Setting the record straight on taxation and disparities in smoking
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* David Hammond
* Jessica L. Reid
* Amanda C. Jones

We were pleased to see the article from Riediger and Bombak highlighting the importance of disparities in tobacco use.1 However, the suggestion that reductions in smoking have been achieved only among high socioeconomic groups — and that tobacco taxes have exacerbated inequalities — is incorrect.

Although smoking rates in Canada remain substantially higher among lower socioeconomic groups, similar reductions have been achieved among all socioeconomic groups over the past 20 years — the period with the largest absolute increases in tobacco taxes. For example, reductions in smoking prevalence among Canadians with less than a secondary school education have been comparable to those among postsecondary graduates in both of Canada’s benchmark surveys, the Canadian Tobacco Use Monitoring Survey (1999–2012; −9.5 v. −7.0 percentage points, respectively)2 and the Canadian Community Health Survey (2000–2014; −8.0 percentage points each).3 Smoking is not simply a problem among socioeconomically disadvantaged Canadians. In fact, there are 2.4 times as many smokers in Canada with a postsecondary education as with less than a high school diploma (2 606 684 v. 1 085 446, respectively).3

Riediger and Bombak are also incorrect to suggest that tobacco taxes have exacerbated inequalities in smoking and are less effective among the economically disadvantaged. Authoritative reviews conducted on behalf of the World Health Organization (WHO), the International Agency for Research on Cancer and other leading public health authorities determined the opposite.4,5 For example, the WHO and National Cancer Institute concluded, “Lower income populations often respond more to tobacco tax and price increases than higher income populations. As a result, significant tobacco tax and price increases can help reduce the health disparities resulting from tobacco use.”6

The evidence to date on the impact of taxing sugar-sweetened beverages shows a pattern similar to that of tobacco taxes: the impact is equal to or greater among low socioeconomic groups, based on greater price sensitivity.7–10 Indeed, the effectiveness of fiscal policies in reducing health disparities — including taxes on tobacco products and sugary drinks — is highlighted in a major new *Lancet* series on the economics of noncommunicable disease.11

Overall, we agree with Riediger and Bombak that disparities in smoking — particularly among Indigenous groups — represent one of Canada’s most urgent public health challenges. These disparities, and those of most other risk behaviours, are the result of deep-seated structural inequities in society. Tobacco-control measures will inevitably be insufficient on their own to eliminate these disparities; however, this should not obscure the fact that tobacco taxation and other policies have been effective in reducing smoking rates across all socioeconomic groups in Canada. Similar measures will be necessary to address the rapidly growing burden of obesity in Canada, which has increased among all population subgroups. The revenue generated from these fiscal policies also provides an opportunity to invest in changing the underlying structural inequities that contribute to poorer health outcomes among disadvantaged populations more generally.

## Footnotes

*   **Competing interests:** None declared.

## References

1.  Riediger ND, Bombak AE. Sugar-sweetened beverages as the new tobacco: examining a proposed tax policy through a Canadian social justice lens. CMAJ 2018;190:E327–30.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMToiMTkwLzExL0UzMjciO3M6NDoiYXRvbSI7czoyMjoiL2NtYWovMTkwLzMyL0U5NjQuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

2.  Reid JL, Hammond D, Rynard VL, et al. Tobacco use in Canada: patterns and trends, 2014 edition. Waterloo (ON): Propel Centre for Population Health Impact, University of Waterloo; 2017:18.
    
    

3.  Physicians for a Smoke-Free Canada. Tobacco use 2000–2014: insights from the Canadian Community Health Survey. Submitted to Health Canada [contract no.: 4500339975]; 2016.
    
    

4.  International Agency for Research on Cancer. IARC handbooks of cancer prevention, tobacco control, volume 14: effectiveness of tax and price policies in tobacco control. Lyon (FR): International Agency for Research on Cancer; 2011. Available: [www.iarc.fr/en/publications/pdfs-online/prev/handbook14/handbook14.pdf](http://www.iarc.fr/en/publications/pdfs-online/prev/handbook14/handbook14.pdf) (accessed 2018 Apr. 3)
    
    

5.  Chaloupka FJ, Yurekli A, Fong GT. Tobacco taxes as a tobacco control strategy. Tob Control 2012; 21:172–80.
    
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6.  US National Cancer Institute and World Health Organization. The economics of tobacco and tobacco control. National Cancer Institute Tobacco Control monograph 21. Bethesda (MD): US Department of Health and Human Services, National Institutes of Health, National Cancer Institute; and Geneva: World Health Organization; 2016:585. Available: [https://cancercontrol.cancer.gov/brp/tcrb/monographs/21/docs/m21_complete.pdf](https://cancercontrol.cancer.gov/brp/tcrb/monographs/21/docs/m21_complete.pdf) (accessed 2018 Apr. 3).
    
    

7.  Silver LD, Ng SW, Ryan-Ibarra S, et al. Changes in prices, sales, consumer spending, and beverage consumption one year after a tax on sugar-sweetened beverages in Berkeley, California, US: a before-and-after study. PLoS Med 2017;14:e1002283
    
    

8.  Colchero MA, Popkin BM, Rivera JA, et al. Beverage purchases from stores in Mexico under the excise tax on sugar sweetened beverages: observational study. BMJ 2016;352:h6704.
    
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9.  Green R, Cornelsen L, Dangour AD, et al. The effect of rising food prices on food consumption: systematic review with meta-regression. BMJ 2013; 346:f3703.
    
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10. Backholer K, Sarink D, Beauchamp A, et al. The impact of a tax on sugar-sweetened beverages according to socio-economic position: a systematic review of the evidence. Public Health Nutr 2016; 19:3070–84.
    
    

11. Sassi F, Belloni A, Mirelman AJ, et al. Equity impacts of price policies to promote healthy behaviours. Lancet 2018;391:2059–70.