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Prabhat Jha, a professor at the University of Toronto Dalla Lana School of Public Health and the founding director of the Centre for Global Health Research, at St. Michael’s Hospital and University of Toronto. His research interests include large scale epidemiology studies of the major causes of death in developing countries, and methods of epidemiological research in low-resource settings.

In this blog post, Prabhat discusses his research article published in Gates Open Research examining the implications of a cigarette tax increase on public health that could provide significant health & economic gains, and suggests disseminating the results more widely and fairly.

I am currently the lead investigator of one of the world’s largest prospective studies of premature mortality called the Million Death Study in India. My research publishes widely on tobacco control, disease control, premature mortality, and health of the global poor.

Epidemiological studies have shown us that regular smokers face three times the risk of death than otherwise similar non-smokers. This leads to at least one decade of life lost among smokers. In addition to the direct health consequences of smoking, smoking also contributes significantly to household impoverishment through catastrophic healthcare expenditures on treating tobacco-attributable diseases among the poor (where smoking prevalence is disproportionately higher) in countries without universal health coverage.

Life years gained

The hazards of smoking accumulate slowly but quitting can quickly improve a smoker’s health.  We found that quitting by age 40 returns nearly the full decade of life lost from continued smoking, and quitting by age 50 returns about 6 years. Smoking cessation is now common among adults in many high-income countries, but remains uncommon in many low and middle-income countries (LMICs). Our research supports increase in tobacco taxes as the most plausible and effective way to reduce tobacco use. A tripling of tobacco excise tax (a tax imposed on goods that can harm the consumer’s health) in most LMICs would increase cigarette prices by about 100% and reduce tobacco use by about 40%. This reduction would be greater among young people and the poor as they are more responsive to price changes than other groups, and would benefit the most from a significant tobacco tax increase. It is among the poor that more life-years would be gained, more premature deaths and treatment costs averted, and more cases of poverty and catastrophic health expenditures avoided than the wealthier income groups.

Welfare implications

We published a study in the British Medical Journal in 2018 in which we examined the health, poverty and financial consequences of a 50% increase in cigarette price through an increase in tobacco excise tax in 13 middle-income countries, comprising a total of about 2 billion men. We found that with a 50% price increase across the 13 countries, men in the bottom income quintile would gain 6.7 times more life years than those in the top income quintile.

The average life years gained from cessation for each smoker in the bottom income quintile would be 5 times that of the top income quintile. By averting significant treatment cost for treating tobacco-attributable diseases, about 15.5 million men would avoid catastrophic health expenditures in seven countries without universal health coverage. As a result, about 8.8 million men, half of whom falls in the bottom income quintile, would avoid falling below the World Bank poverty line of living on less than $1.90 a day. We published another similar study on the impact of a 50% cigarette price increase in India and analyzed the impact at the subnational level and found similar results. 

Here, we selected four states in India: Karnataka, Assam, Uttar Pradesh, and Maharashtra, based on recommendations from the Indian Ministry of Health and Family Welfare. We focused on male smokers aged 15 years and older, as they constitute more than 90% of all cigarette smokers in India. Our findings for each of the four states provide a strong case for higher taxes, which we hope will be used by state-level decision-makers in national debates. Our findings would also help state-level decision makers form the connection between cigarette taxes and the Sustainable Development Goals (SDG), such as SDG 1: End poverty in all its forms everywhere, given the substantial impact that higher taxes could have on alleviating poverty within the study population.

Alleviating poverty

In the 13 countries that we studied, a 50% increase in cigarette prices would lead to a total of about $157 billion in treatment cost averted for treating major tobacco-attributable diseases. The treatment cost averted would be 4.6 times higher among those in the bottom income quintile than those in the top income quintile. In India, across the four states that we analyzed, a 50% cigarette price increase would lead to about INR 1,729 ($955 million) in treatment cost averted, and the cost averted in the bottom income quintile would be 7.4 times higher than the top income quintile.

Our findings provide new evidence on the health and economic impact of tobacco tax increases among the poor and marginalized population. It will reinforce the role of tobacco control program in the overall universal healthcare/health financing strategies of countries with the goal to decrease catastrophic healthcare expenditures at the household level, impoverishment caused by treatment costs and to raise tax revenues for social programs. The countries selected in our study will also benefit from the findings of our study, as our study provides relevant, contemporary inputs in streamlining local tobacco tax policies, which are currently at different stages of policies development, some are still at the advocacy, and some are now at the evaluation stages.