• taxation
• public policy
• price

As Verguet et al note,1 taxing tobacco products has been consistently shown to reduce smoking prevalence by stimulating cessation, deterring uptake and reducing consumption among people who continue to smoke.2–6 Health benefits attributable to tobacco excise tax increases include increased life expectancy and reduced hospitalisations.7 8 Tobacco excise taxes can potentially bring large health benefits at a population level,9 particularly for young people and people with fewer financial resources.3 10 Yet tobacco taxation in most countries is low; in 2014 experts estimated that 200 million deaths could be averted by 2025 if the price of cigarettes was doubled globally, which ‘in many low and middle-income countries’ could be achieved by tripling the tax on tobacco.11

This evidence has led many countries, including the UK, Ireland, France and Canada, to implement regular tobacco excise tax increases. Australia and New Zealand have taken this policy further than other countries; sustained increases in tobacco excise taxes mean a pack of 20 cigarettes now costs around $35 (approximately USD20) in New Zealand and will soon reach $40 per pack (around USD25) in Australia.

The people most likely to quit in response to this policy are those with fewer financial resources (who are thus most responsive to rising prices),12 and increasing the cost of tobacco is also more likely to deter people who have fewer financial resources from taking up smoking. These attributes mean tobacco excise taxes are progressive rather than regressive, and reduce health and social inequities, as concluded by several systematic reviews.2 13–16 As well as stimulating cessation and reducing smoking uptake, increasing excise taxes may also benefit children whose parents quit smoking, by reducing their exposure to secondhand smoke and risk of smoking initiation.14 17

However, because smoking is concentrated among people experiencing higher deprivation, ongoing increases in tobacco excise tax are potentially regressive economically, raising important questions about their broader impacts. Some smokers have reported forgoing food or home heating in order to purchase tobacco.18 19 Ethically, policies should not exacerbate existing disparities or increase inequities among low-income people who continue to smoke. Furthermore, the use of excise tax to address high smoking prevalence among indigenous peoples has indigenous rights implications (article 4/2 c FCTC), and indigenous peoples must be engaged in decisions regarding excise tax measures that will affect their communities.

In many countries, overall declines in smoking prevalence mask serious smoking disparities.20 For example, in New Zealand, Māori and Pacific peoples continue to bear a disproportionate burden of harm from tobacco use. In comparison to 12% for European/Other, 34% of Māori adults were current smokers in 2018/2019, down from 40% in 2011/2012, while prevalence of current smoking remained unchanged at 24% among Pacific peoples in New Zealand.21 Evidence that excise taxes are not having the same effects on all population groups raises important questions, as the consequences of rising tobacco prices affect those people who continue to smoke and also their families.

In most jurisdictions, smokers currently receive little direct benefit from the increased excise tax they pay on tobacco products (other than an incentive to quit) and tobacco excise taxes become part of the Government’s general revenue. There are strong ethical arguments for reallocating funds to those people most affected by smoking and excise tax increases, but who have fewer resources to quit. Currently, only 34 of 133 partners to the WHO Framework Convention on Tobacco Control (FCTC) dedicate tobacco excise tax revenue in this way. Using excise tax revenue to support quitting, and fund national and community cessation interventions and mass media cessation campaigns, directly assists the large majority of people who smoke and wish to quit.22 23 Dedicating tax revenue to facilitate quitting would ensure the communities that currently contribute most via tobacco excise taxes receive something in return, and help address the serious under-resourcing of core FCTC interventions.24

In contrast to calls to abandon tobacco excise tax increases in jurisdictions with high taxes, we suggest tobacco excise increases should continue, but only under specific conditions. First, governments should closely monitor the impact tobacco excise taxes have on smoking prevalence and tobacco consumption among different population groups, and on other measures of well-being, such as food expenditure displacement. Second, governments should allocate a commensurate proportion of the tax revenue gained from tobacco sales to supporting cessation among communities most affected by tobacco use. This support could include better-resourced mass and social media interventions, free or subsidised smoking cessation support and financial incentives to quit, targeted to lower-income smokers and women smoking while pregnant (for which evidence exists25 26). It could also include exploring the impact of subsidising regulated e-cigarettes for smokers who might benefit from such support in switching from smoking to vaping as a temporary harm-reduction measure, until they quit nicotine. Third, as Verguet et al note, excise tax increases need to occur within a comprehensive smokefree strategy and alongside complementary measures designed to reduce the appeal and availability of smoked tobacco products (such as denicotinisation, removal of flavours and additives that enhance palatability and reductions in tobacco supply). Reducing smoking prevalence would not only improve population health, it would reduce social and health inequities, and contribute to a fairer society in which all members have the potential to thrive.