Socio-economic variation in use of price minimizing behaviors and subsequent effects on cessation indicators
Licht, Andrea S.
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Objectives: This thesis broken up into two related sections. First, it examines how socio-economic status (SES) modifies the way smokers adjust to changes in the price of tobacco products through utilization of multiple price minimizing techniques. Second, the impact of these price minimizing behaviors on efforts to stop smoking across various SES groups is assessed. Data Source: Data come from the International Tobacco Control Policy Evaluation (ITC) Four Country Survey, nationally representative samples of adult smokers and includes respondents from Canada, the United States, the United Kingdom and Australia. Part one uses cross-sectional analyses completed among 8,243 respondents (7,038 current smokers) from wave 5 of the ITC-4 Survey, conducted between October 2006 and February 2007. Part two uses data from 4,961 ITC-4 respondents who were smokers in wave 5 and were re-interviewed at a 1-year follow-up. Methods: Part one analyses used both univariate and multivariate logistic regression analyses to describe use of price minimizing behaviors and to examined predictors of purchasing from low/untaxed sources, using discount cigarettes or roll-your-own (RYO) tobacco, purchasing cigarettes in cartons, and engaging in high levels of price and tax avoidance at last purchase. All analyses tested for interactions with SES and were weighted to account for changing and under-represented demographics. Part two analyses examined whether use of these price minimizing behavior at baseline were predictors of the following cessation indicators at 1 year follow-up: (1) cessation, (2) quit attempts, and (3) successful quit attempts at one year follow up using multivariate logistic regression modeling. Statistical tests for interaction were performed to examine the joint effect of SES and price minimizing behaviors on cessation outcomes. Results: Relatively high levels of price and tax avoidance behaviors were present; 8% reported buying from low or untaxed source; 36% used discount or generic brands, 13.5% used RYO tobacco, 29% reported purchasing cartons, and 63% reported using at least one of these high price avoidance behaviors. Respondents categorized as having low SES were approximately 26% less likely to report using low or untaxed sources and 43% less likely to purchase tobacco by the carton. However, respondents with low SES were 85% more likely to report using discount brands/RYO compared to participants with higher SES. Overall, lower SES smokers were 25% more likely to engage in at least one or more tax avoidance behaviors compared to their higher SES counterparts. Smokers who engaged in any price/tax avoidance behaviors were 28% less likely to report smoking cessation. Persons using low/untaxed sources were less likely to quit at follow up, those purchasing cartons were less likely to make quit attempts and quit, and those using discount cigarettes were less likely to succeed, conditional on making attempts. Respondents who utilized multiple behaviors simultaneously were less likely to make quit attempts and to succeed. SES did not modify the effects of price minimizing behaviors on cessation outcomes. Conclusions: Price and tax avoidance behaviors are relatively common among smokers of all SES strata, but strategies used different by SES groups. Because of the strategies lower SES respondents are more likely to use, reducing price differentials between brands may have a greater impact on this group. Further, the availability of lower priced cigarette alternatives may attenuate public health efforts to reduce the smoking prevalence through price or tax increases among all SES strata. Public health policies such as comprehensive minimum price laws or higher, specific tobacco excise taxes may be needed to effectively increase the price of tobacco products across all jurisdictions and brands.