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Tobacco taxes can save the next generation in the Eastern Mediterranean Region

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Review

Asmus Hammerich1, Fatimah El-Awa1, Nibras E Arabi1, Chisomo Kasinja1, Sophia El-Gohary1 and Hina Hafeez1

1Universal Health Coverage/Noncommunicable Diseases and Mental Health, WHO Office for the Eastern Mediterranean Region, Cairo, Egypt (Correspondence to Sophia El-Gohary: This email address is being protected from spambots. You need JavaScript enabled to view it.).

Abstract

Background: Tobacco use remains a significant challenge to public health in the Eastern Mediterranean Region (EMR), particularly among adolescents, despite various control measures implemented by countries.

Aim: To evaluate the effectiveness of tobacco taxation policies in reducing consumption among adolescents in the EMR and identify optimal tax structures and enforcement strategies.

Methods: We analysed data from the Global Youth Tobacco Survey and the Global Tobacco Control Report up to 2023 to assess prevalence of tobacco use among adolescents, access to tobacco products, and types of taxes imposed by EMR countries. Literature reviews were conducted to examine global evidence on tobacco taxation effectiveness

Results: The analysis revealed high accessibility of tobacco products by adolescents in the EMR, with over 50% having easy access to cigarettes. Enforcement of age-related regulations was lacking. Effective tobacco taxation, with high and uniform excise taxes, emerged as a crucial measure for reducing tobacco use among adolescents.

Conclusion: Implementation and enforcement of tobacco taxation policies are vital to curb tobacco use among adolescents in the EMR. Comprehensive taxation strategies that limit affordability and accessibility, in line with WHO recommendations, can help mitigate the health burdens due to tobacco use among adolescents.

Keywords: tobacco use, tobacco taxation, adolescents, affordability, Eastern Mediterranean

Citation: Hammerich A, El-Awa F, Arabi NE, Kasinja C, El-Gohary S, Hafeez H. Tobacco taxes can save the next generation in the Eastern Mediterranean Region. East Mediterr Health J. 2024;30(11):798–802. https://doi.org/10.26719/2024.30.11.798.

Received: 06/03/2024; Accepted: 03/09/2024

Copyright: © Authors 2024; Licensee: World Health Organization. EMHJ is an open access journal. All papers published in EMHJ are available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction

Tobacco use remains a significant public health challenge, particularly among adolescents in the Eastern Mediterranean Region (EMR). Despite various control measures, accessibility and affordability of tobacco products continue to contribute to high prevalence of tobacco use among young people. The Global Youth Tobacco Survey (GYTS) and Global Tobacco Control Report (GTCR) provide essential data on adolescent tobacco use and the impact of tobacco taxes and policies. In this review, we used these sources to assess the effectiveness of tobacco taxation in reducing adolescent tobacco use in the EMR. The primary objective was to provide evidence-based insights to inform and guide policy-makers in implementing robust tobacco tax policies to safeguard the health of future generations.

Methods

In this review, we gathered information from a range of sources to assess the status of tobacco use among adolescents, and the impact of tobacco taxes. Secondary data were taken from the GYTS, and the GTCR provided data on the accessibility to tobacco among 22 EMR countries from 2007 to 2022, with varying collection years among different countries. The GTCR provided comparative data on tax structures and retail prices. The review also involved a comprehensive search for relevant literature and reports, including PubMed and ScienceDirect, as well as WHO websites, manuals and Eastern Mediterranean Health Journal, from where regional insights were drawn. Additionally, the WHO Framework Convention on Tobacco Control (FCTC) was used to study enforcement and legislative measures related to tobacco sales prevention.

Results and discussion

Data from the GYTS

Countries use the GYTS to track adolescent tobacco use and provide guidance for the implementation and assessment of tobacco prevention and control initiatives (1). This is a crucial instrument for helping countries to promote WHO MPOWER (2); a set of 6 evidence-based strategies for reducing tobacco demand, which is part of the FCTC (3). The GYTS is undertaken in schools among students aged 13–15 years. It follows uniform field procedures, management of data processing and analysis, methodology for building the sample frame, choosing schools and classes, and creating questionnaires. There are 43 core questions in 7 domains: attitudes and knowledge regarding smoking cigarettes; prevalence of adolescent tobacco use; impact of media and advertising; cigarette accessibility; school curricula linked to tobacco use; exposure to passive smoke; and quitting smoking (1). All countries in the EMR have successfully conducted the GYTS, totalling 89 rounds across the region, in addition to the United Nations Relief and Works Agency for Palestine Refugees in the Gaza Strip, Jordan, Lebanon, Syrian Arab Republic and West Bank. Twelve of the countries have undertaken 4 or more rounds, reflecting a substantial commitment to monitoring and addressing adolescent tobacco use (4).

Widespread access to and availability of tobacco and nicotine products

According to GYTS data, there is an alarming pattern regarding easy access to and availability of tobacco and nicotine products, notably cigarettes, among young people. More than 50% of young people who smoke cigarettes now have easy access to these products through a variety of channels, including buying them from specialist tobacco retailers, general stores, street sellers and kiosks (5). Over 80% of young smokers aged 13–15 years in the EMR reported that they obtained tobacco products from easily accessible sources (6). The GYTS revealed some concerning data regarding the accessibility of cigarettes to minors aged < 15 years in some EMR countries such as Egypt, Jordan and Yemen in 2014. Over 80% of smokers in these countries reported easy access to tobacco products. Data from the same countries revealed that, on average, 75% of smokers were never stopped from purchasing cigarettes because of their age (6). These findings highlight the necessity for stricter enforcement of laws prohibiting the sale of tobacco to minors. Implementing strict enforcement mechanisms is important to curb underage access to tobacco products and safeguard public health.

Enforcement and legislation of tobacco sales prevention

Effective enforcement of restriction of tobacco sales to minors is critical yet challenging within the EMR. Although 19 countries are signatories to the FCTC, which includes Article 16 that aims at limiting the sale of tobacco and related products to adolescents aged < 18 years, enforcement remains inadequate. Enacting a law without proper enforcement has little to no impact on adolescent tobacco use. Therefore, it is essential to have enforcement mechanisms and serious consequences for those who sell tobacco to young people. Research indicates that enforcement programmes aimed at preventing tobacco sales to minors can indeed reduce smoking (5). Age restriction laws have been found to augment tobacco control measures (7). Despite the success of measures such as smoke-free laws and increased prices through taxation, raising the minimum age for tobacco sales can serve as a supplementary strategy. In certain situations, it may also be more acceptable politically while delivering similar results (8). Smoking initiation among adolescents decreased following introduction of laws that increased the legal age for tobacco purchase (7). A study in the United Kingdom of Great Britain and Northern Ireland showed that tobacco age restriction laws appeared to reduce smoking among adolescents in different socioeconomic groups (9). Despite these findings, there remains a research gap, particularly in low- and middle-income countries, regarding the effects of increasing the legal age for the sale of tobacco (10). Most of the studies were carried out in the United States of America (USA), United Kingdom, Canada and Sweden, highlighting the need for further research in the EMR.

Impact of effective tobacco taxation on prevalence of tobacco use

Implementing taxes and increasing retail prices play an important role in reducing access to and availability of tobacco and related products, and reducing consumption. The FCTC is a pivotal international treaty aimed at mitigating the global health repercussions of tobacco use. It provides guidelines for evidence-based measures to reduce tobacco consumption and exposure, with emphasis on curbing adolescent tobacco consumption in the EMR. A critical component of this strategy, as highlighted in Article 6, is the implementation of price and tax measures to decrease the demand for tobacco (11). Following the best practices outlined by the WHO, effective tobacco taxation should feature a simplified excise tax structure, with a focus on specific tobacco excise to increase prices. The most important ways to discourage customers from switching to cheaper brands is to use taxation that does not distinguish between the characteristics of tobacco products and to adjust taxes to combat inflation and economic growth (11). A variety of taxation structures, such as specific and ad valorem taxes, can be used. According to the WHO Technical Manual on Tobacco Tax Policy and Administration, the best tax structure is one that is at least 75% of the retail price (12).

An example of a country that has reached best practice is Australia. Australia has implemented high tobacco taxes, above the WHO recommended minimum. The excise tax on tobacco products makes up a significant portion of the retail price, contributing to one of the highest cigarette prices in the world (13). This approach has been effective in reducing tobacco consumption and promoting public health.

Several studies have demonstrated the importance of taxes in reducing tobacco use. A study by Gordon et al showed that the EMR has more affordable cigarettes

than the rest of the world due to an increase in the prevalence of smoking among men (6). This study highlights the possible effects of higher taxes on tobacco price increases and reduced usage. In the USA, Van Hasselt et al. showed that after a federal cigarette tax increase in 2009, there was a significant decrease in teenage and young adult smoking (14). Similar findings were reported in Thailand, which showed that several tax increases significantly increased revenue but also significantly reduced tobacco consumption (15). In Viet Nam, a study in 2020 indicated that an increase in excise tax led to a notable decrease in tobacco consumption (16). A study conducted by Saad et al. in Jordan emphasized the consistent effectiveness of significantly increasing excise taxes and prices on tobacco products as a tool to reduce their affordability and use (17). Diaz et al. showed that higher prices and taxes on e-cigarettes in the USA were associated with significant reductions in adolescent use (18). How tobacco control policies affect young people is currently under-researched (19).

Data from the GTCR

Taxation, specifically health taxes on products like tobacco, alcohol and sugar-sweetened beverages, is recognized as a win–win policy (20). Not only does it generate revenue for governments, it also directly and indirectly funds initiatives to combat the consequences of consumption, thus contributing to disease prevention and advancing health equity (21). In the EMR, the retail price of cigarettes, adjusted for purchasing power parity, is US$4.66 (Figure 1). While this is higher than US$4.49 in the African Region (AFR) and US$4.52 in the Western Pacific Region (WPR), it remains significantly lower than US$8.88 in the European Region and US$6.98 in the South-East Asian Region (SEAR). Excise taxes in the EMR are US$2.28, which is notably lower than in many other regions; for example, US$3.19 in the SEAR and US$6.98 in the EUR. This lower excise tax suggests that there is potential to increase taxes further to meet global recommendations. Importantly, the total tax share in the EMR is 65.66%, which, while higher than AFR (46.05%) and WPR (53.75%), still falls short of the WHO recommended benchmark of 75%. The EMR tax share is close to the 65.05% of the SEAR but significantly below the 74.51% of the EUR (22). This indicates that while the EMR has made progress in tobacco taxation, there is room for improvement.

Conclusion

This review underlines the critical role that effective tobacco taxation can play in curtailing adolescent tobacco use within the EMR. Our findings highlight the persistent issue of tobacco affordability and accessibility among adolescents, which are exacerbated by inadequate enforcement of sales restrictions and variable taxation levels. To combat this, it is imperative that EMR countries implement and rigorously enforce high tobacco taxes. These taxes should be uniform across all tobacco products to prevent adolescents from shifting their preferences towards cheaper alternatives, thereby undermining public health objectives. To achieve the WHO target of a 30% reduction in tobacco use by 2030, it is important that EMR countries align their tobacco taxation structures with the best practices recommended by the WHO, ensuring that taxes constitute at least 75% of the retail price of all tobacco products. The implementation of well-structured and adequately adjusted tax measures serves as a revenue source for governments and acts as a powerful instrument for combating the global health burden associated with tobacco use. Countries are encouraged to gather more recent and relevant, national-level data to examine the relationship between tobacco taxes and usage by youth.

Funding: None.

Competing interests: None declared.

Les taxes sur le tabac peuvent sauver la prochaine génération dans les pays de la Région de la Méditerranée orientale

Résumé

Contexte : La consommation de tabac demeure un défi de santé publique majeur dans la Région de la Méditerranée orientale, en particulier chez les adolescents, malgré les diverses mesures de lutte mises en œuvre par les pays.

Objectifs : Évaluer l'efficacité des politiques de taxation du tabac en vue de réduire sa consommation chez les adolescents dans la Région de la Méditerranée orientale et identifier les structures fiscales et les stratégies de mise en œuvre les mieux adaptées.

Méthodes : Nous avons analysé les données issues de l'Enquête mondiale sur le tabagisme chez les jeunes et du Rapport mondial sur la lutte antitabac jusqu'en 2023 afin d'évaluer la prévalence de la consommation de tabac chez les adolescents, l'accès à ces produits et les types de taxes imposées par les pays de la Région de la Méditerranée orientale. Des examens de la littérature ont été effectués pour analyser les données mondiales sur l'efficacité de la taxation du tabac.

Résultats : L'analyse a révélé une forte accessibilité des produits du tabac pour les adolescents dans la Région, avec plus de 50 % d'entre eux pouvant facilement se procurer des cigarettes. L'application de la réglementation relative à l'âge était insuffisante. Une taxation efficace des produits du tabac, comprenant des droits d'accise élevés et uniformes, s'avère être une mesure essentielle pour réduire la consommation chez les adolescents.

Conclusion : La mise en œuvre et l'application de politiques de taxation du tabac sont essentielles afin de freiner sa consommation chez les adolescents dans les pays de la Région de la Méditerranée orientale. Des stratégies de taxation complètes qui limitent l'accessibilité financière et la facilité à se procurer ces produits conformément aux recommandations de l'OMS peuvent contribuer à atténuer la charge sanitaire due à la consommation de tabac chez les adolescents.

ضرائب التبغ يمكن أن تنقذ الجيل القادم في إقليم شرق المتوسط

صوفيا الجوهري، فاطمة العوا، نبراس الحاج عربي، شيسومو كاسينجا، هينا حفيظ

الخلاصة

الخلفية: لا يزال تعاطي التبغ يشكل تحديًا كبيرًا للصحة العامة في إقليم شرق المتوسط، لا سيما في صفوف المراهقين، على الرغم من تدابير المكافحة المختلفة التي تنفذها البلدان.

الهدف: هدفت هذه الدراسة الى تقييم فعالية سياسات فرض الضرائب على التبغ في الحد من استهلاك المراهقين للتبغ في إقليم شرق المتوسط وتحديد الهياكل الضريبية المثلى واستراتيجيات إنفاذها.

طرق البحث: حللنا بيانات من المسح العالمي للتبغ بين الشباب والتقرير العالمي لمكافحة التبغ حتى عام 2023 لتقييم معدل انتشار تعاطي التبغ بين المراهقين، وفرص الحصول على منتجات التبغ، وأنواع الضرائب التي تفرضها بلدان إقليم شرق المتوسط. وإضافة إلى ذلك، أجرينا استعراضات للدراسات السابقة لبحث الأدلة العالمية بشأن فعالية فرض ضرائب على التبغ.

النتائج: كشف التحليل عن زيادة فرص حصول المراهقين في إقليم شرق المتوسط على منتجات التبغ، إذ تصل نسبة من يحصلون بسهولة على السجائر إلى أكثر من 50%، مع غياب إنفاذ اللوائح المتعلقة بالسن. وتبيَّن أن اتباع نظام فعال لضرائب التبغ، مع رفع ضريبة البيع وتوحيدها، تدبيرٌ بالغ الأهمية للحدِّ من تعاطي المراهقين للتبغ.

الاستنتاجات: تطبيق سياسات فرض الضرائب على التبغ وإنفاذها من الأمور البالغة الأهمية للقضاء على تعاطي التبغ في صفوف المراهقين في إقليم شرق المتوسط. والاستراتيجيات الضريبية الشاملة التي تحد من القدرة على تحمل تكاليف تعاطي التبغ وإتاحته، بما يتماشى مع توصيات منظمة الصحة العالمية، من شأنها أن تساعد على تخفيف الأعباء الصحية الناجمة عن تعاطي المراهقين للتبغ.

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