowest 2 quintiles, net loss for highest 3 quintiles
Source: ADB 2013, Verguet 2013

23. United States Distribution of marginal taxes and health benefits by SES group
Low SES group:
Pays 12.4% of increased taxes
Receives 34.0% of health benefits
Health/tax ratio: 2.74
CGHR.ORG

24. No of individuals avoiding catastrophic health expenditure
No of individuals avoiding catastrophic health expenditure* if cigarette prices doubled, by income group, in thousands
INDIA PHILIPPINES MEXICO
* Catastrophic health expenditure: >10% of income, Source Ulep, Mishra forthcoming

25. Non-price interventions help current smokers to quit
Non-price measures: plain packaging, or big, local packet warnings labels with tax stamp (to counter smuggling), absolute ad and promo ban, complete ban on public smoking, effective counter advertising, monitor and report smoking mortality, tackle smuggling
Increased access to nicotine replacement and other cessation therapies
Source: Curbing the Epidemic, Jha et al, 2015, DCP3

26. Plain packaging (Australia) and pictorial warning labels (Canada)

27. A tripling of excise tax in every country would reduce consumption by 1/3 and avoid ~200M deaths this century
Example of South Asia: 1.8 B people, 30% adult men and 4% adult women currently smoke
140 M current and future smokers <35
100 M current smokers >35
A 1/3 reduction would avoid ~35-45 M deaths
25-35 M deaths in smokers <35
~10 M deaths in smokers > 35
Source: NEJM 2014, BMJ 2017 70

28. CONCLUSIONS Prolonged smokers lose a decade of life
Cessation by age 40 (and preferably earlier) avoids 90% of the excess risk of continued smoking
Tobacco is a big cause of poverty and tobacco control reduces poverty
A tripling of the excise tax on cigarettes worldwide would cut consumption by 1/3 and avoid ~200 M deaths
Source: Jha and Peto, NEJM 2014

29. www.cghr.org (Don’t buy my books)
@countthedead