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Abstract
Background Illicit cigarette consumption has increased worldwide. It is important to understand this problem thoroughly.
Objectives To investigate behaviours and factors associated with illicit cigarette consumption in southern Thailand.
Design A survey and qualitative study were conducted in a border province in southern Thailand next to Malaysia. A modified snowballing technique was used to recruit 300 illicit and 150 non-illicit cigarette smokers. A questionnaire was used to interview subjects. Illicit cigarette packs were obtained in order to identify their characteristics. Bivariate and multivariate logistic regression was used for data analysis.
Results Smoking of illicit cigarettes has become accepted in the communities. They were available in supermarkets and vendor shops. Friends and other illicit smokers known by illicit cigarette smokers were an important source of information for access to illicit cigarette products. The main factors associated with smoking illicit cigarettes, compared with smoking non-illicit cigarettes, were younger age, higher education and higher average monthly expenditure on cigarettes (most illicit smokers smoked illicit cigarettes (average price per packet = 33 THB (US$1.1), while most non-illicit smokers smoked hand-rolled cigarettes (average price per packet = 7 THB (US$0.2)) and knowledge of other illicit cigarette smokers. The low price of illicit cigarettes was the main reason for their use. Selling strategies included sale of singles, sale in shops and direct sale through social networking.
Conclusions Illicit cigarette consumption has become more acceptable especially among young adult smokers. Age and extent of social networks are important factors associated with smoking illicit cigarettes.
- Smoking behaviour
- illicit cigarette
- cigarette consumption
- border province
- hand-rolled/RYO tobacco
- health services
- illegal tobacco products
- cessation
- global health
Statistics from Altmetric.com
- Smoking behaviour
- illicit cigarette
- cigarette consumption
- border province
- hand-rolled/RYO tobacco
- health services
- illegal tobacco products
- cessation
- global health
Introduction
An increase in cigarette prices through excise tax is an effective means of reducing cigarette consumption.1 ,2 However, tax avoidance through purchasing of illicit cigarettes at lower prices has also been reported.3–5
Consumption of illicit cigarettes poses a serious threat to public health. It brings tobacco into the market cheaply, making cigarettes more affordable and thus stimulating consumption, especially among youth, and consequently increasing the burden of ill health.6 ,7 Illicit cigarette trade sabotages national tobacco taxation laws and tobacco control strategies and has become a major concern for governments and international organisations.8 WHO Framework Convention on Tobacco Control states that the elimination of the illicit trade in tobacco is an essential component of tobacco control.9
The global illicit cigarette trade represents approximately 10.7% of global sales or 600 million cigarettes annually.10 It is mainly distributed in low- (16.8%), middle- (11.8%) and low- to middle-income (12.1%) countries, while 9.8% is reported in high-income countries.11 However, such problems have rarely been examined, especially in low- to middle-income countries where the problem is highly prevalent.
In Thailand, the prevalence of smoking has decreased during the past two decades due to strong tobacco control policies.12 However, the prevalence of smoking in southern Thailand has remained high and has become the highest in the country.13 The southernmost part of Thailand is adjacent to Malaysia where a high cigarette smuggling rate (21%) has been reported.14 This illicit cigarette trade is a problem near the border areas as evidenced by a high volume of illicit cigarettes seized, especially between 2005 and 2009.15 Further investigations are needed in order to understand and quantify this serious public health problem.
Most previous studies on illicit cigarette consumption used secondary data to examine economic determinants or were conducted among general smokers.16–20 Although information on behaviour and factors associated with illicit cigarette consumption is important, it has been rarely studied partly due to its illegal nature. This study aims to identify smoking behaviours and factors associated with illicit cigarette consumption in a border province of southern Thailand.
Materials and methods
A survey was conducted in three districts characterised by different geographical areas in southern Thailand. Sadao district is located on the border of Malaysia, Hat Yai district is the biggest trade centre in southern Thailand and Ranot district is predominantly a rural area, which is 50 and 130 km from Hat Yai and Sadao, respectively. A modified snowballing technique was used to recruit 100 illicit cigarette smokers and 50 non-illicit smokers from each district. The estimated sample sizes of 300 illicit and 150 non-illicit cigarette smokers in the three districts were based on prevalences of 20% and 50% illicit and non-illicit cigarette smoking in the study area, respectively, and an ability to detect associated factors with an OR of at least 2. A design effect of 1.2 was used to account for the clustering effect. A ratio of 2:1 between illicit and non-illicit cigarette smokers was used to increase the power of the study.
A cigarette was defined as illicit if the packet containing it had any of the following three characteristics: no domestic excise tax stamp, no warning label or having ‘mild or light’ labels. Eligibility criteria were male gender, aged 15 years or above and resident of the study area for >6 months. Illicit and non-illicit cigarette smokers were, respectively, defined as those who smoked at least three packets of illicit cigarettes during the past 6 months and those who had never smoked any illicit cigarettes in their lifetime. Any smokers who smoked less than three packets were excluded. One eligible participant in each district was randomly selected from attendees of a smoking cessation clinic in the district. These three subjects, known as seeds, were then asked to invite other illicit and non-illicit cigarette smokers from their social network in the villages and who did not attend a smoking cessation clinic. One illicit cigarette smoker from this wave who was willing to be a recruiter was randomly selected and asked to invite other illicit and non-illicit cigarette smokers from his social network, known as the second wave of recruitment. This process was continued until the required sample size was reached (figure 1).
An example of study sample recruitment process in one of the three study districts.
A structured questionnaire was modified from the Global Youth Tobacco Survey.21 ,22 Other relevant items including behaviour on illicit cigarette consumption (online appendix), attitude and knowledge of illicit tobacco control policy, and cigarette prices and demands were added. Before interview, each participant was given a full explanation about the research, and after verbally agreeing to participate, written informed consent was obtained. An interview was performed by one researcher in a private room at a health centre in a study site. Illicit cigarette smokers were asked if they were carrying any illicit cigarettes with them and if so, were asked to show them for inspection of the packet. Some financial compensation was given to each subject to cover the costs of transportation to the clinic and time spent being interviewed. In addition to the survey findings, an in-depth interview was conducted among the seeds to gain more insight into their smoking behaviours and attitudes towards illicit cigarette smoking.
All information obtained from the interviews was kept highly confidential. The study was approved by the ethical committee of the Faculty of Medicine, Prince of Songkla University, Thailand.
Survey analysis adjusted for a cluster of samples recruited by each seed was used for descriptive statistics. Comparison of demographic characteristics and other smoking-related factors between illicit and non-illicit cigarette smokers was done using Student t test for continuous variables and the χ2 test for categorical variables. Multivariate logistic regression analysis was used to determine independent factors associated with an increased odd of smoking illicit cigarettes. Likelihood-ratio tests were used for selecting significant variables at each model step. Variables with p values <0.05 were considered statistically significant. Data analysis was carried out using R software, V.2.12.0.23 Content analysis was used for data collected from in-depth interviews.
Results
A total of 300 illicit cigarette smokers and 150 non-illicit cigarette smokers were recruited by 16 seeds. The non-response rate was 7.3% (27 illicit and six non-illicit cigarette smokers). Approximately 90% of illicit cigarette smokers showed their illicit cigarette packets of altogether 20 brands (25 different packets). The top three methods smokers were able to identify that they were smoking illicit cigarettes were having no Thai language on packet (51%), cheap price (42.7%) and having no domestic excise tax stamps affixed (27%). All illicit cigarette packets shown contained a barcode and most (82.3%) of them had a non-Thai language textual health warning displayed, 47.3% had a pictorial warning label and 42.3% indicated the amount of tar and nicotine contained in the cigarettes. None of the packets had a domestic excise tax stamp affixed. Most of them were made in Malaysia (57%) or Indonesia (34.5%).
The characteristics of illicit smokers compared with non-illicit smokers are shown in table 1. Illicit smokers were significantly younger, more likely to be single and had a higher proportion of high school graduates. They knew more people who smoked illicit cigarettes, had a better knowledge of illicit tobacco control policies, had a shorter smoking duration and smoked more cigarettes daily than non-illicit smokers. Illicit cigarette smokers were more likely to smoke illicit cigarettes, hand-rolled and non-illicit cigarettes, respectively. Non-illicit cigarette smokers were most likely to smoke hand-rolled cigarettes and smoked it significantly more than illicit cigarette smokers. The average prices of packets of non-illicit, illicit and hand-rolled cigarettes were 59 THB/1.9 US$, 33 THB/1.1 US$ and 7 THB/0.2 US$, respectively. This, in turn, made the average monthly cigarette expenditure of illicit cigarette smokers significantly higher than for non-illicit cigarette smokers.
Characteristics of illicit (n=300) and non-illicit (n=150) cigarette smokers
Occupation, monthly household income, number of close friends who smoked, number of days smoked per week and attitude towards increasing cigarette taxes were not significantly different between the two groups.
Multivariate analysis (see table 1 in online appendix) confirmed that the odds of illicit cigarette smoking tended to increase with decreasing age and a higher number of illicit smokers known with a linear dose–response relationship (p<0.001).
Price was an important factor in the choice of type of cigarette smoked. A lower consumption of illicit and non-illicit cigarettes was found for higher priced illicit cigarettes with a linear dose–response relationship (p<0.002 and p<0.001, respectively). However, when prices of illicit cigarettes were above 35 THB per pack, smokers had a higher consumption of hand-rolled cigarettes than illicit and non-illicit cigarettes. The price of illicit cigarettes was inversely related to the total number of any types of cigarette smoked daily with a linear dose–response relationship (p<0.001) (figure 2).
Mean and 95% CI of number of cigarettes smoked daily by price of illicit cigarette and type of cigarette.
The price of non-illicit cigarettes did not vary substantially (US$1.6–2.1 per pack) and consumption of non-illicit and illicit cigarettes was stable across the price range (figure 3). However, the number of hand-rolled cigarettes increased as the price of non-illicit cigarettes increased. The total number of cigarettes smoked daily was similar across all price ranges.
Mean and 95% CI of number of cigarettes smoked daily by price of non-illicit cigarette and type of cigarette.
Among the three different study areas, behaviours of illicit cigarette purchase and consumption were different in terms of common place of purchase, main reasons for smoking, price, smoking duration as well as pattern of smoking (table 2).
Characteristics of illicit cigarette smokers by district (N=300)
Supermarkets or vendor shops were the most common places to purchase illicit cigarettes in all districts. In Hat Yai, illicit cigarettes were also commonly purchased from alcohol and cigarette stores. In Ranot, direct sales of illicit cigarettes were commonly reported. Smoking of illicit cigarettes in Ranot had taken place more recently and illicit cigarette smokers in that district were more likely to have encouraged others to smoke similarly.
The commonest reason for illicit cigarette consumption in Hat Yai and Ranot was low price, although cigarette taste was the most common reason for smokers living in Sadao. The average price of illicit cigarettes per pack was significantly higher in Sadao than the other two districts. The number of illicit cigarettes smoked per day across the three areas was not significantly different. The number of hand-rolled cigarettes smoked was highest in Sadao, while the number of non-illicit cigarettes smoked was highest in Ranot. Friends were an important source of information for initiation and accessibility in all three districts.
Results from qualitative method
Sources of and access to illicit cigarettes
Interviewees said that it was easy to buy illicit cigarettes. Smoking of these products was popular and socially acceptable by smokers in the community. Smokers reported that most of their smoking friends smoked illicit cigarettes. The consumption of illicit cigarettes was widely known by community residents, even among persons who did not smoke. Smokers mentioned that the sellers offered cheap cigarettes to them when they purchased other non-illicit cigarettes. Some shops displayed advertisement signs, such as ‘Cheap cigarettes are available here’, and some shop owners promoted cigarettes by asking their customers to share information about product availability to smoker's social networks. Some smokers reported that they heard about cheap illicit cigarettes so they asked for them from the shop sellers. Moreover, some suggested that they could buy cheap cigarettes in small quantities as they could be sold in individual sticks instead of in packets (box 1).
Sources of and access to illicit cigarettes
I1 “My friend and I know a person who sells illicit cigarettes in our village”
I2 “Besides me, there are many smokers who know someone who sells illicit cigarettes, even people who do not smoke”
I3 “It's easy to buy illicit cigarettes; nearly all the people in my village know which shops to buy them from”
I4 “At present, almost all of my friends who smoke buy illicit cigarettes, so sometimes I can share with them”
I5 “The seller told me that she had cheap cigarettes for sale. She showed me the cigarette product, as it is nearly three times cheaper than the legal tobacco product so I bought a packet to first test its taste”
I6 “I know that cheap cigarettes were available from the board in front of the shop, so I asked the seller for those cigarettes”
I7 “The seller asked me to tell my friends that she has cheap priced cigarettes for sale in the shop”
I14 “I heard about foreign cigarettes which are much cheaper than Thai cigarettes, so I asked the seller if she had those cigarettes and she did not but she asked her relative in Hat Yai to look for those cigarettes for sale”
I16 “For me I can buy these cigarettes from my uncle, he makes a profit of 5 baht per packet”
I20 “My son works in the town and he comes back home every Sunday so he can buy those cigarettes for me. They are cheap; only 210 baht per carton, so that I can save my money for smoking”
I22 “The seller sold these cigarettes in sticks at 4 baht for one. It is easy for me to buy 3 sticks for 10 baht”
Shops, relatives and family members were the main sources that smokers could purchase cigarette products. Some respondents reported that they could buy cheap cigarettes from their relatives and make a small profit by reselling them at a higher cost. They could also purchase illicit cigarettes through their family members by asking them to buy these products from their working places in the city.
Attitudes towards tobacco taxation and price
Since it is difficult for smokers to quit completely, smokers mentioned that illicit cigarettes were an alternative product for them to maintain their smoking habit and save money. Some agreed that a tobacco taxation policy was an effective way for preventing youth smoking; however, they disagreed that it could protect all youths. They thought it was unfair for them to pay more for cigarettes while the government increased their tax revenues. Thus, they attempted to find illicit cigarettes that were cheaper price. Smokers said that they also smoked hand-rolled cigarettes, which allowed them to save money as the price was much cheaper than illicit and non-illicit cigarettes (box 2).
Attitudes towards tobacco taxation and price
I3 “As I am unable to quit, it is good for me to have cheap cigarettes as I save money that way”
I5 “I think illicit cigarettes can replace factory made [ones] as I can't quit. If there are no cheap cigarettes I will have some problems in [affording] smoking”
I7 “I think many smokers use illicit cigarettes because the price of Thai cigarettes are very high”
I9 “The high price is a good way to protect the teenagers from smoking, but it cannot protect everyone”
I10 “I think the low price will not encourage people to smoke but we smoke low priced cigarettes because we can't quit”
I21 “I don't agree with the government, the government gets a lot of tax revenue but we still have to pay a lot”
I24 “It is unfair for us. We increase cigarette expenditure and the government gets more revenue”
I25 “Besides smoking illicit cigarettes to save money, I also smoke hand-rolled cigarettes which allow me to save money as well”
Attitudes towards quality and use of illicit cigarettes
Some smokers suspected that illicit cigarettes may be more harmful than non-illicit cigarettes but they still bought them primarily for reducing their cigarette expenditure. Some thought that illicit cigarettes had a lower quality than non-illicit cigarettes, which were more expensive, thus they smoked lower priced hand-rolled cigarettes to dilute the harmful effects of illicit cigarettes while still saving money. The main reasons for replacing hand-rolled cigarettes by illicit cigarettes reported by smokers were convenience and to save time by not having to roll a cigarette. Some smokers also felt that illicit cigarettes provided them with a better image at work and gave them more enjoyable social activities than hand-rolled cigarettes. The taste between illicit and non-illicit was not very different, explained some smokers. Finally, some reported co-use of illicit cigarettes with other illicit substances (box 3).
Attitudes towards quality and use of illicit cigarettes
I1 “I have tested the illicit cigarettes by blowing the smoke on my finger nail. They make my nail look dark brown in colour, more so than legal factory made cigarettes, but I still smoke nowadays”
I2 “I don't know if it is a good cigarette or not but I can smoke and I can save money”
I4 “I think it [illicit cigarettes] has a lower quality than legal cigarettes, and mostly when I am at home I smoke hand-rolled cigarettes but when I work, I mostly smoke illicit cigarettes”
I9 “I like its taste and I can smoke like non-illicit Thai factory-made cigarettes as I smoked before”
I10 “I cannot roll cigarettes when I am in my business or when I go out as my friends do not like their smell, so I smoke illicit cigarettes”
I13 “To roll cigarettes takes time”
I21 “Sometimes it is not easy to roll cigarettes so I must buy illicit cigarettes instead”
I22 “I smoke these [illicit] cigarettes when I have a party and I also smoke when I use other illegal substances with my friends
Discussion
Smoking of illicit cigarettes was popular and socially acceptable by smokers in the study area. It is an alternative cigarette, and being cheaper than non-illicit cigarettes, it is especially popular among young adults. Purchasing of illicit cigarettes was done in the same manner as other goods in the community. Social networks play an important role in the spread of information regarding the illicit cigarette trade. A variety of approaches, some of which contravene Thai legislation, are used to promote illicit cigarette sales by local supermarket and vender shop owners, such as cheaper prices, large variety of products, product advertisement and the sale of singles. Smokers reported price as the main reason for smoking illicit cigarettes (average prices of packets of non-illicit, illicit and hand-rolled cigarettes were 59 THB/US$1.9, 33 THB/US$1.1 and 7 THB/US$0.2, respectively).
Our study shows that illicit cigarette consumption is still a hidden public health risk. It has increased substantially in southern Thailand during the past 3 years, thus it needs to be monitored and investigated carefully. Most illicit cigarette smokers in the present study were young single men with a high school level of education. All of them had friends who smoked and knew other illicit cigarette smokers in their social network and were well aware of illicit cigarette control policies. Young age and having a large social network were the main predictors of illicit cigarette smoking in this study. Previous studies have consistently reported that illicit cigarette smokers were in a younger age group and had a high school education.24–26 This may be due to a low income among this group, thus they try to purchase tax avoidance cigarettes from a private supplier.5 ,27 In addition, smoking of illicit cigarettes may look more acceptable to the youth compared with hand-rolled cigarettes.
This study found that most cigarettes were smuggled in from Malaysia and Indonesia and had no domestic excise tax stamps affixed. A variety of illicit cigarettes of varying brands and prices are available in the market for smokers to buy. In the past, illicit cigarette packets did not have any health warnings, which would easily differentiate them from other legal cigarettes.7 Our study found that many features found on legal cigarette packets have been added to illicit cigarette packets, such as health warning labels, both in text and pictures, and the amount of tar and nicotine contained. Absence of domestic excise tax stamps on imported cigarette packets is currently the best means of identifying illicit cigarettes. However, the most distinguishable feature of illicit cigarettes is its lower price compared with non-illicit cigarettes.
Due to the illegality of consumption and sale, illicit cigarettes are not commonly displayed in shops. Thus, social network plays an important role in providing information on places to purchase illicit cigarettes.16 Members of social network, friends and family members could even be private sellers themselves as reported in this study. Local supermarkets or vendor shops, the owners of which mainly obtain illicit cigarettes from suppliers, were the most common places to purchase illicit cigarettes by subjects in our study, whereas purchasing from duty-free shops in cross border areas was rare. None of the subjects in our study purchased illicit cigarettes from the internet. The three most common places to buy illicit cigarettes reported by a US study were neighbourhood store, private supplier/importer and duty-free shop/overseas, whereas only 12% purchased through the internet.5
Our study found that smokers who are addicted to nicotine find it difficult to avoid smoking cigarettes. Many tobacco products, both illicit and non-illicit, are available in the market offering a large range of quality and prices. Smokers usually smoke more than one type of tobacco product to lessen the harmful effects and/or to reduce their expenditure on cigarettes.
The low price of illicit cigarettes is the strongest incentive of smokers to buy illicit cigarettes. Although illicit cigarettes are much more expensive than hand-rolled cigarettes, its convenience, taste and image outweigh the lower price of hand-rolled ones, especially among young adults. Young people are relatively sensitive to cigarette prices, thus they will increase their tobacco consumption when they find it easy to procure cigarettes.7 A low quality of illicit cigarettes is a concern for some smokers; however, the price-quality trade off is acceptable among illicit cigarette consumers.
Intensity of illicit cigarette consumption was not different in different geographical areas in this study. Illicit cigarette has gradually spread from the border and trade centre areas to the rural areas reflected by different durations of illicit cigarette smoking in different areas. Sources of and access to illicit cigarettes were also different. In the border and trade centre areas, illicit cigarettes can be easily accessed at supermarket and tobacco stores, whereas in the rural areas, a direct sale from friends and relatives was a common source. The highest average price per pack was reported in the border area (Sadao district). This may be due to a high consumption of one high-priced brand available only in the border areas and popularly co-used with other illicit substances.
Proposed solutions of eliminating the illicit tobacco trade by WHO Framework Convention on Tobacco Control include international collaboration of a system management approach such as increasing existing penalties, tax-paid stamp marking and tobacco-specific licenses to identify, monitor and facilitate anti-smuggling enforcement.28 Achieving effective illicit cigarette control at an international level, as recommended, may take time. Seizure of illicit cigarettes and fines are effective ways to control illicit cigarette consumption reported by our sample and elsewhere11; however, wide-ranging involvement of social networks, high availability and accessibility to illicit cigarettes are difficult barriers to overcome. Further studies on appropriate interventions to reduce the problem are required.
Due to the difficulty and limitation in reaching this subgroup, the study used a modified snowballing technique to recruit study subjects. The clustering effect of social network may influence the study findings; however, survey analysis adjusted for the cluster could account for the inter-dependence of smokers in the same social network.
What this paper adds
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Illicit cigarette consumption is popular among the youth and young adults.
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Illicit cigarette use is an accepted behaviour in the community.
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Social networks play important role in the spread of information of availability and places to purchase illicit cigarettes.
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Price is the main reason for smoking illicit cigarettes.
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Approaches to promote illicit cigarette sales include competitive low price, wide variety of products, advertisements and sale of singles.
Acknowledgments
We would like to thank all the staff at the Epidemiology Unit, smoking cessation clinics in community hospitals, health centres and health volunteers in the study area for their support and the respondents for their valuable co-operation.
References
Supplementary materials
Supplementary Data
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Footnotes
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Funding Tobacco Control Research and Knowledge Management Center (TRC) and Thai Health Promotion Foundation (ThaiHealth). Partial support from Research Chair Grant, National Science and Technology Development Agency.
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Competing interests None.
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Patient consent Obtained.
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Ethics approval This study was approved by the ethics committee of Faculty of Medicine, Prince of Songkla University, before carrying out the research.
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Provenance and peer review Not commissioned; externally peer reviewed.