bmj open...for peer review only the relation between cigarette price and hand rolling tobacco...

For peer review only

The relation between cigarette price and hand rolling

tobacco consumption in the United Kingdom

Journal: BMJ Open

Manuscript ID: bmjopen-2015-007697

Article Type: Research

Date Submitted by the Author: 16-Jan-2015

Complete List of Authors: Rothwell, Lucas; University of Nottingham, Britton, John; University of Nottingham, Division of Epidemiology and Public Health Bogdanovica, Ilze; University of Nottingham, Division of Epidemiology and Public Health

<b>Primary Subject Heading</b>:

Epidemiology

Secondary Subject Heading: Addiction, Public health

Keywords: cigarette prices, hand rolling tobacco prices, smoking prevalence

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The relation between cigarette price and hand rolling tobacco consumption in

the United Kingdom

Lucas Rothwell

Medical student University of Nottingham

e-mail: [email protected]

John Britton

Professor of Epidemiology

UK Centre for Tobacco and Alcohol Studies

University of Nottingham

Division of Epidemiology and Public Health

Clinical Sciences Building

City Hospital

Nottingham NG5 1PB

UK


Ilze Bogdanovica

Research Fellow





City Hospital

Nottingham NG5 1PB

UK


All correspondence to Ilze Bogdanovica: [email protected]


Word count: 2,207

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Abstract

Objectives: Cigarette price increases reduce smoking prevalence but as a tobacco

control policy are undermined by the availability of lower cost alternatives such as

hand-rolling tobacco. The aim of this descriptive study is to explore time trends in the

price of manufactured cigarettes and hand-rolling tobacco, and in the numbers of

people who smoke these products, over recent years in the UK.

Settings and participants: United Kingdom

Outcome measures: Trends in the Most Popular Price Category (MPPC) data for

cigarettes and hand-rolling tobacco from 1983 to 2012 adjusted for inflation using the

Retail Price Index, and trends in smoking prevalence and the proportion of smokers

using hand-rolling tobacco from 1974 to 2010.

Results: After adjustment for inflation, the price of manufactured cigarettes increased

substantially between 1983 and 2012 while prices of hand-rolling tobacco remained

relatively stable. Between 1974 and 2010 the prevalence of smoking fell from 45% to

20%, and the estimated total number of smokers from 25.3 to 12.4 million. However

the number of people smoking hand-rolling tobacco increased from 1.4 to 3.2 million,

and MPPC cigarette price was strongly correlated with number of people smoking hand-

rolling tobacco.

Conclusions: The strong association between increases in manufactured cigarette price

and the number of people smoking hand-rolling tobacco suggests that the lower cost of

hand-rolling tobacco encourages down-trading when cigarette prices rise. The

magnitude of this association indicates that the lower cost of hand-rolling tobacco

seriously undermines the use of price as a tobacco control measure.

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Strengths and limitations:

- This is the first study to demonstrate the potential magnitude of the effect of

cigarette price changes on the number of smokers choosing to use hand rolling

tobacco

- This is an ecological study and does not therefore establish causality in the

relation between prices of cigarettes and hand-rolling tobacco consumption, and

due to limited data points available it was not feasible to use more complex

statistical methods that are more suitable for analysis of trends.

- However the findings do provided grounds for more detailed investigation of this

association

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Introduction

Preventing the burden of premature death and disability caused by smoking [1, 2] is

global public health priority. The use of tax to increase the price of tobacco products is a

key policy to prevent smoking uptake, encourage quitting and reduce tobacco

consumption [3, 4], and appears to be particularly effective in the young and the

socio-economically disadvantaged [5-7]. In particular, high prices discourage young

people from purchasing cigarettes [8]. Overall demand for tobacco is inelastic however

[9], and it has been estimated that in Europe a 10% price increase reduces cigarette

consumption by approximately 5-7% [9-11]. Price rises are thought to account for

approximately one third of the decline in smoking prevalence in the UK from 27% to

20% between 1998 and 2009 [12, 13].

Successive UK governments have progressively increased taxes on cigarettes over

recent decades, to the extent that retail cigarette prices in the UK are now among the

highest in Europe [14]. However the metrics used to describe tobacco prices, such as

the Most Popular Price Category (MPPC) and the more recently introduced Weighted

Average Price (WAP) do not reflect the diversity of product prices on the market, some

of which are substantially lower than the MPPC or WAP [15]. Hence when prices

increase, some cigarette smokers cut down or quit smoking in response, but others

might compensate for price increases by switching or ‘downtrading’ to lower priced

cigarette brands [16] or to hand-rolling tobacco (HRT), which provides an even cheaper

alternative for smokers [17].

The availability of these lower priced alternatives therefore undermines the use of price

as a prevention policy, but the extent to which downtrading occurs, particularly to HRT,

has not been well defined in the UK or other markets. This study was carried out to

explore the relation between cigarette prices and the number of people who smoke HRT

using national UK price and smoking data.

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Methods

UK MPPC price data for cigarettes (packs of 20) and HRT (25g) were obtained for the

years 1979-2012 and 1983-2012 respectively from the Tobacco Manufacturers

Association [18]. Retail prices of individual brands of hand-rolling tobacco were

obtained from the monthly Price Checker supplement to the Retail Newsagent magazine

[19], which published retail prices for the years 1995 to 2005 and is held for viewing at

the British Library in Colindale. Two price figures were obtained for each product for

each year, typically February and September. Continuous data were available for six

HRT brands. We converted nominal prices into real prices using the monthly Retail Price

Index (RPI) as a measure of inflation. The Retail Price Index was chosen over the

Consumer Price Index, which is an alternative way for adjusting for inflation, as RPI

data were available for all years included in our analysis. We expressed all product

prices in relation to real prices in March 2012.

Male and female smoking prevalence, and the proportions of male and female smokers

smoking hand-rolling tobacco or cigarettes, were taken for each year from 1974 to

2010 from the General Lifestyle Survey [20], as were data on the prevalence of

cigarette and hand-rolling tobacco smoking by age for 2010. Census data for England

and Wales [21], scaled up to provide UK population estimates [22], were then

interpolated between census years and combined with data on smoking prevalence and

the proportion of smokers smoking HRT to generate estimates of the total number of

smokers, and the number smoking HRT, in the UK each year. Figures for the total

amount of HRT consumed in the UK were also obtained from the Tobacco Manufacturers

Association, and were available for the years 1990-2009 [18].

All data were collated in a Microsoft Excel database, and analysed using SPSS Statistics

22, using simple descriptive statistics and correlation as appropriate.

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Results

The MPPC prices of 20 cigarettes or 25g HRT, adjusted for inflation to 2012 levels,

increased progressively between 1983 and 2012 (Figure 1), though by more for HRT

(from the equivalent of £4.46 in 1983 to £8.12 in 2012) than for cigarettes (£3.15 in

1983 to £7.47 in 2012).

Figure 1: RPI-adjusted prices of MPPC cigarettes and HRT, 1983-2012

Of individual HRT brands for which continuous data were available, adjusted prices of

the two most expensive brands (Golden Virginia and Old Holborn) followed a similar

pattern to the MPPC of cigarettes (indeed the HRT MPPC is thought to be based on the

price of Golden Virginia), and over time the price of a pack of these HRT brands

remained similar to the MPPC cigarette price. Adjusted prices of Cutter’s Choice and

Amber Leaf, two slightly cheaper brands, remained relatively stable. The two cheapest

brands, Turner Halfzware and Auld Kendall Mixed Medium Blend, showed a decrease in

adjusted price between 1998 and 2004 despite consecutive annual budget increases in

tax on HRT, before increasing substantially after February 2004 but still remaining lower

in price than the other brands (Figure 2).

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011

Pr

ice

(G

BP

)

Year

HRT

20 cigarette pack

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Figure 2: RPI-adjusted Prices of specific HRT brands (25g pack) and the MPPC

cigarettes (20 cigarettes) 1995-2005

Although there was a sustained decline in smoking prevalence from 1974 to 2010 in

both men and women (from 51% to 20% and from 41% to 20%, respectively) the

proportion of the total population who smoke HRT remained increased slightly in men

(from 6.6% to 8.2%), and from 0.4% to 4.6% in women (Figure 3). However, the

proportion of all smokers who use HRT increased considerably between 1974 and 2010

both among males and females between (from 13% to 39%, and from 1% to 23%,

respectively).

3.00

3.50

4.00

4.50

5.00

5.50

6.00

6.50

Fe

b 9

5

Jul

95

De

c 9

5

Ma

y 9

6

Oct

96

Ma

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7

Au

g 9

7

Jan

98

Jun

98

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9

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00

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03

Jun

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Ap

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Se

p 0

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Pr

ice

(£

)

Amber Leaf adjusted Old Holborn adjusted

Auld Kendal adjusted Turner Halfzware adjusted

Golden Virginia adjusted Cutters choice adjusted

MPPC cig adjusted

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Figure 3: Overall smoking prevalence and prevalence of smoking of HRT among men

and women in Great Britain, 1974-2010

The estimated number of people smoking any tobacco product also fell substantially

between 1974 and 2010, from 25.3 to 12.4 million, while the number smoking HRT

increased from 1.4 to 3.2 million, in part because of the increase in prevalence of HRT

use among women, and in part because of UK population growth. Total UK consumption

of HRT also increased progressively, from 4,170 to 11,500 tons.

There was a strong correlation between the number of people smoking HRT and price of

MPPC cigarettes (R=0.96; p<0.01; Figure 4).

0

10

20

30

40

50

60

Pr

ev

ale

nc

e,

%

Year

Overal smoking prevalence

in men, %Overall smoking prevalence

in women, %Prevalence of smoking HRT

among men, %Prevalence of smoking HRT

among women, %

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Figure 4: Number of people smoking HRT and RPI-adjusted MPPC price of cigarettes,

1974-2010

0

0.5

1

1.5

2

2.5

3

3.5

0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0

To

tal

nu

mb

er

of

pe

op

le s

mo

kin

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RT

(mil

lio

n)

Adjusted price of MPPC cigarettes (20 cigarette pack in GBP)

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Discussion

This study demonstrates that over recent decades in the UK the inflation-adjusted price

of cigarettes has increased substantially, but the adjusted price of the less expensive

HRT products has remained relatively stable. During this period the overall prevalence

of smoking has fallen, but the proportion and number of smokers who smoke HRT, and

indeed total sales of HRT, has increased markedly. We also found a strong correlation

between MPPC cigarette prices and the total number of people using HRT. Although

several factors could have contributed to the increased use of HRT, and the correlation

between these variables in an observational study does not establish causation, our

data are strongly consistent with the hypothesis that the marked price differential

relative to manufactured cigarettes is a strong main driver of HRT use. Previous

research suggests that flat rates of HRT use can be explained by downtrading, by the

fact that quit rates are lower among smokers of cheap tobacco products, and new

smokers choosing to smoke HRT [23]. Although increases in tobacco prices encourage

smokers, and particularly those with low disposable incomes, to reduce or stop smoking

[14, 24-26], switching to HRT is a logical alternative for those unable or unwilling to

quit. The effectiveness of price rises as a smoking prevention policy is therefore reduced

substantially if smokers have an option to downtrade either to lower-cost manufactured

cigarettes [27], or to the even lower cost alternative of HRT [28]. Although using more

sophisticated analytical techniques such as time series analysis could provide a more

detailed explanation of trends observed, such analysis was not feasible due relatively

small number of data points available to us.

Results from this study are however in line with findings from a study carried out in

Germany suggesting that an increase in price of manufactured cigarettes leads to an

increase in consumption in HRT [28]. Similarly, findings from studies in Italy also

suggest that the proportion of HRT smokers has increased over time although overall

smoking prevalence has decreased. During an economic downturn this effect was

particularly strong in young men [29, 30]. Although a study from Ireland found no

evidence of association between consumption of HRT and the price of manufactured

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cigarettes [31], it has been reported that an increase in income is significantly

associated with reduced consumption of HRT, suggesting that HRT is viewed as a less

desirable option by smokers [31].

Whilst the extent of downtrading to lower-cost cigarettes in the UK has been

documented previously [27], evidence on downtrading to HRT is limited. Whilst our

estimates are approximate, and although we cannot assume that all of the

approximately one third of a million UK smokers who started to use HRT per one pound

increase in the MPPC price of a pack of 20 cigarettes would have quit smoking had the

lower-cost option of HRT not been available to them, it is evident that the availability of

HRT at such a significant price advantage relative to cigarettes is likely to have a major

effect in perpetuating smoking. Switching to HRT may also reflect the fact that many

smokers view it as less harmful than manufactured cigarettes, and the lower levels of

tax levied in the European Union (including the UK) [31] supports this perception. That

the net-of-tax component of the HRT price is higher than for cigarettes also means that

current tobacco price policy not only appears to encourage HRT consumption, but also,

and even with conservative assumptions on the number of cigarettes that are typically

rolled from a 25g pouch of tobacco, probably generates higher income to the tobacco

industry. In contrast to ultra-low price cigarettes therefore, which are likely to be less

profitable than other cigarettes but from a tobacco industry perspective do have the

benefit of retaining customers, the availability of HRT at typical UK prices both

perpetuates smoking and increases profits.

MPPC prices for HRT have been higher than those for cigarettes for all of the period of

this study but, until very recently, have increased in parallel with the cigarette MPPC

price and hence, in relative terms, become less expensive. Hence, in 1983 the HRT

MPPC was about 50% higher than that of cigarettes, whereas by 2009 the difference

was less than 20%; and now, even after relatively large recent increases in tax on HRT

specifically intended to prevent downtrading [32], the difference is only about 33%.

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Given the number of cigarettes that can be generated from 25g of HRT, estimated to be

33 to 42 [29, 33] to achieve price parity with a pack of 20 cigarettes will require the

HRT price to be much higher that of cigarettes. However, MPPC data do not represent

typical prices of tobacco products on sale, since the MPPC typically reflects prices of the

most expensive brands. It appears from the individual brand data in this paper, and

from cigarette brand prices reported elsewhere [27], that manufacturers manipulate

prices across their product range to minimise the impact of tax increases on the lowest

price products [16]. If the effect of price increases as a tobacco control policy is to be

maximized therefore, it is essential that increases apply similarly across all brands, and

that price differences between brands, and including HRT, are minimised.

Overall our findings suggest that the effects of tobacco tax increases, which are a key

component of tobacco control policy in the UK, are being undermined substantially by

price differentials between different types of tobacco, and indeed between different

brands. For example the March 2012 UK budget increased the tax on cigarettes by 37

pence [34], and our study suggests that although some smokers will have quit as a

result of the increase, 180,000 smokers might have downtraded to HRT. The UK

government therefore needs to consider measures to increase the price of cigarettes

and HRT to generate parity of cost per cigarette, and taking more robust measures to

reduce the availability of low price tobacco to smokers.

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Contributorship statement: LR collected and analysed the data, and drafted the

manuscript. JB was involved in designing the study, collecting the data, and interpreting

the findings, and helped to draft the manuscript. IB contributed to data collection and

analysis, and was involved in drafting the manuscript and interpreting findings. All

authors contributed to the final manuscript and have approved its publication.

Competing interests: None.

Funding: The authors salaries are paid by the University of Nottingham, which had no

role in (or indeed awareness of) the writing of this manuscript.

Data sharing: Data are available from authors on request.

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32. Tobacco Products Rates of Duty. Secondary Tobacco Products Rates of Duty 2011.

http://www.hmrc.gov.uk/budget2011/tiin6345.pdf. Archived by WebCite® at

http://www.webcitation.org/6Fwx6zHIW.

33. Lopez-Nicolas A, Belen Cobacho M, Fernandez E. The Spanish tobacco tax loopholes

and their consequences. Tob Control 2013;22: e21-e24 doi:

10.1136/tobaccocontrol-2011-050344[published Online First: Epub Date]|.

34. Tobacco Products Duty Rates. Secondary Tobacco Products Duty Rates 2012.

http://www.hmrc.gov.uk/budget2012/tiin-0730.pdf. Archived by WebCite® at

http://www.webcitation.org/6FwxBX62U.

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tobacco consumption in the United Kingdom: an ecological

study

Journal: BMJ Open

Manuscript ID: bmjopen-2015-007697.R1


Date Submitted by the Author: 14-Apr-2015

Complete List of Authors: Rothwell, Lucas; University of Nottingham, Britton, John; University of Nottingham, Division of Epidemiology and Public Health

Bogdanovica, Ilze; University of Nottingham, Division of Epidemiology and Public Health


Epidemiology




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1


the United Kingdom: an ecological study

Lucas Rothwell



John Britton






City Hospital

Nottingham NG5 1PB

UK


Ilze Bogdanovica

Research Fellow





City Hospital

Nottingham NG5 1PB

UK




Word count: 2,233

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2

Abstract





people who smoke these products, over recent years in the United Kingdom.






Results: After adjustment for inflation, an increase in prices of manufactured cigarettes

was observed between 1983 and 2012 while prices of less expensive hand-rolling

tobacco increased in the beginning of the period but much less so from 1995 onwards.

Between 1974 and 2010 the prevalence of smoking fell from 45% to 20%, and the

estimated total number of smokers from 25.3 to 12.4 million. However the number of

people smoking hand-rolling tobacco increased from 1.4 to 3.2 million, and MPPC

cigarette price was strongly correlated with number of people smoking hand-rolling

tobacco.

Conclusions: Although the ecological study design precludes conclusions on causality,

the association between increases in manufactured cigarette price and the number of

people smoking hand-rolling tobacco suggests that the lower cost of smoking hand-

rolling tobacco encourages down-trading when cigarette prices rise. The magnitude of

this association indicates that the lower cost of hand-rolling tobacco seriously

undermines the use of price as a tobacco control measure.

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tobacco

- This is an ecological study- an observational study based on population level

estimates- and does not therefore establish causality in the relation between

prices of cigarettes and hand-rolling tobacco consumption

- Due to the nature of the data sources used it was not feasible to use more

complex statistical methods that are more suitable for analysis of trends

- However the findings provide grounds for more detailed investigation of this

association

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4

Introduction






people from purchasing cigarettes [8]. Overall demand for tobacco is inelastic [9], and

it has been estimated that in Europe a 10% price increase reduces cigarette


approximately one third of the decline in smoking prevalence in the United Kingdom

(UK) from 27% to 20% between 1998 and 2009 [12, 13].
















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5

Methods












prices in relation to real prices in March 2012 [20].





and Wales (for years 1971, 1981, 1991 and 2001) [22], scaled up to provide UK

population estimates [23], were then interpolated between census years and combined

with data on smoking prevalence and the proportion of smokers smoking HRT to

generate estimates of the total number of smokers, and the number smoking HRT, in

the UK each year. Figures for the total amount of HRT consumed in the UK were also

obtained from the Tobacco Manufacturers Association, and were available for the years

1990-2009 [18].

All data were collated in a Microsoft Excel database (available as Appendix Tables S1-

S4), and analysed using STATA v.11, using simple descriptive statistics and correlation

as appropriate.

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6

Results

The MPPC prices of 20 cigarettes or 25g HRT (equal to 33 to 42 cigarettes[24, 25]),

adjusted for inflation to 2012 levels, increased progressively between 1983 and 2012

(Figure 1), though by more for cigarettes (from the equivalent of 3.15 GBP in 1983 to

7.47 GBP in 2012) than for HRT (from the equivalent of 4.46 GBP in 1983 to 8.12 GBP

in 2012) by 137% and 82%, respectively.













proportion of the total population who smoke HRT increased slightly in men (from 6.6%

to 8.2%), and from 0.4% to 4.6% in women (Figure 3). However, the proportion of all

smokers who use HRT increased considerably between 1974 and 2010 both among

males and females (from 13% to 39%, and from 1% to 23%, respectively).




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of HRT also increased progressively, from 4,170 tons in 1990 to 11,500 tons in 2009.


MPPC cigarettes (Spearman R=0.91; p<0.01, df=15; Figure 4).

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8

Discussion





indeed consumption of HRT, has increased markedly. We also found a strong correlation





relative to manufactured cigarettes is a main driver of HRT use. While some of the

previous research investigates changes and trends in HRT use over time in relation to

tobacco prices in various countries [24, 26], there is limited evidence on how HRT use is

related to changes in cigarette prices in the UK. Previous research suggests that flat

rates of HRT use can be explained by downtrading, by the fact that quit rates are lower

among smokers of cheap tobacco products, and new smokers choosing to smoke HRT

[27]. Although increases in tobacco prices encourage smokers, and particularly those

with low disposable incomes, to reduce or stop smoking [14, 28-30], switching to HRT

is a logical alternative for those unable or unwilling to quit. The effectiveness of price

rises as a smoking prevention policy is therefore reduced substantially if smokers have

an option to downtrade either to lower-cost manufactured cigarettes [31], or to the

even lower cost alternative of HRT [26]. Although using more sophisticated analytical

techniques such as time series analysis could provide a more detailed explanation of

trends observed; such analysis was not feasible due relatively small number of data

points available to us.





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documented previously [31], evidence on downtrading to HRT is limited. Although we

cannot assume that all of the approximately one third of a million UK smokers who

started to use HRT per one pound increase in the MPPC price of a pack of 20 cigarettes

would have quit smoking if the lower-cost option of HRT not been available to them, it

is evident that the availability of HRT at such a significant price advantage relative to

cigarettes is likely to have a major effect in perpetuating smoking. Switching to HRT

may also suggest that many smokers view it as less harmful than manufactured

cigarettes, and the lower levels of tax levied in the European Union (including the UK)

[33] supports this perception. As the net-of-tax component of the HRT price is higher

than for cigarettes current tobacco price policy not only appears to encourage HRT

consumption, but also, and even with conservative assumptions on the number of

cigarettes that are typically rolled from a 25g pouch of tobacco, probably generates

higher income to the tobacco industry. In contrast to ultra-low price cigarettes

therefore, which are likely to be less profitable than other cigarettes but from a tobacco

industry perspective do have the benefit of retaining customers, the availability of HRT

at typical UK prices both perpetuates smoking and increases profits.





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10

was less than 20%; and in 2011, even after relatively large recent increases in tax on

HRT specifically intended to prevent downtrading [34], the difference is only about

33%. Given the number of cigarettes that can be generated from 25g of HRT, estimated

to be 33 to 42 [24, 25] to achieve price parity with a pack of 20 cigarettes will require

the HRT price to be much higher that of cigarettes. However, MPPC data do not

represent typical prices of tobacco products on sale, since the MPPC typically reflects

prices of the most expensive brands. It appears from the individual brand data in this

paper, and from cigarette brand prices reported elsewhere [31], that manufacturers

manipulate prices across their product range to minimise the impact of tax increases on

the lowest price products [16]. If the effect of price increases as a tobacco control

policy is to be maximized therefore, it is essential that increases apply similarly across

all brands, and that price differences between brands, and including HRT, are

minimised.




brands. The UK government therefore needs to consider measures to increase the price

of cigarettes and HRT to generate parity of cost per cigarette, and taking more robust

measures to reduce the availability of low price tobacco to smokers.

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Data sharing: Data included in the study are available to public from sources indicated

in the paper and authors can provide more information on request; we have also

offered to provide data tables used to carry out this study as a supplementary

document.

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Figures:







1978-2010

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References





effects 2012.






England journal of medicine 2014;370(1):60-8 doi: 10.1056/NEJMra1308383.


effects on social inequalities in smoking. Centre for Reviews and Dissemination,

University of York, 2008. Available from:

http://www.york.ac.uk/inst/crd/CRD_Reports/crdreport39.pdf (accessed 10

Oct 2012). York.



24 doi: 10.1136/tc.2010.038786.


control. Tob Control 2011;20(3):235-8 doi: 10.1136/tc.2010.039982.



10.1136/tobaccocontrol-2011-050359.




online/prev/handbook14/handbook14.pdf (accessed 06 Nov 2014).


Tob Control 2006;15(2):114-9 doi: 10.1136/tc.2005.012468.





10.1093/ntr/ntt170.






10.1093/eurpub/cks090.



10.1111/j.1360-0443.2011.03588.x.



2012;7(1):e29871 doi: 10.1371/journal.pone.0029871.

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14



cigarette market. Addiction 2013;108(7):1317-26 doi: 10.1111/add.12159.



10.1016/j.arbres.2011.02.012.







20. Office for National Statistics- Retail Price Index. Available from:

http://ons.gov.uk/ons/taxonomy/index.html?nscl=Retail+Prices+Index

(accessed 16 Jan 2015).






census:England and Wales 1911-2011, 2012.








10.1016/j.ypmed.2013.02.009.






Health Econ 2008;17(6):683-93 doi: 10.1002/hec.1282.



2014 doi: 10.1093/pubmed/fdu048.






29. Townsend J. Price and consumption of tobacco. Br Med Bull 1996;52(1):132-42.





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10.1111/add.12159.


2004-2012. Preventive medicine 2013;56(6):422-23.



10.1093/pubmed/fdt030.




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78x38mm (300 x 300 DPI)

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Table S1: Prices of MPPC cigarettes and HRT adjusted for Retail Price Index (1983-2012)

Date HRT (GBP) 20 cigarette pack (GBP)

24/01/83 3.15

18/03/83 4.46 3.22

24/10/83 4.50

27/10/83 3.26

23/01/84 4.38

25/01/84 3.19

16/03/84 4.76 3.44

28/09/84 4.68

01/10/84 3.37

23/01/85 3.41

25/01/85 4.67

22/03/85 4.83 3.61

25/09/85 3.46

21/10/85 4.76

20/01/86 4.78

22/01/86 3.48

21/03/86 5.18 3.74

24/09/86 3.72

22/10/86 5.16

16/09/87 5.03

01/10/87 3.63

18/03/88 5.07 3.65

03/10/88 3.54

25/10/88 4.90

22/08/89 4.78

02/10/89 3.47

23/03/90 4.86 3.47

01/10/90 3.33

01/11/90 4.65

20/03/91 5.06 3.59

01/04/91 5.10

02/04/91 3.65

15/10/91 5.17

01/11/91 3.69

11/03/92 5.46 3.89

02/11/92 3.91

17/11/92 5.46

17/03/93 5.72 4.10

22/07/93 5.77

02/08/93 4.11

01/12/93 5.99 4.28

01/04/94 4.24

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19/04/94 5.94

01/12/94 6.07 4.35

01/01/95 4.45

03/04/95 6.01 4.43

28/11/95 4.65

01/04/96 4.62

16/04/96 5.93

26/11/96 5.96 4.82

11/03/97 5.97

18/03/97 4.83

28/07/97 4.85

01/12/97 5.85 5.06

31/03/98 4.85

01/04/98 5.85

01/12/98 5.33

09/03/99 5.61

01/07/99 5.66

09/07/99 5.83

31/01/00 5.85

01/02/00 5.64

21/03/00 5.96

22/03/00 6.11

08/08/00 5.96

21/08/00 6.12

29/01/01 6.18

13/02/01 5.98

07/03/01 6.21

08/03/01 6.05

11/09/01 6.05

12/09/01 6.19

17/04/02 6.22 6.10

25/06/02 6.16

09/04/03 6.14 6.10

23/06/03 6.24

01/07/03 6.18

17/03/04 6.25 6.18

14/06/04 6.32

29/06/04 6.21

10/01/05 6.36

18/01/05 6.23

17/03/05 6.41 6.29

11/10/05 6.29

18/10/05 6.42

23/03/06 6.47 6.30

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16/05/06 6.37

23/05/06 6.52

08/01/07 6.51

16/01/07 6.37

22/03/07 6.67 6.41

14/01/08 6.57

22/01/08 6.37

12/03/08 6.55 6.43

01/12/08 6.53 6.41

12/01/09 6.73

17/02/09 6.58

22/04/09 6.76 6.66

25/11/09 6.61

01/01/10 6.83 6.77

24/03/10 6.91 6.86

24/09/10 6.92

23/11/10 6.83

04/01/11 7.01 6.96

23/03/11 7.60 7.20

07/09/11 7.18

24/09/11 7.63

21/03/12 7.91 7.47

07/07/12 8.12

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Table S2: Prices of specific HRT brands (25g pack) and a pack of 20 MPPC cigarette pack adjusted for Retail Price Index (1995-2005)

Month Amber Leaf Old Holborn Auld Kendal Turner Halfzware Golden Virginia Cutters Choice MPPC cigarettes

Feb-95 5.84 6.03 5.16 4.90 6.03 5.70 4.43

Oct-95 5.72 5.98 5.39 5.16 5.98 5.66 4.65

Feb-96 5.68 5.94 5.35 5.12 5.94 5.62 4.68

Sep-96 5.57 5.89 5.24 5.03 5.89 5.57 4.82

Feb-97 5.61 5.92 5.38 5.20 5.92 5.61 4.85

Sep-97 5.58 5.88 5.28 5.12 5.88 5.58 4.79

Feb-98 5.54 5.84 5.24 5.09 5.84 5.54 5.14

Sep-98 5.49 5.79 5.20 5.08 5.79 5.49 5.33

Feb-99 5.52 5.81 5.22 5.10 5.81 5.52 5.62

Sep-99 5.43 5.80 5.14 5.03 5.80 5.43 5.62

Feb-00 5.53 5.82 5.10 4.99 5.82 5.39 5.64

Sep-00 5.79 6.07 4.98 4.87 6.07 5.71 5.92

Feb-01 5.78 6.06 4.97 4.86 6.06 5.78 5.98

Sep-01 5.85 6.12 4.90 4.79 6.19 5.85 6.05

Feb-02 5.87 6.15 4.92 4.81 6.22 5.87 6.17

Sep-02 5.57 6.24 4.81 4.70 6.16 5.57 6.11

Feb-03 5.52 6.18 4.77 4.66 6.10 5.52 6.16

Sep-03 5.66 6.28 4.68 4.58 6.20 5.66 6.14

Feb-04 5.62 6.24 4.65 4.55 6.16 5.62 6.21

Sep-04 5.70 6.27 5.52 5.27 6.27 5.70 6.17

Feb-05 5.65 6.22 5.47 5.23 6.34 5.65 6.21

Sep-05 5.70 6.32 5.37 5.14 6.32 5.55 6.30

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Table S3: Overall smoking prevalence and prevalence of HRT smoking among men and women in

Great Britain (1974-2010)

Year

Overall smoking

prevalence in men, %

Overall smoking

prevalence in

women, %

Prevalence of

smoking HRT

among men, %

Prevalence of

smoking HRT among

women, %

1974 51 41 6.63 0.41

1978 45 37 6.30 0.37

1982 38 33 7.98 0.99

1986 35 31 6.30 0.62

1990 31 29 5.58 0.58

1994 28 26 5.88 1.04

1998 30 26 7.50 2.08

2000 29 25 8.70 2.50

2001 28 26 8.68 3.12

2002 27 25 8.91 3.25

2003 28 24 8.96 2.88

2004 26 23 8.84 3.22

2005 25 23 8.50 3.68

2006 23 21 8.05 3.36

2007 22 20 7.70 3.40

2008 22 21 8.36 4.20

2009 22 20 8.14 4.20

2010 21 20 8.19 4.60

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Table S4: Number of people smoking HRT and price of MPPC cigarettes

Year Total number of HRT smokers (million) MPPC cigarette price (20 cig.pack)

1978 1.404431 2.79

1982 1.901273 3.35

1986 1.473803 3.69

1990 1.358502 3.33

1994 1.550491 4.25

1998 2.202866 5.06

2000 2.573513 5.9

2001 2.73047 6.01

2002 2.824802 6.08

2003 2.756204 6.1

2004 2.827107 6.12

2005 2.880464 6.25

2006 2.713313 6.25

2007 2.717391 6.34

2008 3.099895 6.35

2009 3.067267 6.6

2010 3.203978 6.77

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tobacco consumption in the United Kingdom: an ecological

study

Journal: BMJ Open

Manuscript ID: bmjopen-2015-007697.R2


Date Submitted by the Author: 21-May-2015

Complete List of Authors: Rothwell, Lucas; University of Nottingham, Britton, John; University of Nottingham, Division of Epidemiology and Public Health

Bogdanovica, Ilze; University of Nottingham, Division of Epidemiology and Public Health


Epidemiology




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1


the United Kingdom: an ecological study

Lucas Rothwell



John Britton






City Hospital

Nottingham NG5 1PB

UK


Ilze Bogdanovica

Research Fellow





City Hospital

Nottingham NG5 1PB

UK




Word count: 2,251

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2

Abstract





people who smoke these products, over recent years in the United Kingdom.






Results: After adjustment for inflation, there was an increase in prices of manufactured

cigarettes and hand rolling tobacco between 1983 and 2012. Between 1974 and 2010

the prevalence of smoking fell from 45% to 20%, and the estimated total number of

smokers from 25.3 to 12.4 million. However the number of people smoking hand-rolling

tobacco increased from 1.4 to 3.2 million, and MPPC cigarette price was strongly

correlated with number of people smoking hand-rolling tobacco.

Conclusions: Although the ecological study design precludes conclusions on causality,

the association between increases in manufactured cigarette price and the number of

people smoking hand-rolling tobacco suggests that the lower cost of smoking hand-

rolling tobacco encourages down-trading when cigarette prices rise. The magnitude of

this association indicates that the lower cost of hand-rolling tobacco seriously

undermines the use of price as a tobacco control measure.

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tobacco

- This is an ecological study- an observational study based on population level

estimates- and does not therefore establish causality in the relation between

prices of cigarettes and hand-rolling tobacco consumption

- Due to the nature of the data sources used it was not feasible to use more

complex statistical methods that are more suitable for analysis of trends

- However the findings provide grounds for more detailed investigation of this

association

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4

Introduction






people from purchasing cigarettes [8]. Overall demand for tobacco is inelastic [9], and

it has been estimated that in Europe a 10% price increase reduces cigarette


approximately one third of the decline in smoking prevalence in the United Kingdom

(UK) from 27% to 20% between 1998 and 2009 [12, 13].
















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5

Methods












prices in relation to real prices in March 2012 [20].





and Wales (for years 1971, 1981, 1991 and 2001) [22], scaled up to provide UK

population estimates [23], were then interpolated between census years and combined

with data on smoking prevalence and the proportion of smokers smoking HRT to

generate estimates of the total number of smokers, and the number smoking HRT, in

the UK each year. Figures for the total amount of HRT consumed in the UK were also

obtained from the Tobacco Manufacturers Association, and were available for the years

1990-2009 [18].

All data were collated in a Microsoft Excel database (available as Appendix Tables S1-

S4), and analysed using STATA v.11, using simple descriptive statistics and correlation

as appropriate.

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6

Results

The MPPC prices of 20 cigarettes or 25g HRT (equal to 33 to 42 cigarettes[24, 25]),

adjusted for inflation to 2012 levels, increased progressively between 1983 and 2012

(Figure 1), though by more for cigarettes (from the equivalent of 3.15 GBP in 1983 to

7.47 GBP in 2012) than for HRT (from the equivalent of 4.46 GBP in 1983 to 8.12 GBP

in 2012) by 137% and 82%, respectively.













proportion of the total population who smoke HRT increased slightly in men (from 6.6%

to 8.2%), and from 0.4% to 4.6% in women (Figure 3). However, the proportion of all

smokers who use HRT increased considerably between 1974 and 2010 both among

males and females (from 13% to 39%, and from 1% to 23%, respectively).




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7


of HRT also increased progressively, from 4,170 tons in 1990 to 11,500 tons in 2009.


MPPC cigarettes (Spearman R=0.91; p<0.01, df=15; Figure 4).

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8

Discussion





indeed consumption of HRT, has increased markedly. We also found a strong correlation





relative to manufactured cigarettes is an important driver of HRT use. While some of

the previous research investigates changes and trends in HRT use over time in relation

to tobacco prices in various countries [24, 26], there is limited evidence on how HRT

use is related to changes in cigarette prices in the UK. Previous research suggests that

flat rates of HRT use can be explained by downtrading, by the fact that quit rates are

lower among smokers of cheap tobacco products, and new smokers choosing to smoke

HRT [27]. Although increases in tobacco prices encourage smokers, and particularly

those with low disposable incomes, to reduce or stop smoking [14, 28-30], switching to

HRT is a logical alternative for those unable or unwilling to quit. The effectiveness of

price rises as a smoking prevention policy is therefore reduced substantially if smokers

have an option to downtrade either to lower-cost manufactured cigarettes [31], or to

the even lower cost alternative of HRT [26]. Although using more sophisticated

analytical techniques such as time series analysis could provide a more detailed

explanation of trends observed; such analysis was not feasible due relatively small

number of data points available to us.





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9








documented previously [31], evidence on downtrading to HRT is limited. Although we

cannot assume that all of the approximately one third of a million UK smokers who

started to use HRT per one pound increase in the MPPC price of a pack of 20 cigarettes

would have quit smoking if the lower-cost option of HRT not been available to them, it

is evident that the availability of HRT at such a significant price advantage relative to

cigarettes is likely to have a major effect in perpetuating smoking. Switching to HRT

may also suggest that many smokers view it as less harmful than manufactured

cigarettes, and the lower levels of tax levied in the European Union (including the UK)

[33] supports this perception. As the net-of-tax component of the HRT price is higher

than for cigarettes current tobacco price policy not only appears to encourage HRT

consumption, but also, and even with conservative assumptions on the number of

cigarettes that are typically rolled from a 25g pouch of tobacco, probably generates

higher income to the tobacco industry. In contrast to ultra-low price cigarettes

therefore, which are likely to be less profitable than other cigarettes but from a tobacco

industry perspective do have the benefit of retaining customers, the availability of HRT

at typical UK prices both perpetuates smoking and increases profits.





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10

was less than 20%; and in 2011, even after relatively large recent increases in tax on

HRT specifically intended to prevent downtrading [34], the difference is only about

33%. Given the number of cigarettes that can be generated from 25g of HRT, estimated

to be 33 to 42 [24, 25] to achieve price parity with a pack of 20 cigarettes will require

the HRT price to be much higher that of cigarettes. However, MPPC data do not

represent typical prices of tobacco products on sale, since the MPPC typically reflects

prices of the most expensive brands. It appears from the individual brand data in this

paper, and from cigarette brand prices reported elsewhere [31], that manufacturers

manipulate prices across their product range to minimise the impact of tax increases on

the lowest price products [16]. If the effect of price increases as a tobacco control

policy is to be maximized therefore, it is essential that increases apply similarly across

all brands, and that price differences between brands, and including HRT, are

minimised. Measures to reduce the availability of illicit HRT at even lower prices are also

essential.




brands. The UK government therefore needs to consider measures to increase the price

of cigarettes and HRT to generate parity of cost per cigarette, and taking more robust

measures to reduce the availability of low price tobacco to smokers.

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11









Data sharing: Data included in the study are available to public from sources indicated

in the paper and authors can provide more information on request; we have also

provided data used for this study as a supplementary document.

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12

Figures:







1978-2010

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13

References





effects 2012.






England journal of medicine 2014;370(1):60-8 doi: 10.1056/NEJMra1308383.


effects on social inequalities in smoking. Centre for Reviews and Dissemination,

University of York, 2008. Available from:

http://www.york.ac.uk/inst/crd/CRD_Reports/crdreport39.pdf (accessed 10

Oct 2012). York.



24 doi: 10.1136/tc.2010.038786.


control. Tob Control 2011;20(3):235-8 doi: 10.1136/tc.2010.039982.







online/prev/handbook14/handbook14.pdf (accessed 06 Nov 2014).


Tob Control 2006;15(2):114-9 doi: 10.1136/tc.2005.012468.





10.1093/ntr/ntt170.






10.1093/eurpub/cks090.



10.1111/j.1360-0443.2011.03588.x.



2012;7(1):e29871 doi: 10.1371/journal.pone.0029871.

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14



cigarette market. Addiction 2013;108(7):1317-26 doi: 10.1111/add.12159.



10.1016/j.arbres.2011.02.012.







20. Office for National Statistics- Retail Price Index. Available from:

http://ons.gov.uk/ons/taxonomy/index.html?nscl=Retail+Prices+Index

(accessed 16 Jan 2015).






census:England and Wales 1911-2011, 2012.








10.1016/j.ypmed.2013.02.009.






Health Econ 2008;17(6):683-93 doi: 10.1002/hec.1282.



2014 doi: 10.1093/pubmed/fdu048.






29. Townsend J. Price and consumption of tobacco. Br Med Bull 1996;52(1):132-42.





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10.1111/add.12159.


2004-2012. Preventive medicine 2013;56(6):422-23.



10.1093/pubmed/fdt030.




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78x38mm (300 x 300 DPI)

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78x46mm (300 x 300 DPI)

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78x41mm (300 x 300 DPI)

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78x40mm (300 x 300 DPI)

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Table S1: Prices of MPPC cigarettes and HRT adjusted for Retail Price Index (1983-2012)

Date HRT (GBP) 20 cigarette pack (GBP)

24/01/83

3.15

18/03/83 4.46 3.22

24/10/83 4.50 27/10/83

3.26

23/01/84 4.38 25/01/84

3.19

16/03/84 4.76 3.44

28/09/84 4.68 01/10/84

3.37

23/01/85

3.41

25/01/85 4.67 22/03/85 4.83 3.61

25/09/85

3.46

21/10/85 4.76 20/01/86 4.78 22/01/86

3.48

21/03/86 5.18 3.74

24/09/86

3.72

22/10/86 5.16 16/09/87 5.03 01/10/87

3.63

18/03/88 5.07 3.65

03/10/88

3.54

25/10/88 4.90 22/08/89 4.78 02/10/89

3.47

23/03/90 4.86 3.47

01/10/90

3.33

01/11/90 4.65 20/03/91 5.06 3.59

01/04/91 5.10 02/04/91

3.65

15/10/91 5.17 01/11/91

3.69

11/03/92 5.46 3.89

02/11/92

3.91

17/11/92 5.46 17/03/93 5.72 4.10

22/07/93 5.77 02/08/93

4.11

01/12/93 5.99 4.28

01/04/94

4.24

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19/04/94 5.94 01/12/94 6.07 4.35

01/01/95

4.45

03/04/95 6.01 4.43

28/11/95

4.65

01/04/96

4.62

16/04/96 5.93 26/11/96 5.96 4.82

11/03/97 5.97 18/03/97

4.83

28/07/97

4.85

01/12/97 5.85 5.06

31/03/98

4.85

01/04/98 5.85 01/12/98

5.33

09/03/99

5.61

01/07/99

5.66

09/07/99 5.83 31/01/00 5.85 01/02/00

5.64

21/03/00

5.96

22/03/00 6.11 08/08/00

5.96

21/08/00 6.12 29/01/01 6.18 13/02/01

5.98

07/03/01 6.21 08/03/01

6.05

11/09/01

6.05

12/09/01 6.19 17/04/02 6.22 6.10

25/06/02

6.16

09/04/03 6.14 6.10

23/06/03 6.24 01/07/03

6.18

17/03/04 6.25 6.18

14/06/04 6.32 29/06/04

6.21

10/01/05 6.36 18/01/05

6.23

17/03/05 6.41 6.29

11/10/05

6.29

18/10/05 6.42 23/03/06 6.47 6.30

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16/05/06

6.37

23/05/06 6.52 08/01/07 6.51 16/01/07

6.37

22/03/07 6.67 6.41

14/01/08 6.57 22/01/08

6.37

12/03/08 6.55 6.43

01/12/08 6.53 6.41

12/01/09 6.73 17/02/09

6.58

22/04/09 6.76 6.66

25/11/09

6.61

01/01/10 6.83 6.77

24/03/10 6.91 6.86

24/09/10 6.92 23/11/10

6.83

04/01/11 7.01 6.96

23/03/11 7.60 7.20

07/09/11

7.18

24/09/11 7.63 21/03/12 7.91 7.47

07/07/12 8.12

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Table S2: Prices of specific HRT brands (25g pack) and a pack of 20 MPPC cigarette pack adjusted for Retail Price Index (1995-2005)

Month Amber Leaf Old Holborn Auld Kendal Turner Halfzware Golden Virginia Cutters Choice MPPC cigarettes

Feb-95 5.84 6.03 5.16 4.90 6.03 5.70 4.43

Oct-95 5.72 5.98 5.39 5.16 5.98 5.66 4.65

Feb-96 5.68 5.94 5.35 5.12 5.94 5.62 4.68

Sep-96 5.57 5.89 5.24 5.03 5.89 5.57 4.82

Feb-97 5.61 5.92 5.38 5.20 5.92 5.61 4.85

Sep-97 5.58 5.88 5.28 5.12 5.88 5.58 4.79

Feb-98 5.54 5.84 5.24 5.09 5.84 5.54 5.14

Sep-98 5.49 5.79 5.20 5.08 5.79 5.49 5.33

Feb-99 5.52 5.81 5.22 5.10 5.81 5.52 5.62

Sep-99 5.43 5.80 5.14 5.03 5.80 5.43 5.62

Feb-00 5.53 5.82 5.10 4.99 5.82 5.39 5.64

Sep-00 5.79 6.07 4.98 4.87 6.07 5.71 5.92

Feb-01 5.78 6.06 4.97 4.86 6.06 5.78 5.98

Sep-01 5.85 6.12 4.90 4.79 6.19 5.85 6.05

Feb-02 5.87 6.15 4.92 4.81 6.22 5.87 6.17

Sep-02 5.57 6.24 4.81 4.70 6.16 5.57 6.11

Feb-03 5.52 6.18 4.77 4.66 6.10 5.52 6.16

Sep-03 5.66 6.28 4.68 4.58 6.20 5.66 6.14

Feb-04 5.62 6.24 4.65 4.55 6.16 5.62 6.21

Sep-04 5.70 6.27 5.52 5.27 6.27 5.70 6.17

Feb-05 5.65 6.22 5.47 5.23 6.34 5.65 6.21

Sep-05 5.70 6.32 5.37 5.14 6.32 5.55 6.30

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Table S3: Overall smoking prevalence and prevalence of HRT smoking among men and women in

Great Britain (1974-2010)

Year Overall smoking prevalence in men, %

Overall smoking prevalence in women, %

Prevalence of smoking HRT among men, %

Prevalence of smoking HRT among women, %

1974 51 41 6.63 0.41

1978 45 37 6.30 0.37

1982 38 33 7.98 0.99

1986 35 31 6.30 0.62

1990 31 29 5.58 0.58

1994 28 26 5.88 1.04

1998 30 26 7.50 2.08

2000 29 25 8.70 2.50

2001 28 26 8.68 3.12

2002 27 25 8.91 3.25

2003 28 24 8.96 2.88

2004 26 23 8.84 3.22

2005 25 23 8.50 3.68

2006 23 21 8.05 3.36

2007 22 20 7.70 3.40

2008 22 21 8.36 4.20

2009 22 20 8.14 4.20

2010 21 20 8.19 4.60

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Table S4: Number of people smoking HRT and price of MPPC cigarettes

Year Total number of HRT smokers (million) MPPC cigarette price (20 cig.pack)

1978 1.404431 2.79

1982 1.901273 3.35

1986 1.473803 3.69

1990 1.358502 3.33

1994 1.550491 4.25

1998 2.202866 5.06

2000 2.573513 5.9

2001 2.73047 6.01

2002 2.824802 6.08

2003 2.756204 6.1

2004 2.827107 6.12

2005 2.880464 6.25

2006 2.713313 6.25

2007 2.717391 6.34

2008 3.099895 6.35

2009 3.067267 6.6

2010 3.203978 6.77

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