“They're doing people a service”—qualitative study of smoking, smuggling, and social deprivation
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7306.203 (Published 28 July 2001) Cite this as: BMJ 2001;323:203All rapid responses
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Editor
Wiltshire and colleagues (1) have added to the tobacco control debate
by documenting that smokers in deprived areas perceive a lack of support
for cessation. Their findings need to be interpreted in the totality of
the evidence. Crucially, the study did not pose or answer the key
question: “if the government were to subsidize nicotine replacement or
other cessation programs, would they take advantage of the subsidy and try
to quit?” A yes answer would deserve respect and a public response, such
as increased length of nicotine replacement under the NHS.
Second, the study discussed perceived benefits but not perceived or
actual risks. About half of long-term smokers will be killed by their
addiction, losing about 20 to 25 years of life (2). Smoking appears to
account for much of the observed socioeconomic differences in adult male
mortality (3).
Third, like any other consumer tax, cigarette taxes increases are
regressive among those who continue to consume (smoke). But people on
lower incomes may well respond more to price changes than those on high
incomes (4). Higher tobacco taxes would thus narrow consumption
differences between rich and poor. If more of the poor quit, than the
recent tobacco tax increases in the UK may well be progressive, even
though overall tobacco tax itself is regressive. Importantly, what
matters in defining regressivity is the overall system of expenditure and
taxation, not simply one tax. A priori, one would expect greater welfare
losses among continuing poor smokers, as the study notes. Moreover, many
welfare-enhancing health interventions, such as child immunization or
family planning, are often more costly to poor households. For example,
poor families may have to spend more time in transport to attend clinics
than rich families and may lose income in the process.
Finally, the study implies that individual smuggling is the key
source of contraband. In fact, the key source is large-scale tobacco
smuggling involving criminal organizations. The tobacco industry uses
smuggled cigarettes to argue for lower taxes on cigarettes, and to gain
market share for their brands. But even in the presence of smuggling,
higher taxes reduce consumption. Lowering taxes is a poor way to reduce
smuggling. Cheaper cigarettes are more likely to increase smoking by the
poor and young. For example, when Canada lowered taxes in 1994 in
response to organized smuggling, teenage smoking increased dramatically.
A better solution is to crack down more aggressively on criminal suppliers
(5).
Prabhat Jha (1), Philip Musgrove (2), Frank J Chaloupka (3) Derek
Yach (4)
1. Senior Scientist, World Health Organization, Geneva, Switzerland
2. Lead Economist, World Bank, on assignment to WHO
3. Professor of Economics, University of Chicago, Illinois, Chicago,
USA.
4. Executive Director, WHO
Address for correspondence:
Dr. Prabhat Jha
EAS, WHO,
20 Avenue Appia,
1211 Geneva, Switzerland
Email jhap@who.int
Conflict of interest: None
References
1. Wiltshire S, Bancroft A, Amos A, Parry O. "They're doing people a
service"-qualitative study of smoking, smuggling, and social deprivation.
BMJ. 2001 Jul 28;323(7306):203-7
2. Bobak M, Jha P, Nguyen S, Jarvis M. Poverty and smoking. In Jha P and
Chaloupka FJ, eds. Tobacco Control in Developing Countries. Oxford: Oxford
University Press; 2000:41-61.
3. Peto R, Lopez AD. The future worldwide health effects of current
smoking patterns. In: Koop EC, Pearson CE, Schwarz MR, eds. Critical
Issues in Global Health. New York: Jossey-Bass, 2001:154-161.
4. Townsend J, Roderick P, Cooper J. Cigarette smoking by socioeconomic
group, sex, and age: effects of price, income, and health publicity. BMJ.
1994 Oct 8;309(6959):923-7.
5. Merriman D, Chaloupka FJ, Yurekli A. How big is the worldwide cigarette
smuggling problem? In: Jha P, Chaloupka FJ, eds. Tobacco Control in
Developing Countries. Oxford: Oxford University Press, 2000:365-392.
Competing interests: No competing interests
Wiltshire and colleagues study contains some interesting findings but
seems methodologically flawed. The use of a random sample is inappropriate
for a qualitative study. A purposive sample would be more likely to ensure
that the study explored the range and diversity of the populations' views.
In addition, the authors do not state how many invitations to
participate in the study were issued or how the 100 people were selected
for interview. If the 167 people who did not opt out of the study are a
small proportion of the total they may be an atypical group of recorded
smokers. Again, this casts doubt on the ability of the study to pick up
the full range of views.
Competing interests: No competing interests
Smoking, Smuggling & Social Deprivation
31st July 2001
JRC/jp/1099
The Editor
British Medical Journal
BMA House
Tavistock Square
London
WC1H 9JR
Dear Sir
Your report (28 July) on a qualitative study of smoking, smuggling,
and social deprivation makes depressing reading.
We would agree with much of the authors’ conclusions, as we ourselves
commissioned a similar study in 2000 from DTZ Pieda Consulting who took
parts of Manchester and Newcastle as their case studies in a national
survey of other areas including Scotland.
There is common ground between us in that places of high social
problems are fertile marketing opportunities for the tobacco smuggler, and
people with low resources find illicit goods more attractive as they take
a lesser proportion of their already small income. DTZ Pieda also found a
similar attitude to the bootlegger, that they were providing a ‘social
service’ to the community, and that it was the Government who should be
‘blamed’ because of the high level of taxation.
We respect the view that such smokers are less inclined to quit
because of the easy availability of cheap cigarettes, but would suggest
that if the taxes had not been excessive, the problem would have been
greatly reduced or solved. Other countries, like Canada or Sweden, where
tax levels were high, have found that lowering taxes dramatically reduced
smuggling.
- 2 -
The UK is unique because its tobacco smuggling is probably the
highest in Europe, and this must be as a direct result of the penal level
of tax.
Government measures to curb smuggling have been moderately
successful, but even the most optimistic forecasts still predict a ‘final’
figure of 20% non-UK duty paid.
The policy recommendations in the Report are admirable, but will only
be achieved if the root cause of the problem is tackled at source
Yours faithfully
John Carlisle
Executive Director of Public Affairs
Competing interests: No competing interests